Narrative review of traumatic pneumorrhachis

Pneumorrhachis(PR)is defined as presence of free air in the spinal canal.Trau-matic PR is very rare,and its exact incidence and pathogenesis is unknown.A comprehensive literature search was performed using the PubMed,Cochrane Library,Google Scholar and Scopus databases to identify articles relevant to traumatic PR published till January 2023.A total of 34 resources were selected for inclusion in this narrative review.Traumatic PR can be classified anatomically into epidural and intradural types.In the epidural type,air is present peripherally in the spinal canal and the patients are usually asymptomatic.In contrast,in intradural PR,air is seen centrally in the spinal canal and patients present with neurological symptoms,and it is a marker of severe trauma.It is frequently associated with traumatic pneumocephalus,skull fractures or thoracic spine fracture.Computed tomography(CT)is considered to be the diagnostic modality of choice.Epidural PR is self-limited and patients are generally managed conser-vatively.Patients with neurological symptoms or persistent air in spinal canal require further evaluation for a potential source of air leak,with a need for surgical intervention.Differentiation between epidural and intradural PR is important,because the latter is an indication of severe underlying injury.CT imaging of the entire spine must be performed to look for extension of air,as well as to identify concomitant skull,torso or spinal injuries Most patients are asymp-tomatic and are managed conservatively,but a few may develop neurological symptoms that need further evaluation and management.

Traumatic abdominal wall hernia:a rare and often missed diagnosis in blunt trauma

Dear editor,Traumatic abdominal wall hernia(TAWH)is defined as disruption of the abdominal wall musculature and fascia with herniation of intra-abdominal contents,in the absence of surgery to that area of the abdominal wall.[1]It is rare,with an incidence of 0.17%-0.90%in patients with blunt abdominal trauma.[2,3]Deceleration forces caused by falls from height or seat belt injuries are the most common causes of TAWH.[4]Low-energy blunt injuries from bicycle or motorcycles handlebars or charging animals are less frequent causes.Due to the rare incidence and complex presentation of this condition with other distracting injuries,this diagnosis is often not considered,resulting in missed or delayed diagnosis.We present a case of a 46-year-old male who suffered major abdominal trauma,and was found to have TAWH as well as intra-abdominal organ injury.

Early Postoperative Deaths in the Surgical Intensive Care Unit of CHU-Kara

Aim: Review of early postoperative deaths in the surgical intensive care unit at CHU-Kara. Introduction: Surgery, one of the means of treatment of diseases, also presents risks for the patient, including early postoperative death linked to numerous risk factors. Methodology: This was a retrospective descriptive study conducted on the records of patients who died within 48 hours after surgery from November 1, 2019 to April 30, 2021. The study was conducted in the surgical intensive care unit and in the operating room. Results: Thirty-two early postoperative deaths or 2.22% out of 1442 operated with 30 deaths retained for the study. Male gender predominated (70%). The average age was 31.22 years. Farmers were more concerned (66.67%). The time to surgery was 1.6 days. ASA1 patients (40%) predominated followed by ASA IV (30%). 80% of patients were operated on as an emergency. Digestive pathologies 80% were more represented. General anaesthesia 86.66% was more practiced associating Propofol, Fentanyl, Ketamine and Atropine more frequently. The average duration of the procedures was 132.5 minutes. Intraoperative complications were associated with cardiac arrest and hemorrhage (33.34%). ASA class higher than 2, dirty surgery (46.67%), and delayed recovery (13.34%) were the incriminating risk factors. Death by hemodynamic shock and respiratory distress were the main causes 26.66%. Conclusion: Early postoperative mortality was high and involved all ages. Anesthesia and surgery, the low level of qualification of the intraoperative actors, the lesser intraoperative security;the association of anesthetic effects, the complexity of intraoperative lesions led to the increase of mortality. The combination of two or more factors was pejorative for the deaths.

