Management of traumatic incomplete lacerating rectus muscle injuries using multimodal imaging approach (ASOCT and CT/MRI).

Purpose: To describe the pathophysiology, importance of multimodal imaging approach, and the clinical outcomes of incomplete lacerating rectus muscle injuries. Methods: A retrospective review was conducted to identify patients with ocular deviation secondary to rectus muscle injuries. Between 2019 and 2022, a total of 30 patients were identified, amongst whom eleven patients had incompletely lacerated rectus muscles (secondary to penetrating adnexal trauma and sino-orbital surgeries). Patients' demography, nature of injury, computed tomography/magnetic resonance imaging, anterior segment optical coherence tomography features, intra-operative findings, and post-operative outcomes were reviewed. Results: The mean age of 11 patients was 31.36 ± 14.38 years. All patients had external trauma which severed the muscle in its anterior portion. Five patients had isolated inferior rectus muscle injury (45.45%), three had inferior and medial rectus muscle injuries together (27.27%), two had isolated lateral rectus muscle injury (18.18%), and one remaining patient had isolated medial rectus muscle injury (9.05%). In ten patients (90.90%) CT/MRI revealed features suggestive of muscle injury, however details with respect to muscle insertion and scleral course were lacking. In this difficult scenario, ASOCT filled these lacunae in nearly 90% of the patients by providing surgically useful details. Moreover, when CT/MRI-ASOCT imaging features were combined, the management and outcomes were even more predictable. Conclusions: Penetrating rectus muscle injuries can be better identified as incompletely lacerated muscle using multimodal imaging approach. This simple image correlation process customizes the treatment approach and hence the clinical outcomes.

Successful Management of Uterine Prolapse in Pregnancy: A Case Report of Avoiding a Cervical Laceration by the Reduction of Massive Edema.

We report a case of uterine prolapse in pregnancy, which was successfully managed before delivery. A 35-year-old woman (G2P1) complained consistently of a protruding uterus at 36 weeks gestation, and an engorged uterine cervix without tenderness, urinary disturbance, and incontinence were recognized (Pelvic Organ Prolapse Quantification (POP-Q) score C: +7). Manual retraction of the edematous cervix was gently performed with gauze packing, and strikingly improved edema of the cervix with a POP-Q score of C: -2 was observed one day after the gauze packing. Induction of labor was planned due to a suspected large-for-gestational-age infant, and the patient uneventfully delivered at 39 weeks gestation without any obstacles to delivery and cervical laceration. Cervical edema in pregnancy increases the risk of cervical dystocia and cervical lacerations. However, lacerations with edema are predicted to have a poor wound-healing process. The technique with gauze packing presented in this case may be useful in the protective handling of the uterine cervix during pregnancy.

Aortic valve laceration following rotational atherectomy: a case report.

Background: Iatrogenic aortic valve injury during cardiovascular catheterization interventions is extremely rare. Severe aortic regurgitation that ensues can be catastrophic and the management is typically with surgical valve replacement or repair. Percutaneous management of native pure aortic regurgitation is difficult due to anatomical challenges and the limitations of current transcatheter heart valve technology to anchor in the absence of leaflet or annular calcification. Case Summary: An 82-year-old female underwent rotational atherectomy (RA) for a severely calcified stenosis of the left anterior descending artery. The patient was discharged well following placement of two drug eluting stents. She represented to hospital 7 days later with acute pulmonary oedema. Bedside transthoracic echocardiography demonstrated new, severe AR with preserved left ventricular size and function. Review of the prior percutaneous coronary intervention revealed significant trauma to the aortic valve during RA, with contrast seen refluxing into the LV during diastole, evolving throughout the procedure. Given the patient was not an operative candidate, an oversized transcatheter aortic valve was successfully implanted. In the post-operative setting, the patient suffered a stroke. Extensive hypoattenuated leaflet thickening (HALT) and thrombus was seen on dedicated 4D CT imaging. She made full neurological recovery and valve function returned to normal following a period of anticoagulation. Conclusion: Although iatrogenic aortic valve laceration is rare, this case highlights several important learning points including the importance of good guide catheter support during RA; the feasibility of Transcatheter Aortic Valve Replacement for pure native AR; and the detection and management of HALT.

