Mechanisms of dental injuries in basketball, United States, 2003-2022

BACKGROUND/AIM

Oral injuries such as oral soft tissue lacerations and contusions can occur in basketball by mechanisms such as running into other players or falling. Given a high enough impact force, dental injuries such as tooth fractures and avulsions can occur. Previous research has studied the different types of oral injuries as well as the mechanisms that cause them. Yet, the mechanisms resulting in dental injuries have remained unexplored. The aims of this study were to investigate the distribution of different oral injuries within each injury mechanism and evaluate which mechanisms were most likely to lead to a dental injury.

MATERIALS AND METHODS

This is a retrospective cohort study using the National Electronic Injury Surveillance System (NEISS). Subjects who experienced oral injuries from basketball between January 1, 2003 and December 31, 2022 were included in this study. The independent variable was the injury mechanism. The dependent variable was the dental injury outcome (yes/no). Multivariate logistic regression was used to measure the association between the injury mechanism and the dental injury outcome. A p < .05 was considered statistically significant.

RESULTS

This study included 4419 subjects who experienced oral injuries (national estimate, 138,980). Approximately 14.7% of oral injuries were dental injuries. Subjects experiencing collisions with objects such as walls or the basketball hoop (odds ratio (OR), 4.39; p < .001), falls (OR, 3.35; p < .001), or contact with the basketball (OR, 1.77; p = .006) had significantly higher odds of sustaining a dental injury relative to those experiencing contact with another player.

CONCLUSIONS

Basketball players experiencing contact to the mouth have high odds of sustaining a dental injury. An understanding of injury mechanisms is important for medical teams to manage these injuries and for coaches to educate athletes on safe and proper playing styles. Furthermore, healthcare providers and basketball staff should encourage athletes to wear mouthguards to reduce the risk of traumatic dental injuries.

Scalp wound management: a narrative review from a neurosurgical perspective

OBJECTIVE

This article aims to present a narrative review of current literature about the anatomical characteristics of the scalp as well as current practices in the management of surgical, traumatic and pressure injuries in the scalp, which are common in neurosurgery practice.

METHOD

We searched PubMed for publications and book chapters in English from 2011 to 2021. We also included commonly referenced papers that we considered relevant to the subject with publication before these dates. We used the search terms 'laceration,' and/or 'neurosurgery' and/or, 'pressure injury,' and/or 'craniotomy,' and/or 'surgical incision' in combination with 'scalp,' and/or 'wound care.' We also searched the reference lists of publications identified by the search strategy and selected those that we judged relevant.

RESULTS

We pre-selected 52 articles that covered various aspects of anatomy, pathophysiology, scalp wound management, or general wound care that we considered applied to the anatomical region of our interest. After abstract review, we selected 34 articles that met our search criteria and were included in our review.

CONCLUSION

There is limited evidence regarding classification and care of scalp wounds. As a result, many of the current practices for scalp wound management are based on evidence derived from studies involving different anatomical regions, not considering its particular anatomy, vasculature and microbiome. Further research is needed for more comprehensive and effective protocols for the management of scalp injuries. However, this present review proposes responses to the identified gaps concerning the management of scalp wounds.

Acute and Past Common Lacrimal Canalicular Lacerations: A Report of Two Cases

Lacrimal canalicular lacerations can be caused by trauma to the ocular adnexa, such as a penetrating or blunt injury. Only a few cases involving the common canaliculus or lacrimal sac have been reported, and only a few reports have described the detailed course of treatment. Here, we report an acute case of common lacrimal canalicular laceration and a case of a previous common canalicular laceration. The acute case was treated with a bicanalicular stent directly inserted into the nasolacrimal duct. The case with a previous common canalicular laceration was treated with external dacryocystorhinostomy combined with monocanalicular stent insertion. These treatments may be appropriate for the initial surgery and can be selected before performing conjunctivodacryocystorhinostomy.

Physiotherapy Management Post-operative to Total Extensor Hallucis Longus Rupture: A Case Report

Due to the contracture or degeneration of the ruptured tendon, using primary suturing to treat chronic extensor hallucis longus (EHL) tendon ruptures is challenging. The most common cause of EHL rupture is a laceration when a sharp object drops over the dorsum of the foot. EHL injuries are rare cases. In this report, we present a case of a 23-year-old female who was operated on for EHL rupture; she visited the Physiotherapy department with complaints of pain swelling over the left dorsum of the foot and was unable to perform great toe movements for six weeks. After three weeks of patient-tailored rehabilitation protocol that included interventions like faradic stimulation, strengthening exercises, gripping exercises, proprioception training, etc., we assessed the patient's primary outcomes like pain intensity, muscle strength, and range of motion and functional outcome measures that included lower extremity functional scale score at the end. Improvement in all the outcomes was seen. Our case report concludes that physiotherapy intervention has improved the primary and secondary outcomes and has helped patients to perform functional activities efficiently, such as maintaining balance while standing, walking, and bearing equal weight. This case report portrays that early physiotherapy treatment post-operatively in EHL rupture cases proves to be very beneficial.

Renal Arteriovenous (AV) Fistula after High-Grade Blunt Renal Trauma Caused by Traffic Accidents

PURPOSE

To report a series of three patients with traumatic renal AV fistulas after blunt renal laceration.

METHODS

We retrospectively analyzed the renal trauma cases treated in the Department of Urology of Salzburg University Clinic during a time period of 10 years concerning traumatic AV fistula formation and other clinical parameters.

RESULTS

In total, 3 cases of traumatic AV fistula formation were identified in 106 blunt renal trauma patients (2.8%), with a mean age of 39 (17-56) years. All renal traumas were classified as American Association for the Surgery of Trauma (AAST) grade IV. Two patients were primarily treated with ureteral stent; one was managed conservatively. All AV fistulas were diagnosed after a mean time of 7 (1-13) days. Two patients were symptomatic with gross hematuria, and the mean time between trauma and onset of symptoms was 11 (9-13) days. All cases were managed via coil embolization after a mean of 10 (8-13) days. Two patients received a second intervention after a mean of 18 (11-25) days. The mean AV fistula size was 18.7 (12-24) mm. Mean hemoglobin loss was 3.6 g/dL. One patient received one erythrocyte concentrate. Discharge was after a mean time of 13.3 (7-12) days, with the mean time of intensive care treatment being 2.3 (1-3) days.

CONCLUSIONS

Traumatic renal AV fistula is a rare but severe complication associated with higher-grade renal trauma. It can become evident through hematuria or blood loss several days after the initial trauma. The availability of coil embolization in a trauma center can help kidney preservation management.

Comparative Evaluation of Tissue Adhesives and Sutures in the Management of Facial Laceration Wounds in Children

BACKGROUND

This study evaluated tissue adhesives in comparison to sutures for treating facial lacerations in children.

METHODS

We retrospectively analyzed data from September 2017 to August 2022 involving pediatric facial lacerations managed with either tissue adhesives or sutures.

RESULTS

Among 50 children, 20 received tissue adhesives, and 30 received sutures. Both methods showed comparable outcomes in terms of wound complications such as dehiscence (adjusted odds ratio = 1.56, 95% CI = 0.08-31.25) and infection (adjusted odds ratio = 2.17, 95% CI = 0.08-58.80). The cosmetic outcomes, assessed using the Hollander Wound Evaluation Score, were also consistent between groups (adjusted beta = -0.55, 95% CI = -1.15-0.05). Notably, those treated with tissue adhesives reported greater satisfaction (adjusted beta = 1.13, 95% CI = 0.63 -1.63) and experienced significantly less pain (adjusted beta = -3.03, 95% CI = -4.15--1.90).

