Travma 2012-3 by KAREPUBLISHING

Cilt - Volume 18

Sayı - Number 3

Mayıs - May 2012

TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY

www.tjtes.org Index Medicus, Medline, EMBASE/Excerpta Medica, Science Citation Index-Expanded (SCI-E), Index Copernicus ve TÜB‹TAK-ULAKB‹M Türk Tıp Dizini’nde yer almaktadır. Indexed in Index Medicus, Medline, EMBASE/Excerpta Medica and Science Citation Index-Expanded (SCI-E), Index Copernicus and the Turkish Medical Index of TÜB‹TAK-ULAKB‹M.

ISSN 1306 - 696x

ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA AND EMERGENCY SURGERY Editör (Editor) Recep Güloğlu Yardımcı Editörler (Associate Editors) Kaya Sarıbeyoğlu Hakan Yanar Ahmet Nuray Turhan Geçmiş Dönem Editörleri (Former Editors) Ömer Türel Cemalettin Ertekin Korhan Taviloğlu

ULUSAL BİLİMSEL DANIŞMA KURULU (NATIONAL EDITORIAL BOARD) Fatih Ağalar Yılmaz Akgün Levhi Akın Alper Akınoğlu Murat Aksoy Şeref Aktaş Ali Akyüz Ömer Alabaz Nevzat Alkan Edit Altınlı Acar Aren Gamze Aren Cumhur Arıcı Oktar Asoğlu Ali Atan Bülent Atilla Levent Avtan Yunus Aydın Önder Aydıngöz Erşan Aygün Mois Bahar Akın Eraslan Balcı Emre Balık Umut Barbaros Semih Baskan M Murad Başar Mehmet Bayramiçli Ahmet Bekar Orhan Bilge Mustafa Bozbuğa Mehmet Can Başar Cander Nuh Zafer Cantürk Münacettin Ceviz Banu Coşar Figen Coşkun İrfan Coşkun Nahit Çakar Adnan Çalık Fehmi Çelebi Gürhan Çelik Oğuz Çetinkale M. Ercan Çetinus Sebahattin Çobanoğlu Ahmet Çoker Cemil Dalay Fatih Dikici Yalım Dikmen Osman Nuri Dilek Kemal Dolay Levent Döşemeci Murat Servan Döşoğlu Kemal Durak Engin Dursun Atilla Elhan

İstanbul Çanakkale İstanbul Adana İstanbul İstanbul İstanbul Adana İstanbul İstanbul İstanbul İstanbul Antalya İstanbul Ankara Ankara İstanbul İstanbul İstanbul İstanbul İstanbul Elazığ İstanbul İstanbul Ankara Kırıkkale İstanbul Bursa İstanbul Edirne İstanbul Konya Kocaeli Erzurum İstanbul Ankara Edirne İstanbul Trabzon Erzurum İstanbul İstanbul İstanbul Edirne İzmir Adana İstanbul İstanbul Sakarya Antalya Antalya Düzce Bursa Ankara Ankara

Mehmet Eliçevik İmdat Elmas Ufuk Emekli Haluk Emir Yeşim Erbil Şevval Eren Hayri Erkol Metin Ertem Mehmet Eryılmaz Figen Esen Tarık Esen İrfan Esenkaya Ozlem Evren Kemer Nurperi Gazioğlu Fatih Ata Genç Alper Gökçe Niyazi Görmüş Feryal Gün Ömer Günal Nurullah Günay Haldun Gündoğdu Mahir Günşen Emin Gürleyik Hakan Güven Gökhan İçöz İbrahim İkizceli Haluk İnce Fuat İpekçi Ferda Şöhret Kahveci Selin Kapan Murat Kara Hasan Eşref Karabulut Ekrem Kaya Mehmet Yaşar Kaynar Mete Nur Kesim Yusuf Alper Kılıç Haluk Kiper Hikmet Koçak M Hakan Korkmaz Güniz Meyancı Köksal Cüneyt Köksoy İsmail Kuran Necmi Kurt Mehmet Kurtoğlu Nezihi Küçükarslan İsmail Mihmanlı Mehmet Mihmanlı Köksal Öner Durkaya Ören Hüseyin Öz Hüseyin Özbey Faruk Özcan Cemal Özçelik İlgin Özden Mehmet Özdoğan

