Effectiveness after Designation of a Trauma Center: Experience with Operating a Trauma Team at a Private Hospital

PURPOSE@#The present study aimed to evaluate the influence of how the trauma care system applied on the management of trauma patient within the region.@*METHODS@#We divided the patients in a pre-trauma system group and a post-trauma system group according to the time when we began to apply the trauma care system in the Halla Hospital after designation of a trauma center. We compared annual general characteristics, injury severity score, the average numbers of the major trauma patients, clinical outcomes of the emergency department, and mortality rates between the two groups.@*RESULTS@#No significant differences were found in the annual patients' average age (54.1±20.0 vs. 52.8±18.2, p=0.201), transportation pathways (p=0.462), injury mechanism (p=0.486), injury severity score (22.93 vs. 23.96, p=0.877), emergency room (ER) stay in minutes (199.17 vs. 194.29, p=0.935), time to operation or procedure in minutes (154.07 vs. 142.1, p=0.767), time interval to intensive care unit (ICU) in minutes (219.54 vs. 237.13, p=0.662). The W score and Z score indicated better outcomes in post-trauma system group than in pre-trauma system group (W scores, 2.186 vs. 2.027; Z scores, 2.189 vs. 1.928). However, when analyzing survival rates for each department, in the neurosurgery department, in comparison with W score and Z score, both W score were positive and Z core was higher than +1.96. (pre-trauma group: 3.426, 2.335 vs. post-trauma group: 4.17, 1.967). In other than the neurosurgery department, W score was positive after selection, but Z score was less than +1.96, which is not a meaningful outcome of treatment (pre-trauma group: −0.358, −0.271 vs. post-trauma group: 1.071, 0.958).@*CONCLUSIONS@#There were significant increases in patient numbers and improvement in survival rate after the introduction of the trauma system. However, there were no remarkable change in ER stay, time to ICU admission, time interval to emergent procedure or operation, and survival rates except neurosurgery. To achieve meaningful survival rates and the result of the rise of the trauma index, we will need to secure sufficient manpower, including specialists in various surgical area as well as rapid establishment of the trauma center.

Bilateral Chylothorax Due to Blunt Spine Hyperextension Injury: A Case Report

Bilateral chylothorax due to blunt trauma is extremely rare. We report a 74-year-old patient that developed delayed bilateral chylothorax after falling off a ladder. The patient had a simple 12th rib fracture and T12 lamina fracture. All other findings seemed normal. He was sent home and on the 5th day visited our emergency center at Halla Hospital with symptoms of dyspnea and lower back pain. Computer tomography of his chest presented massive fluid collection in his right pleural cavity and moderate amounts in his left pleural cavity with 12th rib fracture and T11-12 intervertebral space widening with bilateral facet fractures. Chest tubes were placed bilaterally and chylothorax through both chest tubes was discovered. Conservative treatment for 2 weeks failed, and thus, thoracic duct ligation was done by video assisted thoracoscopic surgery. Thoracic duct embolization was not an option. Postoperatively, the patient is now doing well and happy with the results. Early surgical treatment must be considered in the old patient, whom large amounts of chylothorax are present.

Large Focal Extrapleural Hematoma of Chest Wall: A Case Report

Although hemothorax and pneumothorax are common complications seen in rib fractures, focal extrapleural hematoma is quite rare. We report a 63-year-old female patient that developed large focal extrapleural hematoma after falling off a second floor veranda. The patient had sustained 3, 4, 5th costal cartilage rib fractures and a sternum fracture. She had developed suspected empyema with loculations with small amount of hemothorax. She underwent a planned early decortication/adhesiolysis by video assisted thoracoscopic surgery at the 12th post-trauma day due to failed drainage. Unexpectedly, she had no adhesions or any significant retained hematoma mimicking a mass, but was found with the focal extrapleural chest wall hematoma. She was discharged on postoperative 46th day for other reasons and is doing fine today.

