आघात एवं उपचार जर्नल

The hospital in which I have worked in the Galilee for over twenty years is close to the borders of Lebanon and Syria with Israel. I am an Israeli Emergency Room nurse in my sixties. I am also the Trauma Co-ordinator of the hospital. Galilee is a spectacularly beautiful and tranquil part of Israel. Arabs and Jews have lived together here for generations. I have raised my children and grandchildren here. Together we have lived through years of peace and apprehension, and also years of bitter conflict with our neighbor’s. As a father and grandfather I have worried for my family, and, as a nurse, I have always had to make sure that my department is ready to respond immediately to medical emergencies in conflict and mass casualty scenarios.

Atypical fractures are challenging for surgeons, as standard procedures are not applicable [1,2]. An interesting alternative for avulsion fractures of the tibial tubercle is the Bamberg Plate, a selfadjusted calcaneus titanium plate [3,4]. This simple and inexpensive implant was originally developed for displaced fractures of the greater humerus-tuberosity, but has already proved its advantage in various other locations, such as the tibial head or the posterior collum of the acetabulum [3,4].

The persistence of compulsory hospitalization in psychiatry is still a topical question within the atmosphere of violence and even of barbarism which comes to light in our society. Given opinions get more radical and demand zero risk in psychiatry, it becomes a lack of political ambition to carry on speaking of medical approach on the one side and of liberty one the other side.

Clinicians must be aware of this rare but devastating diagnosis, as early diagnosis may improve prognosis. Case presentation: An 11-year-old African American female presented to a pediatric orthopedic clinic with a 6- month history of insidious onset left hip pain. Over 6-months her pain became more severe, and limited her ability to walk. The left hip was fixed in 40-degrees flexion, 20-degrees abduction, and 30-degrees of external rotation. New x-ray findings consistent with idiopathic juvenile chondrolysis of the hip were present. Discussion: First described in the early 1900s, chondrolysis of the hip was initially identified in patients following slipped capital femoral epiphysis. Later, patients with no clear etiology were diagnosed. Associations with trauma, burns, infection, and prolonged immobilization have also been described. The course is variable, with an acute phase lasting 6-16 months followed by a chronic stage of 3-5 years. Conclusion: Idiopathic chondrolysis of the hip is a challenging diagnosis with devastating complications. Ultimately, most patients experience a spontaneous resolution of pain, develop early arthritis, and often arthrodesis

Postero-medial tibial plateau fracture (Moore type 1) is challenging. Since several years a posterior approach has been described in order to use a butteress plate. In our opinion, it is possible to fix accurately this kind of fracture with 2 to 5 antero-posterior 6.5 mm cancellous screws through an anterior approach. The aim of this work was to present anatomical results and return to sport of 15 patients operated on for Moore type 1 tibial plateau fracture. We observed no pseudarthrosis or secondary varus displacement. 87% of patients resumed back to their sporting activities. The anteromedial incision has a dual advantage of anatomical postero-medial fragment reduction and tibial spine fixation (in 80% of our cases).

The environment in which children grow and develop is vital to the trajectory of their development [1]. Risk and protective factors increase or decrease the likelihood of developmental disruptions and the onset of psychopathology [1,2]. Risk factors such as poverty, maternal depression maternal substance use, parenting stress and exposure to potentially traumatic events such as family and community violence have been shown to impact on development and place children at risk for the onset of psychopathology [3-10].

Traumatic brain injury (TBI) is the leading cause of death and disability in children and young adults around the world because it has been the most misunderstood and misdiagnosed problem among the central nervous system (CNS) disorders. Around 90% of TBIs are classified as mild (mTBI). The current detection of mTBI relies heavily on an assessment of behavioral symptoms, often with delay and subject to motivation. Despite notable advances in diagnostic magnetic resonance imaging (MRI), it remains a challenging issue to precisely make early evaluation of the severity of TBI and to predict the long-term outcomes. Currently there are no molecular biomarker-based blood tests that can accurately determine the presence and the severity of TBI because at present no clinical tools are available for measuring glymphatic-derived convective bulk flow in humans. There is an urgent need to call for a concerted effort to search for sensitive and reliable biomarkers of TBI, especially mTBI. There is a growing consensus that TBI, no matter what the cause, leads to dysfunction of the blood-brain barrier (BBB), which is mainly constituted by brain microvascular endothelial cells (BMEC). Our recent preclinical studies have shown that circulating BMEC in the peripheral blood, which are independent of the glymphatic system, could be used as cellbased biomarkers for quantitative assessment of BBB injury caused by various pathogenic insults, including trauma. The vimentin-α7 nAChR pathway significantly contributes to cBMEC shedding during the pathogenesis of BBB/CNS disorders. The cell-based biomarkers cBMEC along with the single cell technology will overcome the limitations of molecular biomarkers mentioned above and make the early diagnosis of TBI.