İstanbul İstanbul İstanbul İstanbul İstanbul Diyarbakır Bolu İstanbul Ankara İstanbul İstanbul Malatya Ankara İstanbul İstanbul Tekirdağ Konya İstanbul Düzce Kayseri Ankara Adana Bolu İstanbul İzmir İstanbul İstanbul İzmir Bursa İstanbul Ankara İstanbul Bursa İstanbul Samsun Ankara Eskişehir Erzurum Ankara İstanbul Ankara İstanbul İstanbul İstanbul Ankara İstanbul Sakarya İstanbul Erzurum İstanbul İstanbul İstanbul Diyarbakır İstanbul Ankara

Şükrü Özer Halil Özgüç Ahmet Özkara Mahir Özmen Vahit Özmen Volkan Öztuna Niyazi Özüçelik Süleyman Özyalçın Emine Özyuvacı Salih Pekmezci İzzet Rozanes Kazım Sarı Esra Can Say Ali Savaş İskender Sayek Tülay Özkan Seyhan Gürsel Remzi Soybir Yunus Söylet Erdoğan Sözüer Mustafa Şahin Cüneyt Şar Mert Şentürk Feridun Şirin İbrahim Taçyıldız Gül Köknel Talu Ertan Tatlıcıoğlu Gonca Tekant Cihangir Tetik Mustafa Tireli Alper Toker Rıfat Tokyay Salih Topçu Turgut Tufan Fatih Tunca Akif Turna Zafer Nahit Utkan Ali Uzunköy Erol Erden Ünlüer Özgür Yağmur Müslime Yalaz Serhat Yalçın Sümer Yamaner Mustafa Yandı Nihat Yavuz Cumhur Yeğen Ebru Yeşildağ Hüseyin Yetik Cuma Yıldırım Bedrettin Yıldızeli Sezai Yılmaz Kaya Yorgancı Coşkun Yorulmaz Tayfun Yücel

Konya Bursa İstanbul Ankara İstanbul Mersin İstanbul İstanbul İstanbul İstanbul İstanbul İstanbul İstanbul Ankara Ankara İstanbul Tekirdağ İstanbul Kayseri Tokat İstanbul İstanbul İstanbul Diyarbakır İstanbul Ankara İstanbul İstanbul Manisa İstanbul İstanbul Kocaeli Ankara İstanbul İstanbul Kocaeli Urfa Balıkesir Adana İstanbul İstanbul İstanbul Trabzon İstanbul İstanbul Tekirdağ İstanbul Gaziantep İstanbul Malatya Ankara İstanbul İstanbul

ULUSLARARASI BİLİMSEL DANIŞMA KURULU INTERNATIONAL EDITORIAL BOARD

Juan Asensio Zsolt Balogh Ken Boffard Fausto Catena Howard Champion Elias Degiannis Demetrios Demetriades Timothy Fabian Rafi Gürünlüoğlu Clem W. Imrie Kenji Inaba Rao Ivatury Yoram Kluger Rifat Latifi Sten Lennquist Ari Leppaniemi Valerie Malka Ingo Marzi Kenneth L. Mattox Carlos Mesquita

Miami, USA New Castle, Australia Johannesburg, S. Africa Bologna, Italy Washington DC, USA Johannesburg, S. Africa Los Angeles, USA Memphis, USA Denver, USA Glasgow, Scotland Los Angeles, USA Richmond, USA Haifa, Israel Tucson, USA Malmö, Sweden Helsinki, Finland Sydney, Australia Frankfurt, Germany Houston, USA Coimbra, Portugal

Ernest E Moore Pradeep Navsaria Andrew Nicol Hans J Oestern Andrew Peitzman Basil A Pruitt Peter Rhee Pol Rommens William Schwabb Michael Stein Spiros Stergiopoulos Michael Sugrue Otmar Trentz Donald Trunkey Fernando Turegano Selman Uranues Vilmos Vecsei George Velmahos Eric J Voiglio Mauro Zago

Denver, USA Cape Town, S. Africa Cape Town, S. Africa Celle, Germany Pittsburgh, USA San Antonio, USA Tucson, USA Mainz, Germany Philadelphia, USA Petach-Tikva, Israel Athens, Greece Liverpool, Australia Zurich, Switzerland Oregon, USA Madrid, Spain Graz, Austria Vienna, Austria Boston, USA Lyon, France Milan, Italy

REDAKSİYON (REDACTION) Erman Aytaç

ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY

Başkan (President) Başkan Yardımcısı (Vice President) Genel Sekreter (Secretary General) Sayman (Treasurer) Yönetim Kurulu Üyeleri (Members)

