Trauma recent issues

Fracture healing and bone repair: an update

Mon, 20 Jul 2009 08:14:23 PDT

Bone healing represents a physiological process of repair and restoration of function. Recent advances in a variety of medical disciplines have enabled scientists and clinicians to characterise this phenomenon at the molecular level. A number of molecular mediators and cells interact utilising different pathways. Despite the involvement of many local and systemic factors failure of the naturally occurring mechanisms can occur leading to either delayed union or non-union. This review article is focused on the recent understanding of the mechanisms governing the bone repair process.

Major trauma in the elderly

Sarkar, S. N — Mon, 20 Jul 2009 08:14:23 PDT

With people living longer and able to undertake more activities, any professional involved in trauma care will inevitably be exposed to older victims of trauma. Increasing numbers of older people are admitted to trauma units, presenting the healthcare professional with challenges including altered physiology, polypharmacy and ethical considerations which may lead to diagnostic and treatment dilemmas. Rib fractures for example are associated with significant morbidity and mortality and optimising analgesia may improve outcomes. There are conflicting views over co-morbidities being associated with mortality, but mortality in UK intensive care units appears to be high in elderly trauma victims. The EAST guidelines provide a thorough management strategy of elderly trauma victims. Old age should not be a sole criterion for limiting or withholding care in trauma patients.

The classification and principles of management of wounds in trauma

Barnard, A., Allison, K. — Mon, 20 Jul 2009 08:14:23 PDT

The correct assessment and early management of wounds is vital in achieving a good outcome in both the acute and chronic setting. A robust management plan for the trauma patient depends upon accurate and timely assessment of all injuries and evaluation of key features such as mechanism of injury, pre-hospital findings and intervention, zone of injury, patient characteristics and structures damaged. This article describes the general principles of wound assessment and management, discussing mechanism and zone of injury, debridement techniques, types of irrigation and the use of antibiotic prophylaxis. Particular attention is given to the management of open tibial fractures, fasciotomy wounds, pretibial lacerations and haematomas and bite wounds.

Traumatic amputation -- a contemporary approach

Healey, A. J, Tai, N. — Mon, 20 Jul 2009 08:14:23 PDT

The management of patients with loss or near loss of a limb secondary to high-energy trauma is particularly challenging. Management consists of an acute phase of resuscitation and initial surgery, followed by a longer chronic phase, consisting of rehabilitation, fitting of a prosthesis and stump care. Acute assessment by the full trauma team along standard ABCDE guidelines should not conflict with early stemming of on-going stump or limb haemorrhage as required. Patients with traumatic limb loss are likely to be shocked and have traumatic coagulopathy; initial and on-going resuscitation should satisfy the need to replace blood with packed cells and plasma in a 1 : 1 ratio consistent with the concept of `Damage Control Resuscitation'. The surgical goal is to tailor surgery to the patients' physiological state, removing dead and unviable tissue, restoring perfusion to live tissue, stabilising fractured bone and addressing the loss of soft tissues. The imperative to preserve length should not outweigh the need to leave the patient with a stump that will heal in a timely fashion. Lifelong prosthetic preventive maintenance is paramount as residual limbs change in volume with muscle atrophy and changes inpatient weight. Replacement may also be indicated as improved designs appear from time to time. Early rehabilitation and prosthetic fitting also improves routine prosthetic use, which has been found to positively affect return to work.

Traumatic hip dislocation in adults

Deakin, D., Porter, K. — Mon, 20 Jul 2009 08:14:23 PDT

Traumatic hip dislocation occurs during high-energy trauma and is often associated with other life threatening injuries. Dislocation can be anterior or posterior and urgent reduction is mandatory to reduce the risk of avascular necrosis of the femoral head. Undisplaced femoral neck fractures should be excluded prior to attempted reduction. Various closed reduction techniques have been described and most dislocations can be reduced with a closed technique. Failure to achieve reduction makes open reduction mandatory. This review describes the diagnosis, investigation and management of this complex and challenging injury.