Rib Fixation for a Patient with Severely Displaced and Overlapped Costal Cartilage Fractures

Rib fixations for flail chest or displaced rib fractures are not a new technique. However, reports on rib fixations involving costal cartilage fractures are very few and surprisingly there are no reports of internal fixations involving only the costal cartilage in the English literature. The diagnosis is difficult and the necessity of the procedure may be quite controversial. Placing plates in screws into the costal cartilage alone may seem unstable and easily dislodged or stripped through the cartilage. We report a 31-year-old male scuba diver instructor who underwent rib fixations over his 7th and 8th costal cartilage ribs for severe pain. The procedure was done with conventional plates and screws. He had the plates and screws removed 2 months later due to lingering pain, but with them removed he is now quite happy with the results without pain. The procedure for fixation of painful overlapped costal cartilage is quite simple and can be done with the usual conventional methods, fixating plate and screws directly over the cartilage alone without fixation over the bony rib.

Esophageal Rupture Due to Diving in Shallow Waters

Delayed esophageal rupture due to blunt injury is not new. However, rupture due to suspected barotrauma is very rare. We describe a case of esophageal rupture in a male 24-year-old patient after diving in shallow waters. The patient was quadriplegic and could not experience the typical chest pain related to rupture and resulting mediastinitis. The rupture was discovered 4 days after emergency decompressive laminectomy and fusion for his cervical spine. The rupture was evidently caused by barotrauma and was discovered four days after admission. He underwent primary closure and pericardial flap as a life-saving procedure.

Generalized infection following facet joint injection: A case report / 대한마취과학회지

Facet joints have been shown to be a source of chronic low back pain, and it is generally accepted in clinical practice that diagnostic and therapeutic facet joint injections are the most reliable technique for the treatment of facet joint pain, which is considered to be an easy and safe procedure. Serious complications and side effects are uncommon after facet joint injection. However, infectious complications including septic arthritis, epidural abscess, meningitis and endocarditis have been reported following facet joint injections. We report here the first case of death following lumbar facet joint injection due to generalized infection.

Spondylodiscitis Misdiagnosed as Spinal Stenosis and Compression Fracture: A report of two cases

Cases of pyogenic spondylodiscitis are relatively rare diseases that concern 2-7% of total cases of osteomyelitis. Owing to the low frequency and initial nonspecific nature of signs and symptoms, diagnosis is often delayed up to 2-6 months. If the proper treatment is not established due to a diagnostic delay, there is a possibility of a serious neurologic deficit and spinal instability. We report two cases of infectious spondylodiscitis which were misdiagnosed as compression fracture and spinal stenosis respectively. They could be correctly diagnosed after MRI and laboratory test and under the recovery state after an antifungal and antibiotic medication. Special careful attention during the diagnostic procedure is a really important step considering the diagnostic delay and its resultant unsatisfactory outcome.

Analysis of Factors Associated with the Therapeutic Duration of Transforaminal Epidural Steroid Injection in Lumbar Spinal Stenosis Patients / 대한통증학회지

BACKGROUND: A transforaminal epidural steroid injection (TFESI) is one of the methods for the conservative treatment of the lumbar spinal stenosis. As efforts to prolong the therapeutic duration and to predict the outcome of TFESI are very important, we analyzed factors considered to be associated with the therapeutic duration of a TFESI. METHODS: Between August 2006 and March 2007, 69 patients (Group A: patients with no pain relief, Group B: patients with pain relief of less than 6 months, Group C: patients with pain relief of more than 6 months) who failed to the medical treatment were included to undertake a fluoroscopic-guided TFESI. Prior to treatment, the VAS (visual analogue scale), ODI (Oswestry disability index), BDI (Beck depression inventory), and BAI (Beck anxiety inventory) scores were determined to evaluate the degree of pain, disability, and psychological status. The VAS and ODI scores were used to assess the degree of pain relief. To identify the total duration of pain relief, regular outpatient visits for six months were conducted, and for the patients who were not able to visit the outpatient clinic regularly, outcome was assessed by telephone interviews after six months. RESULTS: The dural sac cross-sectional area (DSCSA), ODI, pain duration, BDI, BAI, and age showed similar distribution for patients in the A, B, and C groups. CONCLUSIONS: The DSCSA, ODI, pain duration, BDI, BAI, and age were not associated with the therapeutic duration of TFESI in lumbar spinal stenosis patients.

