Prevalence and distribution of air in the leg on preoperative multidetector high-resolution computed tomography in closed and low-grade open tibial shaft fractures.

PURPOSE: The prevalence and distribution of air present in the leg in closed and low-grade open tibial shaft fractures are unknown on multidetector high-resolution computed tomography (CT). The purpose of this study was to determine the rate of surgical site infection (SSI) in cases where debridement was not performed in the area of air infiltration. METHODS: Eighty-one closed and low-grade open tibial shaft fractures that underwent multidetector high-resolution CT on admission and were treated with an intramedullary nail were examined retrospectively. RESULTS: Of the 36 Gustilo type I or II open fractures, all had local air around the fracture site (within 5 cm proximal and distal from the fracture center). Of these, 25 showed remote air (more than 5 cm away from the fracture center). The most frequent site of remote air was in the subcutaneous tissue, followed by the anterior compartment and deep posterior compartment. All open fractures were treated with local irrigation and debridement, regardless of the presence of remote air, followed by a reamed intramedullary nail. No SSI developed until bone union. Of the 45 closed fractures, 3 patients showed air in the leg on the CT. No debridement was performed for closed fractures. One patient who did not have air in the leg developed SSI. All fractures united eventually. CONCLUSIONS: In low-grade open tibial shaft fractures, air can spread far from the fracture site. Even in closed tibial shaft fractures, air can be identified in the leg. The debridement of the area of air infiltration, however, is not necessary for prevention of SSI.

Long-term functional outcome after unstable pelvic ring fracture.

PURPOSE: In patients with unstable pelvic ring fractures, the factors related to poor outcome are still controversial. The purpose of our study was to evaluate the long-term functional outcome of patients with unstable pelvic ring fractures and correlate it with various other factors. METHODS: Fifty-seven patients who had a minimal follow-up of 2 years completed the three-view plain radiographs, physical examination, and functional assessment with questionnaire. There were 28 male and 29 female patients with an average age of 42.4 years and Injury Severity Score of 24.6 points. The mean time of follow-up was 47.2 months. Thirty-nine patients were Tile type B, and 18 were type C. Twenty-three patients were treated conservatively, 22 with external fixation, and 12 with internal fixation. The results were scored with the Majeed score, the Iowa Pelvic Score, and the Medical Outcomes Study Short-Form 36-item Health Survey (SF-36). Statistical analysis was performed by use of the Pearson correlation coefficient test and multiple regression analysis. RESULTS: The average Majeed score was 79.7, the average IPS was 80.7, and the average physical component summary of the SF-36 was 13.4 points worse than that of the population norm. These scores correlate significantly with each other. The average residual displacement was 7.3 mm anteriorly and 5.2 mm posteriorly. Multiple regression analysis revealed that the Majeed score and the physical component summary of the SF-36 correlated with the presence of neurologic injury, and the Iowa Pelvic Score correlated with the presence of a mental disorder, posterior displacement, and neurologic injury. CONCLUSIONS: The long-term functional outcome after unstable pelvic ring fracture was not associated with Injury Severity Score, fracture location or fracture type. We discovered a close correlation between neurologic injury and functional outcome.

Elevated plasma levels of bilirubin in patients with neurotrauma reflect its pathophysiological role in free radical scavenging.

Bilirubin, a powerful endogenous antioxidant, is one of the catabolites of heme oxygenases (HOs). In this study, the plasma bilirubin concentration was measured to establish bilirubin kinesis after traumatic brain injury (TBI). Furthermore, in in vitro studies, the free radical scavenging activity and antioxidant potency of bilirubin was also investigated at various concentrations, including physiological ones. Indirect plasma bilirubin was measured in 25 patients on days 1, 2, 3 and 4 after presentation with TBI. The ability of bilirubin to scavenge the hydroxyl (OH) and 1,1-diphenyl-2-picrylhyrazyl (DPPH) radicals, and its antioxidant potency, were also analyzed using electron spin resonance (ESR) and the bioantioxidant power (BAP) methods, respectively. Plasma bilirubin levels were significantly higher on days 2, 3 and 4 than on patient admission (day 1; p < 0.05). ESR and BAP results revealed that bilirubin has direct OH and DPPH radical scavenging activities and potent antioxidant effects in vitro at physiological concentrations. These data indicate that physiological concentrations of bilirubin have antioxidant properties and that it constitutes one of the biological defense mechanisms in neurotrauma patients.