Sternal fractures

Raghunathan, R., Porter, K. — Tue, 19 May 2009 02:54:39 PDT

Sternal fractures are relatively common and range from simple unicortical cracks to displaced fractures associated with life threatening injuries. This paper describes the relevant anatomy, biomechanics, mechanism of injury, clinical presentation, investigation, treatment and complications and also includes associated and concomitant injuries. A management flow chart including criteria for discharge from the emergency department is presented.

`Clearing' the cervical spine in conscious trauma patients

Blackham, J., Benger, J. — Tue, 19 May 2009 02:54:39 PDT

This is a systematic review of published evidence regarding management of the cervical spine in conscious and co-operative trauma patients. We examine the literature in the following sections: clinical evaluation of the cervical spine; use of plain radiography; use of additional radiographic views; use of computed tomography; use of magnetic resonance imaging. Finally we consider the elderly and paediatric populations, particularly where there are significant differences compared to the general adult population. This paper also reviews the literature regarding non-medical assessment of the cervical spine. We conclude that there are well-validated decision rules available to guide the clinician, and that each imaging strategy has distinct advantages and disadvantages. Familiarity with these issues provides a sound basis for safe and effective decision-making.

Abdominal compartment syndrome -- the new killer

Searle, R., Wenham, T., Garner, J. — Tue, 19 May 2009 02:54:39 PDT

Abdominal compartment syndrome (ACS) results from an increase in intra-abdominal pressure (IAP) within the relatively fixed confines of the abdominal cavity. This increase in abdominal pressure can have deleterious consequences on multiple organ systems and amongst the intensive care population is associated with increased morbidity and mortality. Trauma victims commonly have multiple risk factors for the development of ACS, yet in the past routine measurement of IAP in intensive care patients in the UK has been variable. Recent consensus guidelines have helped to clarify the identification, diagnosis and management of patients at risk of ACS.

Clavicle fractures

Moonot, P., Ashwood, N. — Tue, 19 May 2009 02:54:39 PDT

Clavicular fractures represent 2.6—5% of all fractures, with middle third fractures being the commonest. The shape of the clavicle bone is such that it has a flat medial and lateral expanses, linked by a thin, tubular middle. This central transitional area represents a weak link in clavicular structure, which is not protected by or reinforced with muscle or ligamentous attachments, therefore rendering it prone to fracture. Due to the subcutaneous position of the clavicle, there is an inherent susceptibility to direct injury. These fractures are easy to diagnose due to the presence of swelling and bruising present. Radiographical examination should include an anteroposterior and a 45^° caudal tilt view. Optimal treatment in undisplaced or minimally displaced fractures is with a sling. In displaced or comminuted fractures the risk of non-union and poor functional outcome may be markedly higher and may be best treated with surgical fixation.

Management of female genital trauma

Hall, S., Brown, D. J. — Tue, 19 May 2009 02:54:39 PDT

The management of female genital trauma is complex and should be performed by a well-trained team of health care professionals. It is important to remember that many female genital injuries will cause not just physical injury, but also significant psychological and emotional distress that may lead on to future physical dysfunction. The approach of any health care professional in the immediate diagnosis and management of females with a genital injury must be aimed at getting the best and most appropriate care to the patient as soon as possible. It is also important to remember that many of these injuries are the result of crimes and careful documentation is required so as not to remove or invalidate evidence that may later be required by the courts. This article is aimed at non-specialist healthcare providers who may find themselves faced with a female genital trauma patient. It will cover the range of injuries and conditions that should be expected and describes the treatment that should be given for the best possible physical and psychological outcomes. At all times it should be remembered that the patient should be assessed and resuscitated in accordance with recognised ATLS protocols.