Epidemiological characteristics and factors affecting healing in unintentional pediatric wounds.

Objective: To analyze the epidemiological characteristics and wound healing conditions of common unintentional skin lacerations in children. Methods: A retrospective analysis was conducted on data from 1,107 children, aged 0-12 years, with skin lacerations who received emergency treatment at Qilu Hospital of Shandong University from January 1, 2019, to December 30, 2022. Data on age, injury site, time from injury to suturing, and wound healing conditions were statistically analyzed. Results: Among the 1,107 cases, 714 (64.5%) were male and 393 (35.5%) were female, with a male-to-female ratio of 1.8:1; median age was 5 years (IQR, 3-7). Infants and toddlers (0-3 years old) constituted the highest proportion, accounting for 36.3% (402 cases). The number of children aged over 3 years gradually decreased with increasing age. In younger children, the most common injuries were to the forehead, scalp, and lower jaw; in school-aged children, the proportion of limb and trunk injuries significantly increased. Age (OR, 1.34; 95% CI, 1.23-1.46), outdoor injuries (OR, 2.21; 95% CI, 1.18-4.16), lower limb injuries (OR, 5.35; 95% CI, 2.86-10.00), and wound length greater than 3 cm (OR, 10.65; 95% CI, 5.02-22.60) were significant risk factors for poor wound healing. The risk of poor wound healing increased by 34% for each additional year of age. Conclusion: In children, the common sites of unintentional skin lacerations show distinct age and gender distribution characteristics. Older age, outdoor injuries, longer wound lengths, and lower limb injuries are independent risk factors for poor wound healing.

Effects of Using Virtual Reality Technology on Pain and Hemodynamic Variables in Patients Receiving Hand Laceration Repair in an Emergency Department: A Randomized Controlled Trial.

BACKGROUND: Pain and altered hemodynamic variables are among the most common complications in patients undergoing hand laceration repair in an Emergency Department. AIM: This study aimed to evaluate the effects of using virtual reality (VR) technology on pain and hemodynamic variables in patients receiving hand laceration repair in an Emergency Department. METHOD: This nonblinded randomized clinical trial included 160 patients undergoing laceration repair to their hands under local anesthetics from November 2020 to May 2021. The participants were randomly allocated to the experimental and control groups. Patients in the control group received routine care (such as ambient noise reduction, providing explanations about the surgery, and Lidocaine injection before the surgery). In the experimental group, a video containing natural landscapes and sounds was played using a semi-immersive VR headset during the surgery. Pain level and hemodynamic variables were measured immediately before and after the intervention. The pain was measured using the Critical Care Pain Observation Tool and Visual Analog Scale. RESULTS: Immediately after the intervention, systolic blood pressure (BP), respiration rate, and pain intensity were significantly lower in the intervention group compared with the control group (p < .05). There were no significant differences between the intervention and control groups regarding diastolic BP, mean BP, SPO2, heart rate, and muscular tension (p > .05). CONCLUSIONS: Semi-immersive VR is effective in managing pain and hemodynamic variables during hand laceration repair. The nurses could use the semi-immersive VR to better control of pain and hemodynamic variables during hand laceration repair.

Prevalence and associated factors of maternal birth trauma following vaginal delivery at University of Gondar Comprehensive Specialized Hospital, North-West Ethiopia, 2022.