Colobronchial Fistula as a Late Complication of Esophagocologastrostomy / 대한흉부외과학회지

We report a case of colobronchial fistula, which is an extremely rare complication of esophagocologastrostomy. A 53-year-old man developed recurrent respiratory symptoms 30 months after colon interposition for corrosive esophageal and gastric strictures. Chest radiographs and computed tomography showed an aspiration pneumonia and total atelectasis of the left lower lobe(LLL). Esophagoscopy and barium esophagogram revealed fistula between the colon just below the esophagocolostomy and superior segment of the LLL. The colobronchial fistulectomy and left lower lobe lobectomy were performed. This rare complication should be considered in patients who develop recurrent productive cough whenever they drink or eat something after esophagocologastrostomy.

Colobronchial Fistula as a Late Complication of Esophagocologastrostomy / 대한흉부외과학회지

We report a case of colobronchial fistula, which is an extremely rare complication of esophagocologastrostomy. A 53-year-old man developed recurrent respiratory symptoms 30 months after colon interposition for corrosive esophageal and gastric strictures. Chest radiographs and computed tomography showed an aspiration pneumonia and total atelectasis of the left lower lobe(LLL). Esophagoscopy and barium esophagogram revealed fistula between the colon just below the esophagocolostomy and superior segment of the LLL. The colobronchial fistulectomy and left lower lobe lobectomy were performed. This rare complication should be considered in patients who develop recurrent productive cough whenever they drink or eat something after esophagocologastrostomy.

Clinical Analysis of the Recent Results of Coronary Artery Bypass Grafting / 대한흉부외과학회지

BACKGROUND: Previous reports present that the early results of coronary artery bypass grafting (CABG) has been improving with the accumulation of surgical experience. We conducted a retrospective analysis of the patients who received CABG to evaluate the recent results of CABG. MATERIAL AND METHOD: Between January 1996 and August 2001, 154 patients underwent CABG at Hanyang University Hospital. There were 47 patients(group I) who were operated between 1996 and 1998, and 107 patients(group II) who were operated thereafter. The preoperative diagnosis, operative procedure, mortality, and complications were analyzed retrospectively. RESULT: There were 35 males and 12 females in group I, and 78 males and 29 females in group II, which shows similar ratio of sexes between the two groups. The average age of patients for group I and group II was 55.9+/-6.2 years and 61.0+/-8.0 years, respectively, showing a significant increase in group II(p<0.05). The average left ventricular ejection fraction(LVEF) for group I and group II was 54.6+/-11.8% and 56.9+/-13.0%, respectively. The number of patients who had previous MI in group I and group II were 13 patients(27.7%) and 14 patients(13.1%), respectively, which shows a significant difference (p<0.05). All procedures were performed using the cardiopulmonary bypass(CPB) and moderate systemic hypothermia. Myocardial protection was achieved using intermittent hypothermic ischemia under ventricular fibrillation state or cold crystalloid cardioplegic solution for most of group I patients, whereas cold blood cardioplegic solution was used for group II patients. The mean CPB times for group I and group II were 149.2+/-48.7 minutes and 113.1+/-30.6 minutes, respectively. The mean aortic cross clamp times for group I and group II were 81.3+/-26.5 minutes 72.2+/-23.9 minutes, respectiely. These figures show that CPB and aortic cross clamp times were significantly reduced in group II(p<0.05). The use of the left internal thoracic artery(LITA) was increased from 42%(20/47) for group I to 81% (87/107) for group II. The mean number of grafts also significantly increased from 2.5+/-0.6 for group I to 3.0+/-1.1 for group II(p<0.05). Intra-aortic balloon pump(IABP) was applied in 7 cases in group I and 17 cases in group II. Of these, 28.6%(2/7) and 52.9%(9/17) were broadly applied preoperatively in patients with LVEF<40% or congestive heart failure. The operative mortalities for group I and II were 10.6%(5/47) and 0.9%(1/107), respectively, which shows significant decrease for group II(p<0.05). CONCLUSION: This report suggest that CABG using CPB can recently be performed more safely in virtue of the accumulation of surgical experience with reduction in CPB and aortic cross clamp times and improved surgical techniques and myocardial protection. And we think that the optimal treatment of patients with left ventricular dysfunction associated with congestive heart failure and the extended application of IABP, especially have contributed to the reduction of operative mortality and morbidity.

