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Fagan P, Geiger CD, Chenji G, Preston DC. Neuromuscular ultrasound findings in gunshot wounds. Muscle Nerve 2024; 69:416-421. [PMID: 38328978 DOI: 10.1002/mus.28048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 01/16/2024] [Accepted: 01/21/2024] [Indexed: 02/09/2024]
Abstract
INTRODUCTION/AIMS A spectrum of peripheral nerve injuries is associated with gunshot wounds (GSWs). Due to Wallerian degeneration, distal nerve lesions may go undetected on electrodiagnostic (EDX) testing. In patients with GSW undergoing high-resolution ultrasound (HRUS) for evaluation of neurological deficits, we have observed distal nerve morphological changes, but these have not been systematically studied. The aim of this study was to characterize changes on HRUS in nerves at and distal to gunshot injuries and to identify the frequency with which these changes occur. METHODS A retrospective cohort study was performed on patients referred for HRUS with peripheral nerve injuries from GSW. The primary injured nerve(s) were assessed along with distal segments of the same nerve and those of adjacent nerves. Findings were also compared to EDX studies. RESULTS Twenty-two of the 28 nerves injured proximally by GSW were evaluated distally and of these, 68% showed abnormal ultrasound findings, including enlarged cross sectional area (59%), fascicular enlargement (50%), and decreased nerve echogenicity (59%). In 17 patients, adjacent nerves were evaluated and 8 of the patients (47%) showed abnormalities in at least one distal adjacent nerve, including enlarged cross sectional area (41%), fascicular enlargement (41%), and decreased nerve echogenicity (35%). DISCUSSION This study demonstrated morphological changes at the site of the GSW but also in distal nerve segments including nerve enlargement, fascicular enlargement, and changes in nerve echogenicity. The complementary use of HRUS with EDX was highlighted in evaluation of GSW victims to assess the extent of peripheral nerve injury.
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Affiliation(s)
- Patrick Fagan
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Christopher D Geiger
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Gaurav Chenji
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - David C Preston
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
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Rubio JE, Skotak M, Alay E, Sundaramurthy A, Subramaniam DR, Kote VB, Yeoh S, Monson K, Chandra N, Unnikrishnan G, Reifman J. Does Blast Exposure to the Torso Cause a Blood Surge to the Brain? Front Bioeng Biotechnol 2020; 8:573647. [PMID: 33392161 PMCID: PMC7773947 DOI: 10.3389/fbioe.2020.573647] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 11/16/2020] [Indexed: 02/04/2023] Open
Abstract
The interaction of explosion-induced blast waves with the torso is suspected to contribute to brain injury. In this indirect mechanism, the wave-torso interaction is assumed to generate a blood surge, which ultimately reaches and damages the brain. However, this hypothesis has not been comprehensively and systematically investigated, and the potential role, if any, of the indirect mechanism in causing brain injury remains unclear. In this interdisciplinary study, we performed experiments and developed mathematical models to address this knowledge gap. First, we conducted blast-wave exposures of Sprague-Dawley rats in a shock tube at incident overpressures of 70 and 130 kPa, where we measured carotid-artery and brain pressures while limiting exposure to the torso. Then, we developed three-dimensional (3-D) fluid-structure interaction (FSI) models of the neck and cerebral vasculature and, using the measured carotid-artery pressures, performed simulations to predict mass flow rates and wall shear stresses in the cerebral vasculature. Finally, we developed a 3-D finite element (FE) model of the brain and used the FSI-computed vasculature pressures to drive the FE model to quantify the blast-exposure effects in the brain tissue. The measurements from the torso-only exposure experiments revealed marginal increases in the peak carotid-artery overpressures (from 13.1 to 28.9 kPa). Yet, relative to the blast-free, normotensive condition, the FSI simulations for the blast exposures predicted increases in the peak mass flow rate of up to 255% at the base of the brain and increases in the wall shear stress of up to 289% on the cerebral vasculature. In contrast, our simulations suggest that the effect of the indirect mechanism on the brain-tissue-strain response is negligible (<1%). In summary, our analyses show that the indirect mechanism causes a sudden and abundant stream of blood to rapidly propagate from the torso through the neck to the cerebral vasculature. This blood surge causes a considerable increase in the wall shear stresses in the brain vasculature network, which may lead to functional and structural effects on the cerebral veins and arteries, ultimately leading to vascular pathology. In contrast, our findings do not support the notion of strain-induced brain-tissue damage due to the indirect mechanism.