Recep Güloğlu Kaya Sarıbeyoğlu Ahmet Nuray Turhan Hakan Yanar M. Mahir Özmen Ediz Altınlı Gürhan Çelik

İLETİŞİM (CORRESPONDENCE)

Ulusal Travma ve Acil Cerrahi Derneği İstanbul Üniversitesi İstanbul Tıp Fakültesi Genel Cerrahi Anabilim Dalı, Travma ve Acil Cerrahi Servisi, 34390 Çapa, İstanbul

Tel: +90 212 - 588 62 46 - 531 12 46 Faks (Fax): +90 212 - 533 18 82 e-posta (e-mail): travma@travma.org.tr Web: www.travma.org.tr

ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ YAYIN ORGANI ISSUED BY THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY

Ulusal Travma ve Acil Cerrahi Derneği adına Sahibi (Owner) Yazı İşleri Müdürü (Editorial Director) Yayın Koordinatörü (Managing Editor) Amblem Yazışma adresi (Correspondence address) Tel Faks (Fax)

Recep Güloğlu Recep Güloğlu M. Mahir Özmen Metin Ertem Ulusal Travma ve Acil Cerrahi Dergisi Sekreterliği Deniz Abdal Mah., Köprülü Mehmet Paşa Sok., Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul +90 212 - 531 12 46 - 531 09 39 +90 212 - 533 18 82

Abonelik: 2011 yılı abone bedeli (Ulusal Travma ve Acil Cerrahi Derneği’ne bağış olarak) 75.- YTL’dir. Hesap No: Türkiye İş Bankası, İstanbul Tıp Fakültesi Şubesi 1200 - 3141069 no’lu hesabına yatırılıp makbuz dernek adresine posta veya faks yolu ile iletilmelidir. Annual subscription rates: 75.- (USD) p-ISSN 1306-696x • e-ISSN 1307-7945 • Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus ve TÜBİTAK ULAKBİM Türk Tıp Dizini’nde yer almaktadır. (Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus and Turkish Medical Index) • Yayıncı (Publisher): KARE Yayıncılık (karepublishing) • Tasarım (Design): Ali Cangül • İngilizce Editörü (Linguistic Editor): Corinne Can • İstatistik (Statistician): Empiar • Online Dergi & Web (Online Manuscript & Web Management): LookUs • Baskı (Press): Yıldırım Matbaacılık • Basım tarihi (Press date): Mayıs (May) 2012 • Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur. (This publication is printed on paper that meets the international standard ISO 9706: 1994).

