Chinese Journal of Traumatology
Volume 24 · Issue 02 · 2021
Chin J Traumatol
- Sections
- Review Article
- Comment
- Original Article
- Case Report
Throughout the past 2020, the pandemic COVID-19 has caused a big global shock, meanwhile it brought a great impact on the public health network. Trauma emergency system faced a giant challenge and how to manage trauma under the pandemic of COVID-19 was widely discussed. However, the trauma treatment of special population (geriatric patients and patients taking anticoagulant drugs) has received inadequate attention. Due to the high mortality following severe traumatic hemorrhage, hemostasis and trauma-induced coagulopathy are the important concerns in trauma treatment. Sepsis is another topic should not be ignored when we talking about trauma. COVID-19 itself is a special kind of sepsis, and it may even be called as serious systemic infection syndrome. Sepsis has been become a serious problem waiting to be solved urgently no matter in the fields of trauma, or in intensive care and infection, etc. This article reviewed the research progress in areas including trauma emergency care, trauma bleeding and coagulation, geriatric trauma and basic research of trauma within 2020.
Thrombotic microangiopathy (TMA) is characterized by systemic microvascular thrombosis, target organ injury, anemia and thrombocytopenia. Thrombotic thrombocytopenic purpura, atypical hemolytic uremic syndrome and Shiga toxin E-coli-related hemolytic uremic syndrome are the three common forms of TMAs. Traditionally, TMA is encountered during pregnancy/postpartum period, malignant hypertension, systemic infections, malignancies, autoimmune disorders, etc. Recently, the patients presenting with trauma have been reported to suffer from TMA. TMA carries a high morbidity and mortality, and demands a prompt recognition and early intervention to limit the target organ injury. Because trauma surgeons are the first line of defense for patients presenting with trauma, the prompt recognition of TMA for these experts is critically important. Early treatment of post-traumatic TMA can help improve the patient outcomes, if the diagnosis is made early. The treatment of TMA is also different from acute blood loss anemia namely in that plasmapheresis is recommended rather than platelet transfusion. This article familiarizes trauma surgeons with TMA encountered in the context of trauma. Besides, it provides a simplified approach to establishing the diagnosis of TMA. Because trauma patients can require multiple transfusions, the development of disseminated intravascular coagulation must be considered. Therefore, the article also provides different features of disseminated intravascular coagulation and TMA. Finally, the article suggests practical points that can be readily applied to the management of these patients.
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Hemodynamically unstable patients with pelvic fractures still represent a challenge to trauma surgeons and have a very high mortality. This study was designed to explore the effect of the interventions of direct preperitoneal pelvic packing for the hemodynamically unstable pelvic fractures.
This retrospective study enrolled 67 cases of severe pelvic fractures with unstable hemodynamics from October 2011 to December 2019. All patients presented in our emergency center and received preperitoneal pelvic packing were included in this study. The indication was persistent systolic blood pressure ≤90 mmHg during initial resuscitation and after transfusion of two units of red blood cells. Patients with hemodynamic stability who need no preperitoneal pelvic packing to control bleeding were excluded. Their demographic characteristics, clinical features, laboratory results, therapeutic interventions, adverse events, and prognostic outcomes were collected from digital information system of electronic medical records. Statistics were described as mean ± standard deviation or medium and analyzed using pair sample t-test or Mann-Whitney U-test.
The patients’ average age was 41.6 years, ranging from 10 to 88 years. Among them, 45 cases were male (67.2%) and 22 cases were female (32.8%). Significant difference was found regarding the systolic blood pressure (mmHg) in the emergency department (78.4 ± 13.9) and after preperitoneal pelvic packing in the surgery intensive care unit (100.1 ± 17.6) (p < 0.05). Simultaneously, the arterial base deficit (mmol/L) were significantly lower in the surgery intensive care unit (median -6, interquartile range -8 to -2) than in the emergency department (median -10, interquartile range -14 to -8) (p < 0.05). After preperitoneal pelvic packing, 15 patients (22.4%) underwent pelvic angiography for persistent hypotension or suspected ongoing haemorrhage. The overall mortality rate was 29.5% (20 of 67).
Preperitoneal pelvic packing, as a useful surgical technique, is less invasive and can be very efficient in early intra-pelvic bleed control.