CONCLUSIONS

Both techniques displayed similar rates of infection, dehiscence, and cosmetic outcomes. However, tissue adhesives were associated with increased patient comfort, especially in terms of reduced pain and greater satisfaction.

Good outcome of surgical treatment for contaminated penile wound due to a fall from stairs: a case report

Background

Penile trauma due to the associated stigma poses a diagnostic challenge. The causes of isolated penile injuries include zipper injuries (mainly in children), falls, burns, during fellatio, self-mutilation (Klingsor syndrome), and rarely purposeful forceful bending of the erect penis (Taqaandan). Delayed management of penile trauma might increase the risk of infection, rarely leading to sepsis acutely or structural and functional disabilities in the long run. We believe our report is the first to contribute data on a patient with a delayed presentation of contaminated penile wound who recovered well with prompt management.

Case Description

A traumatic laceration of the penis due to a fall from stairs is extremely unexpected. Here we present the case of a 14-year-old boy who slipped from the stairs and got an isolated American Association for the Surgery of Trauma (AAST) Grade-1 ventrolateral penile skin laceration. He took home remedies for 10 days before reporting with a contaminated wound. The patient was first managed conservatively with antibiotics [Amoxyclav 625 mg thrice daily (TDS) and Metronidazole 400 mg TDS], wound care, and then treated surgically, helping wound repair. He recovered well after the treatment and retained normal urinary and sexual function.

Conclusions

Penile trauma is severely under-reported due to the stigma associated with it. Early diagnosis and prompt management are imperative to limit complications. A detailed history helps to evaluate the exact cause and check out possibilities of sexual assault. Appropriate management in tandem with patient education and an attempt to de-stigmatize the interaction helps favorable long-term outcomes.

Traumatic Tongue Laceration: An Experience of Two Tertiary Centers in South East Nigeria

Background

Traumatic injuries to the orofacial region are common and can be challenging to the oral and maxillofacial surgeon. The tongue is one of the structures that can be involved; however, the incidence of this injury to the tongue appears rare. Most of the reported work on this topic is on children.

Patients and Methods

This is a three-year prospective study of traumatic tongue lacerations managed at the oral and maxillofacial centers of two tertiary hospitals in the southeast of Nigeria.

Result

A total of 37 cases with tongue lacerations among 353 patients with oral and maxillofacial trauma constituting a prevalence of 10.5%. Their age ranged from 6 months to 57 years with a mean of 18.4 years (standard deviation 17.5). Twenty three (62.2%) are males and 14 (37.8%) females in a ratio of 1.6:1. The duration of injury on presentation ranged from 45 minutes to 96 hours with a mean duration of 26.7 hours. Majority of the laceration occurred in the anterior part of the tongue (24) (64.9%). Thirteen falls (35.1%) and nine motor vehicle accidents (24.3%) were the most common etiology. Thirty six (97.3%) were sutured primarily on presentation while only one (2.7%) was delayed before closure. Anesthesia was achieved with only Local Anesthetic agent in 18 (48.6%) cases, whereas in 13 (35.1%) cases a combination of Local Anesthetic agent and sedation.

Conclusion

Tongue lacerations are not very common in the southeast of Nigeria, and management in children may require sedation. Treatment could involve suturing the wound or being left alone to heal.

The Iatrogenic Injury Potential of Self-adherent Elastic Bandages in Finger Injuries

BACKGROUND

The use of a self-adherent, elastic bandage is a practical way to dress finger injuries. Multiple reports describe iatrogenic injuries from elastic bandages, ranging from skin necrosis to finger gangrene, necessitating amputations. This study investigated whether elastic bandages can compromise digital perfusion by occluding arterial blood flow in healthy volunteers and evaluated the utility of pulse oximetry as a monitoring tool for digital perfusion. A technique for safe bandage application is proposed.

METHODS

A commercially available elastic bandage was wrapped around the index finger of 20 healthy volunteers at varying degrees of stretch. Digital perfusion measurements were carried out using photoelectric pulse transduction, laser Doppler flowmetry, and pulse oximetry. Intracompartmental pressure measurements were recorded using a separate in vitro experimental model.

RESULTS

Elastic bandages applied at maximum stretch did not change digital brachial index or pulse oximetry values, suggesting arterial blood flow was preserved distal to the bandage. Intracompartmental pressure measurements at maximum stretch remained below the systolic digital pressure. In contrast, superficial dermal perfusion fell to 32% of normal as measured by laser Doppler flow, at 100% bandage stretch.

CONCLUSION

This study suggests a risk for iatrogenic injury when using elastic bandages for finger dressings. While arterial inflow was never compromised, pressures were high enough to occlude superficial venous outflow, which may begin at 20% bandage stretch. Pulse oximetry failed to detect changes distal to applied dressings, and we do not recommend it to detect digital vascular compromise in this setting.

Referral and Management of Pretibial Lacerations in Two District General Hospitals

Background Pretibial lacerations are common injuries that have a significant yet underestimated association with morbidity and mortality. Although they may occur in any age group, they are commonly followed by an often relatively minor trauma in elderly and frail patients. The six-month mortality among such patients may be more than double the age group average. Currently, 5.2 in 1000 patients per year present to the emergency departments in UK hospitals due to pretibial lacerations. The associated acute admissions have a high financial cost. Despite the significant disease burden, there is a paucity of evidence on the optimal management of such injuries. This study aimed to describe the typical demographic and injury factors of individuals presenting to two district general hospitals, as well as their subsequent management and referral. Methodology Relevant patients were identified through NHS coding searches. Subsequently, it was found that 99 patients presented to an NHS trust with pretibial lacerations throughout 2020. A retrospective manual evaluation of clinical documentation was performed to identify the details of the patients' injury, management, referral, and demographics. Results The patients had a mean age of 55.4 (SD 28.3), and 56.6% were female. The most commonly presenting mechanism of injury was direct blunt trauma. The majority of cases were solely managed and discharged directly by the emergency department (74.8%). Of the 99 patients, 25 (25.3%) were referred to specialist services, 12 (12.1%) were managed conservatively, and 13 (13.1%) underwent operative intervention. The mean length of stay for those referred was 5.9 days, and the mean for the same was greater for those managed conservatively compared to those managed operatively (9.0 vs. 2.6 days). Among patients discharged by the emergency department, the most common method of wound closure was steristrips (n = 40; 54.1%), followed by conservative management with dressings (n = 22; 29.7%), sutures (n = 10, 13.5%) and glue (n = 5; 6.8%). Conclusions Overall, this study showed that the majority of patients presenting with pretibial lacerations have minor wounds that can be effectively managed in the emergency department. However, those with considerably more injuries should be provided an early referral to specialist services, where they would ideally receive early surgery and comprehensive follow-up.

Retrospective evaluation of elevator-related injuries in dogs (2015-2020): 13 cases

OBJECTIVE

To describe elevator-related injuries in dogs.

DESIGN

Retrospective study, August 2015 to October 2020.

SETTING

Four urban referral and emergency veterinary facilities.