For intra-articular and extra-articular distal radius fractures do volar locking plates (VLP) provide patients with functionally, clinically and radiologically superior results compared to fixation methods before their introduction; Kirschner wires, non-locking plates and external fixators? In this prospective, randomized controlled trial 180 participants with a median age of 65 (range 18-96) were followed up for 1 year. Outcome measures included Disability of Arm Shoulder and Hand (DASH) score, range of motion (ROM) and grip strength, radiological measurements (radial length, angle, tilt, ulnar variance and articular step) and complications. There was no statistical difference of DASH scores between groups at any time point. ROM differed at one and six weeks post operatively, favoring the VLP fixation. However these results were not sustained at 12 and 52 weeks. The results have confirmed VLP’s ability to maintain fracture reduction over 12 weeks compared to alternative fixation methods.

It´s very important to know precise, what is to do in the case of a major accidents (for example a plane crash or train accident) with the survivors! The General Psychologist Council in “Nordrhein- Westfahlen“-state in Germany, licensed since any years the certificate “executive emergency psychologies or psychotherapists”! [1,2]. Not only an absolute nonsense, it makes much more disaster and more, it’s a fatal malpractice and/or negligence! But the survivor’s don´t need psychologists or psychotherapy!

Purpose: Pediatric hip fractures are very uncommon and the complications of these fractures are very serious. With this purpose in mind we evaluated retrospectively the treatment of pediatric femur neck fractures admitted during proceeding five years in our hospital. The Aim of study was to evaluate the outcome of our treatment and know preventable complications of pediatric neck fractures in comparison with literature. Method: We evaluated 19 pediatric femur neck fractures with age from 3-12 years including 12 males 7 females. Treatment was by closed reduction and internal fixation at average of 4.5 days after hospital admission. Spica cast was applied for all patients up to age 10. Clinical and radiological evaluation was done by RATLIFF CRITERIA Results: We enrolled 23 cases in study 4 lost to follow up and thus excluded from final study. We had 10 cases of Delbet type II, 7 cases type III and 2 cases of type IV. Patients were treated by closed reduction and internal fixation at average of 4.5 days after admission. Our results were 12 good, 3 fair and 4 poor. Complications encountered included avascular necrosis in 5 patients, 1 coxa vara, 2 cases of superficial infection and 1 septic sequel of sab acute septic arthritis. Conclusion: Fluoroscopic aided reduction and internal fixation is a very good method of treatment for pediatric neck femur fractures. Emphasis should be on measures to reduce avascular necrosis and infection and give maximum smile to the children and their parents. In our under eloped and far-flung area complications are unavoidable but preventable once infrastructure and facilities of emergency and postoperative care are improved. Education regarding prevention of pediatric fractures in general and neck femur in particular and active participation of parents will help in minimizing complication of these fracture thus limiting diability and morbidity of these fractures.

Background: Emergency thoracotomy (ET) has previously been studied and evaluated in an American and African perspective. The mechanism of injury (MOI) varies between different parts of the world. In the Northern European setting, blunt trauma is the most common MOI. Regarding penetrating thoracic injuries stab wounds compromises the majority whereas gunshot wounds (GSW) are relatively scarce. The aim of this study was to describe the situation at a Scandinavian Trauma Hospital. Method: This study was a retrospective case series involving all patients who underwent an ET between 2004 and 2011 at a single centre. Patients were identified and data collection of demographics, trauma scores and physiological values were retrieved from hospital charts and trauma registry. Statistical analyses were performed. Results: A total of 45 ET patients were identified. The patients were predominately male (82%), and severely injured with median ISS of 48. The overall survival rate was 31%. Blunt trauma accounted for 60% of the patients. Survival following penetrating thoracic trauma had a 50% survival rate, whereas blunt trauma had a 19% survival rate. Conclusion: The injury pattern preceding ET is different between America and Europe. Blunt trauma accounts for the majority of cases. Penetrating trauma is mostly caused by stab wounds which carry a better prognosis than gunshot wounds (GSW). There is clearly a value in performing ET for selected cases following penetrating thoracic violence. Most of the surviving cases of thoracotomy for blunt trauma were for aortic cross clamping to control abdominal bleeding. Isolated blunt trauma to the chest carried a dismal prognosis.