Treatment of irreducible femoral intertrochanteric fractures often requires open reduction. However, the technique unavoidably causes patients to suffer greater trauma. As such, minimally invasive techniques should be employed to reduce the surgical-related trauma on these patients and maintain a stable reduction of the fractures. Herein, a minimally invasive wire introducer was designed and used for the treatment of femoral intertrochanteric fractures. The effectiveness of using a wire-guided device to treat irreducible femoral intertrochanteric fractures was evaluated.
Between 2013 and 2018, patients with femoral intertrochanteric fractures who were initially treated by intramedullary nail fixation but had difficult reduction using the traction beds were retrospectively reviewed. Decision for an additional surgery was based on the displacement of the fracture. The patients were then divided into two groups: those in the control group received an open reduction surgery while those in the observation group received a closed reduction surgery using a minimally invasive wire introducer to guide the wire that could assist in fracture reduction. The operation time, blood loss, visual analogue scale scores, angulation, reduction, neck-shaft angle, re-displacement, limb length discrepancy, and union time were then recorded and analyzed to determine the efficiency of the wire introducer technique. Categorical variables were analyzed by using Chi-square test, while continuous variables by independent t-test and the Mann-Whitney test accordingly.
There were 92 patients included in this study: 61 in the control group and 31 in the observation group. There were no significant differences in baseline demographic factors between the two groups. All surgeries were successful with no deaths within the perioperative period. The average follow-up time for the patients was 23.8 months. However, the observation group had a significantly shorter operation time, lower visual analogue scale score, less intraoperative bleeding, and shorter fracture healing time. There were no significant differences in the angulation, reduction, neck-shaft angle, and limb length discrepancy between the two groups.
The minimally invasive wire guide achieved a similar effect to that of open reduction in the treatment of intertrochanteric fractures with difficult reduction. Moreover, the minimally invasive wire introducer is a good technology that accurately guides the wire during reduction. Indeed, it is an effective technique and achieves good clinical outcomes in restoration of irreducible femoral intertrochanteric fractures.
Impending compartment syndrome is a common event following closed tibia fractures, which can progress to sinister compartment syndrome. Fasciotomy is the only definitive treatment available, though it has its own drawbacks and complications. Medical management at present consists of limb elevation and adequate hydration. This study aims at determining whether intravenous administration of Mannitol reduced the intracompartmental pressure in patients with closed tibial fractures.
This is a double blinded, randomized control trial done in a single tertiary care center in India. Forty-five patients were recruited between February 2012 and October 2012. Forty patients who presented to the emergency department with isolated, closed, high velocity, and proximal 2/3 tibia fractures were included in this study. Patients with contraindication to Mannitol were excluded. They were allocated into 2 groups by the investigator using computer generated randomization. The pressure in the anterior compartment of the leg was measured with a handheld Stryker pressure monitor. Then either 20% Mannitol or 0.9% normal saline as given intravenously in a blinded manner, based on the randomization. The intracompartmental pressure was measured at 0, 1 and 3 h after the infusion. The participant, investigator and statistician were masked to the group assessment.
There was no difference in intracompartmental pressures at 1 or 3 h, between the groups. However, in patients with the baseline of compartmental pressures ≥30 mmHg, Mannitol showed a marked reduction in pressure of 8.5 mmHg at 1 h compared to almost no change in pressure in the saline group. There were no adverse events with the use of Mannitol.
This preliminary study appears to show that Mannitol is useful in the management of the increased compartment pressure. The limitations of this study were that it only involved a small group of patients and the baseline pressures in both the groups were not comparable. More studies are required before the use of Mannitol as a standard of care in the management of compartment syndrome can be established.
Trauma has been called the neglected disease of modern society. According to WHO, fall is the second major cause of trauma or deaths resulting from unintentional accidents. The aim of this study was to investigate the different types of fall according to International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) in hospitalized patients visiting specialized accident and trauma hospitals of Mashhad, Iran.
This was a cross sectional retrospective study performed between March 20, 2013 and March 20, 2014. The research population consisted of all medical records of patients for fall injuries in three specialized accident and trauma hospitals. ICD-10 was adopted to categorize all types of falls (w00-w19). The results obtained were analyzed by SPSS 16.
Altogether 7,448 cases were included. The codes w18 (fall on same level) and w09 (fall involving playground equipment) with the frequencies of 1,856 and 1,303, respectively in both genders had the maximum number of falls. The maximum percentage of mortality has been related to "fall on and from ladder" ," fall from cliff "and "fall on same level involving ice and snow" .