ANIMALS

Thirteen client-owned dogs presenting with injuries sustained while using an elevator.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Thirteen dogs were treated for elevator-related injuries. The mean age of this population was 4.9 ± 4.1 years. Median body weight was 4.3 kg (range = 1.5-32 kg). Dogs in this study were significantly smaller than dogs presenting for all types of trauma during the same study period found in the Veterinary Committee on Trauma registry (VetCOT) (median = 14.5 kg, range = 0.1-141; P = 0.038). There was no difference in age between this study population and dogs presenting for trauma in the VetCOT registry (median = 4.2 years, range = 0.1-26.4, P = 0.7358). Nine dogs sustained a crush injury (69%), and 7 of these dogs received surgical intervention. Four dogs experienced leash entrapment in the elevator doors (31%), and none required surgical intervention. Two of these 4 dogs required inpatient hospital care. No deaths occurred in either group.

CONCLUSIONS

Injuries that can be sustained by dogs in an elevator include crush injuries from doors closing on limbs or tails and injury due to leash entrapment in an elevator door. Many elevator-related injuries required surgical intervention, and recovery was often protracted. All dogs survived to hospital discharge in the present study, and none of the injuries in these dogs had serious long-term consequences.

Recreational Motorized Vehicle Use Under the Influence of Alcohol or Drugs Significantly Increases Odds of Craniofacial Injury

Study Design

Cross-sectional study.

Objective

Concurrent substance-use, including alcohol and drugs, increases the risks of many recreational activities. Our purpose was to determine the relationship between substance use and craniofacial injuries in a large population of patients experiencing trauma due to recreational motorized vehicle use.

Methods

We report a cross-sectional study of patients reported to the National Electronic Injury Surveillance System (NEISS) from January 1, 2019 to December 31, 2019, in the United States. Patients were included in our study if they were evaluated in the emergency department (ED) for a recreational motorized vehicle-related injury. Primary outcome was craniofacial injury.

Results

There were a total of 6,485 adult patients who experience an injury after recreational motorized vehicle trauma reported by NEISS-participating EDs during the study period. Of this, 1,416 (21.8%) patients had a craniofacial injury, and 201 patients with craniofacial injuries were under the influence of alcohol/drugs (201/1,416; 14.2%). Injured patients under the influence of alcohol/drugs experienced greater odds of sustaining a general craniofacial injury (OR 2.50, 95% CI: 2.07-3.01, P < .0001), including craniofacial fracture (OR: 2.98, 95% CI: 2.01-4.40, P < .0001), laceration (OR: 2.19, 95% CI: 1.51-3.16, P < .00001) and internal injury (OR: 2.33, 95% CI: 1.84-2.95, P < .00001) than injured patients not under the influence.

Conclusions

Using recreational motorized vehicles under the influence of alcohol or drugs is not safe and increases the likelihood of craniofacial injuries, including fractures, lacerations, and internal injuries. As operating these recreational motorized vehicles under the influence is illegal, the law should be strictly enforced to prevent the occurrence of these injuries. Additional undertakings to increase helmet usage would be valuable.

Preemptive Septal Radiofrequency Ablation to Prevent Left Ventricular Outflow Tract Obstruction With Transcatheter Mitral Valve Replacement: A Case Series

BACKGROUND

Left ventricular outflow tract obstruction may occur following transcatheter mitral valve replacement in the setting of mitral annular calcification.

METHODS

We present a case series whereby preemptive septal radiofrequency ablation (RADIO-TMVR) was used to augment the left ventricular outflow tract for transcatheter mitral valve replacement in 4 patients at risk for left ventricular outflow tract obstruction despite alcohol septal ablation.

RESULTS

All patients were female, average age of 74.9 (68.8-80.4) years. Baseline ejection fraction was 71% (63%-75%). Mean mitral valve area was 1.28 (range, 1.0-1.59) cm². Mean mitral valve gradient at rest was 9.5 (range, 7-11) mm Hg. New York Heart Association symptoms were III to IV at baseline. Patients underwent preemptive septal radiofrequency ablation to prevent left ventricular outflow tract obstruction with transcatheter mitral valve replacement a range between 69 and 154 days after alcohol septal ablation. Procedural time was 384 (337-424) minutes with a fluoroscopic time of 31 (14-71) minutes. Radiofrequency ablation time was 132 (100-175) minutes. As anticipated, 3 patients developed complete heart block and underwent pacemaker implantation, whereas 1 had a preexisting pacemaker. One patient developed groin hematoma and heart failure exacerbation. There were no peri-procedural deaths. Preemptive septal radiofrequency ablation to prevent left ventricular outflow tract obstruction with transcatheter mitral valve replacement resulted in septal end-diastolic wall thickness reduction compared with baseline (28.6%, 30.4%, 30.3%, and 11.1%) and following alcohol septal ablation (23.1%, 12%, 8.5%). Valve replacement in the setting of mitral annular calcification was performed in all patients 89 (range, 38-45) days after preemptive septal radiofrequency ablation to prevent left ventricular outflow tract obstruction with transcatheter mitral valve replacement. Two patients had concomitant laceration of the anterior mitral leaflet to further augment the neo-left ventricular outflow tract. Postprocedure, New York Heart Association symptoms improved to class I (3 patients) and class II (1 patient).

CONCLUSIONS

In at-risk individuals, preemptive septal radiofrequency ablation may be an effective strategy at preventing left ventricular outflow tract obstruction with transcatheter mitral valve replacement.

Severe Lacerations in Alpine Ski Racing: A Case Series and Review of the Literature

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level 4C.

A new technique of suturing using adhesive skin closure for uncooperative patients

Open wounds are usually closed with suture. However, young patients often do not cooperate and prevent proper suture placement. Young patients are often terrified of mild pain and wholly uncooperative, which is why we introduce this timesaving, less painful, more aesthetic technique of placing and removing stitches. 104 patients with facial lacerations aged 5 to 15 years were treated at a single center from May 2019 to March 2021. Patients were randomly assigned equally to a simple interrupted suture group (the SI group) or a continuous locking with Steri‐Strip group (the CS group). Suture times, times for stitch removal, pain scores at stitch removal and mature scar scores were evaluated. Suture and stitch removal times were significantly shorter, and pain scores at stitch removal and observer scar assessment scale scores were lower in the CS group. Patient scar assessment scale score was non‐significantly lower in the SI group. This study shows that the novel continuous locking with the Steri‐Strip technique is easier and quicker to perform, causes less pain when removing stitches, provides better aesthetic results than the simple interrupted suture technique and suggests the continuous locking with Steri‐Strip technique would be very useful for uncooperative young patients.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

Management of Traumatic Soft Tissue Injuries of the Face

Facial soft tissue injuries encompass a broad spectrum of presentations and often present significant challenges to the craniofacial surgeon. A thorough and systematic approach to these patients is critical to ensure that the patient is stabilized, other injuries identified, and the full extent of the injuries are assessed. Initial management focuses on wound cleaning with irrigation, hemostasis, and debridement of nonviable tissue. Definitive management is dependent on the region of the face involved with special considerations for critical structures such as the globe, lacrimal apparatus, facial nerve, and parotid duct. Following sound surgical principles, these injuries can be managed to maximize both functional and aesthetic outcomes while minimizing complications.

Evaluation of the Orofacial Features in the Victims of Abuse and Neglect of 5-16-Year-old Age Children

BACKGROUND

Oral cavity may be considered a pivotal focal point in physical assault or abuse because of its implication in communication and nutrition. Dentists trained in a child abuse curriculum can provide valuable information and assistance to physicians about oral and dental aspects of child abuse and neglect. The present study was conducted to evaluate the orofacial features of children between the age group of 5-16 years suspected to be victims of child abuse/neglect.

MATERIALS AND METHODS

This study was conducted on 250 children ranging between 5 and 16 years were enrolled in the study. All the participants were suspected to be victims of child abuse/neglect. The orofacial features were carefully examined by a well-trained dentist.