YAZARLARA BİLGİ Ulusal Travma ve Acil Cerrahi Dergisi, Ulusal Travma ve Acil Cerrahi Derneği’nin yayın organıdır. Travma ve acil cerrahi hastalıklar konularında bilimsel birikime katkısı olan klinik ve deneysel çalışmaları, editöryel yazıları, klinik olgu sunumlarını ve bu konulardaki teknik katkılar ile son gelişmeleri yayınlar. Dergi iki ayda bir yayınlanır. Ulusal Travma ve Acil Cerrahi Dergisi, 2001 yılından itibaren Index Medicus ve Medline’da, 2005 yılından itibaren Excerpta Medica / EMBASE indekslerinde, 2007 yılından itibaren Science Citation Index-Expanded (SCI-E) ile Journal Citation Reports / Science Edition uluslararası indekslerinde ve 2008 yılından itibaren Index Copernicus indeksinde yer almaktadır. 2001-2006 yılları arasındaki 5 yıllık dönemde SCI-E kapsamındaki dergilerdeki İmpakt faktörümüz 0,5 olmuştur. Dergide araştırma yazılarına öncelik verilmekte, bu nedenle derleme veya olgu sunumu türündeki yazılarda seçim ölçütleri daha dar tutulmaktadır. PUBMED’de dergi “Ulus Travma Acil Cerrahi Derg” kısaltması ile yer almaktadır. Dergiye yazı teslimi, çalışmanın daha önce yayınlanmadığı (özet ya da bir sunu, inceleme, ya da tezin bir parçası şeklinde yayınlanması dışında), başka bir yerde yayınlanmasının düşünülmediği ve Ulusal Travma ve Acil Cerrahi Dergisi’nde yayınlanmasının tüm yazarlar tarafından uygun bulunduğu anlamına gelmektedir. Yazar(lar), çalışmanın yayınlanmasının kabulünden başlayarak, yazıya ait her hakkı Ulusal Travma ve Acil Cerrahi Derneği’ne devretmektedir(ler). Yazar(lar), izin almaksızın çalışmayı başka bir dilde ya da yerde yayınlamayacaklarını kabul eder(ler). Gönderilen yazı daha önce herhangi bir toplantıda sunulmuş ise, toplantı adı, tarihi ve düzenlendiği şehir belirtilmelidir. Dergide Türkçe ve İngilizce yazılmış makaleler yayınlanabilir. Tüm yazılar önce editör tarafından ön değerlendirmeye alınır; daha sonra incelenmesi için danışma kurulu üyelerine gönderilir. Tüm yazılarda editöryel değerlendirme ve düzeltmeye başvurulur; gerektiğinde, yazarlardan bazı soruları yanıtlanması ve eksikleri tamamlanması istenebilir. Dergide yayınlanmasına karar verilen yazılar “manuscript editing” sürecine alınır; bu aşamada tüm bilgilerin doğruluğu için ayrıntılı kontrol ve denetimden geçirilir; yayın öncesi şekline getirilerek yazarların kontrolüne ve onayına sunulur. Editörün, kabul edilmeyen yazıların bütününü ya da bir bölümünü (tablo, resim, vs.) iade etme zorunluluğu yoktur. Yazıların hazırlanması: Tüm yazılı metinler 12 punto büyüklükte “Times New Roman” yazı karakterinde iki satır aralıklı olarak yazılmalıdır. Sayfada her iki tarafta uygun miktarda boşluk bırakılmalı ve ana metindeki sayfalar numaralandırılmalıdır. Journal Agent sisteminde, başvuru mektubu, başlık, yazarlar ve kurumları, iletişim adresi, Türkçe özet ve yazının İngilizce başlığı ve özeti ilgili aşamalarda yüklenecektir. İngilizce yazılan çalışmalara da Türkçe özet eklenmesi gerekmektedir. Yazının ana metnindeyse şu sıra kullanılacaktır: Giriş, Gereç ve Yöntem, Bulgular, Tartışma, Teşekkür, Kaynaklar, Tablolar ve Şekiller. Başvuru mektubu: Bu mektupta yazının tüm yazarlar tarafından okunduğu, onaylandığı ve orijinal bir çalışma ürünü olduğu ifade edilmeli ve yazar isimlerinin yanında imzaları bulunmalıdır. Başvuru mektubu ayrı bir dosya olarak, Journal Agent sisteminin “Yeni Makale Gönder” bölümünde, 10. aşamada yer alan dosya yükleme aşamasında yollanmalıdır. Başlık sayfası: Yazının başlığı, yazarların adı, soyadı ve ünvanları, çalışmanın yapıldığı kurumun adı ve şehri, eğer varsa çalışmayı destekleyen fon ve kuruluşların açık adları bu sayfada yer almalıdır. Bu sayfaya ayrıca “yazışmadan sorumlu” yazarın isim, açık adres, telefon, faks, mobil telefon ve e-posta bilgileri eklenmelidir. Özet: Çalışmanın gereç ve yöntemini ve bulgularını tanıtıcı olmalıdır. Türkçe özet, Amaç, Gereç ve Yöntem, Bulgular, Sonuç ve Anahtar Sözcükler başlıklarını; İngilizce özet Background, Methods, Results, Conclusion ve Key words başlıklarını içermelidir. İngilizce olarak hazırlanan çalışmalarda da Türkçe özet yer almalıdır. Özetler başlıklar hariç 190-210 sözcük olmalıdır. Tablo, şekil, grafik ve resimler: Şekillere ait numara ve açıklayıcı bilgiler ana metinde ilgili bölüme yazılmalıdır. Mikroskobik şekillerde resmi açıklayıcı bilgilere ek olarak, büyütme oranı ve kullanılan boyama tekniği de belirtilmelidir. Yazarlara ait olmayan, başka kaynaklarca daha önce yayınlanmış tüm resim, şekil ve tablolar için yayın hakkına sahip kişiler-

