A New Computed Tomography-Based Measure that Provides Insight Into Hip Stability in Patients With Posterior Wall Acetabular Fractures

OBJECTIVES

To describe the technique and results of a new sagittal plane computed tomography (CT)-based angular measure for predicting stability after posterior wall acetabular fractures (PWF).

METHODS

DESIGN

Retrospective review.

SETTING

Academic Level II trauma center.

PATIENT SELECTION CRITERIA

Fifty-eight consecutive patients with PWF (AO/OTA class 62A.1), 98% were high-energy injuries.

INTERVENTION

A new sagittal CT measure of PWF based on the angle subtending the joint center, cranial and caudal fracture exits.

OUTCOME MEASURES AND COMPARISONS

Hip incongruity or dislocation demonstrated using gold standard test, examination under anesthesia (EUA), or instability on static images. Prediction of hip instability using a sagittal CT angular measure based on cranial and caudal fracture exits was compared with previous axial CT measures suggestive of increased risk for instability including posterior wall size >50%, and those with cranial exit within 5.0 mm of the acetabular dome.

RESULTS

There were 32 operative and 26 nonoperatively treated fractures. Thirty fractures were determined to be unstable, and 28 were stable after EUA. Measurements of >70 degrees using the sagittal CT angular measure predicted instability in 28 of 28 patients, and ≤70 degrees predicted stability in 30 of 30 patients (sensitivity 100% and specificity 100%). Prevalence of EUA confirmed instability for subgroups with PWF based on prior axial CT measures were as follows: ≥50% wall involvement (11/16; sensitivity 67% and specificity 60%; 95% CI, 45%-89%/45%-75%), fracture within 5.0 mm of dome (5/18; sensitivity 86% and specificity 73%; 95% CI, 71%-100%/59%-87%), fracture within 5.0 mm of dome and ≥50% involvement (1/9; sensitivity 89% and specificity 56%; 95% CI, 69%-100%/24%-88%).

CONCLUSIONS

In a sample of 58 mostly high energy posterior wall fractures all having had an EUA, a new sagittal angular CT measurement of ≤70 degrees predicted hip stability and >70 degrees predicted instability with 100% sensitivity and specificity.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does lower extremity fracture fixation technique influence neurologic outcomes in patients with traumatic brain injury? The EAST Brain vs. Bone multicenter trial

OBJECTIVE

This study aimed to determine whether lower extremity fracture fixation technique and timing (≤24 vs. >24 hours) impact neurologic outcomes in TBI patients.

METHODS

A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age 18 years and older, head Abbreviated Injury Scale (AIS) score of >2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN), or open reduction and internal fixation (ORIF). The analysis was conducted using analysis of variamce, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Scale (RLAS-R).

RESULTS

Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN, or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe lower extremity injuries (AIS score, 4-5) compared with the IMN group (16% vs. 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix, 15 [8-24] vs. ORIF, 26 [12-85] vs. IMN, 31 [12-70]; p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of lower extremity fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002-1.03 and OR, 2.37; 95% CI, 1.75-3.22), and a higher Glasgow Coma Scale motor score on admission (OR, 0.84; 95% CI, 0.73-0.97) was associated with higher RLAS-R score at discharge.

CONCLUSION

Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of lower extremity fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Acute Care Surgery and Surgical Rescue: Expanding the Definition

BACKGROUND

Surgical rescue (SR) is the recovery of patients with surgical complications. Patients transferred (TP) for surgical diagnoses to higher-level care or inpatients (IP) admitted to nonsurgical services may develop intra-abdominal infection (IAI) and require emergency surgery (ES). The aims were to characterize the SR population by the site of ES consultation, open abdomen (OA), and risk of mortality.

STUDY DESIGN

This was an international, multi-institutional prospective observational study of patients requiring ES for IAI. Laparotomy before the transfer was an exclusion criterion. Patients were divided into groups: clinic/ED (C/ED), IP, or TP. Data collected included demographics, the severity of illness (SOI), procedures, OA, and number of laparotomies. The primary outcome was mortality. Multivariable logistic regression models were constructed.

RESULTS

There were 752 study patients (C/ED 63.8% vs TP 23.4% and IP 12.8%), with a mean age of 59 years and 43.6% women. IP had worse SOI scores (Charlson Comorbidity Index, American Society of Anesthesiologists Physical Status Classification System, and Sequential Organ Failure Assessment). The most common procedures were small and large bowel (77.3%). IP and TP had similar rates of OA (IP 52.1% and TP 52.3 %) vs C/ED (37.7%, p < 0.001), and IP had more relaparotomies (3 or 4). The unadjusted mortality rate was highest in IP (n = 24, 25.0%) vs TP (n = 29, 16.5%) and C/ED (n = 68, 14.2%, p = 0.03). Adjusting for age and SOI, only SOI had an impact on the risk of mortality (area under the curve 86%).

