J Trauma
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A 5-year experience with 12 sternal fractures treated at the Los Angeles County Harbor/UCLA Medical Center is presented. Our data indicate that sternal fractures with roentgenographic mediastinal widening commonly have associated aortic injuries. There is an almost uniform depression of right ventricular or anterior left ventricular function associated with sternal fractures and these cardiac sequelae are documentable by first-pass biventricular radionuclide angiography including left ventricular segmental wall motion analysis. ⋯ In contrast, the incidence of displaced or unstable fractures is very low. Only one patient in this series had a depressed manubriosternal fracture, and no injury necessitated surgical stabilization. The outcome of isolated sternal fractures is benign, and they should be viewed as harbingers of the discovery of other injuries.
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We present two cases of delayed, massive, life-threatening hemothorax due to intercostal hemorrhage in association with fractured ribs and severe blunt chest trauma (SBCT), a combination we have not seen described in the literature. Blunt chest trauma is not benign. Significant intrathoracic injuries are frequent although usually not life threatening. ⋯ However, rapid blood loss requires immediate open thoracotomy and surgical attention. Several days of observation in hospital may be required for patients with SBCT and fractured ribs even without any other obvious intra- or extra-thoracic injuries. Vigorous activity or chest physical therapy may be dangerous during the first several days after the injury.
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Pneumoperitoneum usually implies perforation of the gastrointestinal tract, although the tracheobronchial tree has been recognized as a source for free intraperitoneal air. We report a case of pneumoperitoneum resulting from tracheobronchial rupture following blunt chest trauma, which was successfully treated by surgical repair.
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Case Reports
An approach to curative effect of large autografts on adipose tissue in special parts with third-degree burns.
Burns involving face, hand, dorsum of foot and areas around joints are regarded as burns of special parts. Because of the structural characteristics we emphasize the importance of preserving subeschar adipose tissue and using large sheets of skin graft in these parts of body during the resurfacing procedures. Thirty-one cases with 56 sites of deep burns were observed. ⋯ We prefer grafting debrided facial wounds with sheets of skin according to regional units. The minimal width of circular grafts around ankle and wrist is discussed. For wrist, the recommended minimal width is 4 cm; for ankle, it is 5 cm.
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A patient with a delayed aorto-right ventricular fistula and aortic valve injury after penetrating trauma is reported, and 17 similar additional cases from the literature reviewed. By examining the aortic root of adults with normal cardiac anatomy at autopsy, we defined the target area for these injuries as a 2 X 2 cm contact surface between the aorta above the right coronary cusp and the right ventricular outflow tract below the pulmonary valve. Five of the 18 patients required emergency exploration due to hemodynamic instability. ⋯ Patients with combination aortic valve and aortocardiac fistula injuries, more so than those with a single intracardiac lesion, fail with nonoperative management. Of the 18 patients, 17 underwent surgery. One of these died: the others did well during short-term followup (less than 1 year).