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Affiliation(s)
- Jose E Rubio
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, Fort Detrick, MD, United States.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
| | - Maciej Skotak
- Department of Biomedical Engineering, Center for Injury Biomechanics, Materials, and Medicine, New Jersey Institute of Technology, Newark, NJ, United States.,Blast Induced Neurotrauma Division, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Eren Alay
- Department of Biomedical Engineering, Center for Injury Biomechanics, Materials, and Medicine, New Jersey Institute of Technology, Newark, NJ, United States
| | - Aravind Sundaramurthy
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, Fort Detrick, MD, United States.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
| | - Dhananjay Radhakrishnan Subramaniam
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, Fort Detrick, MD, United States.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
| | - Vivek Bhaskar Kote
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, Fort Detrick, MD, United States.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
| | - Stewart Yeoh
- Department of Biomedical Engineering, College of Engineering, The University of Utah, Salt Lake City, UT, United States
| | - Kenneth Monson
- Department of Biomedical Engineering, College of Engineering, The University of Utah, Salt Lake City, UT, United States.,Department of Mechanical Engineering, College of Engineering, The University of Utah, Salt Lake City, UT, United States
| | - Namas Chandra
- Department of Biomedical Engineering, Center for Injury Biomechanics, Materials, and Medicine, New Jersey Institute of Technology, Newark, NJ, United States
| | - Ginu Unnikrishnan
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, Fort Detrick, MD, United States.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
| | - Jaques Reifman
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, Fort Detrick, MD, United States
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Affiliation(s)
- David B Powers
- Duke Craniomaxillofacial Trauma Program, Duke Craniomaxillofacial Trauma and Reconstructive Surgery, Division of Plastic, Maxillofacial and Oral Surgery, Duke University Medical Center, DUMC Box 2955, Durham, NC 27710, USA.
| | - John Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Queen Elizabeth Medical Centre, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK; Formerly, Division of Plastic, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, NC, USA
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Chen J, Zhang B, Chen W, Kang JY, Chen KJ, Wang AM, Wang JM. Local and distant trauma after hypervelocity ballistic impact to the pig hind limb. SPRINGERPLUS 2016; 5:1497. [PMID: 27652070 PMCID: PMC5014777 DOI: 10.1186/s40064-016-3160-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 08/25/2016] [Indexed: 11/17/2022]
Abstract
The development of high-energy weapons could increase the velocity of projectiles to well over 1000 m/s. The nature of the injuries caused by the ballistic impact of projectiles at velocities much faster than 1000 m/s is unclear. This study characterizes the mechanical and biochemical alterations caused by high-speed ballistic impact generated by spherical steel ball to the hind limbs of the pig. That the local and distal injuries caused by hypervelocity ballistic impact to the living body are also identified. It is showed that the severity of the injury was positively correlated with the velocity of the projectile. And 4000 m/s seems to be the critical velocity for the 5.6 mm spherical steel ball, which would cause severe damage to either local or distal organs, as below that speed the projectile penetrated the body while above that speed it caused severe damage to the body. In addition, vaporization prevented the projectile from penetrating the body and the consequent pressure wave seems to be the causal factor for the distant damage.