As falls can cause irrecoverable injuries including mortality of people, thus health authorities and policymakers should take preventive measures given the causes of falls and the root of this type of injuries, so that the costs resulting from this cause and its injuries can be reduced.
To determine the trends with fatally or otherwise injured pedestrians lying on the road and the relationship to hit-and-run incidents in Japan.
We extracted data for 2012-2016 from the records of the Institute for Traffic Accident Research and Data Analysis, Japan, a nationwide traffic accident database. All the injured and fatally injured pedestrians were selected. We examined the levels of pedestrian injury, vehicle speed immediately before the collision, whether or not the pedestrian was lying on the road, and hit-and-run incidents. Chi-square test was employed to make a statistical comparison between the two groups.
The database contained data on 286,383 pedestrian casualties and 7256 fatalities; 8.3% of fatalities (602 persons) and 0.6% of casualties (1827 persons) involved pedestrians lying on the road. The rates of fatalities and severe injuries were significantly higher for pedestrians who were lying on the road than for those who were not. Hit-and-run incidents were evident in 4.0% of casualties and 7.3% of fatalities. The rate of hit-and-run cases was also significantly higher among pedestrians who were lying on the road. Among fatally injured pedestrians not lying on the road, the rates with speeds of ≥30 km/h did not differ significantly between hit-and-run and other cases. However, when the pedestrians were lying on the road, the rate was significantly increased in hit-and-run cases.
This is the first report to focus on pedestrians lying on the road and being involved in hit-and-run incidents. In addition to preventing hit-and-run incidents, prevention of pedestrians lying on the road could also decrease fatalities.
This research examined road traffic injury mortality and morbidity disparities across of country development status, and discussed the possibility of reducing country disparities by various actions to accelerate the pace of achieving Sustainable Development Goals target 3.6 - to halve the number of global deaths and injuries from road traffic accidents by 2020.
Data for road traffic mortality, morbidity, and socio-demographic index (SDI) were extracted by country from the estimates of the Global Burden of Disease study, and the implementation of the three types of national actions (legislation, prioritized vehicle safety standards, and trauma-related post-crash care service) were extracted from the Global Status Report on Road Safety by World Health Organization. We fitted joinpoint regression analysis to identify and quantify the significant rate changes from 2011 to 2017.
Age-adjusted road traffic mortality decreased substantially for all the five SDI categories from 2011 to 2017 (by 7.52%-16.08%). Age-adjusted road traffic mortality decreased significantly as SDI increased in the study time period, while age-adjusted morbidity generally increased as SDI increased. Subgroup analysis by road user yielded similar results, but with two major differences during the study period of 2011 to 2017: (1) pedestrians in the high SDI countries experienced the lowest mortality (1.68-1.90 per 100,000 population) and morbidity (110.45-112.72 per 100,000 population for incidence and 487.48-491.24 per 100,000 population for prevalence), and (2) motor vehicle occupants in the high SDI countries had the lowest mortality (4.07-4.50 per 100,000 population) but the highest morbidity (428.74-467.78 per 100,000 population for incidence and 1025.70-1116.60 per 100,000 population for prevalence). Implementation of the three types of national actions remained nearly unchanged in all five SDI categories from 2011 to 2017 and was consistently stronger in the higher SDI countries than in the lower SDI countries. Lower income nations comprise the heaviest burden of global road traffic injuries and deaths.
Global road traffic deaths would decrease substantially if the large mortality disparities across country development status were reduced through full implementation of proven national actions including legislation and law enforcement, prioritized vehicle safety standards and trauma-related post-crash care services.
There were 10%-30% of patients with adult-onset septic arthritis (SA) exhibiting sterile synovial fluid (SF), and the uncertainty in the determining diagnosis of these patients posed a challenge in management. The purpose of this study was to investigate the differences between confirmed (Newman A) and suspected (Newman B & C) SA in adults.