RESULTS

Two hundred and fifty children were enrolled in the study. Seventy-two children (30%) presented with laceration of various sites including lip (n = 13), frenum (n = 8), buccal mucosa (n = 26), palate (n = 16), and floor of the mouth (n = 9). Twenty-nine participants exhibited the features of avulsion (11.6%). Eighteen children revealed dento-alveolar fractures, 104 presented with dental caries (41.6%), 19 presented with missing teeth (7.6%), all the candidates presented with deposits (100%).

CONCLUSION

Careful intraoral and perioral examination of the participants victimized to abuse and/neglect is necessary as the oral cavity is a central focus for physical abuse, which may be allied to its importance in communication and nutrition. Physicians and dentists should work together to increase the prevention, detection, and treatment of these conditions.

Balloon-Augmented Leaflet Modification With Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Artery Obstruction and Laceration of the Anterior Mitral Leaflet to Prevent Outflow Obstruction: Benchtop Validation and First In-Man Experience

BACKGROUND

Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) and laceration of the anterior mitral leaflet to prevent outflow obstruction (LAMPOON) reduce the risk of coronary and left ventricular outflow obstruction obstruction during transcatheter aortic valve replacement and transcatheter mitral valve replacement. Despite successful laceration, BASILICA or LAMPOON may fail to prevent obstruction caused by inadequate leaflet splay in patients having challenging anatomy such as very small valve-to-coronary distance, diffusely calcified, rigid leaflets, or undergoing transcatheter aortic valve replacement inside existing transcatheter aortic valve replacement. We describe a novel technique of balloon-augmented (BA) leaflet laceration to enhance leaflet splay.

METHODS

We measured the incremental leaflet splay from BA-BASILICA in vitro. From November 2019 to March 2021, 16 patients underwent BA-BASILICA and 4 BA-LAMPOON at 3 centers.

RESULTS

BA-BASILICA increased benchtop leaflet tip splay 17%, maximum splay angle 30%, and splay area 23%, resulting in a more rounded apex and larger effective area. Sixteen patients at risk for inadequate BASILICA leaflet splay, including 4 transcatheter aortic valve replacement inside existing transcatheter aortic valve replacement, underwent BA-BASILICA. All had successful leaflet laceration. One had coronary obstruction requiring immediate orthotopic stenting. Two underwent elective orthotopic coronary stenting through the transcatheter valve cells for leaflet prolapse without coronary ischemia. There were no deaths during the procedure or at 30 days. Four patients at risk for inadequate anterior mitral leaflet splay underwent BA-LAMPOON. All had successful target leaflet laceration without left ventricular outflow obstruction obstruction or procedural death. One died within 30 days.

CONCLUSIONS

BA leaflet laceration enhances leaflet splay in vitro and may allow transcatheter aortic valve replacement and transcatheter mitral valve replacement in patients otherwise ineligible for traditional BASILICA or LAMPOON due to challenging anatomy. Graphic Abstract: A graphic abstract is available for this article.

Bacterial adhesion inhibitor prevents infection in a rodent surgical incision model

Surgical site infection risk continues to increase due to lack of efficacy in current standard of care drugs. New methods to treat or prevent antibiotic-resistant bacterial infections are needed. Multivalent Adhesion Molecules (MAM) are bacterial adhesins required for virulence. We developed a bacterial adhesion inhibitor using recombinant MAM fragment bound to polymer scaffold, mimicking MAM7 display on the bacterial surface. Here, we test MAM7 inhibitor efficacy to prevent Gram-positive and Gram-negative infections. Using a rodent model of surgical infection, incision sites were infected with antibiotic-resistant bioluminescent strains of Staphylococcus aureus or Pseudomonas aeruginosa. Infections were treated with MAM7 inhibitor or control suspension. Bacterial abundance was quantified for nine days post infection. Inflammatory responses and histology were characterized using fixed tissue sections. MAM7 inhibitor treatment decreased burden of S. aureus and P. aeruginosa below detection threshold. Bacterial load of groups treated with control were significantly higher than MAM7 inhibitor-treated groups. Treatment with inhibitor reduced colonization of clinically-relevant pathogens in an in vivo model of surgical infection. Use of MAM7 inhibitor to block initial adhesion of bacteria to tissue in surgical incisions may reduce infection rates, presenting a strategy to mitigate overuse of antibiotics to prevent surgical site infections.

Risk Factors for a False-Negative Examination in Complete Upper Extremity Nerve Lacerations

Background: Many patients with complete nerve lacerations after upper extremity trauma have a documented normal peripheral nerve examination at the time of initial evaluation. The purpose of this study was to determine whether physician-, patient-, and injury-related factors increase the risk of false-negative nerve examinations. Methods: A statewide health information exchange was used to identify complete upper extremity nerve lacerations subsequently confirmed by surgical exploration at 1 pediatric and 2 adult level I trauma centers in a single city from January 2013 to January 2017. Charts were manually reviewed to build a database that included Glasgow Coma Scale score, urine drug screen results, blood alcohol level, presence of concomitant trauma, type of injury, level of injury, laterality, initial provider examination, and initial specialist examination. Bivariate and multivariable analyses were performed to evaluate risk factors for a false-negative examination. Results: Two hundred eighty-eight patients met inclusion criteria. The overall false-negative examination rate was 32.5% at initial encounter, which was higher among emergency medicine physicians compared with extremity subspecialists (P < .001) and among trauma surgeons compared with surgical subspecialists (P = .002). The false-negative rate decreased to 8% at subsequent encounter (P < .001). Risk factors for a false-negative nerve examination included physician specialty, a gunshot wound mechanism of injury, injury at the elbow, and age greater than 71 years. Conclusion: There is a high false-negative rate among upper extremity neurotmesis injuries. Patients with an injury pattern that may lead to nerve injury warrant prompt referral to an upper extremity specialist in an effort to optimize outcomes.

The effect of warm compresses on perineal tear and pain intensity during the second stage of labor: A randomized controlled trial

Background

Warm compress is believed to reduce perineal tear occurrence and decrease pain intensity during the second stage of childbirth.

Objective

This study aimed to determine the effect of warm compresses on perineal tear and pain intensity during the second stage of labor.

Methods

A randomized controlled trial was conducted between 28 September 2018 to 30 October 2018 in King Khaled Hospital (KKH), affiliated with the Ministry of National Guard Hospital Affairs, King Abdul-Aziz Medical City Western Region, Saudi Arabia. According to eligibility criteria, the sample randomly recruited through lottery included 100 primigravida pregnant women, with 50 in each intervention and control group. Data were presented in the form of frequency and percentages, standard deviation, and mean. Chi-square test was used for data analysis, with p-value significance at ˂ 0.05.

Results

Sociodemographic data revealed no statistically significant difference in the age, education, occupation, and residence of both the control and experimental group. The perineum area's pain intensity after birth showed a statistically significant difference between the intervention and the control groups (p = 0.001). The perineal tear was also significantly different between both groups (p = 0.001).

Conclusion

The applied warm compresses on the perineum area positively reduce second and third-degree perineal tear and pain intensity during the second stage of labor and after childbirth. Therefore, midwives and nurses are expected to actively provide effective planned in-service training programs regarding warm compresses' advantages in the second stage of labor and apply this procedure actively.

The Application of Tissue Glue in Eyelid Laceration Repair in Children During the Coronavirus Disease 2019 Pandemic Lockdown in Wuhan

OBJECTIVE

To discuss a rapid and effective treatment used for children with eyelid lacerations during the COVID-19 lockdown in Wuhan to limit the risk of cross-infection.