Bone Regeneration Based on Tissue Engineering Conceptions – A 21st Century Perspective

The role of Bone Tissue Engineering in the field of Regenerative Medicine has been the topic of substantial research over the past two decades. Technological advances have improved orthopaedic implants and surgical techniques for bone reconstruction. However, improvements in surgical techniques to reconstruct bone have been limited by the paucity of autologous materials available and donor site morbidity. Recent advances in the development of biomaterials have provided attractive alternatives to bone grafting expanding the surgical options for restoring the form and function of injured bone. Specifically, novel bioactive （second generation） biomaterials have been developed that are characterised by controlled action and reaction to the host tissue environment, whilst exhibiting controlled chemical breakdown and resorption with an ultimate replacement by regenerating tissue. Future generations of biomaterials （third generation） are designed to be not only osteo- conductive but also osteoinductive, i.e. to stimulate regeneration of host tissues by combining tissue engineer- ing and in situ tissue regeneration methods with a focus on novel applications. These techniques will lead to novel possibilities for tissue regeneration and repair. At present, tissue engineered constructs that may find future use as bone grafts for complex skeletal defects, whether from post-traumatic, degenerative, neoplastic or congenital/developmental ＂origin＂ require osseous reconstruction to ensure structural and functional integrity. Engineering functional bone using combinations of cells, scaffolds and bioactive factors is a promising strategy and a particular feature for future development in the area of hybrid materials which are able to exhibit suitable biomimetic and mechanical properties. This review will discuss the state of the art in this field and what we can expect from future generations of bone regeneration concepts.

Use of Teriparatide to improve fracture healing: What is the evidence?

Teriparatide is a recombinant form of the biologicallyactive component of Parathyroid hormone. It has been shown to increase bone mass and prevent fractures in osteoporotic bone. It is licensed by the Food and Drug Administration for the treatment of Osteoporosis. Over the last decade, a growing body of evidence has accumulated suggesting a role for Teriparatide in the management of fractures. Studies in both normal and delayed healing models have shown improvement in callus volume and mineralisation, bone mineral content, rate of successful union and strength at fracture sites. However most of these results have been derived from animal studies. The majority of this research on humans has comprised low level evidence, with few randomised controlled trials, many case reports and case series. Nevertheless, the results from these studies seem to support research from animal models. This has led to a growing number of clinicians using Teriparatide "off license" to treat fractures and non-unions in their patients. This review presents a critical appraisal of the current evidence supporting the use of Teriparatide for fracture healing, delayed unions and non unions and in the setting of osteoporotic fractures, the studies producing this evidence and their transferability to human beings.

The Training and Performance of Emergency Physicians as Anesthetists for International Medical Surgical Response Teams: The Emergency Physician’s General Anesthesia Syllabus (EP GAS)

Background: The availability of an anesthesiologist is often a limiting factor in the number of operations that can be performed by International Medical Surgical Response Teams (IMSuRT). Because emergency physicians (EPs) possess skills in airway control, management of moderate and deep sedation, and ventilator management, we propose that with proper training in general anesthesia, EPs can serve as anesthetists for IMSuRT with anesthesiologist supervision. Methods: During a 10-week period, a board-certified EP administered general anesthesia to 60 patients prior to a surgical medical mission trip. The breakdown of surgical cases was: 11 orthopedic, 2 genitourinary, 20 ear, nose, and throat, 8 obstetrics and gynecological, 13 general surgery, and 6 vascular. A simplified protocol for induction, maintenance, and emergence was adhered to for all cases. Results: Fourteen orthopedic cases using general anesthesia were performed in a one-week period in Haiti. These cases involved open reduction and internal fixation (ORIF), hemiarthoplasty, hardware removal, tendon transfer and external fixation of fractured bone. Conclusion: We demonstrate the feasibility of a model curriculum to train EPs in the basics of anesthesia. The EP can safely and effectively deliver general anesthesia for major cases on surgical medical mission trips under the auspices of an anesthesiologist in an austere environment.