Background: Platelet rich plasma and corticosteroid injection have both been suggested to treat chronic lateral epicondylosis. The aim of this study was to compare the safety and effectiveness of corticosteroid, PRP and xylocaine infiltration for lateral epicondylosis. Materials and Methods: 150 patients with chronic lateral epicondylosis were randomly divided into three groups. Group A was treated with a single injection of 2 ml of corticosteroid mixed with 1 ml of xylocaine, Group B with 2 ml of PRP mixed with 1 ml of xylocaine and Group C with 3 ml of 2% xylocaine through peppering needle technique. Pain and functional improvements were assessed using visual analogue scale (VAS) and Nirschl’s staging at 0,2,6,12,26 and 52 weeks. Results: Baseline evaluation showed no difference between the three groups (p>0.05). Analysis at 2 weeks showed no difference in Nirschl staging but showed significant decrease in VAS score in favour of corticosteroid group. No statistically significant difference was noted between groups at 6 weeks (p>0.05). At 12 weeks VAS score was comparable but Nirschl stage was significantly low in corticosteroid group. Evaluation at 26 and 52 weeks demonstrated a statistically significant difference between groups favouring PRP group (p<0.05). Conclusion: PRP, Corticosteroid and Xylocaine are safe and effective in treatment of lateral epicondylosis. Both steroid and xylocaine are effective on a short term period. However, on long term follow-up, PRP seems to be the more effective treatment with more persistent efficacy than corticosteroid and xylocaine in relieving pain.

The T-shaped pelvic fracture represents from 3%-12% 1 of all acetabulum fractures. It is defined as a transverse acetabulum fracture in combination with a vertical fracture that divides the posterior column from the anterior column (Figure 1). Although the T-type fracture affects both columns, it differs by definition from a fracture of both columns in that part of the acetabulum articular surface still remains stably attached to the iliac pelvic ring.

Introduction: Results of the treatment of open fractures primarily depend on the treatment of connected soft tissue injuries. Objective: The aim was to present the experience and methods gained during the treatment of diaphyseal bone defects as a consequence of gunshot fractures of war trauma. Patients and Methods: The study consisted of 116 patients with the diaphyseal bone defect who were treated with the usage of primary and delayed autotransplatation of bones, transplants of the fibula and Ilizarov distraction osteogenesis. The results of compensation of bone defect less than 4 cm and conducted by an early corticospongioplastics were as follows: good in 8 respondents (45%), satisfactory in 6 (34%) and poor in 4 respondents (21%). In cases of delayed cortico-spongioplastics, the abovementioned results were: good in 36 (41%) respondents, satisfactory in 24 (34%) and poor in 16 (25%) respondents. The results of compensation of bone defect greater than 4 cm with the usage of fibular transplant were as follows: good in 3 (38%) respondents, satisfactory in 3 (38%) and poor in 2 (24%), and with the usage of using the Ilizarov method, the results were as follows: good in 8 (57%) respondents, satisfactory in 3 (21.5%) and poor in 3 (21.5%) respondents. Conclusion: The results showed that, in cases of compensation of bone defects less than 4 cm, the advantage is given to the primary spongioplastics over the delayed one. In cases of compensation of bone defects greater than 4 cm, the advantage is given to the Ilizarov distraction osteogenesis when compared to the fibular transplant. War wounds caused by firearms; characterize the extensive destruction of tissues, organs and the primary contamination polymorphic bacterial flora. Upon receipt of the injured we have not been in position to take from contributory a swab from the wounds of war, to identify the primary causes of infection and prescribe targeted, obtained by the antibiotic, antibiotic therapy. This is due to the material and technical conditions. We are a small country, where there is no industry for the production of medical equipment, disposable medical supplies, antibiotics. We were dependent on the humanitarian organizations and the not specially organized industry, we organized the production of external fixator because it was easiest.