Acute traumatic compartment syndrome: a systematic review of results of fasciotomy

Hayakawa, H., Aldington, D. J, Moore, R A. — Wed, 04 Mar 2009 02:53:01 PST

Issues around diagnosis and treatment of acute compartment syndrome were investigated through a systematic review that examined results of 55 reports of fasciotomy published over four decades and reporting on 1920 fasciotomies. Most were reported since 2000. Injuries below the elbow and knee accounted for at least 75% of cases. The consensus was that diagnosis of compartment syndrome remains primarily based on a high index of suspicion and interpretation of clinical signs and symptoms over high technology methods of diagnosis. Compartment syndrome related amputation occurred in 5.5% of cases and death in 3.3% overall. Compared with fasciotomy before 6 h, delayed fasciotomy beyond 12 h was associated with a lower rate of acceptable outcome (15% for more than 12 h vs. 88% for <6 h), a higher rate of amputation (14% vs. 3.2%) and death (4.3% vs. 2.0%).

Update on global trends in trauma

Leppaniemi, A. — Wed, 04 Mar 2009 02:53:01 PST

The significance of trauma as a mechanism and cause of mortality and morbidity on a global scale is increasing. The combination of both large-scale disasters, whether natural or man-made, and the every day accidents, and intentional violence pose a grave challenge to the ability of our medical systems' ability to cope with the increasing demands of trauma care at system level as well as on individual providers. Despite significant advances in clinical practice, the economical, educational, and organisational limitations prevent us from providing the best available care to many of our patients, at least on a global scale. Fresh solutions and new paradigms are needed, and in order to approach the key issues successfully a wider scope with a look at the global perspective forming the 'environment of trauma' is required. This review updates the recent trends in trauma with emphasis on the causes and manifestations of trauma on a global scale.

The management and treatment of peri-prosthetic fractures around both total hip and hemiarthroplasty

Higgins, G., Davis, E., Revell, M, Porter, K — Wed, 04 Mar 2009 02:53:01 PST

Peri-prosthetic fractures are an increasingly common phenomenon. They are associated with a high mortality, morbidity and economic burden. We reviewed the literature and look at historical aspects, risk factors, clinical assessment, classification and management of peri-prosthetic fractures around the hip. This article is intended to provide an overview to enable safe initial management of peri-prosthetic fractures and insight into definitive treatment.

Flail chest: pathophysiology and management

Qasim, Z., Gwinnutt, C. — Wed, 04 Mar 2009 02:53:01 PST

Thoracic trauma is an important cause of morbidity and mortality in the UK, frequently found in drivers of motor vehicles following high-speed accidents. One of the more serious injuries is a flail chest, particularly when there are also underlying pulmonary contusions. For many years the optimal therapeutic regimen for the management of this condition has remained somewhat controversial. More recently, the role of epidural analgesia, the use of non-invasive techniques of ventilation and identification of those who may benefit from surgical stabilisation have been more clearly defined.

The role of chest computed tomography in trauma

Plurad, D., Rhee, P. — Fri, 07 Nov 2008 03:28:49 PST

Chest computed tomography (CCT) evaluation for trauma encompasses two main objectives: (1) The evaluation of the acutely injured in the search for diagnoses and (2) follow up assessment or diagnosis of pulmonary complications in the hospitalised patient. In the acute phase of evaluation, CCT has become particularly helpful for the diagnosis of blunt thoracic aortic injury (BAI), great vessel injury, extent of lung contusion, occult hemothorax, occult pneumothorax, spinal fractures and spinal cord injuries and to determine the tract of transmediastinal gun shot wounds. In the subacute phase, CCT has gained popularity for diagnosing pulmonary embolism and evaluation of retained hemothorax. Technological advances have lead to better diagnostic capabilities that can be obtained quickly but, particularly in the trauma patient, there is little consistent data supporting an outcome improvement in the majority of patients despite changes in clinical management. Further data is needed to support use of CCT in select trauma patient populations to increase useful diagnostic yield and cost effectiveness.