A New Model to Study Healing of a Complex Femur Fracture with Concurrent Soft Tissue Injury in Sheep

High energy bone fractures resulting from impact trauma are often accompanied by subcutaneous soft tissue injuries, even if the skin remains intact. There is evidence that such closed soft tissue injuries affect the healing of bone fractures, and vice versa. Despite this knowledge, most impact trauma studies in animals have focussed on bone fractures or soft tissue trauma in isolation. However, given the simultaneous impact on both tissues a better understanding of the interaction between these two injuries is necessary to optimise clinical treatment. The aim of this study was therefore to develop a new experimental model and characterise, for the first time, the healing of a complex fracture with concurrent closed soft tissue trauma in sheep. A pendulum impact device was designed to deliver a defined and standardised impact to the distal thigh of sheep, causing a reproducible contusion injury to the subcutaneous soft tissues. In a subsequent procedure, a reproducible femoral butterfly fracture (AO C3-type) was created at the sheep’s femur, which was initially stabilised for 5 days by an external fixator construct to allow for soft tissue swelling to recede, and ultimately in a bridging construct using locking plates. The combined injuries were applied to twelve sheep and the healing observed for four or eight weeks (six animals per group) until sacrifice. The pendulum impact led to a moderate to severe circumferential soft tissue injury with significant bruising, haematomas and partial muscle disruptions. Posttraumatic measurements showed elevated intra-compartmental pressure and circulatory tissue breakdown markers, with recovery to normal, pre-injury values within four days. Clinically, no neurovascular deficiencies were observed. Bi-weekly radiological analysis of the healing fractures showed progressive callus healing over time, with the average number of callus bridges increasing from 0.4 at two weeks to 4.2 at eight weeks. Biomechanical testing after sacrifice showed in- creasing torsional stiffness between four and eight weeks healing time from 10% to 100%, and increasing ultimate torsional strength from 10% to 64% (relative to the contralateral control limb). Our results demonstrate the robust healing of a complex femur fracture in the presence of a severe soft tissue contusion injury in sheep and demonstrate the establishment of a clinically relevant experimental model, for research aimed at improving the treatment of bone fractures accompanied by closed soft tissue injuries.

Congenital Gangrene in a Premature Newborn: A Case Report

Introduction: Congenital limb gangrene is a rare pathology. In the majority of cases, no cause is identified and its treatment is not codified. Observation: 29-week premature newborn, female from poorly followed twin pregnancy. Clinical examination at admission found an unstable neonate, the presence of necrosis of the left hand and forearm well limited, with absent humeral pulse and absence of hand movement. Surgical treatment was scheduled for amputation of the limb after the agreement of the parents whose postoperative follow-ups were simple. Conclusion: Congenital gangrene remains a rare entity in neonatology.

Isolated free intra-abdominal fluid on CT in blunt trauma： The continued diagnostic dilemma

Purpose： The clinical significance of isolated flee fluid （FF） without solid organ injury on computed to- mography （CT） continues to pose significant dilemma in the management of patients with blunt abdominal trauma （BAT）. Methods： We reviewed the incidence of FF and the clinical outcome amongst patients with blunt abdominal trauma in a metropolitan trauma service in South Africa. We performed a retrospective study of 121 consecutive CT scans over a period of 12 months to determine the incidence of isolated FF and the clinical outcome of patients managed in a large metropolitan trauma service, Results： Of the 121 CTs, FF was identified in 36 patients （30%）. Seven patients （6%） had isolated FF. Of the 29 patients who had free fluid and associated organ injuries, 33 organ injuries were identified. 86% （25/ 29） of all 29 patients had a single organ injury and 14% had multiple organ injuries. There were 26 solid organ injuries and 7 hollow organ injuries. The 33 organs injured were： spleen, 12; liver, 8; kidney, 5; pancreas, 2; small bowel, 4; duodenum, 1. Six （21%） patients required operative management for small bowel perforations in 4 cases and pancreatic tail injury in 2 cases. All 7 patients with isolated FF were initially observed, and 3 （43%） were eventually subjected to operative intervention. They were found to have an intra-peritoneal bladder rupture in 1 case, a non-expanding zone 3 haematoma in I case, and a negative laparotomy in 1 case. Four （5？%） patients were successfully managed without surgical interventions. Conclusions： Isolated FF is uncommon and the clinical significance remains unclear. Provided that reli- able serial physical examination can be performed by experienced surgeons, an initial non-operative approach should be considered.