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Affiliation(s)
- Jin Chen
- 6th Department of Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042 China ; State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Bo Zhang
- 6th Department of Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042 China ; Department of Orthopedics, Nanchong Central Hospital, North Sichuan Medical College, Nanchong, China
| | - Wei Chen
- 6th Department of Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042 China
| | - Jian-Yi Kang
- 6th Department of Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042 China
| | - Kui-Jun Chen
- 6th Department of Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042 China ; State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Ai-Min Wang
- Department of Orthopedics, Daping Hospital, The Third Military Medical University, Chongqing, China
| | - Jian-Min Wang
- 6th Department of Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042 China ; State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Third Military Medical University, Chongqing, China
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Elder GA, Gama Sosa MA, De Gasperi R, Stone JR, Dickstein DL, Haghighi F, Hof PR, Ahlers ST. Vascular and inflammatory factors in the pathophysiology of blast-induced brain injury. Front Neurol 2015; 6:48. [PMID: 25852632 PMCID: PMC4360816 DOI: 10.3389/fneur.2015.00048] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 02/23/2015] [Indexed: 11/13/2022] Open
Abstract
Blast-related traumatic brain injury (TBI) has received much recent attention because of its frequency in the conflicts in Iraq and Afghanistan. This renewed interest has led to a rapid expansion of clinical and animal studies related to blast. In humans, high-level blast exposure is associated with a prominent hemorrhagic component. In animal models, blast exerts a variety of effects on the nervous system including vascular and inflammatory effects that can be seen with even low-level blast exposures which produce minimal or no neuronal pathology. Acutely, blast exposure in animals causes prominent vasospasm and decreased cerebral blood flow along with blood-brain barrier breakdown and increased vascular permeability. Besides direct effects on the central nervous system, evidence supports a role for a thoracically mediated effect of blast; whereby, pressure waves transmitted through the systemic circulation damage the brain. Chronically, a vascular pathology has been observed that is associated with alterations of the vascular extracellular matrix. Sustained microglial and astroglial reactions occur after blast exposure. Markers of a central and peripheral inflammatory response are found for sustained periods after blast injury and include elevation of inflammatory cytokines and other inflammatory mediators. At low levels of blast exposure, a microvascular pathology has been observed in the presence of an otherwise normal brain parenchyma, suggesting that the vasculature may be selectively vulnerable to blast injury. Chronic immune activation in brain following vascular injury may lead to neurobehavioral changes in the absence of direct neuronal pathology. Strategies aimed at preventing or reversing vascular damage or modulating the immune response may improve the chronic neuropsychiatric symptoms associated with blast-related TBI.
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Affiliation(s)
- Gregory A Elder
- Neurology Service, James J. Peters Department of Veterans Affairs Medical Center , Bronx, NY , USA ; Department of Psychiatry, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Department of Neurology, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Friedman Brain Institute, Icahn School of Medicine at Mount Sinai , New York, NY , USA
| | - Miguel A Gama Sosa
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Friedman Brain Institute, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center , Bronx, NY , USA
| | - Rita De Gasperi
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Friedman Brain Institute, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center , Bronx, NY , USA
| | - James Radford Stone
- Department of Radiology and Medical Imaging, University of Virginia , Charlottesville, VA , USA ; Department of Neurosurgery, University of Virginia , Charlottesville, VA , USA
| | - Dara L Dickstein
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Fishberg Department of Neuroscience, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai , New York, NY , USA
| | - Fatemeh Haghighi
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Friedman Brain Institute, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center , Bronx, NY , USA ; Fishberg Department of Neuroscience, Icahn School of Medicine at Mount Sinai , New York, NY , USA
| | - Patrick R Hof
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Fishberg Department of Neuroscience, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai , New York, NY , USA
| | - Stephen T Ahlers
- Department of Neurotrauma, Operational and Undersea Medicine Directorate, Naval Medical Research Center , Silver Spring, MD , USA
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Stefanopoulos PK, Filippakis K, Soupiou OT, Pazarakiotis VC. Wound ballistics of firearm-related injuries--part 1: missile characteristics and mechanisms of soft tissue wounding. Int J Oral Maxillofac Surg 2014; 43:1445-58. [PMID: 25128259 DOI: 10.1016/j.ijom.2014.07.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 04/08/2014] [Accepted: 07/21/2014] [Indexed: 10/24/2022]
Abstract
Firearm-related injuries are caused by a wide variety of weapons and projectiles. The kinetic energy of the penetrating projectile defines its ability to disrupt and displace tissue, whereas the actual tissue damage is determined by the mode of energy release during the projectile-tissue interaction and the particular characteristics of the tissues and organs involved. Certain projectile factors, namely shape, construction, and stability, greatly influence the rate of energy transfer to the tissues along the wound track. Two zones of tissue damage can be identified, the permanent cavity created by the passage of the bullet and a potential area of contused tissue surrounding it, produced mainly by temporary cavitation which is a manifestation of effective high-energy transfer to tissue. Due to the complex nature of these injuries, wound assessment and the type and extent of treatment required should be based on an understanding of the various mechanisms contributing to tissue damage.