BACKGROUND: Maternal injury with any form of perineal trauma following vaginal delivery is very common which ranges globally from 16.2 to 90.4%. The frequency of Obstetric anal sphincter Injuries and the incidence of cervical laceration increases rapidly. However, in Ethiopia, there is limited evidence on the prevalence of maternal birth trauma and its determinant factors after vaginal delivery. OBJECTIVE: To assess the magnitude and associated factors of Maternal Birth Trauma after vaginal delivery at University of Gondar Comprehensive Specialized Hospital, Gondar, North-West Ethiopia, 2022. METHODS: An Institution based cross-sectional study was conducted among mothers with singleton vaginal delivery at University of Gondar Comprehensive Specialized Hospital from 9th May to 9th August 2022 among 424 study participants. Pre-tested semi-structured questioner was utilized. Epi-Data version 4.6 was used for data entry and exported to SPSS version 25 for data management and analysis. To identify the determinant factors, binary logistic regression model was fitted and variables with p-value < 0.2 were considered for the multivariable binary logistic regression analysis. In the multivariable binary logistic regression analysis, Variables with P-value < 0.05 were considered to have statistical significant association with the outcome variable. The Adjusted Odds Ratio (AOR) with 95% CI was reported to declare the statistical significance and strength of association between Maternal Birth Trauma and independent variables. RESULTS: A total of 424 mothers who delivered vaginally were included. The mean age of participants was 26.83 years (± 5.220 years). The proportion of birth trauma among mothers after vaginal delivery was47.4% (95%CI: 43.1, 51.7). Of different forms of perineal trauma, First degree tear in 42.8%, OASIs in 1.5% and Cervical laceration in 2.5% study participants. In the multivariable binary logistic regression analysis being primiparous (AOR = 3.00; 95%CI: 1.68, 5.38), Gestational age ≥ 39 weeks at delivery (AOR = 2.96; 95%CI: 1.57, 5.57), heavier birth weight (AOR = 12.3; 95%CI: 7.21, 40.1), bigger head circumference (AOR = 5.45; 95%CI: 2.62, 11.31), operative vaginal delivery (AOR = 6.59; 95%CI: 1.44, 30.03) and delivery without perineum and/or fetal head support (AOR = 6.30; 95%CI: 2.21, 17.94) were significantly associated with the presence of maternal birth trauma. CONCLUSION AND RECOMMENDATION: Maternal birth trauma following vaginal delivery was relatively high in this study. Prim parity, gestational age beyond 39 weeks at delivery, heavier birth weight, bigger head circumference, operative vaginal delivery and delivery without perineum and/or fetal head supported were factors affecting perineal outcome. The Ministry of Health of Ethiopia should provide regular interventional training as to reduce maternal birth trauma.

Topical Tranexamic Acid to Control Vaginal Laceration Bleeding after Sexual Assault.

BACKGROUND: Sexual assault survivors may sustain vaginal trauma that requires intervention in the emergency department, or operating room. CASE REPORT: We describe the case of a 16-year-old female who was referred to the emergency department for evaluation of continued bleeding from a vaginal laceration following sexual assault 38 h prior. The bleeding limited the medical forensic medical examination, but she was hemodynamically stable. After the application of tranexamic acid (TXA)-soaked gauze, the patient's bleeding was controlled and the wound was able to be evaluated and the examination completed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is the first case in the literature that describes the use of topical TXA in a patient to achieve hemostasis in a vaginal laceration sustained from sexual violence.

Severe perineal lacerations in induction of labor versus expectant management: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: This study aimed to evaluate if induction of labor (IOL) is associated with an increased risk of severe perineal laceration. DATA SOURCES: A systematic search was conducted in MEDLINE, Ovid, Scopus, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, and CINHAL using a combination of keywords and text words related to "induction of labor," "severe perineal laceration," "third-degree laceration," "fourth-degree laceration," and "OASIS" from inception of each database until January 2023. STUDY ELIGIBILITY CRITERIA: We included all randomized controlled trials (RCTs) comparing IOL to expectant management of a singleton, cephalic pregnancy at term gestation that reported rates of severe perineal laceration. STUDY APPRAISAL AND SYNTHESIS AND METHODS: The primary outcome of interest was severe perineal laceration, defined as 3rd- or 4th-degree perineal lacerations. We conducted meta-analyses using the random effects model of DerSimonian and Laird to determine the relative risks (RR) or mean differences with 95% confidence intervals (CIs). Bias was assessed using guidelines established by Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: A total of 11,187 unique records were screened and ultimately eight RCTs were included, involving 13,297 patients. There was no statistically significant difference in the incidence of severe perineal lacerations between the IOL and expectant management groups (209/6655 [3.1%] vs 202/6641 [3.0%]; RR 1.03, 95% CI 0.85, 1.26). There was a statistically significant decrease in the rate of cesarean birth (1090/6655 [16.4%] vs 1230/6641 [18.5%], RR 0.89, 95% CI 0.82, 0.95) and fetal macrosomia (734/2696 [27.2%] vs 964/2703 [35.7%]; RR 0.67: 95% CI 0.50, 0.90) in the IOL group. CONCLUSION: There is no significant difference in the risk of severe perineal lacerations between IOL and expectant management in this meta-analysis of RCTs. Furthermore, there is a lower rate of cesarean births in the IOL group, indicating more successful vaginal deliveries with similar rates of severe perineal lacerations. Patients should be counseled that in addition to the known benefits of induction, there is no increased risk of severe perineal lacerations.

