Severe hemothorax due to traumatic fracture of thoracic vertebra.

BACKGROUND: Hemothorax occurs in approx. 0.4% of all chest injury patients, but hemothorax due to a thoracic vertebral fracture is rare. CASE PRESENTATION: A 76-year-old Japanese man was transported to our hospital for right hemothorax due to a car accident. We performed emergency hemostasis surgery and tried to stop the bleeding by several methods, but it was difficult to control the bleeding because the bleeding point was an artery branch that runs in front of the vertebral body. CONCLUSION: It is important to be aware that a fractured vertebra can damage the aorta's arterial branch and follow a severe course.

Impact of Antithrombin Activity Levels Following Recombinant Antithrombin Gamma Therapy in Patients with Sepsis-Induced Disseminated Intravascular Coagulation.

Recombinant antithrombin gamma (rAT) is reported as an effective drug for patients with disseminated intravascular coagulation (DIC) in Japan. As the appropriate dose and targeted AT activity remain unknown, this study aimed to determine these aspects for sepsis-induced DIC. Thirty-one patients with septic shock and DIC with AT levels <70% were treated with rAT between May 2018 and December 2020. The recovery rates from DIC were 32.2% and 63.3% on day 3 and 5 post administration, respectively. Recovery and survival rates were significantly higher in patients who achieved AT activity ≥70% or 80% on day 3 post administration. Receiver operating characteristic curve analysis revealed that the cutoff values of post-treatment AT activity on day 3 for 28-day survival and 5-day recovery from DIC were 79.5% and 81.5%, respectively. Patients who did not achieve AT activity ≥80% on day 3 presented a lower base level of AT activity and lower dose supplementation. Our results suggest that targeted AT activity should be at least 70%, and ideally 80%, and sufficient doses to maintain this activity are required to achieve better outcomes.

Sagittal femoral bowing contributes to distal femoral valgus angle deviation in malrotated preoperative radiographs.

BACKGROUND: The coronal whole-leg radiograph is generally used for preoperative planning in total knee arthroplasty. The distal femoral valgus angle (DFVA) is measured for distal femoral bone resection using an intramedullary guide rod. The effect of coronal and sagittal femoral shaft bowing on DFVA measurement in the presence of malrotation or knee flexion contracture has not been well reported. The objectives of this study were: (1) to investigate the effects of whole-leg malrotation and knee flexion contracture on the DFVA in detail, (2) to determine the additional effect of coronal or sagittal femoral shaft bowing. METHODS: We studied 100 consecutive varus and 100 valgus knees that underwent total or unicompartmental knee arthroplasty. Preoperative CT scans were used to create digitally reconstructed radiography (DRR) images in neutral rotation (NR, parallel to the surgical epicondylar axis), and at 5° and 10° external rotation (ER) and internal rotation (IR). The images were also reconstructed at 10° femoral flexion. The DFVA was evaluated in each DRR image, and the angular variation due to lower limb malposition was investigated. RESULTS: The DFVA increased as the DRR image shifted from IR to ER, and all angles increased further from extension to 10° flexion. The DFVA variation in each position was 1.3° on average. A larger variation than 2° was seen in 12% of all. Multivariate regression analysis showed that sagittal femoral shaft bowing was independently associated with a large variation of DFVA. Receiver operating characteristic analysis showed that more than 12° of sagittal bowing caused the variation. CONCLUSION: If femoral sagittal bowing is more than 12°, close attention should be paid to the lower limb position when taking whole-leg radiographs. Preoperative planning with whole-leg CT data should be considered.

Risk factors for excessive postoperative sliding of femoral trochanteric fracture in elderly patients: A retrospective multicenter study.