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Affiliation(s)
| | - K Filippakis
- 401 General Army Hospital of Athens, Athens, Greece
| | - O T Soupiou
- 401 General Army Hospital of Athens, Athens, Greece
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7
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Eardley WGP, Watts SA, Clasper JC. Modelling for conflict: the legacy of ballistic research and current extremity in vivo modelling. J ROY ARMY MED CORPS 2013; 159:73-83. [PMID: 23720587 DOI: 10.1136/jramc-2013-000074] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Extremity ballistic injury is unique and the literature intended to guide its management is commonly misinterpreted. In order to care for those injured in conflict and conduct appropriate research, clinicians must be able to identify key in vivo studies, understand their weaknesses and desist the propagation of miscited and misunderstood ballistic dogma. This review provides the only inclusive critical overview of key studies of relevance to military extremity injury. In addition, the non-ballistic studies of limb injury, stabilisation and contamination that will form the basis from which future small animal extremity studies are constructed are presented. With an awareness of the legacy of military wound models and an insight into available generic models of extremity injury and contamination, research teams are well placed to optimise future military extremity injury management.
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Affiliation(s)
- William G P Eardley
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Institute of Research and Development, Birmingham, UK.
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8
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Breeze J, Sedman AJ, James GR, Newbery TW, Hepper AE. Determining the wounding effects of ballistic projectiles to inform future injury models: a systematic review. J ROY ARMY MED CORPS 2013; 160:273-8. [PMID: 24109099 DOI: 10.1136/jramc-2013-000099] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Penetrating wounds from explosively propelled fragments and bullets are the most common causes of combat injury experienced by UK service personnel on current operations. There is a requirement for injury models capable of simulating such a threat in order to optimise body armour design. METHOD A systematic review of the open literature was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. Original papers describing the injurious effects of projectiles on skin, bone, muscle, large vessels and nerves were identified. RESULTS Projectiles injure these tissues by producing a permanent wound tract (PWT), comprised of a central permanent wound cavity, in conjunction with a zone of irreversible macroscopic tissue damage laterally. The primary mechanism of injury was the crushing and cutting effect of the presented surface of the projectile, with an additional smaller component due to macroscopic damage produced by the radial tissue displacement from the temporary tissue cavity (TTC). No conclusive evidence could be found for permanent pathological effects produced by the pressure wave or that any microscopic tissue changes due to the TTC (in the absence of visible macroscopic damage) led to permanent injury. DISCUSSION Injury models should use the PWT to delineate the area of damage to tissues from penetrating ballistic projectiles. The PWT, or its individual components, will require quantification in terms of the amount of damage produced by different projectiles penetrating these tissues. There is a lack of information qualifying the injurious effect of the temporary cavity, particularly in relation to that caused by explosive fragments, and future models should introduce modularity to potentially enable incorporation of these mechanisms at a later date were they found to be significant.
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Affiliation(s)
- John Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK Biomedical Sciences Department, Dstl, Porton Down, Salisbury, Wiltshire, UK
| | - A J Sedman
- Biomedical Sciences Department, Dstl, Porton Down, Salisbury, Wiltshire, UK
| | - G R James
- Biomedical Sciences Department, Dstl, Porton Down, Salisbury, Wiltshire, UK
| | - T W Newbery
- Land Battlespace Systems Department, Dstl, Fort Halstead, Sevenoaks, Kent, UK
| | - A E Hepper
- Biomedical Sciences Department, Dstl, Porton Down, Salisbury, Wiltshire, UK
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9
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Ramasamy A, Hughes A, Carter N, Kendrew J. The effects of explosion on the musculoskeletal system. TRAUMA-ENGLAND 2013. [DOI: 10.1177/1460408613484683] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Explosions remain the leading cause of death and injury to combatants in conflict. The current ‘Global War on Terror’ has resulted in a shift of explosive-related injuries from the battlefield into civilian centres. Despite musculoskeletal injuries being the most common injury witnessed in blast, there remains little research into the effects of blast on this system. In order to develop new treatment regimens and mitigation systems, there is a requirement to have a better understanding of skeletal trauma in this unique environment. The aim of this review article is to deconstruct the complex injury mechanisms witnessed in blast and relate them to its effects on the musculoskeletal system.