CONCLUSIONS

IP had the highest unadjusted mortality after ES for IAI and was followed by the TP; SOI drove the risk of mortality. SR must be extended to IP for timely recognition of the IAI.

Emergency General Surgery Procedures in Older Adults: Where You Live Matters!

BACKGROUND

Neighborhood location and its built environment are important social determinants of health that impact health outcomes. Older adults (OAs) represent the fastest growing population in the United States with many requiring emergency general surgery procedures (EGSPs). The aim of this study was to evaluate whether neighborhood location, represented by zip code, influences mortality and disposition in OAs undergoing EGSPs in Maryland.

METHODS

A retrospective review was undertaken of hospital encounters in the Maryland Health Services Cost Review Commission from 2014 to 2018 of OAs undergoing EGSPs. Older adults residing in the 50 most affluent (MANs) and 50 least affluent (LANs) neighborhoods based on zip codes were compared. Data collected included demographics, all patient-refined (APR)-severity of illness (SOI), APR-risk of mortality (ROM), Charlson Comorbidity Index, complications, mortality, and discharge to a higher level of care.

RESULTS

Of the 8661 OAs analyzed, 2362 (27.3%) resided in MANs and 6299 (72.7%) in LANs. Older adults in LANs were more likely to undergo EGSPs, had higher APR-SOI and APR-ROM, and experienced more complications, discharge to higher level of care, and mortality. Living in LANs was independently associated with discharge to higher level of care (OR 1.56, 95% CI: 1.38-1.77, P < .001) and increased mortality (OR 1.35, 95% CI: 1.07-1.71, P = .01).

DISCUSSION

Mortality and quality of life in OAs undergoing EGSPs are dependent on environmental factors likely determined by neighborhood location. These factors need to be defined and incorporated in predictive models of outcomes. Public health opportunities to improve outcomes for those who are socially disadvantaged are necessary.

Validation of the American Association for the Surgery of Trauma Emergency General Surgery Grading System for Colorectal Resection: An EAST Multicenter Study

BACKGROUND

The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection.

METHODS

Patients enrolled in the "Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS-to anastomose or not to anastomose" study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality.

RESULTS

There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy (P = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not.

CONCLUSION

The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.

Surgical Intensivist-Led Training in Critical Care Ultrasound Improves Performance

BACKGROUND

Critical care ultrasound (CCUS) is essential in modern practice, with CCUS including cardiac and noncardiac ultrasound. The most effective CCUS training is unknown, with a diverse skill set and knowledge needed for competence. The objective of this project was to evaluate the effect of a surgical intensivist-led training program on CCUS competence in critical care fellows.

METHODS

This was a single institution retrospective review from 2016 to 2018 at the R Adams Cowley Shock Trauma Center. Our yearlong surgical intensivist (SI)-led CCUS training program for critical care fellows includes a daylong CCUS training class, CCUS lectures, a CCUS rotation, and bedside CCUS instruction during rotations. Fellows take a knowledge test and skills test before (pretest) and after (posttest) this program. Critical care ultrasound skill was graded on a scale from 1-5, with 4 (minimal help) or 5 (no help) considered competent. Emergency medicine, surgery, and medicine-trained critical care fellows were included.

RESULTS

Forty-two critical care fellows were included. Mean posttest scores increased significantly for 21/22 (96%) of skills tested and for 14/30 (47%) of knowledge questions compared to pretest scores. The mean composite skill score increased from 3.25 to 4.82 from pretest to posttest (P < .001). The mean composite knowledge score increased from 60% to 80% from pretest to posttest (P < .001).

CONCLUSION

SI-led training improves CCUS competence and knowledge despite the breadth of CCUS.

Comparison of individual and composite radiographic markers of frailty in trauma

BACKGROUND

Clinical frailty scores usually involve questionnaires or physical testing. Many trauma patients are not able to participate in these. Radiographic measurement of frailty may be a viable alternative. Individual radiographic markers of frailty have been investigated, such as sarcopenia or osteopenia. The ideal radiographic variable (or variables) to measure frailty in trauma is unknown.