INTRODUCTION: The application of a load on the internal fixation of a trochanteric fracture exerts a moment along the lag screw, causing the proximal bone fragment to slide along the lag screw, allowing contact between the proximal and distal bone fragments, which promotes healing. However, excessive sliding is related to poor postoperative outcomes. We aimed to identify the risk factors for excessive sliding. MATERIALS AND METHODS: We conducted a multicenter retrospective study including 115 trochanteric fractures sustained through low-energy trauma in 19 male and 96 female patients aged 60 years or older (mean age: 82.9 years) between September 2013 and December 2014. We measured the postoperative sliding distance after osteosynthesis using a sliding hip screw or intramedullary nailing, and classified participants with ≥8 mm of sliding into the excessive sliding group (ESG) and with <8 mm into non-ESG. Finally, we investigated the risk factors of excessive postoperative sliding. RESULTS: Fifty participants were classified into the ESG and 65 participants into the non-ESG. Female sex (p = 0.0264), an A3 fracture type (p = 0.0003), greater tip-apex distance (p = 0.0250), and poor reduction in either the anteroposterior or lateral radiographic views (p = 0.0156) were identified as risk factors for excessive sliding by multivariate regression analysis. CONCLUSIONS: Female sex, an unstable fracture type, a greater tip-apex distance, and a poor reduction, in either the anteroposterior or lateral views, are associated with excessive postoperative sliding. Therefore, surgery should aim to achieve good reduction and stabilization from both radiographic views.

A new combination technique of the modified Robicsek wire fixation and plate fixation achieves effective repair of transverse sternal fracture: a report of two cases.

BACKGROUND: To maximize the therapeutic effect for complicated sternal fracture, we should know advantages and disadvantages of each surgical repositioning technique, and the choice of an appropriate procedure is essential. We report two successful cases for which a combination of two existing techniques, modified Robicsek wire fixation and locked titanium plate fixation, was applied to transverse sternal fracture with flail chest. CASE PRESENTATION: One patient experienced a transverse sternal and rib fracture due to a traffic injury. Flail chest due to a highly displaced transverse sternal fracture made withdrawal of the ventilator impossible. Another patient, who developed fulminant myocarditis, experienced a transverse sternal fracture resulting from chest compression during cardiopulmonary resuscitation. Severe paradoxical respiratory movement was a limiting factor for cardiac and respiratory rehabilitation. In both cases, a transverse sternal fracture was difficult to correct non-invasively and indicated surgical repair. The surgical repositioning and fixation greatly contributed to the improvement of the respiratory movement, and the patients were successfully withdrawn ventilator support. CONCLUSION: The combination of modified Robicsek wire fixation and locked titanium plate fixation for a complicated sternal fracture employs the complementary and comparative advantages of each procedure and effective fixation may be achieved.

Use of venovenous extracorporeal membrane oxygenation for perioperative management of acute respiratory distress syndrome caused by fat embolism syndrome: A case report and literature review.

INTRODUCTION: Fat embolism syndrome (FES) is a known complication of long bone fracture and can affect multiple organs. The organ most commonly affected with FES is the lung. Severe cases of FES from long bone fracture can cause acute respiratory distress syndrome (ARDS). Although the treatment of ARDS remains challenging, it is reported that a lung protection strategy and prone positioning are effective. In addition, early fixation is reported to be beneficial in respiratory failure due to FES, though it may exacerbate respiratory failure during the perioperative period. We report the use of venovenous extracorporeal membrane oxygenation (VV-ECMO) for the successful perioperative management of a patient diagnosed with ARDS due to FES. PATIENT CONCERNS: A 24-year-old man injured in a traffic accident was brought to our emergency department due to shock and consciousness disorder. DIAGNOSIS: After examining the patient, we noted bilateral pneumothorax, liver and spleen injuries, and multiple long bone fractures. Four days after admission, he was diagnosed with FES due to a prolonged consciousness disorder, progressive hypoxia with diffuse lung damage, and cutaneous and mucosal petechiae. INTERVENTION: As respiratory failure progressed, VV-ECMO was initiated on the 6th day. To improve the respiratory failure caused by ARDS, prone position therapy was necessary. Thus, we performed osteosynthesis on the 9th day under ECMO. Prone position therapy was started after surgery. OUTCOMES: Subsequently, his respiratory condition and chest radiographs improved steadily. VV-ECMO was discontinued on the 17th day and the ventilator was removed on the 28th day. His consciousness levels improved without residual central nervous system complications. CONCLUSION: Our study reveals the successful improvement of FES-induced ARDS by osteosynthesis and prone positioning under VV-ECMO. This strategy prioritizes supportive treatment over pharmacologic interventions.

Prognostic factors for the short-term mortality of patients with rheumatoid arthritis admitted to intensive care units.