Extensive skin laceration on the forearm due to closed reduction of a dislocated shoulder. A case report.

We report the case of an 80-year-old man who suffered an anteroinferior shoulder dislocation with rupture of the rotator cuff following a fall. An attempt at closed reduction under analgosedation resulted in extensive skin laceration on the elbow and forearm. The wound treatment was complex and resulted in numerous complications.

Development of aids to relieve vulvodynia during the postpartum period.

Postpartum women live with a low quality of life due to pain caused by episiotomy and perineal laceration. In particular, they endure pain when sitting for long periods of time to breastfeed. The purpose of this study is to develop a sitting aid to alleviate postpartum vulvodynia. This study was conducted in the following four phases from July 2017 to May 2019. They are: material selection and molding, cleaning and disinfection testing, pressure distribution measurement testing, and trial testing by postpartum women. The main material was a 100% polypropylene object with a three-dimensional reticular fiber spring structure and fiber density of 3.8 kg/m2. As a result, a sitting aid that withstands washing and disinfection well in the medical field and is breathable. It had moderate resilience and elasticity and reduced pressure on the seating surface for women weighing approximately 45 kg and 55 kg, but we were skeptical about its use for women weighing more than that. The completed sitting aid is noninvasively effective in improving the quality of life of many postpartum women, but the density and thickness of the main material should be reexamined to meet the needs of women in a wider weight range. In addition, a self-administered questionnaire survey of trial users revealed that some women did not experience relief from vulvodynia even after using the sitting aid. Such women also had physical problems such as discomfort in the lower back, difficulty breastfeeding, and difficulty standing up. For women with multiple physical problems, individual causes should be addressed.

Functional outcomes of canalicular laceration repair with self-retaining masterka stent in a tertiary eye care center in France: A retrospective study of 30 patients.

PURPOSE: To evaluate the long-term functional outcomes of canalicular laceration repair using the Masterka® monocanalicular intubation system. METHODS: this interventional case series included the data from 30 patients who underwent canalicular laceration repair with a 30-mm pushed monocanalicular stent (Masterka®) and suturing of the lacerated canaliculus with 8/0 Vicryl interrupted sutures. Operative details and complications were meticulously noted. Stent removal took place as early as 3 months post-surgery, with functional success defined as the absence of epiphora four years after surgery. RESULTS: The average age of patients was 28.5±26.3 years, with 20 out of 30 patients (66.6%) being male. Lower canaliculus involvement was noted in 23 patients (76.6%), while the upper canaliculus was affected in 7 patients (23.4%). On average, patients presented for medical attention within approximately one day of sustaining with injuries, and all underwent successful repairs. Notably, functional success was observed in all 30 cases, constituting a 100% success rate. Stent-related complications were encountered in two patients (6.6%). One patient reported stent removal after an average follow-up period of one month, while the other developed a punctal granuloma one-month post-surgery, which regressed following one month of topical steroid treatment. CONCLUSION: Repairing canalicular lacerations using the self-retaining Masterka® monocanalicular intubation system demonstrated a notable achievement in long-term functional success while presenting minimal complications. To further substantiate these promising results, an interventional study that includes a comparison analysis with other types of intubation methods is warranted.

Perineoplasty for anal incontinence after obstetric anal sphincter injury repair: a case report.