Outcome of severely injured trauma patients at a designated trauma centre in the Hong Kong Special Administrative Region

Background The Hong Kong Special Administrative Region （HKSAR） of the People＇s Republic of China （PRC） has seen significant changes in its trauma service over the last ten years including the implementation of a regional trauma system. The author＇s institution is one of the five trauma centres designated in 2003. This article reports our initial clinical experience. Methods A prospective single-centre trauma registry from January 2004 to December 2008 was reviewed. The primary clinical outcome measure was hospital mortality. The Trauma and Injury Severity Score （TRISS） methodology was used for bench-marking with the North America Major Trauma Outcome Study （MTOS） database. Results There were 1451 patients. The majority （83.9%） suffered from blunt injury. The overall mortality rate was 7.8%. Severe injury, defined as the Injury Severity Score 〉15, occurred in 22.5% of patients, and was associated with a mortality rate of 31.6%. A trend of progressive improvement was noted. The M-statistic was 0.99, indicating comparable case-mix with the MTOS. The Z- and W-statistics of each individual year revealed fewer, but not significantly so, number of survivors than expected. Conclusions Trauma centre designation was feasible in the HKSAR and was associated with a gradual improvement in patient care. Trauma system implementation may be considered in regions equipped with the necessary socio-economic and organizational set-up.

The effect of the quality of vital sign recording on clinical decision making in a regional acute care trauma ward

Purpose： Recording vital signs is important in the hospital setting and the quality of this documentation influences clinical decision making. The Modified Early Warning Score （MEWS） uses vital signs to categorise the severity of a patient＇s physiological derangement and illustrates the clinical impact of vital signs in detecting patient deterioration and making management decisions. This descriptive study measured the quality of vital sign recordings in an acute care trauma setting, and used the MEWS to determine the impact the documentation quality had on the detection of physiological derangements and thus, clinical decision making. Methods： Vital signs recorded by the nursing staff of all trauma patients in the acute care trauma wards at a regional hospital in South Africa were collected from January 2013 to February 2013. Investigator- measured values taken within 2 hours of the routine observations and baseline patient information were also recorded. A MEWS for each patient was calculated from the routine and investigator-measured observations. Basic descriptive statistics were performed using EXCEL Results： The details of lgl newly admitted patients were collected. Completion of recordings was 81% for heart rate, 88~; for respiratory rate, 98~; for blood pressure, 92% for temperature and 41~ for GCS. The recorded heart rate was positively correlated with the investigator＇s measurement （Pearson＇s correlation coefficient of 0.76）; while the respiratory rate did not correlate （Pearson＇s correlation coefficient of 0.02）. In 59~ of patients the recorded respiratory rate （RR） was exactly 20 breaths per minute and 27~ had a recorded RR of exactly 15. Seven percent of patients had aberrant Glasgow Coma Scale readings above the maximum value of 15. The average MEWS was 2 for both the recorded （MEWS（R）） and investigator （MEWS（1）） vitals, with the range of MEWS（R） 0-7 and MEWS（1） 0-9. Analysis showed 59% of the MEWS（R） underestimated the physiological derangement （scores were lower than the MEWS（1））; 80%; of patients had a MEWS（R） requiring 4 hourly checks which was only completed in 2%;; 86% of patients had a MEWS（R） of less than three （i.e. not necessitating escalation of care）, but 33% of these showed a MEWS（1） greater than three （i.e. actually necessitating escalation of care）. Conclusion： Documentation of vital signs aids management decisions, indicating the physiological derangement of a patient and dictating treatment. This study showed that there was a poor quality of vital sign recording in this acute care trauma setting, which led to underestimation of patients＇ physi- ological derangement and an inability to detect deteriorating patients. The MEWS could be a powerful tool to empower nurses to become involved in the diagnosis and detection of deteriorating patients, as well as providing a framework to communicate the severity of derangement between health workers. However, it requires a number of strategies to improve the quality of vital sign recording, including continuing education, increasing the numbers of competent staff and administrative changes in vital sign charts.

Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study

Background:Early control of haemorrhage and optimisation of physiology are guiding principles of resuscitation after injury.Improved outcomes have been previously associated with single,timely interventions.The aim of this study was to assess the association between multiple timely life-saving interventions(LSIs)and outcomes of traumatic haemorrhagic shock patients.Methods:A retrospective cohort study was undertaken of injured patients with haemorrhagic shock who presented to Alfered Emergency&Trauma Centre between July 01,2010 and July 31,2014.LSIs studied included chest decompression,control of external haemorrhage,pelvic binder application,transfusion of red cells and coagulation products and surgical control of bleeding through angio-embolisation or operative intervention.The primary exposure variable was timely initiation of≥50%of the indicated interventions.The association between the primary exposure variable and outcome of death at hospital discharge was adjusted for potential confounders using multivariable logistic regression analysis.The association between total pre-hospital times and pre-hospital care times(time from ambulance at scene to trauma centre),in-hospital mortality and timely initiation of≥50%of the indicated interventions were assessed.Results:Of the 168 patients,54(32.1%)patients had≥50%of indicated LSI completed within the specified time period.Timely delivery of LSI was independently associated with improved survival to hospital discharge(adjusted odds ratio(OR)for in-hospital death 0.17;95%confidence interval(CI)0.03–0.83;p=0.028).This association was independent of patient age,pre-hospital care time,injury severity score,initial serum lactate levels and coagulopathy.Among patients with pre-hospital time of≥2 h,2(3.6%)received timely LSIs.Pre-hospital care times of≥2 h were associated with delayed LSIs and with in-hospital death(unadjusted OR 4.3;95%CI 1.4–13.0).Conclusions:Timely completion of LSI when indicated was completed in a small proportion of patients and reflects previous research demonstrating delayed processes and errors even in advanced trauma systems.Timely delivery of a high proportion of LSIs was associated with improved outcomes among patients presenting with haemorrhagic shock after injury.Provision of LSIs in the pre-hospital phase of trauma care has the potential to improve outcomes.

Trauma system in New Zealand

New Zealand(NZ)is a country that is renowned for its beautiful scenery and numerous activities for leisure.It also has a modern health system that is sometimes called upon to assist neighboring Pacific countries with advanced medical care.In this article,we discuss the different components of the NZ trauma system ranging from prehospital to governance.This may be of interest to practitioners involved in developing or upgrading their country’s trauma systems.

计算机辅助外科在创伤骨科中的目前观念

计算机辅助外科（computer assisted surger，CAS）技术已经开始对创伤骨科的临床实际操作产生了重要的影响。虽然计算机已广泛应用于患者的术前检查中，尤其是在影像学上的应用，但事实上将计算机辅助设备引入创伤骨科手术室始于20世纪90年代末。

世界腹腔间隙学会腹内高压和腹腔间隙综合征2013版专家共识与诊疗指南

随着人们对腹内压（intra-abdominal pressure,IAP）的重视,大量研究开始关注腹内高压（intraabdominal hypertension,IAH）和腹腔间隙综合征（abdominal compartment syndrome,ACS）.世界腹腔间隙学会（The abdominal compartment society,WSACS）先后在2006年提出了IAH和ACS的专家共识,2007年发表了诊疗指南,2009年明确了疾病相关研究的推荐方向.2013年WSACS发布了新的IAH和ACS专家共识与诊疗指南.该指南由多学科专家共同参与制定,大部分是外科专家和重症监护专家.专家们首先明确24个临床医师关心的IAH和ACS问题,随后进行了系统有序的文献整理.

The principles and practice of open fracture care, 2018

The principles of open fracture management are to manage the overall injury and specifically prevent primary contamination becoming frank infection. The surgical management of these complex injuries includes debridement ＆ lavage of the open wound with combined bony and soft tissue reconstruction. Good results depend on early high quality definitive surgery usually with early stable internal fixation and associated soft tissue repair. While all elements of the surgical principles are very important and depend on each other for overall success the most critical element appears to be achieving very early healthy soft tissue cover. As the injuries become more complex this involves progressively more complex soft tissue reconstruction and may even requiring urgent free tissue transfer requiring close co-operative care between orthopaedic and plastic surgeons. Data suggests that the best results are obtained when the whole surgical reconstruction is completed within 48-72 h.

