Prospective randomized trial of two wound management strategies for dirty abdominal wounds.
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OBJECTIVE: To determine the optimal method of wound closure for dirty abdominal wounds. SUMMARY BACKGROUND DATA: The rate of wound infection for dirty abdominal wounds is approximately 40%, but the optimal method of wound closure remains controversial. Three randomized studies comparing delayed primary closure (DPC) with primary closure (PC) have not conclusively shown any advantage of one method over the other in terms of wound infection. METHODS: Fifty-one patients with dirty abdominal wounds related to perforated appendicitis, other perforated viscus, traumatic injuries more than 4 hours old, or intraabdominal abscesses were enrolled. Patients were stratified by cause (appendicitis vs. all other causes) and prospectively randomized to one of two wound management strategies: E/DPC (wound packed with saline-soaked gauze, evaluated 3 days after surgery for closure the next day if appropriate) or PC. In the E/DPC group, wounds that were not pristine when examined on postoperative day 3 were not closed and daily dressing changes were instituted. Wounds were considered infected if purulence discharged from the wound, or possibly infected if signs of inflammation or a serous discharge developed. RESULTS: Two patients were withdrawn because they died less than 72 hours after surgery. The wound infection rate was greater in the PC group than in the E/DPC group. Lengths of hospital stay and hospital charges were similar between the two groups. CONCLUSION: A strategy of DPC for appropriate dirty abdominal wounds 4 days after surgery produced a decreased wound infection rate compared with PC without increasing the length of stay or cost. (+info)
Penetrating neck injuries: analysis of experience from a Canadian trauma centre.
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OBJECTIVE: To study the demographics and treatment outcome of penetrating neck injuries presenting to a major trauma centre in order to develop a treatment protocol. DESIGN: A case review. SETTING: A trauma centre at a tertiary care institution. PATIENTS: One hundred and thirty consecutive patients who had 134 neck wounds penetrating the platysma and presented to the trauma service between 1979 and 1997. INTERVENTION: Surgical exploration or observation alone. MAIN OUTCOME MEASURES: The location of injury, patient management, number of significant injuries, duration of hospital stay and outcome. RESULTS: Injuries were caused by stab wounds in 124 patients (95%) and gunshot wounds in 6 (5%). The location of injury was zone I (lower neck) in 20 cases (15%), zone II (midportion of the neck) in 108 (81%) and zone III (upper neck) in 5 (4%). The location was not recorded in 1 case. Fifty patients were managed by observation alone and 80 were managed surgically. Neck exploration in 48 asymptomatic patients was negative in 32 (67%). Significant injuries, including major vascular (12), nerve (13) and aerodigestive tract (19) injuries, were identified in 34 patients. Two of the 130 patients (1.5%) died of major vascular injuries. Seventy-six percent of significant injuries, including all zone II major vascular injuries, were symptomatic on presentation. The mean (and standard deviation) hospital stay for asymptomatic patients treated with observation alone and surgical exploration was similar (3.5 [6.02] versus 4.3 [5.46] days respectively, p = 0.575). Long-term disability, all neurologic in nature, was documented in 3 patients managed by observation alone and 6 patients managed by surgical exploration. CONCLUSIONS: Penetrating neck trauma, in particular stab wounds to zone II in asymptomatic patients, is associated with low morbidity and mortality. A selective management protocol with investigations directed by symptoms is the most appropriate approach for the patient population and resource base in this setting. (+info)
Penetrating missile injuries of the brachial plexus.
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We studied a consecutive series of 58 patients with penetrating missile injuries of the brachial plexus to establish the indications for exploration and review the results of operation. At a mean of 17 weeks after the initial injury, 51 patients were operated on for known or suspected vascular injury (16), severe persistent pain (35) or complete loss of function in the distribution of one or more elements of the brachial plexus (51). Repair of the nerve and vascular lesions abolished, or significantly relieved, severe pain in 33 patients (94%). Of the 36 patients who underwent nerve graft of one or more elements of the plexus, good or useful results were obtained in 26 (72%). Poor results were observed after repairs of the medial cord and ulnar nerve, and in patients with associated injury of the spinal cord. Neurolysis of lesions in continuity produced good or useful results in 21 of 23 patients (91%). We consider that a vigorous approach is justified in the treatment of penetrating missile injury of the brachial plexus. Primary intervention is mandatory when there is evidence of a vascular lesion. Worthwhile results can be achieved with early secondary intervention in patients with debilitating pain, failure to progress and progression of the lesion while under observation. There is cause for optimism in nerve repair, particularly of the roots C5, C6 and C7 and of the lateral and posterior cords, but the prognosis for complete lesions of the plexus associated with damage to the cervical spinal cord is particularly poor. (+info)
Fishhook removal.
