J Trauma
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Scapulothoracic dissociation, although rare, causes significant morbidity and mortality by completely disrupting the attachments of the scapula to the axial skeleton with the skin remaining intact. The defining constellation of injuries is subclavian or axillary vascular disruption, lateral displacement of the scapula, separation of the clavicular articulations with or without fracture of the clavicle, and cervical nerve root avulsion or brachial plexus injury. Orthopedic stabilization, vascular repair, and brachial plexus exploration are mandatory. Above elbow amputation, either primarily or within 24 hours, is recommended for the flail extremity.
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This retrospective study of 100 consecutive patients with inhalation injury documents that adult respiratory distress syndrome (ARDS) and pneumonia are common complications. Pulmonary complications cause or directly contribute to death in 77% of patients with combined inhalation and cutaneous burn injury. Additionally, the high fluid requirements of these patients worsens their pulmonary injury and is associated with adverse outcome. ⋯ An abnormal chest roentgenogram in the first 48 hours after injury is also associated with death. The development of ARDS is predicted by the actual volume of fluid resuscitation, despite normal pulmonary wedge pressure or normal central venous pressure reflecting increased microvascular permeability. These findings indicate a need for reevaluation of fluid resuscitation of patients with inhalation injury.
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In June 1990, the Ministry of Health designated 11 hospitals throughout Ontario to be lead hospitals in trauma care. An integral part of a trauma system is the evaluation of care, in particular, outcome of the trauma patients. The Trauma and Injury Severity Score (TRISS) methodology, which offers a standard approach for evaluating outcomes for different populations of trauma patients, was used to determine if there was an improvement in outcomes after the designation of trauma centers of patients involved in motor vehicle crashes (ICD-9-CM, E810.0-825.9), with an Injury Severity Score > 12 for two 12-month periods: one predesignation (1989/1990) and one postdesignation (1992/1993). ⋯ When the bias introduced by patients intubated before arrival at the trauma center being excluded from TRISS analysis was removed, using a TRISS-like (as per Offner et al: J. Trauma 32:32, 1992) logistic regression equation that allows analysis of intubated patients, the improvement was even greater, with z = +1.34 predesignation and z = +2.97 postdesignation. Only the statistically significant z-score of the postdesignated year required the W-score to be calculated, W = +5.60.(ABSTRACT TRUNCATED AT 250 WORDS)
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Upper extremity injuries are commonly seen in the sport of in-line skating. The use of protective equipment, including wrist splints, has been advocated as a means to decrease both the incidence and severity of upper extremity injuries in this sport. We report on four cases of open forearm fractures in the in-line skaters that occurred adjacent to the proximal border of the wrist splints. ⋯ The splint and distal forearm may act as a single unit to convert the impact from the level of the wrist to a torque moment, with the fulcrum located at the proximal border of the splint. The energy from the fall is then dissipated by the fracturing of the forearm bones at this level. These cases suggest that the use of wrist splints may be associated with their own specific set of injury patterns.
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Case Reports
Management of thoracic duct injury associated with fracture-dislocation of the spine following blunt trauma.
Thoracic duct injuries accompanying blunt thoracic trauma are rare. A significant number of these lesions, however, are associated with fracture-dislocation of the spine. In this report, we discuss the surgical management of chylothorax in this setting.