Extremity injuries as predictors of emergency care resource needs among blunt trauma patients in Japan

This study aimed to exhaustively examine associations between prehospital variables and emergency care resource needs among blunt trauma patients. The study included blunt trauma patients aged 15 years or older who were admitted to a tertiary care medical center in Osaka, Japan, from January 2005 to December 2009. The primary end point was a composite measure of overall emergency care resource needs. Predictive variables were easily detectable upper and lower extremity injuries. A multivariate logistic regression model was used to identify associations between the predictive variables and the end point; this model included other covariates known to be associated with emergency care resource needs (demographic characteristics, mechanism of injury, and physiological parameters). Of 982 blunt trauma patients, 81 died, and 573 required overall emergency care resources. Upper extremity injury (odds ratio [OR], 2.60) and lower extremity injury (OR, 4.50) were significantly associated with overall emergency care resource needs after controlling for other covariates. The results of this study suggest that easily detectable extremity injuries may be useful predictors of the emergency care resource needs of trauma patients. Further studies are needed to validate the predictive values of these injuries and to determine ways to use information about extremity injuries to improve triage decisions.

Partial rupture of the hamstring muscle complex: a literature review on treatment options

Injuries of the hamstring muscle complex (HMC) often affect athletes participating in specific sporting activities. Mild injuries that constitute a mere strain of the muscle can be managed symptomatically, while severe injuries often require surgical intervention to precipitate a return to function. Neglected injuries usually result in a long-term functional impairment. Therefore, surgical reconstruction of the HMC is advised for both partial and complete lesions. Without acute repair, a chronic lesion referred to as hamstring syndrome can result due to dysfunction of the HMC. Surgical intervention is usually recommended. A case of a chronic severe partial injury to the HMC managed conservatively in a 49-year old female is presented to illustrate the level of function that can be achieved after non-operative management. The clinical and radiological findings are presented 18 months post-injury along with a review of the current literature. There are no previous reports in the literature describing this scenario. This case indicates the need for re-evaluation in treatment options in partial hamstring muscle ruptures. A surgical treatment of partial rupture should be considered more often as an adequate treatment option and cofactors that influence the prognosis must be revealed. The indication of surgical intervention should be re-evaluated within the first months in case of conservative treatment.

Comparison of fondaparinux with low molecular weight heparin for venous thromboembolism prevention in patients requiring rigid or semi-rigid immobilization for isolated non-surgical below-knee injury

BACKGROUND

In several small studies, anticoagulant therapy reduced the incidence of venous thromboembolism (VTE) in patients with isolated lower-limb injuries.

OBJECTIVES

To compare the efficacy and safety of fondaparinux 2.5 mg (1.5 mg in patients with a creatinine clearance between 30 and 50 mL min(-1) ) over nadroparin 2850 anti-factor Xa IU.

PATIENTS AND METHODS

In this international, multicenter, randomized, open-label study, patients with an isolated non-surgical unilateral below-knee injury having at least one additional major risk factor for VTE and requiring, in the Investigator's opinion, rigid or semi-rigid immobilization for 21-45 days with thromboprophylaxis up to complete mobilization received subcutaneously once-daily either fondaparinux or nadroparin. The primary efficacy outcome was the composite of VTE (symptomatic or ultrasonographically detected asymptomatic deep vein thrombosis of the lower limb or symptomatic pulmonary embolism) and death up to complete mobilization. The main safety outcome was major bleeding.

RESULTS

We randomized 1349 patients (mean age 46 years): 88.7% had a bone fracture, and 83.8% had a plaster cast fitted (mean duration of immobilization, 34 days). The primary efficacy outcome occurred in 15 of 584 patients (2.6%) in the fondaparinux group and 48 of 586 patients (8.2%) in the nadroparin group (odds ratio, 0.30; 95% confidence interval [CI], 0.15-0.54; P < 0.001). A single major bleed was experienced by fondaparinux-treated patients and none by nadroparin-treated patients. These results were maintained up to the end of follow-up.

CONCLUSIONS

Fondaparinux 2.5 mg day(-1) may be a valuable therapeutic option over nadroparin 2850 anti-FXa IU day(-1) for preventing VTE after below-knee injury requiring prolonged immobilization in patients with additional risk factors.

Tennis leg: mechanism of injury and radiographic presentation

As summer is upon us, we thought a discussion of tennis leg would be beneficial to our fellow clinicians. Tennis leg is a relatively common clinical condition, classically manifesting as acute, sports-related pain in the mid-calf. First described in 1883, the pathogenesis has been debated--tennis leg was first attributed to rupture of the plantaris tendon, though more recent investigations have implicated rupture of the medial head of the gastrocnemius at its myotendinous junction. For simplicity, many authors use the term tennis leg to describe all such acute muscle injuries in the superficial calf.

The effects of equine peripheral blood stem cells on cutaneous wound healing: a clinical evaluation in four horses

Stem-cell therapy represents a promising strategy for the treatment of challenging pathologies, such as large, infected wounds that are unresponsive to conventional therapies. The present study describes the clinical application of peripheral blood stem cells (PBSCs) for the treatment of four adult Warmblood horses with naturally occurring wounds, which were unresponsive to conventional therapies for at least 3 months. A visual assessment was performed, and a number of wound-healing parameters (granulation tissue, crust formation and scar formation) were evaluated. In all cases, tissue overgrowth was visible within 4 weeks after PBSC injection, followed by the formation of crusts and small scars in the centre of the wound, with hair regeneration at the edges. In conclusion, this is the first report of PBSC therapy of skin wounds in horses, and it produced a positive visual and clinical outcome.

