http://www.traumamanagement.org The most accessed research articles published by Journal of Trauma Management & Outcomes 2010-10-29T00:00:00Z Whereas a non-operative approach for hemodynamically stable patients with free intraabdominal fluid in the presence of solid organ injury is generally accepted, the presence of free fluid in the abdomen without evidence of solid organ injury not only presents a challenge for the treating emergency physician but also for the surgeon in charge. Despite recent advances in imaging modalities, with multi-detector computed tomography (CT) (with or without contrast agent) usually the imaging method of choice, diagnosis and interpretation of the results remains difficult. While some studies conclude that CT is highly accurate and relatively specific at diagnosing mesenteric and hollow viscus injury, others studies deem CT to be unreliable. These differences may in part be due to the experience and the interpretation of the radiologist and/or the treating physician or surgeon.A search of the literature has made it apparent that there is no straightforward answer to the question what to do with patients with free intraabdominal fluid on CT scanning but without signs of solid organ injury. In hemodynamically unstable patients, free intraabdominal fluid in the absence of solid organ injury usually mandates immediate surgical intervention. For patients with blunt abdominal trauma and more than just a trace of free intraabdominal fluid or for patients with signs of peritonitis, the threshold for a surgical exploration - preferably by a laparoscopic approach - should be low. Based on the available information, we aim to provide the reader with an overview of the current literature with specific emphasis on diagnostic and therapeutic approaches to this problem and suggest a possible algorithm, which might help with the adequate treatment of such patients. http://www.traumamanagement.org/content/3/1/10 Vanessa Banz Mohammad Butt Victor Jeger Heinz Zimmermann Aristomenis Exadaktylos Journal of Trauma Management & Outcomes 2009, null:10 2009-12-15T00:00:00Z doi:10.1186/1752-2897-3-10 /content/figures/1752-2897-3-10-toc.gif Journal of Trauma Management & Outcomes 1752-2897 ${item.volume} 10 2009-12-15T00:00:00Z XML Background: Unstable proximal femoral fractures and pathological lesions involving the trochanteric region in the elderly comprise an increasing workload for the trauma surgeon as the ageing population increases. This study aims to evaluate use of the Russell-Taylor reconstruction nail (RTRN) in this group with regard to mortality risk, complication rates and final outcome. Methods: Retrospective evaluation of 42 patients aged over 60 years who were treated by reconstruction nailing for proximal femoral fractures over a 4 year period. Results: Over two-thirds of patients were high anaesthetic risk (ASA > 3) with ischemic heart disease the most common co-morbidity. 4 patients died within 30 days of surgery and 4 patients required further surgery for implant related failure. Majority of patients failed to regain their pre-injury mobility status and fewer than half the patients returned to their original domestic residence. Conclusion: Favourable fixation of unstable complex femoral fractures in the elderly population can be achieved with the Russell-Taylor reconstruction nail. However, use of this device in this frail population was associated with a high implant complication and mortality rate that undoubtedly reflected the severity of the injury sustained, co-morbidity within the group and the stress of a major surgical procedure. http://www.traumamanagement.org/content/1/1/7 Ulfin Rethnam James Cordell-Smith Thirumoolanathan Kumar Amit Sinha Journal of Trauma Management & Outcomes 2007, null:7 2007-12-10T00:00:00Z doi:10.1186/1752-2897-1-7 /content/figures/1752-2897-1-7-toc.gif Journal of Trauma Management & Outcomes 1752-2897 ${item.volume} 7 2007-12-10T00:00:00Z XML Background: Management of orthopaedic injuries in polytrauma cases continues to challenge the orthopaedic traumatologist. Mass disasters compound this challenge further due to delayed referral. Recently there has been increasing evidence showing that damage control surgery has advantages that are absent in the early total care modality. We studied the damage control modality in the management of polytrauma cases with orthopaedic injuries who had been referred to our hospital after more than 24 hours of sustaining their injuries in an earthquake. This study was conducted on 51 