This was a descriptive study with a cross-sectional study design conducted at a tertiary referral centre from July 2016 to February 2019. Patients aged over 18 years presented to the emergency department with clinical features suggestive of SA and were scheduled to undergo arthrotomy and joint lavage by the treating surgeon were included in the study. Patients with prosthetic joint infections and open joint injuries were excluded. Patients’ demographic data, clinical features and laboratory parameters were collected. The clinical and laboratory profile (blood and SF) of the adult patients presenting with features suggestive of SA based on Newman criteria was statistically analyzed by SPSS version 20 software and Microsoft Excel. The categorical variables were expressed as proportions while the continuous variables were expressed as mean (SD) or median (IQR) depending upon the normality of distribution. The difference between the two groups for categorical variables was assessed using the Chi-square test and the difference for continuous variables was assessed using the unpaired t-test and the Mann-Whitney test depending upon normality. A p value < 0.05 was considered significant.
Thirty-six patients were divided into confirmed (n = 19) or suspected (n = 17) SA for assessment based on SF culture. The median (IQR) age of the patients was 50 years (37-60 years). There was no significant difference in demographic, clinical and laboratory parameters between the concerned groups. Eight patients presented with fever. Among the confirmed SA cases, 8 were negative for C-reactive protein and 6 had synovial white blood cell count <50,000. Staphylococcus species were isolated in 8 cases. The most common risk factors for SA were chronic kidney disease (25.0%), diabetes mellitus (25.0%), pharmacologic immunosuppression (16.7%), recent joint surgery (11.1%) and distant site infection (11.1%).
SA is an orthopaedic emergency that needs prompt and aggressive treatment to prevent catastrophic complications. Confirmed and suspected cases of SA exhibit similar demography, clinical features and laboratory parameters at presentation which may mislead the treating surgeon. Management should be based on sound clinical judgment in the event of failure to culture microorganisms.
Total elbow arthroplasty as a treatment option for open elbow fracture is relatively rare described. We reported a 39 years old polytrauma patient with complex open elbow fracture (Gustilo-Anderson type IIIB). The patient presented with large soft tissues defect on dorsal part of the left elbow, ulnar palsy due to the irreparable loss of the ulnar nerve, distal triceps loss due to the complete loss of the olecranon, loss of both humeral condyles with collateral ligaments and complex elbow instability. Only few similar cases have been published. Reconstructive surgery included repetitive radical debridement, irrigation, vacuum assisted closure system therapy, external fixation, coverage of the soft tissue defect with fascia-cutaneous flap from the forearm. Four months after the injury, total elbow arthroplasty with autologous bone graft (from the proximal radius) inserted in the ulnar component, was performed. At 3 years postoperatively, the patient is able to perform an active flexion from 0° to 110° with full pronosupination. Only passive extension is allowed. The ulnar neuropathy is persistent. Patient has no signs of infection or loosening of the prosthesis.
Iatrogenic femoral artery pseudoaneurysm caused by invasive procedures is one of the common complications for endovascular interventions. We present a case of a young male with a complex iatrogenic femoral artery pseudoaneurysm as a result of iatrogenic femoral artery puncture. The defective femoral artery was repaired with combined bovine pericardial tube and autologous great saphenous vein grafts. Computed tomography angiography showed the grafts were still patent one year after the surgery.
Fat embolism syndrome (FES) is a serious life-threatening manifestation of the fat embolism phenomenon characterized by Bergman’s triad of dyspnea, petechiae and mental confusion. While fat embolization into systemic circulation is common, FES occurs in a meagre 0.05%-3% of patients having isolated long bone fractures. Though visual symptoms are commonly attributed to fat embolism retinopathy and is a later occurrence, it may not always be the case. Cortical blindness has been seldom reported in association with FES, and less so as a presenting complaint. Furthermore, no previous literature has described the same in context of an isolated tibia fracture. We report a 20-year-old gentleman with an isolated right tibia shaft fracture who developed sudden onset diminution of vision in both eyes less than 24 h following trauma with no other complaints. Lack of any remarkable ophthalmoscopic findings or other symptoms left us with a diagnostic conundrum. He later went on to develop altered mentation, hypoxia and generalized tonic-clonic seizures with subsequent MRI revealing multiple cerebral fat emboli also involving both occipital lobes. Supportive measures were instituted and his general condition as well as vision gradually improved following which he underwent plate fixation of the fracture under spinal anaesthesia. The perioperative period was uneventful and he was discharged following staple removal. At one month of follow-up, the patient had no residual visual field defects or neurological deficits. Though FES is rare among isolated tibia fractures, this clinical catastrophe may strike in any unsuspected setting thereby warranting a high index of suspicion to ensure early diagnosis and improved patient outcomes.
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