Clinical outcomes of isolated lower extremity or foot burns in diabetic versus non-diabetic patients: a 10-year retrospective analysis

INTRODUCTION

The incidence of diabetes mellitus (DM) in the United States is expected to increase from 8 per 1000 in 2008 to 15 per 1000 by 2050 [20]. As a result, DM patients will constitute a large proportion of Burn Center admissions, with burns typically due to contact burn or scalding. Peripheral vascular disease (PVD) and peripheral neuropathy (PN) are far more common in DM patients, particularly in those with poorly controlled disease, and are often associated with worse outcomes than non-diabetic (nDM) burn patients. This study sought to analyze whether the outcome of isolated leg and foot burns among DM and nDM individuals differed significantly.

MATERIALS AND METHODS

Retrospective data on 207 consecutive patients (>18 years old) admitted to a Burn Center with isolated leg or foot burns between 1999 and 2009 was collected and analyzed for this study. Age, gender, ethnicity, total body surface area (TBSA), degree of burn, etiology, hospital and burn intensive care unit (ICU), length of stay (LOS), and status at discharge were reviewed. Patients were grouped as diabetic (DM) or non-diabetic (nDM). Differences were analyzed using either the Student's t-test or Chi-square.

RESULTS

43 DM and 164 nDM patients with isolated lower extremity or foot burns were treated during the study period (1999-2009). The mean age of DM and nDM patients was 54.6 and 43.7 years, respectively (p<0.001). The most common burn etiology was scalding, flame, or contact burn. Percentage of total body surface area (TBSA) burn in DM patients averaged±standard deviation 1.8±1.3% compared to 1.8±1.6% in nDM (p<0.9). Among DM patients, 86% (N=37) of patients suffered third degree burns and 14% (N=6) of patients had second degree burns compared to 76% (N=125) of patients and 24% (N=39) of patients among nDM patients, respectively (p<0.16). The DM group had significantly higher burn ICU admission rates, 16.3% of patients versus 8.5% of patients (p<0.001), total length of hospital stay (mean±standard deviation), 14.1±10 versus 9.8±9.3 days (p<0.01) and renal failure, 4.7% of patients versus 0.6% of patients (p<0.05) compared to the nDM group. 93% of DM patients were discharged to home without further medical attention while 4.7% of patients underwent further treatment. In comparison, 85.4% of the nDM patients were discharged home with no further treatment while 8.5% of patients received home care (p<0.01).

CONCLUSION

DM patients who suffer isolated burns to the feet or lower extremities have poorer clinical outcomes and more complicated and protracted hospital courses when compared to nDM patients with similar burns. Although diabetics in the current study did not experience larger or more severe burns than nDM patients, they were nearly twice as likely to be admitted to the ICU, spent an average of four days longer in the hospital, and had a higher likelihood of developing renal failure compared to nDM patients.

Ultrasound and shockwave therapy for acute fractures in adults

BACKGROUND

The morbidity and socioeconomic costs of fractures are considerable. The length of time to healing is an important factor in determining a patient's recovery after a fracture. Ultrasound may have a therapeutic role in reducing the time to union after fracture.

OBJECTIVES

To assess the effects of low intensity ultrasound (LIPUS), high intensity focused ultrasound (HIFUS) and extracorporeal shockwave therapies (ECSW) as part of the treatment of acute fractures in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2011), the Cochrane Central Register of Controlled Trials (in The Cochrane Library 2011, Issue 4), MEDLINE (1950 to November Week 3 2011), EMBASE (1980 to 2011 Week 49), trial registers and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials evaluating ultrasound treatment in the management of acute fractures in adults. Studies including participants over 18 years of age with acute fractures, reporting functional outcomes, time to union, non-union, secondary procedures such as for fixation or delayed or non-union, adverse effects, pain, costs or patient adherence were included.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data from the included studies. Treatment effects were assessed using mean differences or risk ratios and, where there was substantial heterogeneity, pooled using a random-effects model. Results from 'worst case' analyses, which gave more conservative estimates of treatment effects for time to fracture union, are reported in preference to those from 'as reported' analyses.

MAIN RESULTS

Twelve studies, involving 622 participants with 648 fractures, were included. Eight studies were randomised placebo-controlled trials, two studies were randomised controlled trials without placebo controls, one study was a quasi-randomised placebo controlled trial and the remaining study was a quasi-randomised controlled trial without placebo control. Eleven trials tested LIPUS and one trial tested ECSW. Four trials included participants with conservatively treated upper limb complete fractures and six trials included participants with lower limb complete fractures; these were surgically fixed in four trials. The remaining two trials reported results for conservatively treated tibial stress fractures.Very limited data from two complete fracture studies showed no difference between ultrasound and placebo control in functional outcome. Pooled estimates from two studies found LIPUS did not significantly affect the time to return to training or duty in soldiers or midshipmen with stress fractures (mean difference -8.55 days, 95% CI -22.71 to 5.61).Based on a 'worst case' analysis, which adjusted for incomplete data, pooled results from eight heterogeneous studies showed no statistically significant reduction in time to union of complete fractures treated with LIPUS (standardised mean difference -0.47, 95% CI -1.14 to 0.20). This result could include a clinically important benefit or harm, and should be seen in the context of the highly significant statistical heterogeneity (I² = 90%). This heterogeneity was not explained by the a priori subgroup analyses (upper limb versus lower limb fracture, smoking status). An additional subgroup analysis comparing conservatively and operatively treated fractures raised the possibility that LIPUS may be effective in reducing healing time in conservatively managed fractures, but the test for subgroup differences did not confirm a significant difference between the subgroups.Pooled results from eight trials reporting proportion of delayed union or non-union showed no significant difference between LIPUS and control. Adverse effects directly associated with LIPUS and associated devices were found to be few and minor, and compliance with treatment was generally good. One study reporting on pain scores found no difference between groups at eight weeks.One quasi-randomised study (59 fractures) found no significant difference between ECSW and no-placebo control groups in non-union at 12 months (risk ratio 0.56, 95% CI 0.15 to 2.01). There was a clinically small but statistically significant difference in the visual analogue scores for pain in favour of ECSW at three month follow-up. The only reported complication was infection, with no significant difference between the two groups.