cases after reviewing their records and complete management one year after the trauma. Results: At one year, out of the 62 fractures, 3 were still under treatment, while the others had united. As per the radiological and functional scoring there were 20 excellent, 29 good, 5 fair and 5 poor results. In spite of the delayed referral there was no mortality. Conclusion: In situations of delayed referral in areas where composite trauma centers do not exist the damage control modality provides an acceptable method of treatment in the management of polytrauma cases. http://www.traumamanagement.org/content/2/1/2 Shabir Dhar Masood Bhat Ajaz Mustafa Mohammed Mir Mohammed Butt Manzoor Halwai Amin Tabish Murtaza Ali Arshiya Hamid Journal of Trauma Management & Outcomes 2008, null:2 2008-01-29T00:00:00Z doi:10.1186/1752-2897-2-2 /content/figures/1752-2897-2-2-toc.gif Journal of Trauma Management & Outcomes 1752-2897 ${item.volume} 2 2008-01-29T00:00:00Z XML Background: Floating Knee injuries are complex injuries. The type of fractures, soft tissue and associated injuries make this a challenging problem to manage. We present the outcome of these injuries after surgical management. Methods: 29 patients with floating knee injuries were managed over a 3 year period. This was a prospective study were both fractures of the floating knee injury were surgically fixed using different modalities. The associated injuries were managed appropriately. Assessment of the end result was done by the Karlstrom criteria after bony union. Results: The mechanism of injury was road traffic accident in 27/29 patients. There were 38 associated injuries. 20/29 patients had intramedullary nailing for both fractures. The complications were knee stiffness, foot drop, delayed union of tibia and superficial infection. The bony union time ranged from 15 – 22.5 weeks for femur fractures and 17 – 28 weeks for the tibia. According to the Karlstrom criteria the end results were Excellent – 15, Good – 11, Acceptable – 1 and Poor – 3. Conclusion: The associated injuries and the type of fracture (open, intra-articular, comminution) are prognostic indicators in the Floating knee. Appropriate management of the associated injuries, intramedullary nailing of both the fractures and post operative rehabilitation are necessary for good final outcome. http://www.traumamanagement.org/content/1/1/2 Ulfin Rethnam Rajam Yesupalan Rajagopalan Nair Journal of Trauma Management & Outcomes 2007, null:2 2007-11-26T00:00:00Z doi:10.1186/1752-2897-1-2 /content/figures/1752-2897-1-2-toc.gif Journal of Trauma Management & Outcomes 1752-2897 ${item.volume} 2 2007-11-26T00:00:00Z XML Healthcare professionals and the public have increasing concerns about the ability of emergency departments to meet current demands. Increased demand for emergency services, mainly caused by a growing number of minor and moderate injuries has reached crisis proportions, especially in the United Kingdom. Numerous efforts have been made to explore the complex causes because it is becoming more and more important to provide adequate healthcare within tight budgets. Optimisation of patient pathways in the emergency department is therefore an important factor.This paper explores the possibilities offered by dynamic simulation tools to improve patient pathways using the emergency department of a busy university teaching hospital in Switzerland as an example. http://www.traumamanagement.org/content/2/1/11 Aristomenis Exadaktylos Dimitrios Evangelopoulos Marcel Wullschleger Leo Burki Heinz Zimmermann Journal of Trauma Management & Outcomes 2008, null:11 2008-11-17T00:00:00Z doi:10.1186/1752-2897-2-11 /content/figures/1752-2897-2-11-toc.gif Journal of Trauma Management & Outcomes 1752-2897 ${item.volume} 11 2008-11-17T00:00:00Z XML Background: Pedestrians are at a high risk for crash and injury. This study aims at comparing data from real world crashes with data gathered from experimental settings. Methods: IMPAIR (In-Depth Medical Pedestrian Accident Investigation and Reconstruction) was a prospective, observational study performed in a metropolitan area. Data was collected on-scene, from clinical records, and interviews. Data comprise crash data, details on injury pattern and injury severity. Results: Thirty-seven pedestrians (of which 19 males) with a mean 37.1 years of age were included in the study. The mean collision speed was 49.5 km/h (SD 13.7, range, 28 - 93). The mean ISS (31.0, SD 25.4) and the 24% fatality rate indicate a substantial trauma load. The most common