METHODS

A comparative study was conducted of forty-five patients with eyelid lacerations who attended the Ophthalmology Department of Wuhan Children's Hospital between January 23, 2020 and March 6, 2020. The tissue glue Histoacryl was used to bond the wounds in 24 cases, while the traditional suture method was used for 21 cases. The wound healing time, complications, treatment satisfaction, and number of visits of the two groups were compared.

RESULTS

The two groups had similar baseline characteristics. The wound healing time (from wound disinfection to wound dressing) was shorter in the tissue glue group (4.35 ± 0.47min versus 11.71 ± 1.85 min, P< 0.01). There was 1 case of wound dehiscence in the tissue glue group. Twenty-two cases in the tissue glue group were satisfied, 2 cases were basically satisfied, and 0 were dissatisfied. Eleven cases in the traditional suture group were satisfied, 9 cases were basically satisfied, and 1 case was dissatisfied. The difference was statistically significant (P < 0.05). In terms of the number of visits, the tissue glue group visited (1.54 ± 0.88) times, while the traditional suture group visited (2.38 ± 0.59) times. The difference between the two groups was statistically significant (P < 0.01). The real-time reverse transcriptase polymerase chain tests for severe acute respiratory syndrome coronavirus 2 of all medical staff in the ophthalmology emergency room were negative.

CONCLUSION

Compared with the traditional suture method, tissue glue used in eyelid laceration in children has the advantages of painlessness, shorter operation duration, higher safety and satisfaction, greater ease of care, and fewer hospital visits. Tissue glue can be widely used to reduce the risk of cross-infection.

Comparison of preadministered and coadministered lidocaine for treating pain and distress associated with intranasal midazolam administration in children: A randomized clinical trial

OBJECTIVE

Pain and distress associated with intranasal midazolam administration can be decreased by administering lidocaine before intranasal midazolam (preadministered lidocaine) or combining lidocaine with midazolam in a single solution (coadministered lidocaine). We hypothesized coadministered lidocaine is non-inferior to preadministered lidocaine for decreasing pain and distress associated with intranasal midazolam administration.

METHODS

Randomized, outcome assessor-blinded, noninferiority trial. Children aged 6 months to 7 years undergoing laceration repair received intranasal midazolam with preadministered or coadministered lidocaine. Pain and distress were evaluated with the Observational Scale of Behavioral Distress-Revised (OSBD-R) (primary outcome; non-inferiority margin 1.8 units) and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Faces, Legs, Activity, Cry, Consolability (FLACC) scales and cry duration (secondary outcomes). Secondary outcomes also included adverse events, clinician and caregiver satisfaction, and pain and distress associated with intranasal lidocaine administration.

RESULTS

Fifty-one patients were analyzed. Mean OSBD-R scores associated with intranasal midazolam administration were 6.4 (95% confidence interval [CI] 5, 7.8) and 7 (95% CI 5.2, 8.9) units for preadministered and coadministered lidocaine, respectively. The difference of 0.6 (95% CI -1.7, 2.8) units represented an inconclusive non-inferiority determination. CHEOPS and FLACC scores and cry duration were similar between groups. OSBD-R, CHEOPS, and FLACC scores and cry duration associated with intranasal lidocaine administration were 3.8, 9.9, and 6 units, and 56 seconds, respectively. Clinicians considered coadministered lidocaine easier to administer.

CONCLUSION

Pain and distress associated with intranasal midazolam administration were similar when using coadministered or preadministered lidocaine, but our non-inferiority determination was inconclusive. Administration of intranasal lidocaine by itself was associated with a measurable degree of pain and distress.Keywords: intranasal, midazolam, anxiolysis, sedation, emergency department, emergency medicine, pain, distress, pediatric, lidocaine, laceration.

Annular intubation with pigtail probe for canalicular lacerations

Purpose:

Pigtail probe as a procedure of choice for canalicular laceration.

Methods:

Retrospective, consecutive interventional case series of patients with eyelid laceration involving the canaliculus undergoing repair. All patients were subjected to repair with pigtail probe as first choice and only if this was not possible, they were repaired by other method. Outcome was analyzed in terms of cosmetic, functional, and anatomic success.

Results:

A total of 35 patients (mean age, 10.88 years) underwent eyelid and canaliculus repair by a single surgeon (RM). In all, 32 (91.42%) canalicular lacerations were repaired by annular intubation using a pigtail probe, while the remaining 3 (8.58%) lacerations in which pigtail probe intubation was not possible, were repaired by an alternative method. Upper canaliculus was involved in 6 (17.14%) and lower canaliculus in 29 (82.86%) eyes. Mean follow-up was 8.2 months (range 3–13 months). Intubation tubes were removed after at least 3 months (range 12–20 weeks). None of the patients had complaints of epiphora. All the patients had good cosmesis, anatomic alignment and functional success as assessed by dye disappearance test in younger children and lacrimal irrigation in older children and adults.

Conclusion:

Bicanalicular annular repair with pigtail probe achieved excellent functional and cosmetic results. The loop minimizes the chances of extrusion of the tube, maintains natural anatomic alignment of the cut ends of the canaliculus and thus retains the integrity of the delicate canalicular system. Pigtail probe intubation can be considered as the first choice in canalicular lacerations.

Outcomes of laceration suture repair in the emergency department

OBJECTIVE

To assess patient satisfaction with laceration management, post-ED care, cosmesis and complication rates.

METHODS

We undertook a prospective observational study of adult patients with lacerations sutured in two EDs over a 4-month period. ED data included participant demographics, laceration characteristics and management. A telephone survey was undertaken approximately 14 days post-ED discharge. Patient satisfaction with post-ED pain management, advice on wound care and follow up, overall management and wound cosmesis were evaluated using a six-item satisfaction scale (very dissatisfied to very satisfied). Details of wound infection, dehiscence and suture failure were recorded.

RESULTS

Eighty-nine patients participated. The number (% [95% confidence interval]) of patients very satisfied with their laceration management were: post-ED pain management 55 (62.5% [51.5-72.4]), wound care advice 51 (57.3% [46.4-67.6]), follow-up advice 39 (43.8% [33.5-54.7]), overall management 61 (68.5% [57.7-77.7]) and cosmetic appearance 46 (51.7% [40.9-62.3]). Infection, dehiscence and suture failure occurred in 5 (5.6%), 8 (9.0%) and 8 (9.0%) cases, respectively. These complications were not associated with being very satisfied overall (P = 0.96). Patients very satisfied with post-ED pain management, wound care advice, follow-up advice or wound cosmesis were much more likely to be very satisfied overall (P < 0.001).

CONCLUSIONS

Most patients are very satisfied with their laceration management. However, there is scope for improvement, especially for follow-up and wound care advice. Complications are infrequent and not associated with overall satisfaction.

Impact of Leaflet Laceration on Transcatheter Aortic Valve-in-Valve Washout: BASILICA to Solve Neosinus and Sinus Stasis

OBJECTIVES

The aim of this study was to evaluate any potential leaflet washout benefits after bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction during TAVR (BASILICA) in transcatheter valve-in-valve (ViV) in the context of leaflet thrombosis.

BACKGROUND

Leaflet thrombosis after transcatheter aortic valve replacement is secondary to flow stasis in both the sinus and neosinus. Strategies to improve washout and ameliorate neosinus and sinus flow velocities may have the potential to mitigate the occurrence of clinical and subclinical leaflet thrombosis.