BACKGROUND: Patients with rheumatoid arthritis (RA) have high mortality risk and are frequently treated in intensive care units (ICUs). METHODS: This was a retrospective observational study. This study included 67 patients (20 males, 47 females) with RA who were admitted at the ICU of our institution for ≥48 h between January 2008 and December 2017. We analyzed the 30-day mortality of these patients and the investigated prognostic factors in RA patients admitted to our ICU. RESULTS: Upon admission, the median age was 70 (range, 33-96) years, and RA duration was 10 (range, 0-61) years. The 5-year survival after ICU admission was 47%, and 30-day, 90-day, and 1-year mortality rates were 22, 27, and 37%, respectively. The major reasons for ICU admission were cardiovascular complications (24%) and infection (40%) and the most common ICU treatments were mechanical ventilation (69%), renal replacement (25%), and vasopressor (78%). In the 30-day mortality group, infection led to a fatal outcome in most cases (67%), and nonsurvival was associated with a significantly higher glucocorticoid dose, updated Charlson's comorbidity index (CCI), and acute physiology and chronic health evaluation (APACHE) II score. Laboratory data obtained at ICU admission showed that lower platelet number and total protein and higher creatinine and prothrombin time international normalized ratio (PT-INR) indicated significantly poorer prognosis. The multivariate Cox proportional hazard model revealed that nonuse of csDMARDs, high updated CCI, increased APACHE II score, and prolonged PT-INR were associated with a higher risk of mortality after ICU admission. CONCLUSION: Our study demonstrated that the nonuse of csDMARDs, high updated CCI, elevated APACHE II score, and coagulation abnormalities predicted poorer prognosis in RA patients admitted to the ICU.

Refracture of pediatric both-bone diaphyseal forearm fracture following intramedullary fixation with Kirschner wires is likely to occur in the presence of immature radiographic healing.

PURPOSE: Refracture of pediatric both-bone diaphyseal forearm fractures (PBDFFs) may occur, even if the fractures are treated with intramedullary nailing. The purpose of this study was to investigate the risk of refracture of PBDFFs treated with intramedullary Kirschner wires (K-wires), which are commonly used in our clinic. METHODS: The present multicenter retrospective study included 60 consecutive patients with 60 PBDFFs who were treated with intramedullary K-wires at 5 hospitals between 2007 and 2016. The age of the patients at the time of the primary fracture ranged from 2 to 15 years. The characteristics of the primary fractures and treatment course were evaluated. RESULTS: Refracture occurred in 6 patients (10.0%). Three of the patients were young girls; the other 3 were adolescent boys. Refractures were caused by falling or during sports activity. The duration from primary fracture to refracture ranged from 46 to 277 days, and in 5 of the 6 patients refractures occurred within 6 months. Although we were unable to identify factors significantly contributing to refracture (e.g. fracture type or treatment procedures), radiographs at the latest visit before refracture demonstrated findings of immature healing in five of six patients. Both K-wires and external immobilization had been removed before complete fracture healing in a large proportion of patients with refracture (80.0%). CONCLUSIONS: Refracture of PBDFF may occur several months after treatment with intramedullary K-wires if the primary fracture shows immature healing. Physicians should pay special attention when judging radiographic fracture healing, even when the fracture is deemed to have clinically healed.

Revascularization of the necrotic femoral head after traumatic open anterior hip dislocation in a child: a case report.

INTRODUCTION: Avascular necrosis of the femoral capital epiphysis is the most serious complication after traumatic dislocation of the hip in children. This case report discusses the localization and revascularization of the necrotic femoral head following rarely experienced traumatic open anterior hip dislocation in children. CASE PRESENTATION: Our patient was an 11-year-old Japanese boy who had open anterior hip dislocation sustained in a traffic accident. Reduction of the hip joint was performed in an emergency operation, and he was evaluated using serial gadolinium-enhanced magnetic resonance imaging. T1-weighted magnetic resonance images showed two bands with low signal intensity in the femoral capital epiphysis on coronal and oblique axial planes, indicating the existence of avascular osteonecrosis of the femoral head. We observed gadolinium enhancement in the central region of the epiphysis, where the area between the two bands with low signal intensity was located. Serial assessment with enhanced magnetic resonance images during a non-weight-bearing period of 1.5 years after injury showed revascularization starting from the central region and converging toward the peripheral region. Although the patient had leg-length discrepancy due to the early epiphyseal closure, non-weight-bearing treatment for the avascular osteonecrosis of the femoral head achieved a favorable outcome without any hip joint dysfunction, pain, or sign of secondary osteoarthritic change within 4.5 years after injury. CONCLUSION: We confirmed the revascularization process of the necrotic lesion in the femoral capital epiphysis in an 11-year-old boy using serial gadolinium-enhanced magnetic resonance imaging. Conservative non-weight-bearing treatment achieved a favorable outcome.