A Case Report of Primary Pulmonary Extranodal Marginal Zone B-cell Lymphoma of MALT Type / 대한흉부외과학회지

Primary malignant lymphoma of the lung is a very rare disease, which consists of 0.34% of entire malignant lymphoma. The majority are low-grade B-cell tumors, and because of their morphological peculiarities and overall excellent prognosis, many cases, like many other extranodal lymphomas, have been mislabelled as "pseudolymphomas" in the past. For these reasons their true incidence is difficult to estimate. An incidentally discovered mass in the right middle lobe of a 36-year-old woman was operated on November 9, 2001 at Hanyang University Hospital. A right upper lobectomy was done and the pathologic diagnosis of extranodal marginal zone B-cell lymphoma of MALT type was made.

Mode of tooth movement according to the timing of orthodontic force application after extraction / 대한치과교정학회지

This study was performed to compare and analyzed the mode of tooth movement according to the timing of orthodontic force application after extraction. The upper right and left third incisors were carefully extracted at three-week interval in four adult dogs. Both canines were used as an anchorage for the bodily movement of the upper second incisors. Orthodontic force of 100gm was simultaneously applied at one week after extraction on one side four weeks after extraction on the other side using NiTi closed coil spring. While orthodontic force was applied for twelve weeks, the amount of tooth movement was measured at every second week with calipers. The animals were sacrificed at twelve weeks and histologic examination was executed to reveal any difference between both sides. The results were obtained as follows: 1. The tooth movement was likely to be faster in four-week side for the first two seeks while faster in one-week side during next two weeks 2. The rate of tooth movement was fastest during four to six weeks period, then decreased gradually. 3. The total amount of tooth movement was likely to be larger in one-week side compared to four-week side. 4 Any damage to tooth and periodontal tissue could not be seen in the histologic section of one-week side. These results suggest that earlier application of orthodontic force is better than later after extraction in terms of the rate of tooth movement.

A Design of Electronic Textbook Using the Multimedia Data Server / 대한의료정보학회지

Clinical education is difficult for actual practice of medical students. In particular, the practice in the field of obstetrics is more difficult to many students. Moreover, the education of sub-fields of obstetrics such as birth or abortion needs many materials of women's reproductive organs. However, the ordinary paper-based textbooks have some limitations for clinical education of obstetrics. The electronic textbook system based on multimedia data enables that many student, doctor, and public user overcome these difficulties, as a computer assisted learning. We developed multimedia database system which is connected with web using ODBC(Open DataBase Connectivity)and ASP(Active Server Page)/IDC(Internet DataBase Connection). Many text and multimedia data are gathered in the database. This system serves various multimedia data using internet and intranet in the student's class or home. In conclusion, providing multimedia data of obstetrics using ODBC, ASP/IDC method reduce the limitation of clinical education. This model of the electronic textbook would be a reference to develop multimedia database on the network.

Neer's Inferior Capsular shift for Involuntary Inferior and Multidirectional Instability of the Shoulder / 대한정형외과학회잡지

Multidirectional shoulder instability is often difficult to diagnose and treat and can be cause of significant disability. Nonoperative rehabilitations and life tyle modifications are the primary treatments. Hiwever, the inferior capsular shift procedure, performed either from an anterior or posterior approach, as described by Neer and Foster, is recommended for symptomatic multidirectional instability that is unresponsive to nonoperative therapy. Twenty-seven shoulders in twenty-seven patients with inferior and multidirectional instability were managed with Neer s inferior capsular shift, through anterior or posterior approach depending on the direction in which the shoulder is most unstable. All of the patients were followed up for an average of 3 years (range one to seven years). The postoperative range of motion of the shoulders was well maintained except 1 patient. Three patients had recurrence of symptomatic and disabling multidirectional instability, but twenty-four (89%) of the shoulders continued to function well with no instability, no pain, no recurrence and no remarkable limitation of motion.

Reconstruction of old posterior cruciate ligament injuries with the medial gastrocnemius tendon / 대한정형외과학회잡지

No abstract available.