STUDY DESIGN

A retrospective review was performed of restrained drivers ages 40 and greater at a single institution from 2010-2015. Multiple markers of radiographic frailty were measured including: sarcopenia, osteopenia, vascular calcifications, sarcopenic obesity, emphysema, renal volume, cervical spine degeneration, and cerebral atrophy. Frailty was defined as the worst quartile for each radiographic variable, and these values were summed to create a composite marker of frailty. The primary outcome was discharge disposition. We hypothesized that a composite frailty score would be associated with discharge disposition while individual markers would not be associated with discharge disposition.

RESULTS

Overall 489 patients were included in this study. Cerebral atrophy (p = 0.05), renal volume (p = 0.004), sarcopenia (p = 0.05), vascular calcifications (p = 0.02) and sarcopenic obesity (p = 0.01) were associated with discharge disposition. Pearson's correlation coefficients between radiographic frailty markers were all less than 0.4. Youden's Index was 0.26 (p < 0.001) at a composite score of 3. In multivariable analysis, the composite score of 3 or greater was associated with poor discharge disposition (OR 2.39, 95% CI 1.10-5.18, p = 0.03).

CONCLUSIONS

Individual radiographic frailty markers are inadequate markers of frailty, as they may miss patients who are frail. This study also suggests that a composite radiographic frailty score may better predict patient outcome than individual radiographic markers of frailty.

Association between early hyperoxia and worse outcomes after traumatic brain injury

OBJECTIVE To investigate the relationship between oxygenation and short-term outcomes in patients with traumatic brain injury (TBI). DESIGN Logistic regression analysis was used to determine whether average high (&gt;200 mm Hg) or low (&lt;100 mm Hg) PaO2 levels within the first 24 hours of hospital admission correlated with patient outcomes relative to patients with average PaO2 levels between 100 and 200 mm Hg. SETTING Level 1 trauma center. PATIENTS We retrospectively reviewed 1547 consecutive patients with severe TBI who survived past 12 hours after hospital admission. MAIN OUTCOME MEASURES We measured mortality, intensive care unit length of stay, hospital length of stay, and discharge Glasgow Coma Scale (GCS) score. RESULTS Of the 1547 patients, 77% were male and 89% sustained blunt trauma. Mean (SD) age, admission GCS score, and Injury Severity Score were 41.3 (20.6) years, 8.3 (4.7), and 31.9 (12.5), respectively. Mean (SD) intensive care unit length of stay and hospital length of stay were 8.7 (10.5) days and 13.8 (13.7) days, respectively. Mean (SD) discharge GCS score was 10.1 (4.7). The mortality rate was 28%. After controlling for age, sex, Injury Severity Score, mechanism of injury, and admission GCS score, patients with high PaO2 levels had significantly higher mortality and lower discharge GCS scores than patients with a normal PaO2 (P &lt; .05). Patients with low PaO2 levels also had increased mortality (P &lt; .05). CONCLUSIONS Hyperoxia within the first 24 hours of hospitalization is associated with worse short-term functional outcomes and higher mortality after TBI. Although the mechanism for this has not been completely elucidated, it may involve hyperoxia-induced oxygen-free radical toxicity with or without vasoconstriction. Hyperoxia and hypoxia were found to be equally detrimental to short-term outcomes in patients with TBI. A narrower therapeutic window for oxygenation may improve mortality and functional outcomes.

Frailty and injury causation

PURPOSE

: The current study will attempt to elucidate whether frailty has a role in motor vehicle crash injury causation.

METHODS

: The association between frailty and injury was studied among Crash Injury Research Engineering Network (CIREN) cases. The baseline "physical functioning" (PF) score of the SF-36 was used as a marker of frailty (i.e., PF score <75). Frailty associations with ISS and occupant, vehicular and crash factors were explored. Frailty association with delta V was analyzed among injured (i.e., brain, rib, or femur) belted occupants in frontal crashes to establish whether frailty confers a different risk of each particular injury.

RESULTS

: Frailty occurred in 13.7 % of the cohort (n=1,747). Median (q1-q3) ISS was 14.0 (10-22) among the frail and 17.0 (10-24) among the non frail (p=0.40). Frailty was significantly associated with advanced age, male gender, the presence of co-morbidities, extreme BMIs, frontal and near-side crashes and delta V < 45 km/h. Seat belt use and ISS<16 were not associated with frailty. Multiple linear regressions, adjusting for age, gender and BMI revealed a negative association between frailty and log delta V (coefficient -0.188, p=0.04) among those with rib fractures but not among those with brain injuries or femur fractures.

CONCLUSION

: PF score, a marker of frailty, is associated with similar ISS and lower delta V and is independently linked to lower delta V thresholds for some injuries (i.e. rib fractures) but not for others (i.e. brain injuries and femur fractures). These associations suggest a potential role of frailty in injury causation.