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Affiliation(s)
- Arul Ramasamy
- Academic Department of Traumatology, Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Birmingham, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK
| | - Anna Hughes
- Academic Department of Traumatology, Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Birmingham, UK
| | - Nicholas Carter
- Academic Department of Traumatology, Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Birmingham, UK
| | - Jon Kendrew
- Academic Department of Traumatology, Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Birmingham, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK
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Wang Y, Pan L, Fan W, Zhou Z, Zhu L, Wang Y, Hu R. Influence of vagal injury on acute traumatic reaction after blast injury. Eur J Trauma Emerg Surg 2013; 39:385-92. [PMID: 26815399 DOI: 10.1007/s00068-013-0277-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 03/12/2013] [Indexed: 10/27/2022]
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Abstract
Ballistic injury wounds are formed by variable interrelated factors, such as the nature of the tissue, the compositional makeup of the bullet, distance to the target, and the velocity, shape, and mass of the of the projectile. This complex arrangement, with the ultimate outcome dependent on each other, makes the prediction of wounding potential difficult to assess. As the facial features are the component of the body most involved in a patient's personality and interaction with society, preservation of form, cosmesis, and functional outcome should remain the primary goals in the management of ballistic injury. A logical, sequential analysis of the injury patterns to the facial complex is an absolutely necessary component for the treatment of craniomaxillofacial ballistic injuries. Fortunately, these skill sets should be well honed in all craniomaxillofacial surgeons through their exposure to generalized trauma, orthognathic, oncologic, and cosmetic surgery patients. Identification of injured tissues, understanding the functional limitations of these injuries, and preservation of both hard and soft tissues minimizing the need for tissue replacement are paramount.
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Affiliation(s)
- David B Powers
- Duke Craniomaxillofacial Trauma Program, Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center, DUMC Box 2955, Durham, NC 27710, USA.
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13
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Working toward exposure thresholds for blast-induced traumatic brain injury: Thoracic and acceleration mechanisms. Neuroimage 2011; 54 Suppl 1:S55-61. [DOI: 10.1016/j.neuroimage.2010.05.025] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Revised: 05/10/2010] [Accepted: 05/11/2010] [Indexed: 12/28/2022] Open
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Courtney A, Courtney M. Links between traumatic brain injury and ballistic pressure waves originating in the thoracic cavity and extremities. Brain Inj 2009; 21:657-62. [PMID: 17653939 DOI: 10.1080/02699050701481571] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Identifying patients at risk of traumatic brain injury (TBI) is important because research suggests prophylactic treatments to reduce risk of long-term sequelae. METHOD This review considers results from the lateral fluid percussion model of TBI, ballistic experiments in animal models and analyses of human studies. RESULTS Taken together, these results support the hypothesis that bullet impacts distant from the brain produce pressure waves that travel to the brain and can retain sufficient magnitude to induce brain injury. CONCLUSIONS The link to long-term sequelae could be investigated via epidemiological studies of patients who were gunshot in the chest to determine whether they experience elevated rates of epilepsy and other neurological sequelae.
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Affiliation(s)
- Amy Courtney
- Department of Physics, United States Military Academy, West Point, NY 10996, USA.
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Courtney AC, Courtney MW. A thoracic mechanism of mild traumatic brain injury due to blast pressure waves. Med Hypotheses 2008; 72:76-83. [PMID: 18829180 DOI: 10.1016/j.mehy.2008.08.015] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2008] [Revised: 07/31/2008] [Accepted: 08/03/2008] [Indexed: 10/21/2022]
Abstract
The mechanisms by which blast pressure waves cause mild-to-moderate traumatic brain injury (mTBI) are an open question. Possibilities include acceleration of the head, direct passage of the blast wave via the cranium, and propagation of the blast wave to the brain via a thoracic mechanism. The hypothesis that the blast pressure wave reaches the brain via a thoracic mechanism is considered in light of ballistic and blast pressure wave research. Ballistic pressure waves, caused by penetrating ballistic projectiles or ballistic impacts to body armor, can only reach the brain via an internal mechanism and have been shown to cause cerebral effects. Similar effects have been documented when a blast pressure wave has been applied to the whole body or focused on the thorax in animal models. While vagotomy reduces apnea and bradycardia due to ballistic or blast pressure waves, it does not eliminate neural damage in the brain, suggesting that the pressure wave directly affects the brain cells via a thoracic mechanism. An experiment is proposed which isolates the thoracic mechanism from cranial mechanisms of mTBI due to blast wave exposure. Results have implications for evaluating risk of mTBI due to blast exposure and for developing effective protection.
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Affiliation(s)
- A C Courtney
- Department of Physics, United States Military Academy, West Point, NY 10996, United States.