METHODS

A 23-mm Edwards SAPIEN 3 and a 26-mm Medtronic Evolut were deployed in a 23-mm transparent surgical aortic valve model before and after leaflet laceration. The valves were placed in the aortic position of a pulse duplicator flow loop. Particle image velocimetry was performed to quantify sinus flow hemodynamic status. A tracing fluorescent dye was injected to evaluate the number of cycles to washout in both regions of interest.

RESULTS

The leaflet laceration procedure led to an increase in the velocities in the sinus and the neosinus by 50% for Evolut ViV and 61.9% for SAPIEN 3 ViV. In addition, leaflet laceration led to a reduction in overall cycles to washout in the neosinus by at least 56% with the Evolut and 54.5% with the SAPIEN 3 and in the sinus by at least 16.7% with the Evolut and 60.8% with the SAPIEN.

CONCLUSIONS

Leaflet laceration using a BASILICA-type approach may hold the potential to mitigate neosinus and sinus flow stasis. Controlled in vivo trials are necessary to establish the potential benefit of BASILICA to reduce the occurrence of leaflet thrombosis.

Use of calendula ointment after episiotomy: a randomized clinical trial

Objective: Episiotomy is associated with an increased risk of postpartum pain, bleeding, and dyspareunia. The hypothesis of this trial was that in women with singleton pregnancy, and spontaneous labor at term, use of calendula ointment would reduce pain after episiotomy.Methods: This was a single-center parallel group randomized trial of women with singleton pregnancies and spontaneous labor at term who were randomized to either use of calendula ointment (i.e. intervention group) or standard care (i.e. control group) after episiotomy. Eligible women were those with singleton gestations in spontaneous labor and vertex presentation at term. Women with premature rupture of membranes were excluded from the study. Women in the intervention group were recommended use of calendula ointment 4 h after the episiotomy and then every 8 h for 10 days. The primary outcome was the pain level. Pain level was self-reported and recorded using the verbal rating scale (VRS). The effect of the calendula ointment was quantified as mean difference (MD) with 95% confidence interval (CI).Results: During the study, 100 women agreed to take part in the study, underwent randomization, and were enrolled in this trial. Of the 100 randomized women, 50 were randomized to the calendula ointment group, and 50 to the control group. No women were excluded after randomization or lost to follow up.Women who received calendula ointment after episiotomy compared to standard care had a significantly lower pain level starting from day two and during all the follow-up. Calendula ointment also improve wound healing in terms of redness and edema.Conclusions: Use of calendula ointment significantly reduce pain after episiotomy.

Successful anesthetic management of a massive thoracoabdominal impalement injury

We describe the management, focusing on the anesthetic preparedness, of a 44-year-old man who presented with impalement of a 1 m long serrated rod through the right supraclavicular fossa extending up to the right iliac fossa, along with rib fractures and laceration of the liver and diaphragm.

Management outcomes of canalicular laceration in children

PURPOSE:

To report the epidemiological data, clinical profile, management, and outcomes of canalicular lacerations in the pediatric age group in a tertiary eye care hospital in Saudi Arabia.

METHODS:

This retrospective study evaluated pediatric patients who underwent canalicular laceration repair in the last 15 years at King Khalid Eye Specialist Hospital (KKESH), Saudi Arabia. Demographics, causes of injury, type of trauma, surgical approach, and outcomes were analyzed. The success of repair was defined as the absence of epiphora after canaliculus repair with negative dye disappearance test (DDT). Success within subgroups was compared. P < 0.05 was considered statistically significant.

RESULTS:

The study sample was comprised of 43 patients, with a median age of 6.35 years (range, 1.77–17.96 years). Most of the patients were males (69.8%). Sharp objects were the most common cause of canalicular laceration (46.5%), being 9 (20.9 %) caused by a metallic clothing hanger. Lower canaliculus was involved in 65.1%, upper canaliculus in 32.6%, and both canaliculi in 2.3% of patients. Canaliculus repair was performed with a bicanalicular stent in 58.1 % and monocanalicular stent in 41.9 % of patients.The success rate and risk of complications using bicanalicular or monocanalicular stent did not differ (P = 0.065). Functional success was achieved in 87.5% of patients.

CONCLUSION:

Canalicular laceration is common in male children, mainly affecting the lower canaliculus. There was no difference in success rate between monocanalicular and bicanalicular stent. As canalicular laceration could be related to social determinants, the main causes should be highlighted in community health education initiatives.

Variations in the aftercare of facial wounds: a survey of maxillofacial clinicians

Good aftercare of traumatic wounds reduces the risk of infection and improves functional and aesthetic outcomes. Inconsistencies in the instructions given by oral and maxillofacial (OMF) surgeons to patients with facial lacerations have previously been noted. We therefore sent anonymous online surveys to OMF clinicians in the United Kingdom to investigate the extent of the variation in aftercare advice given to patients who have had traumatic lacerations of the skin of the head and neck. Respondents were asked about their current practice, including instructions on how to clean wounds, the provision of cleaning materials, use of topical dressings, and advice regarding dry time; also the number of days before the removal of sutures, and specialist review of facial wounds. A total of 63 responded. There was considerable variation within and between grades regarding the advice given. Advice varied and there was no consensus in any of the areas questioned. Robust evidence on the aftercare of traumatic lacerations is lacking. To develop practical guidelines for advice there is a need for further research in the area and further discussion about the aftercare of lacerations.

Prognostic Factors for Iatrogenic Tracheal Rupture: A Single-Center Retrospective Cohort Study

Iatrogenic tracheal ruptures are rare but severe complications of medical interventions. The main goal of this study was to explore prognostic factors for all-cause mortality and rupture-related (adjusted) mortality. We retrospectively analyzed patients admitted to an academic referral center over a 15-year period (2004-2018). Fifty-four patients met the inclusion criteria, of whom 36 patients underwent surgical repair and 18 patients were treated conservatively. In a 90-day follow-up, the all-cause mortality was 50%, while the adjusted mortality was 13%. Rupture length was identified as a predictor for all-cause mortality (area under the curve, 0.84; 95% confidence interval (CI) 0.74-0.94) with a cutoff rupture length of 4.5 cm (sensitivity, 0.70; specificity, 0.81). Multivariate analysis confirmed rupture length as a prognostic factor for all-cause mortality (adjusted hazard ratio (HR) 1.5; 95% CI 1.2-1.9; p = 0.001), but not for adjusted mortality (HR 1.5; 95% CI 0.97-2.3; p = 0.068), while mediastinitis predicted adjusted mortality (HR 5.8; 95% CI 1.1-31.7; p = 0.042), but not all-cause mortality (HR 1.6; 95% CI 0.7-3.5; p = 0.243). The extent of iatrogenic tracheal rupture and mediastinitis might be relevant prognostic factors for all-cause mortality and adjusted mortality, respectively.

School Nurses on the Front Lines of Medicine: When You Don't Need to "STOP AT AN ER STAT!"-The Role of Urgent Care Centers in the Management of Students With Nonemergent Chief Complaints

In the midst of our nation's growing primary care provider shortage and subsequent overutilization of the emergency room (ER), urgent care centers represent an accessible, convenient, and affordable alternative for the management of "urgencies" or nonemergent illnesses and injuries. Despite the presence of competent healthcare providers and a wide array of services at urgent care centers, patients continue to pursue care in the ER for urgencies. School nurses may utilize urgent care centers for the evaluation and management of students with nonemergent medical or traumatic chief complaints. This article discusses the field of urgent care medicine, describes the pediatric services provided at urgent care centers, and summarizes the capabilities of centers to deal with potential urgencies versus emergencies in children and adolescents based on their chief complaint.