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Fishing is a common recreational sport. While serious injuries are uncommon, penetrating tissue trauma involving fishhooks frequently occurs. Most of these injuries are minor and can be treated in the office without difficulty. All fishhook injuries require careful evaluation of surrounding tissue before attempting removal. Ocular involvement should prompt immediate referral to an ophthalmologist. The four most common techniques of fishhook removal and injury management are described in this article. The choice of the method for fishhook removal depends on the type of fishhook embedded, the location of the injury and the depth of tissue penetration. Occasionally, more than one removal technique may be required for removal of the fishhook. The retrograde technique is the simplest but least successful removal method, while the traditional advance and cut method is most effective for removing fishhooks that are embedded close to the skin surface. The advance and cut technique is almost always successful, even for removal of large fishhooks. The string-yank method can be used in the field and can often be performed without anesthesia. Wound care following successful removal involves extraction of foreign bodies from the wound and the application of a simple dressing. Prophylactic antibiotics are generally not indicated. Tetanus status should be assessed and toxoid administered if needed. (+info)
The radial and posterior interosseous nerves. Results fo 260 repairs.
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The outcome of 260 repairs of the radial and posterior interosseous nerves, graded by Seddon's modification of the Medical Research Council Special Committee's system, was analysed according to four patterns of injury; open 'tidy', open 'untidy', closed traction, and those associated with injury to the axillary or brachial artery. We studied the effect on the outcome of delay in effecting repair and of the length of the defect in the nerve trunk. Of the 242 repairs of the radial nerve we found that 30% had good results and 28% fair; 42% of the repairs had failed. The violence of injury was the most important factor in determining the outcome. Of the open 'tidy' repairs, 79% achieved a good or fair result, and 36% of cases with arterial injury also reached this level. Most repairs failed when the defect in the nerve trunk exceeded 10 cm. When the repairs were carried out within 14 days of injury, 49% achieved a good result; only 28% of later repairs did so. All repairs undertaken after 12 months failed. Of the 18 repairs of the posterior interosseous nerve, 16 achieved a good result. (+info)
Transorbital penetrating injury by a chopstick--case report.
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A one-year-old boy presented with orbitocranial penetrating injury by a chopstick. Neurological examination did not reveal abnormal findings. Skull radiography did not reveal any sign of fracture and there were no abnormal findings. Initially, computed tomography (CT) of the head did not reveal any intracranial lesions. However, bone window CT showed a well-defined low-density abnormality measuring 2.5 cm in length in the right orbit and parasellar region. Magnetic resonance imaging clearly revealed a low-intensity structure extending from the orbit to the prepontine area. Surgical exploration was emergently performed and the wooden fragment was removed. The postoperative course was uneventful. Transorbital penetrating injury by a wooden foreign body is relatively rare. The wound may be superficial and trivial. Major neurological deficit does not usually manifest immediately, so the penetrating injury may be overlooked. If the foreign body is retained in the orbit and cranium, severe infectious complications may occur later. (+info)
Hypopharyngeal perforation: an uncommon cause of pneumoperitoneum.
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Endotracheal intubation is common practice being performed both electively and as an emergency. Complications of this procedure are uncommon. A case is described of hypopharyngeal rupture after emergency intubation that presented with a pneumoperitoneum. The clinical signs, relevant investigations and management options are discussed for this injury and the need is emphasised for a high index of suspicion in order to make an early diagnosis. (+info)
Gelatin sheet incorporating basic fibroblast growth factor enhances healing of devascularized sternum in diabetic rats.
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BACKGROUND: Poor healing of the sternum often limits the use of bilateral internal thoracic arteries (BITAs) after coronary bypass surgery in diabetic patients. We have reported that a gelatin sheet that incorporates basic fibroblast growth factor (bFGF) accelerates sternal healing after BITA removal in normal rats. This study evaluated the effects of the above method for sternal healing in diabetic animals. METHODS AND RESULTS: Diabetic Wistar rats with blood glucose levels >400 mg/dL and body-weight loss >20 g were established by a single intravenous injection of streptozotocin (55 mg/kg). After median sternotomy and BITA removal, 16 diabetic rats received either a gelatin sheet that incorporated bFGF (100 microg/sheet) on the posterior table of the sternum (FGF group, n=9) or no gelatin sheet (control, n=7). Peristernal blood flow, as measured by a noncontact laser Doppler 4 weeks after surgery in the FGF group, recovered to the preoperative level (106+/-10% versus 82+/-9%, P<0.01), and marked angiogenesis was also observed around the sternum in the FGF group (30.5+/-3.2 versus 15.8+/-2.7 vessels/unit area, P<0.01). Deep sternal wound complications developed in 5 control rats but only in 1 rat in the FGF group (P<0.05). In the FGF group, histological examination showed improved sternal healing (excellent in 6 rats and slow/poor healing in 3). Bone mineral content as assessed by dual-energy x-ray absorptometry was greater in the FGF group (75.9+/-18.1 versus 48.9+/-10.7 mg, P<0.05). Bone mineral density of the sternum was similar between the 2 groups. CONCLUSIONS: A gelatin sheet that incorporates bFGF may offset sternal ischemia and accelerate sternal bone regeneration and healing, even in diabetic patients. (+info)