AUTHORS' CONCLUSIONS

While a potential benefit of ultrasound for the treatment of acute fractures in adults cannot be ruled out, the currently available evidence from a set of clinically heterogeneous trials is insufficient to support the routine use of this intervention in clinical practice. Future trials should record functional outcomes and follow-up all trial participants.

Updates in the management of orthopedic soft-tissue injuries associated with lower extremity trauma

Management of traumatic soft-tissue injuries remains a challenging and ever evolving field within orthopedic surgery. The basic principle of addressing life before limb in the initial assessment of critically injured patients has not changed. Although arteriography remains the gold standard for vascular injury screening, computed tomography angiography is being used more often to determine limb viability, and its sensitivity and specificity for detecting vascular lesions are reported to be excellent. Thorough debridement and irrigation with early institution of antibiotics are crucial in preventing infection; debridement should be performed urgently once life-threatening conditions have been addressed. Increasing use of vacuum-assisted closure therapy has created a trend down the reconstructive ladder, with improvements in resulting wound closure. Although the orthoplastics approach and new microsurgical techniques have made limb salvage possible in even the most severely injured extremities, it is important to clearly identify the zone of injury and to inform patients and their families of the outcomes of limb salvage versus amputation. Results from the LEAP (Lower Extremity Assessment Project) trials and similar studies should guide orthopedic surgeons in the management of these complex injuries. Nevertheless, it is important to individualize management plans according to patient factors.

Bioelectrical impedance assessment of wound healing

Objective assessment of wound healing is fundamental to evaluate therapeutic and nutritional interventions and to identify complications. Despite availability of many techniques to monitor wounds, there is a need for a safe, practical, accurate, and effective method. A new method is localized bioelectrical impedance analysis (BIA) that noninvasively provides information describing cellular changes that occur during healing and signal complications to wound healing. This article describes the theory and application of localized BIA and provides examples of its use among patients with lower leg wounds. This promising method may afford clinicians a novel technique for routine monitoring of interventions and surveillance of wounds.

Hamstring injuries

Hamstring injuries are a frequent injury in athletes. Proximal injuries are common, ranging from strain to complete tear. Strains are managed nonoperatively, with rest followed by progressive stretching and strengthening. Reinjury is a concern. High grade complete tears are better managed surgically, with reattachment to the injured tendon or ischial tuberosity. Distal hamstring injury is usually associated with other knee injuries, and isolated injury is rare.

Electromagnetic field stimulation for treating delayed union or non-union of long bone fractures in adults

BACKGROUND

Delayed union and non-union of fractures are a considerable cause of morbidity to patients. Laboratory studies have shown that electromagnetic fields can stimulate the formation of new bone, indicating a potential role for electromagnetic stimulation in the treatment of fractures that have failed to heal.

OBJECTIVES

To assess the effects of electromagnetic stimulation for treating delayed union or non-union of long bone fractures in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2010), the Cochrane Central Register of Controlled Trials (in The Cochrane Library 2010, Issue 2), MEDLINE (1966 to May 2010) and EMBASE (1980 to 2010 Week 20), trial registers and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials evaluating electromagnetic field stimulation for the treatment of delayed union or non-union of long bones in adults.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies and performed data extraction and risk of bias assessment. Treatment effects were assessed using risk ratios and, where appropriate, data were pooled using a random-effects model.

MAIN RESULTS

Four studies, involving 125 participants, were included. Three studies evaluated the effects of pulsed electromagnetic fields and one study, capacitive coupled electric fields. Participants with delayed union and non-union of the long bones were included, but most data related to non-union of the tibia. Although all studies were blinded randomised placebo-controlled trials, each study had limitations.The primary measure of the clinical effectiveness of electromagnetic field stimulation was the proportion of participants whose fractures had united at a fixed time point. The overall pooled effect size was small and not statistically significant (risk ratio 1.96; 95% confidence interval 0.86 to 4.48; 4 trials). There was substantial clinical and statistical heterogeneity in this pooled analysis (I(2) = 58%). A sensitivity analysis conducted to determine the effect of multiple follow-up time-points on the heterogeneity amongst the studies showed that the effect size remained non-significant at 24 weeks (risk ratio 1.61; 95% confidence interval 0.74 to 3.54; 3 trials), with similar heterogeneity (I(2) = 57%).There was no reduction in pain found in two trials. No study reported functional outcome measures. One trial reported two minor complications resulting from treatment.

AUTHORS' CONCLUSIONS

Though the available evidence suggests that electromagnetic field stimulation may offer some benefit in the treatment of delayed union and non-union of long bone fractures, it is inconclusive and insufficient to inform current practice. More definitive conclusions on treatment effect await further well-conducted randomised controlled trials.