Clinical characteristics of pelvic fracture patients with gluteal necrosis resulting from transcatheter arterial embolization.

BACKGROUND: Transcatheter arterial embolization (TAE) can cause gluteal skin and muscle necrosis. However, the ultimate and typical signs of gluteal necrosis resulting from TAE have not yet thoroughly been investigated. METHODS: From January 1995 to December 2003, 165 pelvic fractures were managed with TAE to control retroperitoneal bleeding at our level 1 trauma center. From these, 12 patients suffered gluteal muscle and skin necrosis. We reviewed the medical records of these 12 patients for age, gender, fracture type, embolic sites, computed tomography (CT) findings, serum creatine kinase level, site of skin necrosis, time from injury to skin necrosis, treatment, and outcome. RESULTS: All 12 patients underwent TAE of the bilateral internal iliac arteries with gelatin sponge slurries. One patient suffered from an infection of the gluteal muscle from an open fracture site. Five patients presented with signs of gluteal soft tissue injuries on admission. Of these, four had skin abrasions and three revealed fluid or air collection under the gluteal skin on CT. The remaining six patients showed no evidence of soft tissue injuries on admission, and the lesions appeared between 2 days and 7 days after their admission. In these six patients, low-density areas (LDAs) of gluteal muscle with a clear border on the CT were observed following the appearance of skin lesion. The skin necrosis was located in the center of either or both buttocks, and signs of ischemia were clearly demarcated from the adjacent normal tissue. Four of 12 patients died from sepsis, three of whom suffered from uncontrollable gluteal infections that had been pointed out as LDAs on the CT. CONCLUSIONS: In every patient with gluteal necrosis associated with pelvic fracture following TAE, initial traumatic contusion cannot be ruled out as contributing to the development of the necrosis. However, for patients who undergo TAE of the bilateral internal iliac artery and who show clear-border LDAs on CT, skin necrosis centered on the buttock, and the delayed appearance of a skin lesion, careful attention must be given in the event of an arterial obstruction due to TAE.

Trauma care systems in Japan.

The trauma care system in Japan was set up in the 1960s in response to social problems caused by traffic accidents and has since been altered extensively. First-aid and patient transfer are performed by emergency personnel belonging to a fire station. Instead of 'western-style trauma centres', three types of facilities exist: (1) primary emergency care facilities for treating mild cases not requiring hospitalisation; (2) secondary emergency hospitals directed to treating moderately severe disease or injury; (3) tertiary emergency hospitals corresponding to the emergency departments of university hospitals, or lifesaving emergency centres, able to manage the most severe cases such as myocardial infarction, cerebrovascular accident and polytrauma. Although the quantity of emergency facilities and hospitals appears sufficient, the quality of emergency care needs to be improved. This could be accomplished by the unification of small hospitals to create larger hospitals, and/or by the establishment of trauma centres, as well as by improvements in relevant education and training.

Treatment outcome of nonclostridial gas gangrene at a Level 1 trauma center.

OBJECTIVE: To evaluate the results of treatment of nonclostridial gas gangrene at a Level 1 trauma center. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS: Seven patients with nonclostridial gas gangrene were studied. The average age of all patients at the time of admission was 40.3 years (range 14 to 67 years). RESULTS: Three of seven patients had posttraumatic infection, and the remaining four were strongly associated with underlying diseases: diabetes mellitus in three and paraplegia as the result of a spinal cord injury in two. The time of symptom onset was clearly defined in four cases, and the average interval between symptom onset and transfer to our hospitals was six days (range 2 to 10 days). Surgical debridement was performed immediately on admission in six patients (86 percent). A triple antibiotic regimen consisting of penicillin, gentamicin, and clindamycin was used initially in all patients. In three patients, hyperbaric oxygen therapy was also used. The overall mortality rate was 42.9 percent (three of seven patients). In these patients, the interval from onset of symptom to transfer to our hospital was ten days in one patient, which was longer than average, and was not accurately known in the other two patients. CONCLUSION: Nonclostridial gas gangrene is extremely rare but life-threatening. The greatest pitfall for the emergency department physician is failure to suspect it clinically. Aggressive treatment, including surgical debridement and intravenous antibiotics with or without hyperbaric oxygen therapy, must be initiated immediately to minimize morbidity and mortality.