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Courtney M, Courtney A. Comments on "Ballistics: a primer for the surgeon". Injury 2008; 39:964-5; author reply 965-6. [PMID: 18620354 DOI: 10.1016/j.injury.2008.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 03/13/2008] [Accepted: 03/20/2008] [Indexed: 02/02/2023]
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Krave U, Höjer S, Hansson HA. Transient, powerful pressures are generated in the brain by a rotational acceleration impulse to the head. Eur J Neurosci 2005; 21:2876-82. [PMID: 15926935 DOI: 10.1111/j.1460-9568.2005.04115.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A rotational acceleration impulse to a head, as occurs at traffic accidents, sport injuries, assaults and falls, induces a diffuse brain damage that eventually could result in persistent neuropsychiatric deficits and neurodegeneration. Emphasis has been concentrated on the relative motion of the brain inside the skull during head impact, whereas less attention has been paid to whether intracranial pressure changes are generated and, if so, the implications thereof. In the present experimental study we investigated in an animal model system, based on rabbits, if a sagittal, anterior-posterior rotational acceleration of a head generated intracranial pressure changes, recorded by fibre optic pressure sensors, inserted ipsilaterally in the parieto-temporal and the occipital lobes. Two levels of rotational acceleration were used in the experiments; one higher, corresponding to the threshold limit for moderate diffuse brain injury, and one lower, close to being noninjurious. Several pressure recordings were performed in each rabbit at the two acceleration levels. The pressure recordings invariably revealed the same general characteristics of rapid, positive and negative pressures within the brain, with variations in amplitude and duration, lasting for up to 10 ms. A major finding was the generation of powerful negative pressures, as low as 0.3 bars in absolute pressure. The most prominent difference in amplitudes of the negative peak pressures between the two applied acceleration levels was demonstrated at the parieto-temporal location. The presented pressure recordings are the first to disclose the generation of transient, powerful intracerebral pressures at rotational acceleration of the head, which must be considered in studies of brain injury generation and distribution as well as prevention.
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Affiliation(s)
- Ulrika Krave
- Vehicle Safety, Department of Applied Mechanics, Chalmers University of Technology, SE 412 96 Göteborg, Sweden
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Wang Q, Wang Z, Zhu P, Jiang J. Alterations of Myelin Basic Protein and Ultrastructure in the Limbic System at the Early Stage of Trauma-Related Stress Disorder in Dogs. ACTA ACUST UNITED AC 2004; 56:604-10. [PMID: 15128132 DOI: 10.1097/01.ta.0000058122.57737.0e] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The secondary injury and related complications after trauma are still the focus of trauma research. However, whether the remote effects on the central nervous system could be induced by high-energy missile extremity impact remains unclear. Also, the possible biomarker for brain damage in traumatic stress disorder has not been determined. METHODS Forty-two healthy adult dogs were divided into three groups: the control group (n = 12), the high-speed trauma group (n = 15), and the low-speed trauma group (n = 15). Bilateral thighs of dogs were wounded with a smoothbore 6.2-mm rifle at a speed of 1,368 m/s (1.03-g steel bullet) for the high-speed trauma group and 625 m/s for the low-speed trauma group. The expression of myelin basic protein (MBP) in cerebrospinal fluid (CSF), hypothalamus and hippocampus of the limbic system, and temporoparietal cortex was investigated by enzyme-linked immunosorbent assay and dot-blot analysis. Also, the ultrastructure of the above areas was observed with light and electron microscopy. RESULTS Neuronal degeneration and nerve fiber demyelination were seen in the hypothalamus and hippocampus in the high-speed trauma group at 8 hours after impact. The MBP level was markedly increased in the CSF (p < 0.01) in the two trauma groups, in the hypothalamus of the low-speed trauma group (p < 0.05), and in both the hypothalamus and the hippocampus of the high-speed trauma group (p < 0.01). The expression of MBP mRNA was also significantly enhanced in these areas at the same time. The increase of MBP content in the CSF was positively correlated with the elevation of MBP concentration in the hypothalamus and hippocampus. CONCLUSION The hypothalamus and hippocampus of the limbic system in the central nervous system are vulnerable to damage after high-energy missile extremity impact, indicating that it might be one of the important pathologic bases involved in the development of trauma-related complications. Meanwhile, the MBP level in the CSF may be a sensitive biological indicator for brain damage at the early stage of trauma-related stress disorder.
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Affiliation(s)
- Qingsong Wang
- Department 4, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing 400042, People's Republic of China.
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Cunningham LL, Haug RH, Ford J. Firearm injuries to the maxillofacial region: an overview of current thoughts regarding demographics, pathophysiology, and management. J Oral Maxillofac Surg 2003; 61:932-42. [PMID: 12905447 DOI: 10.1016/s0278-2391(03)00293-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Larry L Cunningham
- Department of Oral and Macillofacial Surgery, College of Dentistry, University of Kentucky, Lexington, KY, 40536-0297, USA.