Burst Lacerations: A New Term for a Common Injury to the Foot

OBJECTIVE

This case series describes four cases with a similar mechanism of injury: crush injuries to the foot from hydraulic presses/trailers. The aim of the study was to review a specific cohort of pneumatic compression injuries of the foot in terms of their soft-tissue component, and in particular relating to the burst lacerations.

METHOD

The mechanism and patterns of injury were reviewed to identify common features in a case series of four crush injuries to the foot which presented to the Emergency Department of University Hospital Galway over a period of 6 months between January and July 2017.

RESULTS

There were four cases of high-energy crush injuries to the feet seen in involved farmers (mean age 55). The cases presented with similar soft-tissue injuries, despite having quite varied bony injuries. All patients had lacerations of the webbed spaces, which is likely due to extrusion of the interosseous muscles as they are flattened. Three patients had lacerations along the medial side of their foot extending transversely across the plantar surface.

CONCLUSION

A common pattern of soft-tissue injury was present in these cases. We feel the term "burst laceration" is an appropriate term for describing this pattern. Burst lacerations are a marker of high-energy crush injuries and should alert surgeons to the severe soft-tissue injury that likely overlies the more obvious fracture. The importance of soft-tissue management in high-energy lower limb injury cannot be overstated. We feel the presence of burst lacerations to the foot should alert the surgeon to a high-energy crush-injury type mechanism of injury, and guide both soft-issue and bony management to optimize patient outcomes.

Endovascular Radial Artery Sacrifice in an Unsalvageable Transradial Access Site Bleeding due to Cutting Balloon Angioplasty

The radial artery access site laceration is rare. We hereby described a case of radial artery access site laceration during retrieval of a cutting balloon. The bleeding site was not responsive to hemostatic maneuvers such as application of an external blood pressure cuff, balloon inflation, and an external compression bandage and was eventually coil embolized. Sacrifice using endovascular coiling averted surgical ligation which was the alternative.

Traumatic perineal injury in a 13-year-old female: Case report and review of the literature

Traumatic perineal injury in children is a rather underestimated condition, in terms of occurrence. The rapid stretching of the soft perineal environment, combined with the surrounding osseous tissue of the pelvis, can cause severe injuries. The key to successful management of these injuries includes timely resuscitation, thorough physical examination and quick and safe repair of damages.

Experience of nail bed injuries at a tertiary hand trauma unit: a 12-month review and cost analysis

The aim of this study was to analyse the management of nail bed injuries from a clinical and economic perspective. We carried out a retrospective analysis of nail bed injuries treated operatively at a tertiary Plastic Surgery Hand Trauma Unit during 2016. The National Schedule of Reference Costs (2015-2016) was used to estimate the costs of treating 630 patients. The most common mechanism was a crush injury in a door (33%). Fifty-five per cent of patients had an associated tuft fracture. The minimum cost per annum for patients treated for nail bed injuries in our unit was calculated to be £511,560 (€573,362; US$666,664). Many nail bed injuries are preventable and because they present a very high financial burden on the National Health Service, targeted prevention strategies should be considered. Level of evidence: IV.

Intralesional application of medical grade honey improves healing of surgically treated lacerations in horses

BACKGROUND

Infection and dehiscence of simple lacerations is common in horses, and consistently effective methods of prevention are yet to be found. Honey has been shown to promote wound healing when applied topically; however, intralesional application prior to wound closure has not been reported.

OBJECTIVES

To examine whether intralesional application of medical grade honey (MGH) would reduce the incidence of infection and dehiscence following wound closure.

STUDY DESIGN

Prospective, open-label randomised block design clinical study.

METHODS

Lacerations, treated by field practitioners, were divided into treatment and control groups using block randomisation. Horses in the treatment group received a single intralesional treatment with l-mesitran gel (MGH). Data were collected at the time of wound closure and at suture removal.

RESULTS

Data from 127 horses were included, 69 MGH-treated and 58 control cases. No adverse effects of the MGH were recorded. MGH-treated horses were more likely to completely heal (P = 0.006, odds ratio [OR] 3.40 95% confidence interval [CI] 1.41-8.20), to have no signs of infection (P = 0.007, OR 3.64, CI 1.42-9.26) and for the veterinarians to report some degree of satisfaction (P = 0.04, OR 2.72, CI 1.05-7.09) compared to control cases. Numbers needed to treat for complete healing was 5.1 (CI 2.8-40).

MAIN LIMITATIONS

Clinical studies have inherent flaws compared to wound healing models, because of variability between wounds. There were more horses with limb injuries in the control group, although not statistically significant, this may have biased the results. Clinical satisfaction and signs of infection were subjective evaluations and evaluators were not blinded to the treatment group.

CONCLUSIONS

Intralesional application of MGH to lacerations prior to wound closure may be beneficial in preventing infection and dehiscence. Larger, blinded studies focusing on wounds at a specific location with more objective assessment should be pursued.

Surgical management of postpartum hemorrhage

When medical management of PPH is unsuccessful, surgical options should be utilized in a timely fashion in order to reduce maternal morbidity and mortality. This chapter describes ways of effective preparation, mobilization of resources and an organized approach to evaluation and surgical amelioration of PPH. Multiple fertility preserving surgical techniques to control PPH are described. Although a variety of conservative surgical approaches can be used in the setting of PPH, in a hemodynamically unstable patient, readiness for definitive management with a hysterectomy is necessary in order to reduce the risk of maternal mortality.

Trigger finger secondary to a neglected flexor tendon rupture

Secondary trigger finger caused by trauma to the hand, especially associated with partial flexor tendon rupture, is not a common condition. Thus, the clinical manifestations of these patients are not well-known. The aim of this study is to present secondary trigger finger caused by a neglected partial flexor tendon rupture including discussion of the mechanism and treatment.We retrospectively reviewed the records of 6 patients with trigger finger caused by a neglected partial flexor tendon rupture who had been treated with exploration, debridement, and repairing of the ruptured tendon from August 2010 to May 2015. The average patient age was 41 years (range, 23-59). The time from injury to treatment averaged 4.7 months. The average follow-up period was 9 months (range, 4-18). Functional outcome was evaluated from a comparison between the Quick-disabilities of the arm, shoulder, and hand (DASH) score and the visual analogue scale (VAS) for pain, which were measured at the time of preoperation and final follow up.Four patients showed partial rupture of the flexor digitorum profundus (FDP) tendon and 3 showed partial rupture of the flexor digitorun superficialis (FDS) tendon. Both the FDP and FDS tendons were partially ruptured in 2 patients, and the remaining patient had a partial rupture of the flexor pollicis longus tendon. All patients regained full range of motion, and there has been no recurrence of triggering. The average VAS score decreased from 3.6 (range, 3-5) preoperatively to 0.3 (range, 0-1) at the final follow up. The average Quick-DASH score decreased from 33.6 preoperatively to 5.3 at the final follow up.When we encounter patients with puncture or laceration wounds in flexor zone 2, even when the injury appears to be simple, partial flexor tendon laceration must be taken into consideration and early exploration is recommended.