Hyperbaric oxygen therapy after Bothrops lanceolatus snake bites in Martinique: a brief report

Every year 10 to 20 cases of snake bites are reported on the Caribbean island of Martinique. The only snake involved, Bothrops lanceolatus, is endemic on the island, and its bite may lead to systemic multifocal thrombotic complications in the'absence of the monospecific antivenom. Between January 1988 and January 2009, more than 250 snake bites have been reported, and five patients were treated with hyperbaric oxygen (HBO2) therapy for local complications. The patients were male, bitten on the leg or the hand, and presented with severe complications such as necrotizing soft tissue infections, compartment syndrome or abscesses despite prompt wound care and administration of antivenomous serum. Outcomes were favorable for these five patients, except for one who was left with a functional defect of the hand. Although snake bites are not part of the currently recommended indications for HBO2 therapy, local complications, namely compartment syndrome, necrotizing soft tissue infections and enhancement of healing in selected problem wounds, are approved uses of HBO2 therapy as defined by the Hyperbaric Oxygen Therapy Committee and would benefit from prospective studies.

Shin pain in athletes - assessment and management

BACKGROUND

Shin pain is a common complaint among running athletes and can be caused by bony, muscular, vascular or neural pathology.

OBJECTIVE

This article discusses the likely causes, assessment and management of shin pain in athletes presenting in the general practice setting.

DISCUSSION

Accurate diagnosis is important as treatment differs depending on the cause. The characteristics of the pain and examination findings after exercise give strong clues to the diagnosis; further investigation may be unnecessary. Bony stress reactions and fractures are the most common cause of shin pain; patients describe a 'jarring' sensation along the bone margin with heel strike. Other causes include recurrent exertional compartment syndrome (RECS), tenosynovitis, neurological entrapment and rarely, vascular entrapment. Symptoms of vascular entrapment may be similar to RECS and this may cause diagnostic confusion. Increased bone stress in athletes is largely due to inappropriate training program design and can usually be alleviated by reducing impact loading until pain resolves.

Management of severe crush injury in a front-line tent ICU after 2008 Wenchuan earthquake in China: an experience with 32 cases

INTRODUCTION

The experience on management of crush injury after a devastating earthquake is lacking, and there are even less reports on the front-line critical care of these patients. A front-line intensive care unit (ICU) was set up in a tent after the disastrous Wenchuan earthquake (May, 12, 2008, China), where 32 patients suffering from crush injury were treated from May 12 to May 26. This study summarized our experience on management of 32 crush injury patients in a front-line tent ICU.

METHODS

We retrospectively analyzed the clinical data of 32 crush injury patients treated in our frontline tent ICU. Using limited equipment, we observed the arterial blood gas parameters, blood routine, alanine aminotransferase, lactate dehydrogenase, creatine kinase, creatinine, blood urea nitrogen, and urine protein of patients. We also closely watched for changes in crush injury symptoms, urine output, and the dangerous complications of crush injury.

RESULTS

Eighteen of the 32 patients developed traumatic shock, 9 had acute renal failure, 6 had acute heart failure, 2 had stress ulcers and 4 had multiple organ dysfunction syndrome (MODS). The symptoms of 17 patients met the criteria of crush syndrome; hemodialysis and prompt surgical intervention were given to them when necessary. Prompt treatment in our tent ICU improved the symptoms of patients to different degrees. The limb distension and sensory dysfunction were improved and the urine output was increased or even restored to the normal level in some patients. Serological parameters were improved in most patients after admission. Five (15.63%) patients underwent amputation due to severe infection in our group. Six (18.75%) patients died, 4 due to MODS and 2 due to acute renal failure.

CONCLUSIONS

Severe crushing injuries and life-threatening complications are major causes of death after major disasters like earthquakes. Prompt treatment and close monitoring of the severe complications are of great importance in saving patients' lives. Establishment of a well-equipped front-line ICU close to the epicentre of the earthquake allows for prompt on the spot rescue of critical patients with crush injury, greatly decreasing the mortality rate and complications and avoiding amputation. There should be sufficient equipment to meet the needs of more patients.

T IME TO A NALGESIA FOR P ATIENTS WITH P AINFUL E XTREMITY I NJURIES T RANSPORTED TO THE E MERGENCY D EPARTMENT BY A MBULANCE

OBJECTIVE

To measure the time to analgesia for patients with painful, isolated extremity injuries brought to the emergency department (ED) by emergency medical services (EMS).

METHODS

A retrospective chart review of all patients presenting with isolated, painful extremity injuries during an 18-month period to a Level 1 trauma center. Medical records were reviewed by diagnostic codes for extremity injuries.

INCLUSION CRITERIA

patients 18 years or older transported to the ED by EMS; isolated, painful extremity injuries; received parenteral analgesia in the ED or by EMS. Excluded: multiple trauma patients, interfacility transfers, hemodynamically unstable patients, head-injured patients, intoxicated patients, and patients with mental status changes. Data elements: age, sex, EMS arrival time, EMS medication time, hospital triage time, and ED medication time. All "times to analgesia" were calculated from the EMS arrival time on scene.

RESULTS

Extremity injuries were identified in 706 patients. Of these, 104 patients with painful, isolated, extremity injuries met all inclusion criteria. Thirteen (12.5%) of 104 received analgesia by EMS during prehospital care. Ninety-one patients (88%) first received parenteral analgesia in the ED. The mean time to analgesia for EMS treated patients was 23 minutes (95% CI 16.7-30.2). Mean time to analgesia for patients treated in the ED was 113 minutes (95% CI 99.2-128.1). Mean time to analgesia after triage in this group was 75 minutes (95% CI 60.8-89.7).

CONCLUSION

In this study, patients received analgesia sooner when administered by EMS during prehospital care. There was a significant time delay after triage for patients first medicated in the ED.

[Treatment of a wide cutaneous post-traumatic loss of substance by cell cultures. Case report]

Bioengineering skin represents a successful outcome in the interdisciplinary research applied to reconstructive surgery. In this study we report our experience in the reconstruction of a wide traumatic wound by autologous engineered skin, grown on a biomaterial scaffold. Advantages were rapid reparation of the trauma and good scars.