钳夹辅助复位治疗高位股骨转子下骨折手术技术

背景：股骨转子下骨折的治疗具有复杂性。由于该部位具有较大的（肌肉）牵拉应力而使得近端骨折块较易移位以致于使骨折端的精确复位及内固定物放置困难。本研究的目的是评价一组高位股骨转子下骨折患者采取钳夹辅助复位及髓内钉内固定对于骨折愈合率及骨折复位质量的影响。方法：自2003年12月到2007年1月，来自于两个一级创伤中心共55例移位型高位股骨转子下骨折患者，其中2例死亡，9例失访。剩余44例患者均得到随访至术后6个月或至骨性愈合；男27例，女17例，平均年龄55岁。均采用扩髓型顺行静态锁定髓内钉内固定系统，同时通过外侧小切口使用钳夹辅助复位，其中9例患者加用线缆环扎骨折端。术后常规X线检查，评价骨折复位质量及骨折愈合情况。结果：随访44例患者中，43例患者达到骨性愈合，骨折复位后冠状面及矢状面成角均不大于5°。38例（86％）达到解剖复位，6例患者骨折端发生轻微的内翻畸形（2°-5°），所有的患者均无并发症发生。结论：使用钳夹辅助复位髓内钉固定适时加用线缆环扎骨折端治疗股骨转子下骨折可达到满意的骨折复位和较高的术后骨折愈合率。手术成功要点是操作细微，尽量减少对软组织的剥离。可信水平：治疗性研究Ⅳ级。关于证据等级的完整描述详见投稿须知。

合理的影像学检查——急性膝关节损伤的检查

普通x线片对于膝关节损伤的评估可能是不适当的；可能还需要其他的影像学技术，特别是核磁共振。

Grade 4 renal injury： current trend of management and future directions

The management of blunt renal trauma has been evolving. The past management largely based on American Association for Surgery of Trauma （AAST） grading system, i.e. necessitated a computed tomography （CT） scan. Although the CT scan use is increasing and becomes the standardized mode of investigation, AAST grading no longer plays the sole role in the decision of surgical interventions. Two case reports of blunt renal trauma managed successfully by conservative methods are presented. Case one was an 18 year-old boy who had a fall when riding a motorbike at 20 km/h with a helmet and full protective equipments. He was landed by his left flank onto a rock. Contrast abdominal CT revealed a 4 era, grade III splenic tear and a grade IV left kidney injury with large perirenal haematoma. His international severity score （ISS） was 34. He was managed conservatively with bed rest and frequent serum haemoglobin monitoring. Subsequent CT with delayed contrast revealed stable perirenal haematoma with urine extravasation which was consistent with a grade IV renal injury. Case two was a 40 year-old male who had a motor bike accident on a racetrack when he was driving at 80 to 100 km/h, wearing a helmet. He lost control and hit onto the sidewall of the racetrack. Contrast abdominal CT revealed a grade IV left renal injury with a large urine extravasation. His renal injury was managed conservatively with interval delayed phase CT of the abdomen. A repeat CT on abdomen was performed five months after the initial injury which revealed no residual urinoma. In this study, moreover, a review of the literature to the management of blunt renal trauma was conducted to demonstrate the trend of increasing conservative management of such traumas. Extra radiological parameters may guide future decision making. However, the applicability of data may be limited until randomized trials are available.

Burn injury differentially alters whole-blood and organ glutathione synthesis rates: An experimental model

Previous studies from our laboratories revealed a reduced rate of whole-blood (WB) glutathione (GSH) synthesis in severely burned patients. To determine whether WB GSH metabolism is an indicator of the status of GSH metabolism in one or more of the major organs, we used a burn rabbit model to determine GSH concentrations and rates of synthesis in WB, liver, lungs, kidney, and skeletal muscle. L-[1-13C]-cysteine was infused intravenously for 6 h in rabbits at 3 days post-burn and in sham burn controls. WB and organ 13C-enrichment of cysteine and GSH was determined by gas chromatography/mass spectrometry. Plasma cysteine metabolic flux was increased significantly (P < 0.01) following burn injury. WB, liver, and lung GSH concentrations (P = 0.054, P < 0.05, and P < 0.05, respectively) and fractional rates of GSH synthesis (P < 0.05, P< 0.01, and P< 0.05, respectively) were reduced at 3 days post-burn. Kidney was unaffected. There also appears to be an increased rate of GSH transport out of the liver after burn injury. Hence, there is a differential impact of burn injury on tissue and organ GSH status, with WB qualitatively reflecting the changes in lung and liver. It will be important to determine whether these changes are due to alterations in the intrinsic capacity for GSH synthesis and/or availability of amino acid precursors of GSH.