Incidence, Risk Factors and Consequences of Epilepsy-Related Injuries and Accidents: A Retrospective, Single Center Study

Introduction: This study was designed to evaluate risk factors and incidence of epilepsy-related injuries and accidents (ERIA) at an outpatient clinic of a German epilepsy center providing healthcare to a mixed urban and rural population of over one million inhabitants. Methods: Data acquisition was performed between 10/2013 and 09/2014 using a validated patient questionnaire on socioeconomic status, course of epilepsy, quality of life (QoL), depression, injuries and accidents associated with seizures or inadequate periictal patterns of behavior concerning a period of 3 months. Univariate analysis, multiple testing and regression analysis were performed to identify possible variables associated with ERIA. Results: A total of 292 patients (mean age 40.8 years, range 18-86; 55% female) were enrolled and analyzed. Focal epilepsy was diagnosed in 75% of the patients. The majority was on an antiepileptic drug (AEDs) polytherapy (mean number of AEDs: 1.65). Overall, 41 patients (14.0%) suffered from epilepsy-related injuries and accidents in a 3-month period. Besides lacerations (n = 18, 6.2%), abrasions and bruises (n = 9, 3.1%), fractures (n = 6, 2.2%) and burns (n = 3, 1.0%), 17 mild injuries (5.8%) were reported. In 20 (6.8% of the total cohort) cases, urgent medical treatment with hospitalization was necessary. Epilepsy-related injuries and accidents were related to active epilepsy, occurrence of generalized tonic-clonic seizures (GTCS) and drug-refractory course as well as reported ictal falls, ictal loss of consciousness and abnormal peri-ictal behavior in the medical history. In addition, patients with ERIA had significantly higher depression rates and lower QoL. Conclusion: ERIA and their consequences should be given more attention and standardized assessment for ERIA should be performed in every outpatient visit.

Hepatic Complications of Umbilical Venous Catheters in the Neonatal Period: The Ultrasound Spectrum

OBJECTIVES

Umbilical venous catheterization is commonly used in the neonatal period; however, it has some complications. In this study, we evaluated neonates who underwent umbilical venous catheterization and developed hepatic complications. Furthermore, we aimed to define all of the possible lesions and to clarify the imaging findings of umbilical venous catheter-induced hepatic injury.

METHODS

Two hundred forty-four neonates who underwent umbilical venous catheterization between March 2013 and September 2015 in a single tertiary care referral center were included in this study. To determine whether they had any hepatic complications, all patients underwent abdominal grayscale and Doppler ultrasound examinations, and their clinical data were recorded.

RESULTS

The frequency of liver-related complications from umbilical venous catheterization was 33.6% (82 of 244). Air in the portal venous system was the most frequent complication (20.1% [49 of 244]). Left portal venous thrombosis was noted in 6.1% (15 of 244). Parenchymal lesions in the liver related to umbilical venous catheterization were seen in 7.4% of patients (18 of 244) as follows: single nodular echogenic lesions (4.1% [10 of 244]), branching small nodular echogenic lesions (2.1% [5 of 244]), and large irregular heterogeneous lesions with laceration and perihepatic fluid (1.2% [3 of 244]). There was no statistical significance for any type of complication according to the gestational age (P > .05).

CONCLUSIONS

Hepatic complications due to umbilical venous catheters are not uncommon in the neonatal period. Ultrasound is the best imaging modality for confirming the diagnosis and for follow-up.

Table Saw Injuries: Are Our Safety Features Really Keeping Us Safe?

BACKGROUND

Currently, table saws sold in the United States have 3 safety features (riving knife, blade guard, and antikickback device) designed to prevent personal injury; however, these features can hinder the user's movements and are often disabled or removed. Despite the frequency of table saw injuries, there is relatively limited literature regarding them.

METHODS

We performed a retrospective, observational study of characteristics associated with injuries incurred while using a table saw. Electronic medical records from Bassett Medical Center were reviewed from 2002 to 2014 to identify patients who sustained table saw injury, and surveys were sent to the patients. Tests of association between survey variables (eg, presence/absence of safety device vs severity of injury) were carried out using chi-square or Fisher exact test.

RESULTS

Seventy-three percent of those injured had disabled their safety features or had no safety features present; 27% of those injured had one or more safety features enabled when they sustained the injury. Of those injured, 18% sustained a "mild" injury (skin laceration), 39% sustained a "moderate" injury (nerve or tendon injury), and 43% sustained a "severe" injury (partial or complete amputation). There was no statistically significant association between severity of the injury and presence/absence of safety features.

CONCLUSIONS

This study highlights 2 major problems with the current safety features: People are dissatisfied with current safety features, disabling them and sustaining injuries, and even when they are enabled, people are still getting injured-suggesting inadequacy of the current features.

Low-Intensity Vibration Improves Muscle Healing in a Mouse Model of Laceration Injury

Recovery from traumatic muscle injuries is typically prolonged and incomplete, leading to impaired muscle and joint function. We sought to determine whether mechanical stimulation via whole-body low-intensity vibration (LIV) could (1) improve muscle regeneration and (2) reduce muscle fibrosis following traumatic injury. C57BL/6J mice were subjected to a laceration of the gastrocnemius muscle and were treated with LIV (0.2 g at 90 Hz or 0.4 g at 45 Hz for 30 min/day) or non-LIV sham treatment (controls) for seven or 14 days. Muscle regeneration and fibrosis were assessed in hematoxylin and eosin or Masson's trichrome stained muscle cryosections, respectively. Compared to non-LIV control mice, the myofiber cross-sectional area was larger in mice treated with each LIV protocol after 14 days of treatment. Minimum fiber diameter was also larger in mice treated with LIV of 90 Hz/0.2 g after 14 days of treatment. There was also a trend toward a reduction in collagen deposition after 14 days of treatment with 45 Hz/0.4 g (p = 0.059). These findings suggest that LIV may improve muscle healing by enhancing myofiber growth and reducing fibrosis. The LIV-induced improvements in muscle healing suggest that LIV may represent a novel therapeutic approach for improving the healing of traumatic muscle injuries.

Imaging Patterns of Injuries After the 2015 Amtrak Philadelphia Train Derailment

OBJECTIVE

The purpose of this article is to describe the injury patterns observed in the 2015 Philadelphia Amtrak train derailment.

CONCLUSION

Fractures accounted for most observed injuries, but uncommon and potentially serious injuries included posterior sternoclavicular dislocation and mesenteric contusion. Imaging plays a critical role in the triage of patients during mass-casualty events, and familiarity with the injury patterns associated with high-velocity unrestrained blunt force trauma will aid diagnosis in any future similar occurrence.

Predictors of Nerve Injury After Gunshot Wounds to the Upper Extremity

BACKGROUND

The purpose of this study is to examine the incidence of nerve injury, clinical variables associated with nerve palsy, and predictive factors of nerve laceration after gunshot wounds to the upper extremity.

METHODS

Forty-one patients from a level I trauma center with gunshot wounds to the upper extremity who underwent surgical exploration between 2007 and 2014 were identified retrospectively. Patients with proximal ipsilateral injuries, inadequate documentation, imaging, or with a pre-existing neurologic deficit were excluded. Patient demographics, clinical sensory and motor examination, the presence of retained bullet fragments, fracture, vascular injury, and compartment syndrome were recorded. Univariate analysis was performed to determine significant predictors of intraoperative nerve laceration. Significance was set at P < .05.

RESULTS

Fifty-nine nerves were explored in 41 patients. There were higher frequencies of fractures, retained fragments, vascular injury, and compartment syndrome in patients with nerve palsies, although none were associated with nerve laceration. Patients with palsies on presentation were significantly more likely to have a nerve laceration found intraoperatively.

CONCLUSIONS

Gunshot wounds to the upper extremity with focal nerve deficits remain a difficult problem for orthopedic surgeons. The present study provides evidence that may help guide operative decision making in treatment of these injuries.