Simultaneous deep inferior epigastric and bilateral anterolateral thigh perforator flap reconstruction of an extended perineoscrotal defect in Fournier's gangrene: A case report.

Fournier's gangrene is lethal necrotizing fasciitis that involves the perineum and external genitalia. We describe the case of a 52-year-old man with Fournier's gangrene who underwent reconstruction of an extensive perineoscrotal defect using three pedicled perforator flaps. Three debridement procedures resulted in a skin and soft tissue defect of 36 × 18 cm involving the perineum, scrotum, groin, medial thigh, buttocks, and circumferential perianal area and left the perforating arteries originating from these locations unavailable for reconstruction. We repaired the defect using left deep inferior epigastric artery perforator (DIEP) (29 × 8 cm) and bilateral anterolateral thigh perforator (ALT) flaps (35 × 8 cm and 22 × 7 cm). The flaps reached the defect without tension, and the defect was successfully covered without a skin graft. No postoperative complications occurred except for epidermal necrosis involving a tiny part of the DIEP flap tip. Nine months postoperatively, the patient experienced no impairment of bowel function or hip joint movement. There was also no avulsion or ulceration of the reconstructed perineal skin, and the cosmetic appearances of the healed wound and donor site were satisfactory. The combination of these three perforator flaps enabled us to achieve a satisfactory outcome while avoiding skin grafts.

Anatomic Reconstruction of Lateral Ankle Ligaments and Both Peroneus Tendons After Open Fracture Dislocation of the Ankle: A Case Report.

Extensive soft tissue defects of the ankle are an uncommon but challenging problem that require a combination of reconstructive options. We report the case of a complex injury involving the skin, lateral ankle ligaments, and peroneal tendons that were anatomically reconstructed. A 15-year-old girl was injured in an automobile accident resulting in extensive soft tissue defects and marked instability of her right ankle. The lower two-thirds of the anterior talofibular ligament (ATFL) had segmental defects, and calcaneofibular ligament (CFL) was completely torn, and both peroneal longus and brevis tendons were severely damaged. Initial debridement was performed on the day on injury. Two weeks after injury, the ATFL and CFL were reconstructed using a semitendinosus autograft and suture tape augmentation. Both peroneal tendons were reconstructed using a gracilis autograft. The skin defect (10 × 10 cm) was covered with an anterolateral thigh flap. After removing a short leg cast at 3 weeks postoperatively, the patient started range of motion exercises without using any brace. Weightbearing was allowed at 4 weeks. At the 24-month follow-up examination, she had returned to her preoperative level of work and sports activities.

Management of Intra-Articular Calcaneal Fractures: Clinical Results of Reduction Technique Using a Bone Spreader.

The purpose of the present study was to examine the clinical results of surgery for intra-articular calcaneal fractures using a calcaneal locking plate and a bone spreader as a reduction tool. Ten patients with intra-articular calcaneal fractures were treated. An extended lateral approach was used. The reduction of the intra-articular fragments of the posterior facet was temporarily held using a bone spreader and Kirschner wires. Internal fixation was achieved with a locking calcaneal plate. Böhler's angle and Preiss' angle were assessed on the day of injury and the day of the final follow-up examination. The step off and gap of the posterior facet were assessed on the day of injury and the first week after surgery. The functional outcome was evaluated using the American Orthopaedic Foot and Ankle Society ankle hindfoot scale score. The mean Böhler's angle ranged from 2.1° ± 11.0° to 30.4° ± 5.0° (p < .0001), the mean Preiss' angle ranged from 23.5° ± 4.5° to 15.5° ± 2.9° (p < .0001), the mean step off ranged from 4.0 ± 1.9 mm to 0.1 ± 0.2 mm (p = .0002), and the mean gap ranged from 2.6 ± 1.0 mm to 1.2 ± 0.6 mm (p = .0035). The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score was 89.2 (range 85 to 100) at a mean of 14.3 months after surgery. Our results suggest that a locking calcaneal plate can be used to restore and reduce an intra-articular calcaneal fracture and achieve good clinical results.