Self-reported health indicators in the year following a motor vehicle crash: a comparison of younger versus older subjects

Motor vehicle crash injuries among the elderly are an important public health problem. We sought to determine if older individuals (65 years and older) had worse self-reported physical functioning and mental health status than younger adults (18-64 years) at 6 and 12 months post-injury, while controlling for pre-injury functional status, comorbidity, and injury severity. We used data from two sites of the Crash Injury Research and Engineering Network (CIREN) study. After exclusion based on missing Short Form-36 (SF-36) values, the final sample consisted of 579 CIREN cases; there were 500 individuals age 18-64 and 79 individuals (13.6%) age 65 or older. The outcome measures included the physical functioning scale (PFS), vitality scale (VS), and mental health scale (MHS) of the SF-36. The proportion of younger and older adults that had comorbidity was 17.6% and 54.4%, respectively. Multivariate linear regression models indicated that comorbidity, baseline PFS, and severe injury (Injury Severity Score [ISS] 25+ vs. ISS ≤ 8) were significantly associated with PFS scores at 6 months, but only comorbidity and baseline PFS were associated with PFS at 12 months. Multivariate models indicated that only pre-injury VS (p < .001) was associated with the VS at 6 months, but that both comorbidity (p < .01) and pre-injury VS (p < .001) were associated with VS at 12 months. MHS at 6 months was significantly associated with only the baseline MHS score, but both comorbidity and pre-injury MHS were associated with MHS at 12 months. There was no significant difference in the change in any of the SF-36 domains during the study year. Advanced age was not associated with lower self-reported health in any of the three SF-36 domains compared to younger age when pre-injury ISS and comorbidity were included in the model.

Smoking is a marker of risky behaviors independent of substance abuse in injured drivers

OBJECTIVE

Smoking has been linked to disease and injury. The purpose of this study is to investigate the smoking habits of motor vehicular driver trauma center patients and their association with previous injury history and risky behaviors.

METHODS

The studied population included 323 motor vehicular driver injury patients (123 smokers and 200 non-smokers) interviewed as part of a larger study of psychoactive substance use disorders at an adult Level I trauma center. Patients with head injuries, hospital stays of less than two days, and diminished cognition were excluded. Interviews included demographics (age, gender, race, marital status), socioeconomic status (SES; income, education, employment), risky behaviors (seatbelt non-use, drinking and driving, riding with drunk driver, binge drinking), and trauma history information (vehicular, assault, and other injuries). Substance abuse (alcohol and drug dependence) was evaluated in depth using DSM III-R criteria. Smokers and non-smokers were compared in relation to control and dependent variables using student's t test and chi-square (alpha = 0.05). Outcome variables included previous trauma history and risky behaviors. Multiple logistic regression models using step-down selection methods (alpha = 0.05) were constructed with risky behaviors and trauma history as dependent variables including demographics, SES and substance as independent variables.

RESULTS

Smokers represented 38 percent of the 323 patients studied. Smokers (n = 123) were younger (34 vs. 43 years), more likely to be male (72 percent vs. 50 percent), not married (72 percent vs. 56 percent), and had higher rates of alcohol (29 percent vs. 9 percent) and drug dependence (14 percent vs. 3 percent) than non-smokers (n = 200). Educational achievement (20 percent vs. 15 percent less than high school) and income level (24 percent vs. 23 percent with less than $15,000 of yearly income) were not different between smokers and non-smokers. Smokers were more likely than non-smokers to have a history of prior vehicular trauma (48 percent vs. 26 percent), assault (25 percent vs. 9 percent), or other injury (50 percent vs 37 percent). The following injury-prone behaviors were also more common among the smokers than non-smokers: seatbelt non-use (49 percent vs. 29 percent), drinking and driving (38 percent vs. 15 percent), riding with drunk driver (38 percent vs. 13 percent), and binge drinking (68 percent vs. 26 percent). In multiple logistic regression models adjusting for demographics, SES, and substance abuse, smoking revealed significantly higher odds ratios (OR) for the following dependent variables: seatbelt non-use (OR = 2.9), riding with drunk driver (OR = 2.2), binge drinking (OR = 2.4), previous vehicular (OR = 2.0), and assault injuries (OR = 2.5). Smoking did not reach significance for drinking and driving and other (non-vehicular and non-assault) injury.

CONCLUSION

Smoking is independently associated with risky behaviors and repeated history of vehicular or assault injury within the vehicular trauma population.