A Clinical Study of the Myositis Ossificans Traumatica of Quadiceps Femoris / 대한정형외과학회잡지

Myositis Ossificans Traumatica, ossifying hematoma and calcifying hematoma have been used interchangeably to dcscribe the process of calcification and ossification occuring within muscle tissue in response to trauma. Authors analysed 27 cases of traumatic myositis ossificans of the Quadriceps who were diagnosed and treated at the department of orthopaedic surgery, National Police Hospital from January 1978 to June 1984. The results are as follows: 1. In sex distribution, in all cases 27 were males, in age distribution they were between 19 and 25 years old. 2. The causes of trauma consisted of 11 in kicking and treading, 6 in falling and slipping, 6 in football, 4 in demonstration injury. 3. The duration from injury to initial visit was variable. The average duration was 2 weeks. 4. Quadriceps contusions in all cases were grouped according to severity of trauma as mild, moderate and severe. Among 27 cases, 4 cases were mild, 11 cases were moderate, 12 cases were grouped as severe. According to the severity of trauma, duration of treatment and restoration of affected knee joint motion were more prolonged. 5. Among 27 cases, 6 cases sustained reinjury. 6. Total 27 cases, average duration of treatment was 4.6 weeks. 7. In those patients presenting after 2 weeks from injury, the duration of treatment was 3.8 weeks, and in those patients presenting within 2 weeks it was 5.4 weeks. Thc moderate cases were required 3.8 weeks of the duration of treatment, severe cases were required 6.5 weeks. Reinjury cases, 6 cases required more prolonged treatment, 6.8 weeks. These results suggest that early treatment, low violence of trauma and prevention of reinjury were the factor of minimizing the impairment of knee joint motion and shortening the duration of treatment. 8. The earlist X-ray change was found of the 14th day from injury. (average the 27th day from injury). 9. Within 6 months, all cases regained full range of motion of knee joint. 10. With only conservative treatment applied on all cases, we get the satisfactory result.

The Clinical Analysis of Spondylolisthesis / 대한정형외과학회잡지

The morbidity of spondylolisthesis tends to increase in accordance with the popularization of sports and increase of mean life span by the development of medicine. We had applied surgical treatment for 39 cases of spondylolisthesis during the period of 8 yrs. from Jan. 1976 to Dec. 1983 at Department of Orthopaedic Surgery, National Police Hospital, among them 35 cases were followed up for mean 27 months. Twenty eight cases with posterolateral spinal fusion were isthmic spondylolisthesis and seven cases with posterior spinal fusion and facetectomy were degenerative type. We analysed them with clinical aspects and surgical treatment for 35 cases. The results were as follows: 1. The most common clinical symptoms were low back pain (96.7%) and tenderness (93.5%). 2. The degree of slipping was Grade I by Meyerding's classification in all cases and mean 12.5% by Taillard method. 3. In the 7 cases of isthmic spondylolisthesis, the degree of slipping increased on standing lateral view. And in these cases the clinical symptoms were aggrevated at welking. 4. In the degenerative spondylolisthesis with posterior spinal fusion and facetectomy, we found mean 70% spontaneous correction of slipping commpared with preoperative. 5. In postoperative evaluation we gained 94.3% above good according to Gill's criteria and no pseudarthrosis.

Results of Putti / 대한정형외과학회잡지

During the period from July 1975 to June 1982 we performed 17 Putti-Platt operations on 16 males and one female, ranging from 19 to 39 years. The average follow-up period was 3.8 years in 13 cases of them. The results were as follows: 1. The ages in initial dislocation were ranged from 14 to 31 with an average of 18.5 years. 2. Right side was involved in 15 cases and. left in 2 cases. 3. On radiological finding Hill-Sachs lesion was found in 41%.0n pathological finding at operation of 15 cases, Bankart lesion was seen in 73%, Hill-Sachs lesion in 60%, glenoid erosion in 33%, capsular loosening in 33%, and capsular tear in 13%. 4. Limitation of external rotation compared with sound opposite side was measured in 12 to 40 with an average of 19.2 degrees. 5. The Putti-Platt operation is considered as sound, surgical procedure that gives excellent functional results.

The Simple Excision of Ossicles for Osgood-Schlatter Lesion / 대한정형외과학회잡지

Of 35 patients with 38 knees treated using simple excision method for Osgood-Schlatter lesion, had a distinct and separate ossicle at the tibial tubercle. All ossicles were attached to the distal part of the undersurface of the ligamentum patellae and were separated from the tuberosity by a bursa or scar tissue. Surgical excision of ossicle along with adjacent bursa was satisfactory and simplest procedure to relieve the symptoms, did not respond to conservative treatment.