Esophageal perforation due to blunt chest trauma: Difficult diagnosis because of coexisting severe disturbance of consciousness.

Esophageal perforation due to blunt trauma is a rare clinical condition, and the diagnosis is often difficult because patients have few specific symptoms. Delayed diagnosis may result in a fatal clinical course due to mediastinitis and subsequent sepsis. In this article, we describe a 26-year-old man with esophageal perforation due to blunt chest trauma resulting from a motor vehicle accident. Because a severe disturbance of consciousness masked the patient's trauma-induced thoracic symptoms, we required 11h to diagnose the esophageal perforation. Therefore, the patient developed septic shock due to mediastinitis. However, his subsequent clinical course was good because of prompt combined therapy involving surgical repair and medical treatment after the diagnosis.

Clinical characteristics of type A acute aortic dissection with CNS symptom.

BACKGROUND AND PURPOSE: Accurate diagnosis of acute aortic dissection (AAD) is sometimes difficult because of accompanying central nervous system (CNS) symptoms. The purpose of this study was to investigate the clinical characteristics of Type A AAD (TAAAD) with CNS symptoms. METHODS: We retrospectively reviewed the medical records of 8403 patients ambulanced to our emergency and critical care center between April 2009 and May 2014. RESULTS: We identified 59 TAAAD patients for the analysis (mean age, 67.3±10.5years; 37 (62.0%) male). Eleven patients (18.6%) presented CNS symptoms at the onset of TAAAD, and these patients complained less frequently of typical chest and back pain than those without CNS symptoms (p<0.0001). Initial systolic and diastolic blood pressure were lower (p=0.003, and p=0.049, respectively) and involvement of the supra-aortic artery was more frequent in patients with CNS symptoms (p<0.0001). CONCLUSION: Because CNS symptom can mask chest and back pain caused by TAAAD, physicians should always consider the possibility of TAAAD in patients with CNS symptoms in emergency medicine settings.

Polymyxin-B immobilized column-direct hemoperfusion for adolescent toxic shock syndrome.

Toxic shock syndrome (TSS) is a critical illness associated with toxin from Staphylococcus aureus. Despite recent advances in critical care, mortality remains high and additional effective therapy is required. We report an adolescent case of TSS successfully treated with direct hemoperfusion using polymyxin-B immobilized fiber (PMX-DHP). The patient with spina bifida also had ischial pressure ulcer, and developed TSS associated with methicillin-resistant S. aureus. Despite conventional treatment, the patient developed refractory shock, which was immediately improved with PMX-DHP. PMX-DHP has been widely used for the treatment of sepsis to remove circulating endotoxins produced by Gram-negative bacteria, but beneficial effects have also been reported for Gram-positive bacterial infection. To our knowledge, this is the first report on PMX-DHP for TSS in an adolescent patient, and we propose that PMX-DHP could be a new treatment strategy for severe TSS in children as well.

Sarcopenia is a predictive factor for prolonged intensive care unit stays in high-energy blunt trauma patients.

Aim: Sarcopenia has been increasingly reported as a prognostic factor for outcome in settings such as cirrhosis, liver transplantation, and emergent surgery. We aimed to elucidate the significance of sarcopenia in severe blunt trauma patients. Methods: We retrospectively analyzed 84 patients emergently admitted to the intensive care unit at Kyushu University Hospital (Fukuoka, Japan) from May 2012 to April 2015. We assessed the amount of skeletal muscle present according to computed tomography and its relevance to ventilation-free days, patients' length of stay in the intensive care unit, and 28-day mortality. Results: Twenty-five (29.7%) patients were defined as sarcopenic. Sixteen (19.7%) patients required 15 days or more in the intensive care unit. The major reason was a prolonged ventilation requirement due to flail chest (n = 7) or pneumonia (n = 3). Sarcopenic patients' stays in intensive care were significantly longer than those of non-sarcopenic patients (18.7 versus 6.4 days, respectively; P < 0.001). Univariate and multivariate analyses showed sarcopenia to be a significant risk factor for prolonged intensive care unit stay. Conclusion: Sarcopenia is a risk factor that predicts prolonged intensive care unit stay in high-energy blunt trauma patients.