Retained risk-taking behaviors among past alcohol dependent trauma patients

Alcohol dependence has been associated with behavioral risk factors and risk-taking tendencies. We investigated whether past alcohol dependent trauma center patients (n=42) retain the characteristics of current alcohol dependent patients (n=67) or whether they resemble patients without history of alcohol dependence (n=262). We found that past alcohol dependence patients retain some of the risk-taking tendencies (impulsivity and sensation seeking) and risk-taking behaviors (drinking and driving, riding with a drunk driver, binge drinking, speeding for the thrill) common to current alcohol dependent patients and they remain at a higher injury risk than the non alcohol dependent population.

Causes and outcomes of mild traumatic brain injury: an analysis of CIREN data

Approximately one-half of vehicle occupants with traumatic brain injury (TBI) have a mild TBI (admission Glasgow Coma Scale (GCS) score of 13-15 with transient loss of consciousness). However, despite the label of "mild", many of these injuries result in long-term consequences; frequently these sequelae go unrecognized, as the patients are lost to medical follow-up. The Crash Injury Research Engineering Network (CIREN) project affords us the opportunity to examine the crash circumstances, injury sources and outcomes of mild TBI cases in greater detail.

Association of HIV-1 viral phenotype in the MT-2 assay with perinatal HIV transmission

A case-control design study was used to investigate the association of maternal HIV-1 phenotype in MT-2 cells at or near the time of delivery with perinatal transmission of HIV-1, controlling for maternal CD4 percentage and duration of rupture of membranes, in 48 transmitting and 96 non-transmitting HIV-1-infected mothers who gave birth between 1990 and 1995. The non-syncytium-inducing (NSI) phenotype was more commonly seen in transmitting mothers compared with non-transmitting mothers (90% vs. 75%, p =.04). In a multivariable logistic regression model, the following maternal characteristics were significantly associated with HIV transmission: NSI phenotype (odds ratio [OR] = 6.08; 95% confidence interval [CI]: 1.73-21.35) and log(10) viral load (OR = 2.11; CI: 1.19-3.74). Finally, the association of NSI phenotype with transmission was stronger in transmitting women who received azidothymidine during pregnancy compared with transmitters who did not.

Discourse after closed head injury in young children

This study examined narrative discourse in 23 children, ages 6 to 8 years, who sustained a severe closed head injury (CHI) at least 1 year prior to assessment. Narratives were analyzed at multiple levels using language and information structure measures. Results revealed significant discourse impairments in the CHI group on all measures of information structure, whereas differences in the linguistic domain failed to reach significance. In addition, effects of age at injury and lateralization of lesion on discourse were considered. Although no significant differences were found according to age at injury, a consistent pattern of generally poorer discourse scores was found for the early injured group (< 5 years). With regard to lesion focus, the group findings were unimpressive. However, preliminary examination of individual CHI cases with relatively large lateralized lesions suggested that the late injured children may show the language-brain patterns reported in brain-injured adults, whereas early injured children may not.

Frontal lobe changes after severe diffuse closed head injury in children: a volumetric study of magnetic resonance imaging

In view of the pathophysiology and biomechanics of severe closed head injury (CHI) in children, we postulated that the frontal lobes sustain diffuse injury, even in the absence of focal brain lesions detected by magnetic resonance imaging (MRI). This study quantitated the morphological effects of CHI on the frontal lobes in children who sustained head trauma of varying severity. The MRI findings of 14 children who had sustained severe CHIs (Glasgow Coma Scale score of < or = 8) were compared with the findings in a matched group of 14 children having sustained mild head injuries (Glasgow Coma Scale score of 13-15). The patients ranged in age from 5 to 15 years at the time of their MRIs, which were acquired at least 3 months postinjury. MRI findings revealed no focal areas of abnormal signal in the frontal lobes. Volumetric analysis disclosed that the total prefrontal cerebrospinal fluid increased and the gray matter volume decreased in the patients with severe CHI, relative to the mildly injured comparison group. Gray matter volume was also reduced in the orbitofrontal and dorsolateral regions of the brains of children with severe CHI, relative to the children who sustained mild head trauma. These volumetric findings indicate that prefrontal tissue loss occurs after severe CHI in children, even in the absence of focal brain lesions in this area. Nearly two-thirds of the children who sustained severe CHIs were moderately disabled after an average postinjury interval of 3 years or more, whereas 12 of the 14 patients with mild CHIs attained a good recovery (2 were moderately disabled) by the time of study.(ABSTRACT TRUNCATED AT 250 WORDS)