AIS 4+ injuries were to the head (23 subjects), followed by chest (8), pelvis (4), and abdomen (2). An association of impact side and injury side (right/left) was found for abdominal, chest, pelvic, and upper limb injuries. Primary head impacts were documented on the windscreen (19 subjects), hood (10), A-pillar (2), and edge of the car roof (2). With bivariate analysis, a significant increase of MAIS 4+ head injury risk was found for collision speeds of >40 km/h (OR 9.00, 95% CI 1.96-41.36). Conclusion: The real-world data from this study is in agreement with previous findings from biomechanical models and other simulations. This data suggest that there may be reason to include further pedestrian regulations in EuroNCAP. http://www.traumamanagement.org/content/4/1/2 Uli Schmucker Melissa Beirau Matthias Frank Dirk Stengel Gerrit Matthes Axel Ekkernkamp Julia Seifert Journal of Trauma Management & Outcomes 2010, null:2 2010-02-16T00:00:00Z doi:10.1186/1752-2897-4-2 /content/figures/1752-2897-4-2-toc.gif Journal of Trauma Management & Outcomes 1752-2897 ${item.volume} 2 2010-02-16T00:00:00Z XML Background: Historically neurosurgeons have accepted head injured patients only in the presence of a mass lesion requiring surgical decompression. Underpinning this is an assumption that these patients have a better outcome than patients without a surgical lesion. This has meant that many patients without a surgical lesion have been managed locally in the referring hospital. However, there is now evidence that treatment of all head injured patients in a specialist centre leads to improved outcomes. Therefore, we have asked the question: does the presence of a surgical lesion imply better outcome from severe head injury? Results: We prospectively recorded the Glasgow Outcome score (GOS), at 3 months, of all the severely head injured patients treated at our institution over a two and a half year period. Of 116 patients admitted with an initial Glasgow Coma Score (GCS) of 8 or less, 58 had surgical lesions and 58 non-surgical head injuries. The two groups were well matched for presenting GCS and age. Overall our favourable outcome rate (GOS 4 and 5) at 3-months for the patients with a surgical lesion and for the non-surgical group were 47.3% and 46.6% respectively, with no significant difference between the two (P = 0.54). Conclusion: The assumption in the past has always been that patients presenting in coma from traumatic diffuse brain injury will do worse than those that have a mass lesion amenable to surgical decompression. Our series would suggest that this is not the case and all severely head injured patients should expect similar outcome when cared for in a neuroscience centre. http://www.traumamanagement.org/content/3/1/5 Paul Leach Omar Pathmanaban Hiren Patel Julian Evans Raphael Sacho Richard Protheroe Andrew King Journal of Trauma Management & Outcomes 2009, null:5 2009-04-03T00:00:00Z doi:10.1186/1752-2897-3-5 /content/figures/1752-2897-3-5-toc.gif Journal of Trauma Management & Outcomes 1752-2897 ${item.volume} 5 2009-04-03T00:00:00Z XML Pneumothorax is a recognized cause of preventable death following chest wall trauma where a simple intervention can be life saving. In cases of trauma patients where cervical spine immobilization is mandatory, supine AP chest radiograph is the most practical initial study. It is however not as sensitive as CT chest for early detection of a pneumothorax. "Occult" pneumothorax is an accepted definition of an existing but usually a clinically and radiologically silent disturbance that in most patients can be tolerated while other more urgent trauma needs are attended to. However, in certain patients, especially those on mechanical ventilation (with subsequent increase of intrapleural air with positive pressure ventilation), missing the diagnosis of pneumothorax can be deleterious with fatal consequences. This review will discuss the occult pneumothorax in the context of 3 radiological examples, which will further emphasize the entity. Because a negative AP chest radiograph can dangerously delay its recognition, we recommend that any trauma victim presenting to the emergency department with symptoms of respiratory distress should be screened with either thoracic ultrasonography or chest CT scan to avoid missing a pneumothorax. http://www.traumamanagement.org/content/4/1/12 Hesham Omar Hany Abdelmalak Devanand Mangar Rania Rashad Engy Helal Enrico Camporesi Journal of Trauma Management & Outcomes 2010, null:12 2010-10-29T00:00:00Z