Introduction: The Management of Polytrauma remains a challenge in regions of sub-Saharan Africa. We sought to document our experiences with Polytrauma management in a resource poor setting. Methods: It was a retrospective review of cases of Polytrauma managed at a regional trauma centre in Northwest Nigeria from January 2014 to December 2014. Trauma records of patients were retrieved and collated. Statistical analysis was done with SPSS 21. Results: A total of 84 patients were seen with a mean age of 29.34 ± 14.82. There were 78 males and 6 females giving a male to female ratio of 13:1. Road traffic accidents were the commonest mechanism in 66 (78.6%) patients while assault 6 (7.1%), fall from height 6 (7.1%), collapsed building 4 (4.8%) were observed. Forty-two percent of patients arrived at our facility 24 hrs after the trauma while 10.7% arrived within an hour and 28.6% arrived after 6 hours. Head and extremity injuries were the commonly encountered with 71% and 65% respectively. The common injury combination observed were head\extremity 39%, head\facial 27.4%, head\extremity\facial 27.4%, and head\ chest 11.9%. Mortality was 9.5% and those with major and minor disability were 9.5% and 7.1% respectively. Duration of more than 1 hour of arrival at facility was statistically significant on mortality, while age, mechanism of injury, distance from health facility was not statistically significant on mortality. Conclusion: Measures aimed at improving road safety would help to reduce the incidence of Polytrauma. Efficient Pre-hospital care would ensure prompt arrival at designated health facilities.

Abdominal compartment syndrome (ACS) is a life-threatening condition which can occur in patients with hemophilia although they have trivial traumas. Hemostatic control for bleeding episodes in hemophilia patients with inhibitors is difficult particularly when the availability of bypassing agents, recombinant activated factor VII (rFVIIa) and activated prothrombin complex concentrate (APCC), is constrained. Plasma exchange with continuous infusion of factor concentrate has been reported as a life-saving intervention in these patients. We reported a teenager with severe hemophilia A and a high-titer inhibitor who underwent two surgeries for ACS which developed after a minor trauma. Computerized tomography angiogram (CTA) of abdomen revealed a large pelvic hematoma and a bleeding from the sigmoidal artery. He underwent an abdominal angiography followed by the first surgery to relieve the ACS, and the second surgery for abdominal closure. The patients received plasma exchange with cryo-removed plasma peri-operatively. High-dose factor VIII (FVIII) concentrate (100 U/kg) was started after plasma exchange followed by continuous infusion at the rate 14 units/kg/hour for 7 days. rFVIIa and APCC concomitant with tranexamic acid were used for breakthrough bleeding. He received six times of plasma exchange, three doses of rFVIIa and five doses of APCC. Bleeding was successfully stopped and the titers of inhibitor decreased from the maximum of 4,400 BU to 3,680 BU. Plasma exchange and continuous FVIII infusion can be considered as an option for life-threatening hemorrhage in hemophilia patients with high-titer inhibitors in the countries where an access to bypassing agents is limited.

Background: Accelerated osteogenesis associated with traumatic brain injury TBI or spinal cord injury SCI is inconclusive and its cause remains obscured. The purpose of this study was to ensure a clinical evidence of its presence and to reveal the possible underlying mechanism. Methods: Healing indicators of diaphyseal femoral fractures in 20 patients with TBI and 20 patients with SCI were compared to 20 patients with femoral fracture only. The effect of sera of blood samples withdrawn from these patients on cell count proliferation rate of human bone marrow-derived mesenchymal stem cells MSCs (ATCC-USA) were measured and compared to sera from 20 patients with TBI only, 20 patients with SCI only, and a control group. Results: The study showed that femoral fractures with TBI or SCI heal more expectedly, faster with exuberant callus (p<0.0001) and showed statistically significant increased cell count and mean growth rate of MSCs with sera from TBI and SCI patients with or without femoral fractures of 82.34 ± 6.93%, 83.9 ± 8.57%, 81.46 ± 5.37%, 81.5 ± 6.49% versus 52.96 ± 5.11% in the control and 59.77 ± 5.98% in patients with femoral fractures only (p<0.0001). Conclusion: These results suggested enhancement of fracture-healing secondary to TBI and SCI due to the presence of factors in the serum that have a mitogenic effect on MSCs.

We report a rare case of a 33-year-old female patient who sustained bilateral closed femoral shaft fractures as a result of motor vehicle collision. The left femoral shaft fracture was associated with primary complete sciatic nerve palsy. The patient underwent intramedullary nail fixation of both femoral shaft fractures. Throughout the postoperative course, no functional recovery was observed. Nerve conduction studies and magnetic resonance imaging studies confirmed the diagnosis of a complete transection of the sciatic nerve at the level of the fracture site. Subsequently, the patient underwent surgical exploration and nerve grafting resulting in improved nerve function. Reports on complete sciatic nerve transections associated with closed femoral shaft fractures are limited. We document a unique injury and illustrate the patient’s management and outcome.