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Abstract
The present study was designed to detect the change of substance P (SP) in firearm wounds and its relationship with wound healing. Twenty two rabbits were randomly divided into two groups, one with firearm wounds created by steel balls shooting rabbits' thighs and another with stab wounds created by knife. The experimental design did not include direct injury to femora major peripheral nerve trunks or blood vessels. SP content in wound tissue of both groups was measured with radioimmunoassay (RIA). Histologic examination was performed on the wound and the saphenous and sciatic nerves away from the wound-track edges. It was found that both types of injuries caused an increase of SP content in the wound compared with normal tissue. At three to 10 days after injury, SP content was lower in firearm wounds than that in stab wounds. Pathomorphologic observation showed the indirect injuries to the saphenous and sciatic nerves in the rabbits with firearm wounds were more severe than those with stab wounds. Meanwhile, wound healing in the firearm wounds was poor compared with that in the stab wounds. The results suggest that the change in SP in firearm wounds differs from that in cold weapon wounds as a result of the presence of indirect injuries to major peripheral nerve trunks created by laceration shock wave and cavity effects, and SP in vivo may participate in wound healing as a growth factor. Therefore, the improvement of neuropeptide metabolism in firearm wound may be an important measure for accelerating wound healing.
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Affiliation(s)
- L Xinan
- Research Institute of Surgery, Third Military Medical University, Chongqing, People's Republic of China.
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Cernak I, Savic J, Malicevic Z, Zunic G, Radosevic P, Ivanovic I, Davidovic L. Involvement of the central nervous system in the general response to pulmonary blast injury. THE JOURNAL OF TRAUMA 1996; 40:S100-4. [PMID: 8606388 DOI: 10.1097/00005373-199603001-00023] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The local, general, and cerebral responses of rabbits exposed to pulmonary blasts were examined to define the role of vagal afferentation in cardiorespiratory as well as metabolic control after a blast injury. Two series of experiments were conducted on rabbits to analyze the general, local, and cerebral responses to pulmonary injury caused by blast overpressure, and to evaluate the effects of bilateral vagotomy on the general, local, and cerebral responses to local (pulmonary) blast injury. The blast wave was generated in laboratory conditions using an air-driven shock tube that was able to cause moderate pulmonary blast injury, i.e., four pulmonary contusions characterized as confluent ecchymoses involving 30 to 60% of the lungs. One group of animals was subjected to pulmonary deafferentation, performed by bilateral transections of the vagus, glossopharyngeal, and hypoglossal nerves. Numerous hemodynamic as well as biochemical parameters were observed in systemic circulation and in lung and brain (medulla oblongata) tissues. After observation during the early posttraumatic period, rabbits were sacrificed by decapitation 30 minutes after the blast injury. On the basis of obtained results, it was concluded that vagal afferents have an important role in the modification of general and local responses to a pulmonary blast injury. Furthermore, it was suggested that functional changes in medulla oblongata may be the consequences of afferent neural impulses from the injured region (lungs) rather than consequences of ischemia, energy transfer to the brain, or both.
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Affiliation(s)
- I Cernak
- Institute for Medical Research, Military Medical Academy, Beograd, Yugoslavia
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Swan KG, Swan RC. Principles of ballistics applicable to the treatment of gunshot wounds. Surg Clin North Am 1991; 71:221-39. [PMID: 2003247 DOI: 10.1016/s0039-6109(16)45376-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Ballistics is the science of the motion of a projectile through the barrel of a firearm (internal ballistics), during its subsequent flight (external ballistics), and during its final complicated motion after it strikes a target (terminal ballistics). Wound ballistics is a special case of terminal ballistics. Although wound ballistics is at best sets of approximations, its principles enter usefully into an evaluation of a gunshot wound and its treatment. A special consideration in these cases is their medicolegal aspects. At a minimum, the medical team receiving the patient should exert care not to destroy the clothing and in particular to cut around and not through bullet holes, to turn over to law enforcement officials any metallic foreign body recovered from the patient, and to describe precisely, or even to photograph, any entrance or exit wounds.
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Affiliation(s)
- K G Swan
- Section of General Surgery, University of Medicine and Dentistry of New Jersey, Newark
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