doi:10.1186/1752-2897-4-12 /content/figures/1752-2897-4-12-toc.gif Journal of Trauma Management & Outcomes 1752-2897 ${item.volume} 12 2010-10-29T00:00:00Z XML Deep venous thrombosis prophylaxis is essential to the appropriate management of multisystem trauma patients. Without thromboprophylaxis, the rate of venous thrombosis and subsequent pulmonary embolism is substantial. Three prophylactic modalities are common: pharmacologic anticoagulation, mechanical compression devices, and inferior vena cava filtration. A systematic review was completed using PRISMA guidelines to evaluate the potential complications of DVT prophylactic options. Level one evidence currently supports the use of low molecular weight heparins for thromboprophylaxis in the trauma patient. Unfortunately, multiple techniques are not infrequently required for complex multisystem trauma patients. Each modality has potential complications. The risks of heparin include bleeding and heparin induced thrombocytopenia. Mechanical compression devices can result in local soft tissue injury, bleeding and patient non-compliance. Inferior vena cava filters migrate, cause inferior vena cava occlusion, and penetrate the vessel wall. While the use of these techniques can be life saving, they must be appropriately utilized. http://www.traumamanagement.org/content/4/1/1 Indraneel Datta Chad Ball Lucas Rudmik S. Morad Hameed John Kortbeek Journal of Trauma Management & Outcomes 2010, null:1 2010-01-06T00:00:00Z doi:10.1186/1752-2897-4-1 /content/figures/1752-2897-4-1-toc.gif Journal of Trauma Management & Outcomes 1752-2897 ${item.volume} 1 2010-01-06T00:00:00Z XML Background: In conventional multi-trauma care service (CTCS), patients are admitted to hospital via the accident & emergency room. After surgery they are transferred to the IC-unit followed by the general surgery ward. Ensuing treatment takes place in a hospital's outpatient clinic, a rehabilitation centre, a nursing home or the community. Typically, each of the CTCS partners may have its own more or less autonomous treatment perspective. Clinical evidence, however, suggests that an integrated multi-trauma rehabilitation approach ('Supported Fast-track multi-Trauma Rehabilitation Service': SFTRS), featuring: 1) earlier transfer to a specialised trauma rehabilitation unit; 2) earlier start of 'non-weight-bearing' training and multidisciplinary treatment; 3) well-documented treatment protocols; 4) early individual goal-setting; 5) co-ordination of treatment between trauma surgeon and physiatrist, and 6) shorter lengths-of-stay, may be more (cost-)effective.This paper describes the design of a prospective cohort study evaluating the (cost-) effectiveness of SFTRS relative to CTCS.Methods/designThe study population includes multi-trauma patients, admitted to one of the participating hospitals, with an Injury Severity Scale score > = 16, complex multiple injuries in several extremities or complex pelvic and/or acetabulum fractures. In a prospective cohort study CTCS and SFTRS will be contrasted. The inclusion period is 19 months. The duration of follow-up is 12 months, with measurements taken at baseline, and at 3,6,9 and 12 months post-injury.Primary outcome measures are 'quality of life' (SF-36) and 'functional health status' (Functional Independence Measure). Secondary outcome measures are the Hospital Anxiety & Depression Scale, the Mini-Mental State Examination as an indicator of cognitive functioning, and the Canadian Occupational Performance Measure measuring the extent to which individual ADL treatment goals are met. Costs will be assessed using the PROductivity and DISease Questionnaire and a cost questionnaire.DiscussionThe study will yield results on the efficiency of an adapted care service for multi-trauma patients (SFTRS) featuring earlier (and condensed) involvement of specialised rehabilitation treatment. Results will show whether improved SFTRS logistics, combined with shorter stays in hospital and rehabilitation clinic and specialised early rehabilitation training modules are more (cost-) effective, relative to CTCS.Trial registrationCurrent Controlled Trials register (ISRCTN68246661) and Netherlands Trial Register (NTR139). http://www.traumamanagement.org/content/3/1/1 Sevginur Kosar Henk Seelen Bena Hemmen Silvia Evers Peter Brink Journal of Trauma Management & Outcomes 2009, null:1 2009-01-30T00:00:00Z doi:10.1186/1752-2897-3-1 /content/figures/1752-2897-3-1-toc.gif Journal of Trauma Management & Outcomes 1752-2897 ${item.volume} 1 2009-01-30T00:00:00Z XML