Speaking Tracheostomy Tube and Modified Mouthstick Stylus in a Ventilator-Dependent Patient with Spinal Cord Injury.

Communication is a serious problem for patients with ventilator-dependent tetraplegia. A 73-year-old man was presented at the emergency room in cardiopulmonary arrest after falling from a height of 2 m. After successful resuscitation, fractures of the cervical spine and cervical spinal cord injury were found. Due to paralysis of the respiratory muscles, a mechanical ventilator with a tracheostomy tube was required. First, a cuffed tracheostomy tube and a speaking tracheostomy tube were inserted, and humidified oxygen was introduced via the suction line. Using these tubes, the patient could produce speech sounds, but use was limited to 10 min due to discomfort. Second, a mouthstick stylus, fixed on a mouthpiece that fits over the maxillary teeth, was used. The patient used both a communication board and a touch screen device with this mouthstick stylus. The speaking tracheostomy tube and mouthstick stylus greatly improved his ability to communicate.

A simple predictive formula for the blood requirement in patients with high-energy blunt injuries transferred within one hour post-trauma.

Aims: To recognize patients who require massive transfusion at the early stage of blunt trauma, we retrospectively investigated patients with high-energy blunt injuries transferred within 1 h post-trauma. Methods: Between August 2007 and July 2011, 233 trauma patients were: (i) injured by a high-energy blunt mechanism with Injury Severity Score ≥9; (ii) not dead on arrival; (iii) older than 9 years; and (iv) at our center within 1 h after injury. The findings for 113 of those patients were analyzed, including those produced by ultrasonography, computed tomography, and arterial blood gas analyses. Results: Of 113 patients, 33 underwent massive transfusion (≥6 units) within 8 h of arrival. A logistic regression analysis revealed that an arterial lactate level ≥28 mg/dL (P < 0.001; odds ratio, 105.11; 95% confidence interval, 12.58-2,718.84) and a flat ratio of the inferior vena cava on computed tomography ≥3 (P < 0.001; odds ratio, 32.50; 95% confidence interval, 4.44-714.44) were significant independent predictors for a massive transfusion within 8 h. In a receiver operating curve analysis, the area under the curve of the need for massive transfusion was 0.956, with a sensitivity of 0.94 and a specificity of 0.90. A linear predictive formula for the probability (P) of receiving a massive transfusion was generated as P = 2 × lactate (mg/dL) + 15 × the flat ratio of inferior vena cava - 103. Using another 52 trauma patients, the formula was validated. Conclusions: An elevated level of arterial lactate and the flat ratio of inferior vena cava were significant predictors for identifying the patients who would require a massive transfusion in the early stage after high-energy blunt trauma.

Open pelvic ring fracture and multiple fractures of the lower extremities: a case report.

A 73-year-old female was hit by a car, and transferred to our hospital. On examination, her consciousness was alert, but her vital signs were unstable. There are three 10-cm open wounds on her right buttock. X-rays showed an unstable pelvic ring fracture, a right femoral shaft, a right proximal tibia and a right tibial plafond fractures. One hour after the injury, transarterial embolization (TAE) followed by external fixation (EF), and retroperitoneal pelvic packing (RPP) was performed. Two days and five days after the injury, thorough debridement of the open wounds was performed. The skin defect on the right buttock and the lower abdomen had enlarged to 40 x 35 cm, therefore, negative pressure wound therapy was applied. On the same day, right femur was fixed using a retrograde intramedullary nailing. 12 days after the injury, the proximal tibial fracture was fixed using a plate, and the tibial plafond fracture was fixed using screws and external fixators. 28 days after the injury, the split-thickness skin graft was performed on the right buttock and the lower abdomen. Seven months after the injury, the open wounds were completely healed without infection. She was able to walk smoothly with a T-cane. For the management of open pelvic ring fractures, it is essential to perform TAE, EF and RPP as soon as possible. Providing aggressive management, including thorough debridement, is mandatory to prevent severe infection and sepsis. We achieved a good clinical outcome by using a combination of TAE, EF, RPP and staged surgery, including thorough debridement.