[Clinical, epidemiological and treatment aspects of 10 cases of saltwater stingray envenomation]

INTRODUCTION

Stingrays are cartilaginous elasmobranches fishes that can cause severe and potentially fatal injuries in humans.

OBJECTIVE

A descriptive and prospective survey was conducted to analyze epidemiological, clinical and treatment aspects of injuries caused by marine stingrays in Adicora, Paraguaná peninsula, Falcon State, a northwestern, semiarid region of Venezuela.

METHODS

Between December 2006 and April 2007, patients with saltwater stingray injuries, attended in the ambulatory emergency service of Adicora, were clinically examined and interrogated. Treatment consisted on the application of a topical antiseptic solution (povidone-iodine), intravenous administration of an anti-inflammatory analgesic, antibiotic therapy per os and tetanus immunization.

RESULTS

Ten cases of injures caused by the marine stingray Dasyatis guttata (Dasyatidae) were recorded. 6 (60%) of the envenomation cases occurred in males and 4 (40%) in females, being 8 (80%) adults between 20 and 64 years-old and 2 (2%) above that age. Most of the accidents occurred at December and April holidays (90%) and during the late part of the day (80%) when bathing or swimming at or near the beach (70%). The time between ambulatory medical assistance and the accident varied from 5 to 7 minutes, with a mean time of 5.6 +/- 0.84. Injuries were located at lower limbs in all patients with circular lesions of diameters ranging from 1 to 1.53 cm (X: 1.41 +/- 0.22); bleeding was observed in 70% of the cases while 20% showed cellulitis and cutaneous necrosis. Other clinical manifestations were intense local and irradiated pain [Visual analog scale (VAS) = X: 9.5 +/- 0.71)] and erythema (100%). Systemic symptoms included dyspnea (50%) (VAS = X: 5.4 +/- 1.52) and tachycardia (10%). All patients had a satisfactory post-treatment evolution after 20 to 30 minutes (X = 23.1 +/- 3.41) with pain and dyspnea VAS mean values significantly lower (X = 0.55 +/- 0.44; t = 35.5, p = 0.0001; X = 0.1 +/- 0.22; t = 5.57, p = 0.002, respectively). CONCLUSIONS. Injuries caused by the marine stingray D. guttata are a public health problem, appear to have seasonal pattern, and can produce clinical manifestations of significant severity.

Lower-limb amputee needs assessment using multistakeholder focus-group approach

To assess the needs of lower-limb amputees and identify differences between diabetic dysvascular amputees and traumatic amputees, we held a multistakeholder focus-group workshop whose participants included veteran lower-limb amputees, clinicians, researchers, and prosthetic device manufacturers. We conducted the initial workshop sessions as traditional focus-group meetings with homogeneous participant groups generating lists of issues relevant to the individual groups. Subsequent sessions assembled heterogeneous participant groups for a two-phase approach: Discovery and Codesign. The Discovery phase used observation and discussion to elicit specific needs. The Codesign phase focused on emergent topics and explored potential solutions. The participants identified needs associated with desired improvements to the socket system, foot and ankle components, and alignment with the residual limb. One need was a comprehensive understanding of the recovery path following amputation that could be addressed through enhanced education and communication. Another need was remote monitoring systems that could potentially improve quality of care. No dichotomy of needs between diabetic dysvascular amputees and traumatic amputees was evident among the participants of this workshop. The lively, open-ended discussions produced numerous suggestions for improving amputee quality of life that are listed to facilitate future research and development.

["Tennis leg"--calf muscle rupture of the middle-aged tennis aficionado]

During tennis, the patient heard a bang from his left calf. The inferior edge of the calf muscle at the musculotendinous junction of the medial branch of m. gastrocnemius was tender to pressure, indicating a rupture called as "tennis leg". Foot movements are usually normal, but moving about is painful. The finding is confirmed by ultrasonography. First aid will limit the injury, and when the pain allows, active exercise therapy is initiated. Healing occurs in 2 to 6 weeks, the more difficult ones in 3 to 4 months. Return to the court may take place gradually with a bandaged calf.

[Follow-up study on platelet-rich plasma in repairing chronic wound nonunion of lower limbs in 47 cases]

OBJECTIVE

To study the effect of platelet-rich plasma (PRP) on repairing chronic wounds of lower limbs.

METHODS

From May 2007 to November 2007, 47 patients suffering from chronic wounds of lower limbs were treated. There were 41 males and 6 females, aged from 15 to 68 years (43.2 years on average). The disease was caused by tibiofibular fracture in 20 cases, calcaneus fracture in 4 cases, metatarsal fracture in 1 case, multiple open fracture of lower limbs in 3 cases, tibia osteomyelitis in 10 cases, femur osteomyelitis in 1 case, soft tissue injury of ankle in 4 cases, infection after amputation in 2 cases, infection after foot orthomorphia in 1 case, and infection after calcaneus tendon neoplasia in 1 case. Their chronic wounds did not healed after 2 to 4 months of therapy. Among them, chronic wounds complicated with fracture nonunion in 23 cases and positive bacterial culture result in 38 cases. Debridement and autogenous PRP gel injection were applied every 2 months and for twice.

RESULTS

The patients were followed up for 4 months after the first PRP injection. Two months after the first PRP injection, chronic wounds contracted significantly in 34 patients with purulence and necrosis tissue cleaned up, circulation of soft tissue improved and exposed bone or muscle tissue covered by neurogenetic granulation. No patient was completely cured. Two months after the second PRP injection, the average coverage rate was 79.3% +/- 18.0%, the total cure rate was 29.8%. The volume of the chronic wounds decreased by (9.3 +/- 4.9) mL after PRP therapy (2.5 +/- 2.7) mL when compared with (11.8 +/- 5.6) mL of before therapy, showing significant difference (P < 0.05). X-ray photograph showed that among the 23 cases of fracture nonunion, fracture healed completely in 9 cases; bony callus formation increased obviously in 12 cases; no significant change was observed in 2 cases. No aggravated sign of osteomyelitis was notified. Positive results of bacterial culture reduced to 15 cases.