BACKGROUND: The rectal and vaginal walls are typically sutured if severe perineal lacerations with rectal mucosal damage occur during vaginal delivery. In case of anal incontinence after the repair, re-suturing of the anal sphincter muscle is standard procedure. However, this procedure may not result in sufficient improvement of function. CASE PRESENTATION: A 41-year-old woman underwent suture repair of the vaginal and rectal walls for fourth-degree perineal laceration at delivery. She was referred to our department after complaining of flatus and fecal incontinence. Her Wexner score was 15 points. Examination revealed decreased anal tonus and weak contractions on the ventral side. We diagnosed anal incontinence due to sphincter dysfunction after repair of a perineal laceration at delivery. We subsequently performed sphincter re-suturing with perineoplasty to restructure the perineal body by suturing the fascia located lateral to the perineal body and running in a ventral-dorsal direction, which filled the space between the anus and vagina and increased anal tonus. One month after surgery, the symptoms of anal incontinence disappeared (the Wexner score lowered to 0 points), and the anorectal manometry values increased compared to the preoperative values. According to recent reports on the anatomy of the female perineal region, bulbospongiosus muscle in women does not move toward the midline to attach to the perineal body, as has been previously believed. Instead, it attaches to the ipsilateral surface of the external anal sphincter. We consider the fascia lateral to the perineal body to be the fascia of the bulbospongiosus muscle. CONCLUSIONS: In a case of postpartum anal incontinence due to sphincter dysfunction after repair of severe perineal laceration, perineoplasty with re-suturing an anal sphincter muscle resulted in improvement in anal sphincter function. Compared to conventional simple suture repair of the rectal wall only, this surgical technique may improve sphincter function to a greater degree.

An Unusual Case of Tongue Entrapped in an Electronic Nail Clipper: A Case Report.

Children with entrapped foreign objects in their tongues require a careful and knowledgeable approach to calm their anxiety, as not all patients may be appropriate for moderate sedation. Deciding the best treatment approach is often challenging due to conflicting advice and unclear guidelines. Recently, the emergency department has started favoring natural healing over suturing, especially for small tongue lacerations not involving the tip of the tongue. However, in cases of large lacerations or involvement of the tip of the tongue, suturing is usually recommended. This case report presents a rare incident of a tongue trapped in an electronic nail device in a pediatric patient.

Utility of the occipital nerve block in the emergency department: A case series.

INTRODUCTION: Tension headaches, as well as various scalp pathologies including lacerations and abscesses are commonly treated in the emergency department (ED). The occipital nerve block (ONB), previously described in anesthesia and neurology literature, offers analgesia of the posterior scalp on the side ipsilateral to the injection while maintaining a low adverse effect profile. CASE REPORT: We report three cases in which ONB was utilized for tension headache, scalp laceration repair, and incision and drainage of scalp abscess. These patients all reported significant pain improvement without any reported complications. CONCLUSION: The ONB is a landmark based technique that offers an opportunity to provide analgesia in the ED that is simple, effective, and without known significant risks that are associated with other modalities of treatment.

Prevention of nostril lacerations in endonasal drilling procedures by use of a conventional protective ear speculum.

PURPOSE: Injuries of the nasal vestibular skin caused by the rotating burr shafts can represent a tedious complication following endonasal drilling and is experienced sooner or later by every rhino-surgeon. MATERIAL AND METHODS: To protect the nasal entrance from laceration by the free rotating drill shaft we position an otology speculum in the nasal entrance. The speculum is held in place by the scrub nurse during the critical phase of bone drilling. RESULTS: Following the introduction of the ear speculum protection, we successfully treated our dacryocystostamia procedures (n = 27) and median maxillectomia procedures (n = 6) without any further soft tissue erosions. DISCUSSION: Preventive measures for injuries by endonasal drilling procedures are not reported extensively in literature. This stands in contrast to the fact that these injuries are prone to cause significant suffering as amply described in the case of nostril laceration due to nasogastric intubation or nasogastric feeding tubes. CONCLUSION: The use of a readily available, reusable ear speculum in endonasal drill application eliminated the complication of nasal entrance lacerations throughout our institution, hitherto.

Incidence of Pure Orbital Fractures with Concomitant Lacrimal Drainage System Injury in the Japanese Population: A Retrospective Study.