The radiological assessment of injuries to the atlanto-axial-occipital complex (C1 and C2 vertebrae)

Banerjee, A., Clayton-Jolly, A., Mbamalu, D. — Fri, 07 Nov 2008 03:28:49 PST

Upper cervical spine injuries are a source of diagnostic difficulty. While CT scanning is being used more widely in assessing the cervical spine, especially in unconscious patients, plain film radiology remains an important first point of assessment in the UK in less dramatic situations. We summarise relevant literature on plain film radiology of the upper cervical spine, and make some suggestions for structured evaluation of films under review.

Triage in children

Patel, M., Maconochie, I. — Fri, 07 Nov 2008 03:28:49 PST

The importance of triage tools designed specifically for children in major incidents and in the emergency department (ED) is being increasingly recognised. Triage tools should be clinically safe and evidence based where possible. This review aims to summarise the triage systems available for children in the pre-hospital and ED setting, discuss the differences in triage systems around the world and look at possible triage solutions of the future.

Beyond splenectomy -- options for the management of splenic trauma

Whitfield, C., Garner, J. — Fri, 07 Nov 2008 03:28:49 PST

The spleen remains a vulnerable organ to blunt or penetrating abdominal trauma and recognition of its important immunological role has meant that alternatives to mandatory splenectomy for splenic injury are now available. This article examines the alternatives to splenectomy and then discusses the post-splenectomy management of patients.

Recent advances in clot biology and assessment of clotting

Hedner, U., Ezban, M. — Fri, 07 Nov 2008 03:28:49 PST

Since the first description of the haemostatic process by Morawitz in 1904, knowledge about the haemostasis mechanism has undergone substantial modifications. Increasing knowledge of enzymology, purification and characterisation of coagulation proteins led to the introduction of the waterfall or cascade model of coagulation. However, these models were based on in vitro studies in the presence of artificial phospholipids and the absence of cells. Two pathways to achieve the formation of a haemostatic fibrin plug were identified, the so-called `extrinsic system' involving both factors present in the circulation and from the extravascular space, and the `intrinsic system' using only factors present in the circulation. However, with increasing knowledge about the interaction between factors from the two systems, the relevance of this model was questioned. The availability of recombinant FVIIa has made further research of the role of FVII/FVIIa and TF feasible, resulting in the current concept of haemostasis according to which the process principally occurs on two cell surfaces, the TF-bearing cell and the thrombin-activated platelet. A limited amount of thrombin is generated by the FVIIa-TF complex on the TF-bearing cell resulting in activation of platelets, FIX, FVIII and FV. The further and full thrombin generation then takes place on the activated platelet surface. The most frequently used assays for evaluation of the global haemostatic capacity are the prothrombin time (PT) and the activated partial thromboplastin time (APTT). The PT measures the formation of a fibrin clot in the presence of an abundance of TF thereby principally reflecting the initial thrombin generation dependent especially on FVII, FV and FX, while the APTT mimics the processes on the activated platelet surface involving FVIII, FIX, FXl, FV, FX and prothrombin. For more specific analyses, assay systems measuring the level of various coagulation factors are available. Platelet function is measured by platelet count and bleeding time. The platelet aggregation response to different agonists can be measured in special aggregometers. The usefulness of these techniques in evaluating a potential bleeding risk is, however, doubtful.

Hamstring injuries

Gokaraju, K., Garikipati, S., Ashwood, N. — Fri, 07 Nov 2008 03:28:49 PST

Hamstring strains or ruptures require accurate diagnosis and appropriate management for a successful return to normal function. Such injuries may occur to varying severities in one or more of the individual muscles at any point throughout their length. Understanding of the anatomy and mechanics of the lower limb are essential for accurate assessment and treatment of the insult. The type and severity of the injury determines whether conservative or surgical approaches are utilised for definitive management. In addition, the importance of immediate measures and appropriate rehabilitation should not be underestimated