CONCLUSION

PRP efficiently enhances the recovery of soft tissue defect and speeds up the chronic wounds healing of lower limbs.

Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-leg immobilization

BACKGROUND

Immobilization of the lower leg is associated with venous thromboembolism. Low molecular weight heparin (LMWH) is an anticoagulant treatment which might be used in adult patients with lower-leg immobilization to prevent deep venous thrombosis and its complications.

OBJECTIVES

To investigate the current literature on thromboprophylactic practice for patients with lower-limb injuries who are immobilized in plaster casts or braces, to assess the need for concrete guidelines, and to assess whether it is possible to come to an evidence-based conclusion.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Disease Group searched their Specialized Register (last searched 20 May 2008) and the Central Register of Controlled Trials (CENTRAL) (last searched The Cochrane Library 2008, Issue 2). We searched MEDLINE (until May 2008) and EMBASE (until May 2008) and reference lists of articles. We contacted pharmaceutical companies of LMWHs for relevant studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that described thromboprophylaxis by means of LMWH compared with no prophylaxis or placebo in adult patients with lower-leg immobilization. Immobilization was by means of a plaster cast or brace.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. The review authors contacted the trial authors for additional information if required. Statistical analysis was carried out using Review Manager (RevMan 5).

MAIN RESULTS

We included six RCTs fulfilling the above criteria with a total of 1490 patients. We found an incidence of venous thromboembolism ranging from 4.3% to 40%, in patients who had a leg injury that had been immobilized in a plaster cast or a brace for at least one week and who received no prophylaxis, or placebo. This number was significantly lower in patients who received daily subcutaneous injections of LMWH during immobilization (event rates ranging from 0% to 37%; odds ratio (OR) 0.49; fixed 95% confidence interval (CI) 0.34 to 0.72; with minimal evidence of heterogeneity with an I(2) of 20%, P = 0. 29). Comparable results were seen in the following subcategories: operated patients, conservatively treated patients, patients with fractures, patients with soft-tissue injuries, patients with proximal thrombosis, patients with distal thrombosis and patients with below-knee casts. Complications of major bleeding events were extremely rare (0.3%) and there were no reports of heparin-induced thrombocytopenia.

AUTHORS' CONCLUSIONS

Use of LMWH in outpatients significantly reduces VTE when immobilization of the lower leg is required.

[Catastrophic left leg V.A.C. Therapy First Prize in 2008. Second convocation]

This report received the V.A.C. Therapy Prize, second convocation, in the clinical case category of note is the spectacular nature of its results.

Parameters influencing thromboprophylaxis management of a lower leg trauma treated with a cast/splint

Lower leg trauma is a frequent pathology in the emergency department of every hospital. Given the lack of a general consensus and the poor knowledge in the current use of pharmacological thromboprophylaxis, a cross-sectional, observational and epidemiological disease registry with 261 patients included by 16 centers was designed. These patients presented with a lower leg trauma and all needed a cast or splint to immobilize the injured leg. First, the different risk factors for thromboembolism and the type of injury in this population are mapped out. Secondly, the importance of both parameters in the decision making process to use or not to use prophylaxis in a lower leg trauma is discussed. In the absence of clear guidelines, the presence of thromboembolic risk factors (type and number in a specific patient) and the type of injury are leading the decision to use thromboprophylaxis in emergency department of non-university hospitals, in patients with a lower leg trauma receiving a cast or splint to immobilize an injured leg.

Negative pressure wound therapy: a systematic review on effectiveness and safety

OBJECTIVES

We reviewed the use of negative pressure wound treatment (NPWT) for problematic wounds.

METHODS

A systematic literature review was undertaken to assess the effectiveness and safety of NPWT. Randomized controlled trials (RCTs) assessing NPWT were included.

RESULTS

A total of 14 RCTs were included. Trials included patients with pressure wounds (2), post-traumatic wounds (3), diabetic foot ulcers (4) and miscellaneous chronic ulcers (5). In all trials NPWT was at least as effective and in some cases more effective than the control treatment. Most evidence supports the effectiveness of NPWT on chronic leg ulcers and posttraumatic ulcers. NPWT appears to be a safe treatment, and serious adverse events have been rarely reported. Only two trials were classified as high quality studies, whereas the remaining were classified as having poor internal validity.

CONCLUSIONS

Reliable evidence on the effectiveness of NPWT is scarce. Tentative evidence indicates that the effectiveness of NPWT is at least as good as or better than current local treatment for wounds. The need for large high-quality randomised studies is apparent.

Vacuum-assisted wound closure (VAC) with simultaneous bone transport in the leg: a technical note

Successful treatment of infected non union in long bone fractures has always been a challenge. Segmental excision followed by bone transport is one of the common modalities of treatment in such difficult cases. The soft tissue coverage of the resulting wounds was however not well described in the literature. The authors would like to report a simple technique that was used. After segmental bone excision and application of a ring fixator, a vacuum assisted closure (VAC) dressing was applied to the wound, which resulted in not only a remarkable growth of granulation tissue that filled the soft tissue defect, but also satisfactory signs of bony union across the docking site. The authors would like to emphasise the benefits of a simple method such as VAC therapy in enhancing cover of the large soft tissue defects during simultaneous bone transportation, and thus avoiding complex plastic surgical procedures.