PURPOSE: This study aims to determine the incidence of pure orbital fractures with concomitant lacrimal drainage system injuries. METHODS: A retrospective observational study involving 956 sides from 940 pure orbital blowout fracture patients was conducted in our institution. Patients with concomitant orbital rim fracture and those with old orbital fractures were excluded. RESULTS: A total of 13 sides (1.4%) from 13 patients were included in the study. Canalicular laceration, bony nasolacrimal canal fracture, and lacrimal sac wall laceration were found in 9, 4, and 1 patients, respectively (one overlapping). Majority of the injuries resulted from either sports or falls. Inferomedial orbital strut fracture (23.1% vs. 7.6%; p = .075) and orbital floor fracture occurring lateral to the infraorbital groove (30.8% vs. 9.9%; p = .035) tended to be higher in patients with lacrimal drainage system injuries. CONCLUSION: There is a 1.4% incidence rate of pure orbital fractures with concomitant lacrimal drainage system injuries among the Japanese population included in this study. Inferomedial orbital strut fractures and orbital floor fracture lateral to the infraorbital groove were found to have higher association with lacrimal drainage system injuries.

Novel valve-in-surgical bioprosthetic transcatheter aortic valve replacement: Undermining iatrogenic coronary obstruction with radiofrequency needle (UNICORN).

An 86-year-old female with history of surgical aortic valve replacement presented with clinical signs of heart failure. Echocardiography revealed a reduction in left ventricular systolic function and severe bioprosthetic aortic valve dysfunction. This is the first reported case of valve-in-valve transcatheter aortic valve replacement with concomitant undermining iatrogenic coronary obstruction with radiofrequency needle procedure in a surgical bioprosthetic valve.

Thoracic trauma in children.

Isolated thoracic trauma is rare in children. Because of their small body size, the trauma often also affects other spaces, such as the abdomen and head, and these coexistences significantly increase the rate of mortality. However, in isolated thoracic traumas, the children can quickly recover if they can survive the initial period of trauma. Pediatric thoracic trauma cases can have a different clinical course compared to adults due to the unique anatomic and physiologic properties of children's thoracic cages. Their ribs are nonossified and are very elastic, and therefore, as their ribs can sustain significant deformation without breaking, some significant intrathoracic injuries can be overlooked. In this review, the most common thoracic injuries, including pulmonary contusion, hemopneumothorax, pulmonary laceration, rib fractures, flail chest, tracheobronchial injuries, traumatic asphyxia, and other less common mediastinal injuries are discussed in detail in regard of clinical presentation and management.

How does vertical laminar fracture impact the decision-making in thoracolumbar fractures? A systematic scoping review and meta-analysis.

OBJECTIVE: Although vertical laminar fracture (VLF) is generally considered a severity marker for thoracolumbar fractures (TLFs), its exact role in decision-making has never been established. This scoping review aims to synthesize the research on VLF's role in the decision-making of TLFs. METHODS: A systematic review was conducted following PRISMA guidelines. We searched PubMed, Scopus, and Web of Science from inception to  June 11, 2023, for studies examining the association of VLF in thoracolumbar fractures with dural lacerations, neurological deficits, radiographic parameters, or treatment outcomes. Additionally, experimental studies that analyze the biomechanics of burst fractures with VLF were included. The studies extracted key findings, objectives, and patient population. A meta-analysis was performed for the association of VLF with dural laceration and neurological deficit, and ORs were pooled with a 95% confidence interval (CI). RESULTS: Twenty-eight studies were included in this systematic review, encompassing 2021 patients, and twelve were included in the meta-analysis. According to the main subject of the study, the association of VLF with a dural laceration (n = 14), neurological deficit (n = 4), radiographic parameters (n = 3), thoracolumbar fracture classification (n = 2), and treatment outcome (n = 2). Seven studies with a total of 1010 patients reported a significant association between VLF and neurological deficit (OR = 7.35, 95% CI [3.97, 14.25]; P < 0.001). The pooled OR estimates for VLF predicting dural lacerations were 7.75, 95% CI [2.41, 24.87]; P < 0.001). CONCLUSION: VLF may have several important diagnostic and therapeutic implications in managing TLFs. VLF may help to distinguish AO type A3 from A4 fractures. VLF may help to predict preoperatively the occurrence of dural laceration, thereby choosing the optimal surgical strategy. Clinical and biomechanical data suggest VLF may be a valuable modifier to guide the decision-making in burst fractures; however, more studies are needed to confirm its prognostic importance regarding treatment outcomes.