Oligoanalgesia in a rural emergency department

OBJECTIVE

Multiple studies conducted over many years have demonstrated that pain is poorly managed in the emergency department (ED). This phenomenon has been referred to in the medical literature as "oligoanalgesia." However, little is known about whether oligoanalgesia occurs in a rural ED. National Ambulatory Care Reporting System data from 2003 for a small rural hospital in Ontario showed patients were satisfied with the amount of pain medicine they received in the ED. We designed a study to replicate a published urban study that investigated the use of analgesia in isolated lower limb injuries. Our objective was to see if oligoanalgesia was also a problem in a rural ED.

METHODS

In 2003 we conducted a retrospective chart review of patients who presented to the South Huron Hospital ED with isolated lower extremity injuries for which radiographs of the foot, ankle or both were obtained. Demographics of the ED patients with lower extremity injuries were quantified. Other parametres included whether or not patients received analgesia in the ED; how long it took to get assessed, treated and discharged; whether patients received any analgesia upon discharge; what type of analgesia they received; and whether it required a prescription.

RESULTS

A total of 189 patients met inclusion criteria, with 35 fractures identified (18.5%). Sixty-three percent of patients were male. The average age was 32.6 years. The mean Canadian Emergency Department Triage and Acuity Scale level was 4.4. The mean time to physician assessment was 31.6 minutes. The mean length of time spent in the ED was 74 minutes. Over one-half of the patients received analgesia upon discharge from the ED whether or not they had a fracture. In addition, 73% of the people in the fracture group received analgesia requiring a prescription, versus only 46% in the nonfracture group. Narcotics were used more often in the fracture group than in the nonfracture group (26% v. 6%).

CONCLUSION

The phenomenon of oligoanalgesia was not observed as often in our rural ED for isolated lower limb injuries, when compared with the published urban study.

Pain syndromes in competitive elite level female artistic gymnasts. Role of specific preventive-compensative activity

The pain is a serious problem in advanced level female artistic gymnasts because it decreases the performance. The pain is due to the high numbers of hours spent in training sessions and may be associated to injuries that have relatively high incidence and severity in these athletes. We investigated the role of a preventive-compensative physical activity program, implemented in the warm-up and the cool-down session of standard training, in the prevention and reduction of the pain syndromes, evaluated in elite level young female artistic gymnasts. Thirty elite level female athletes, 10-14 years old, participated in this study and were followed for 12 weeks during the competition preparation period. Fifteen athletes were trained with preventive-compensative motory program implemented in the ordinary training (intervention group) and fifteen (control group) followed the standard training. All athletes completed a self-administered questionnaire regarding the pain intensity on the basis of a Visual Analogue Scale pre- and post- intervention. The experimental protocol consisted of three steps: the treatment of the shortened muscle chains according to Active Posture Reeducation method, the propriocettive-coordinative training with wobble board and the mobilization and stretching of back using fitball. Before intervention, the pain in practicing this sport was reported by 83% of all the athletes. The most common primary pain sites were the ankle and low back; the pain anatomical location was correlated to the training. After intervention, low back pain assessment showed a decrease of pain identified as mild (from 56% to 44%) or moderate (from 33% to 22%) and a disappearance of severe pain (from 11% to 0%). Ankle pain decreased and/or disappeared: the mild pain from 33% to 27%, moderate from 27% to 13% and severe from 13% to 0%. The pain analysis did not show different results in the control group. Our results indicated that the performed preventive-compensative training is of value, in a short time perspective, in preventing and reducing the pain syndromes in these athletes.

Global effects estimation for multidimensional outcomes

Many health studies focus on multifaceted outcomes that are not easily measured with a single variable; examples include studies on quality of life (QOL) and general health. To fully explore such an outcome, researchers typically collect information on multiple endpoints. The resulting measurements constitute multidimensional outcome data. An object of great interest is the overall-or global-effect of a covariate, such as a treatment intervention, on the multidimensional outcome. Quantifying such an effect can be difficult because multiple clinical outcomes are usually measured on different scales; the problem is enhanced by the fact that multiple measurements on a given subject are typically correlated. We present a regression modeling scheme permitting estimation of global treatment effects when multiple continuous endpoints are examined in concert either once or for several times. The global effect is conceptualized as a change in the distribution functions of the outcome variables. It may thus be interpreted as a connection between outcome distribution quantiles for the treatment and control groups. This concept allows the presentation of a global effect as a scalar quantity applicable to all outcomes simultaneously, easing interpretation of results. Model estimation proceeds directly from existing methods for multivariate survival analysis. The assumption that the treatment effect is homogenous across different outcomes is testable. To illustrate the application, we present data analytic results from a motivating example, an analysis of patients' QOL during recovery from lower limb trauma. We also explore the performance properties of global effects estimation through simulation.

Socioeconomic considerations regarding a land mine victim with maxillofacial injuries

This article describes a case we experienced while doing volunteer medical work in Cambodia for six months in 2002. By examining treatment of a 14-year-old female land mine victim with maxillofacial injuries, we report on the present socio-medical situation in Cambodia. This case suggests the lack of infrastructure, facilities, human resources, and patient education make it extremely difficult to provide patients with proper treatment, including general anesthesia. A comparison of land mine victim statistics between 2002 and 2005 reveals significant problems.

Pediatric orthopaedic patients presenting to a university emergency department after visiting another emergency department: demographics and health insurance status

BACKGROUND

The disparity in access to and delivery of health care among children has become increasingly apparent. The purpose of our study was to analyze demographic information, including health insurance status, of children with extremity injuries seen at a University Hospital emergency department (UH ED) after visiting another ED for the same complaint.

METHODS

A database of pediatric orthopaedic consults requested for extremity injuries at UH ED was reviewed. Information regarding patients' age, ethnicity, orthopaedic diagnosis, type of health insurance, time from injury to presentation at the first ED and at UH ED, mode of transportation to UH ED, and orthopaedic treatment rendered was analyzed. All patients with Medicaid, health maintenance organization-Medicaid, no insurance, or charity care were classified as having public insurance, whereas those with commercial insurance, including health maintenance organization and preferred provider organization plans, were placed in the private insurance category.

RESULTS

Over a 30-month period, 125 children, of whom 18% had private health insurance, were noted to have recently visited another ED seeking treatment for an extremity injury. A closed fracture was diagnosed in 117 patients, 94% of whom were discharged from UH ED after cast application. There was no difference with regard to patients' age, sex, ethnicity, diagnosis, and time to presentation at the initial ED between private and public insurance groups. However, 52% of children with private insurance received orthopaedic care within 24 hours compared with 22% with public insurance (P = 0.013). Children with public insurance were more likely to have visited another health facility besides the initial ED before presenting to UH ED (P = 0.004). Moreover, 74% of privately insured patients presenting to UH ED arrived via ambulance compared with 34% with public insurance (P < 0.001).

CONCLUSIONS

Most children with an extremity injury who received orthopaedic consultation at a tertiary-level ED after visiting another ED had an isolated fracture requiring cast treatment only. There was a trend for delay in receiving definitive orthopaedic care for patients with public health insurance compared with those with private insurance.

Endovascular treatment of lower limb penetrating arterial traumas

PURPOSE

The purpose of this study was to evaluate the effectiveness of percutaneous arterial embolization in patients with penetrating peripheral arterial trauma.

MATERIALS AND METHODS

Twelve patients with penetrating peripheral arterial trauma were treated with percutaneous arterial embolization between 2002 and 2007. All injuries were secondary to penetrating stab wounds. Active bleeding (eight patients), recurrent bleeding episodes (one patient), persistent pain and mass (one patient), leg edema, claudication, swelling (one patient), local hyperemia, and pain (one patient) were the presenting symptoms. Microcatheter systems were used for catheterization. We used n-butyl cyanoacrylate mixture as the embolizing agent in all patients.

RESULTS

On angiograms the inferior gluteal artery (one patient), internal pudendal artery (one patient), perforating branch of the profundal femoral artery (six patients), superficial femoral artery (one patient), peroneal artery (two patients), and anterior tibial artery (one patient) were found to be injured. In all patients, the source of arterial bleeding could be reached, and a safe embolization was achieved. Nontarget embolization due to backflow of n-butyl cyanoacrylate mixture was detected in two patients and inguinal hematoma at the puncture site occurred in one patient.

CONCLUSIONS

We conclude that embolization-particularly n-butyl cyanoacrylate embolization-is technically feasible in patients with penetrating peripheral arterial trauma.

Emergency Department Management of Selected Orthopedic Injuries

Rather than providing an encyclopedic review of extremity injuries, this article reviews selected serious injuries of the extremities that can be missed in the emergency department, either because they are relatively uncommon or because they are subtle in their clinical and radiographic presentation. They include injuries to the scapula, the shoulder, the forearm, the femur and hip, the knee, the tibia (which is the most common long bone fracture), and the ankle and foot. Their various causes include sports injuries, falls, and motor vehicle accidents. Several of these injuries can result in emergent complications or have time-dependent outcomes. Consequently, these injuries often must be managed by emergency physicians before specialist expertise becomes available.

Lower extremity injuries in the skeletally immature athlete

The heightened intensity of training and competition among young athletes places them at increased risk for both acute and chronic injuries. Prompt recognition and treatment of such injuries are critical to prevent long-term functional disability and deformity. These injuries occur in patterns unique to the skeletally immature athlete, given their developing epiphyses and ossification centers and supporting ligamentous structures. Children and adolescents who participate in recreational and organized sports are particularly susceptible to a broad spectrum of lower extremity injuries involving both the osseous and soft-tissue structures. Fundamental knowledge of the pathophysiology of injury helps the clinician in determining management. Early recognition of acute traumatic injuries, along with preventive regimens and knowledge of both nonsurgical and surgical treatment protocols, has helped to restore and maintain normal lower extremity function in the skeletally immature athlete.

Treatment options for pretibial lacerations

Pretibial lacerations are a common occurrence in the older patient, however there is no clearly recognized protocol for the management of these wounds. This article aims to look at the published literature and identify what treatments are recommended and what work if any has been undertaken to develop protocols for the management of these wounds.

Conservative treatment of an acute compartment syndrome of the thigh

Compartment syndromes of the thigh after blunt trauma without any fracture are rare. Most surgeons recommend operative treatment. There are different rules for compartment syndromes of the thigh in young athletes after blunt trauma compared to compartment syndromes at other locations [(1) the large volume of the quadriceps muscle, (2) its relatively elastic fascia, (3) the direct proximal contact to the hip muscles which allows extravasation of fluid out of the compartment)]. We present a case of conservative treatment of elevated intra-compartmental pressure (ICP) of the anterior thigh after blunt trauma and the follow-up until return to sport. Conservative treatment of a compartment syndrome of the thigh after blunt trauma in a young patient without fracture or vascular damage was successful without short-term sequelae. Recovery of muscle strength is delayed but return to sport is possible. Depending on the severity the diagnosis and follow-up with ICP measurements and MRI is necessary. There is a very good chance for excellent outcome without any risk of surgery. However, a long healing time is possible.

An audit of footwear for patients with leg bandages

Brenda King conducted an audit to identify how many patients do not have adequate footwear as a consequence of wearing bandages and dressings on their feet and legs, and discusses the impact this has on quality of life.