den izin alınmalı ve izin belgesi dergi editörlüğüne ayrıca açıklamasıyla birlikte gönderilmelidir. Hastaların görüntülendiği fotoğraflara, hastanın ve/veya velisinin imzaladığı bir izin belgesi eşlik etmeli veya fotoğrafta hastanın yüzü tanınmayacak şekilde kapatılmış olmalıdır. Renkli resim ve şekillerin basımı için karar hakemler ve editöre aittir. Yazarlar renkli baskının hazırlık aşamasındaki tutarını ödemeyi kabul etmelidirler. Kaynaklar: Metin içindeki kullanım sırasına göre düzenlenmelidir. Makale içinde geçen kaynak numaraları köşeli parantezle ve küçültülmeden belirtilmelidir. Kaynak listesinde yalnızca yayınlanmış ya da yayınlanması kabul edilmiş çalışmalar yer almalıdır. Kaynak bildirme “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” (http:// www.icmje.org) adlı kılavuzun en son güncellenmiş şekline (Şubat 2006) uymalıdır. Dergi adları Index Medicus’a uygun şekilde kısaltılmalıdır. Altı ya da daha az sayıda olduğunda tüm yazar adları verilmeli, daha çok yazar durumunda altıncı yazarın arkasından “et al.” ya da “ve ark.” eklenmelidir. Kaynakların dizilme şekli ve noktalamalar aşağıdaki örneklere uygun olmalıdır: Dergi metni için örnek: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of duodenal injuries. Am Surg 1999;65:972-5. Kitaptan bölüm için örnek: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 735-62. Sizlerin çalışmalarınızda kaynak olarak yararlanabilmeniz için www.travma.org.tr adresli web sayfamızda eski yayınlara tam metin olarak ulaşabileceğiniz bir arama motoru vardır. Derleme yazıları: Bu tür makaleler editörler kurulu tarafından gerek olduğunda, konu hakkında birikimi olan ve bu birikimi literatüre de yansımış kişilerden talep edilecek ve dergi yazım kurallarına uygunluğu saptandıktan sonra değerlendirmeye alınacaktır. Derleme makaleleri; başlık, Türkçe özet, İngilizce başlık ve özet, alt başlıklarla bölümlendirilmiş metin ile kaynakları içermelidir. Tablo, şekil, grafik veya resim varsa yukarıda belirtildiği şekilde gönderilmelidir. Olgu sunumları: Derginin her sayısında sınırlı sayıda olgu sunumuna yer verilmektedir. Olgu bildirilerinin kabulünde, az görülürlük, eğitici olma, ilginç olma önemli ölçüt değerlerdir. Ayrıca bu tür yazıların olabildiğince kısa hazırlanması gerekir. Olgu sunumları başlık, Türkçe özet, İngilizce başlık ve özet, olgu sunumu, tartışma ve kaynaklar bölümlerinden oluşmalıdır. Bu tür çalışmalarda en fazla 5 yazara yer verilmesine özen gösterilmelidir. Editöre mektuplar: Editöre mektuplar basılı dergide ve PUBMED’de yer almamakta, ancak derginin web sitesinde yayınlanmaktadır. Bu mektuplar için dergi yönetimi tarafından yayın belgesi verilmemektedir. Daha önce basılmış yazılarla ilgili görüş, katkı, eleştiriler ya da farklı bir konu üzerindeki deneyim ve düşünceler için editöre mektup yazılabilir. Bu tür yazılar 500 sözcüğü geçmemeli ve tıbbi etik kurallara uygun olarak kaleme alınmış olmalıdır. Mektup basılmış bir yazı hakkında ise, söz konusu yayına ait yıl, sayı, sayfa numaraları, yazı başlığı ve yazarların adları belirtilmelidir. Mektup bir konuda deneyim, düşünce hakkında ise verilen bilgiler doğrultusunda dergi kurallarına uyumlu olarak kaynaklar da belirtilmelidir. Bilgilendirerek onay alma - Etik: Deneysel çalışmaların sonuçlarını bildiren yazılarda, çalışmanın yapıldığı gönüllü ya da hastalara uygulanacak prosedür(lerin) özelliği tümüyle anlatıldıktan sonra, onaylarının alındığını gösterir bir cümle bulunmalıdır. Yazarlar, bu tür bir çalışma söz konusu olduğunda, uluslararası alanda kabul edilen kılavuzlara ve T.C. Sağlık Bakanlığı tarafından getirilen yönetmelik ve yazılarda belirtilen hükümlere uyulduğunu belirtmeli ve kurumdan aldıkları Etik Komitesi onayını göndermelidir. Hayvanlar üzerinde yapılan çalışmalarda ağrı, acı ve rahatsızlık verilmemesi için neler yapıldığı açık bir şekilde belirtilmelidir. Yazı gönderme - Yazıların gönderilmesi: Ulusal Travma ve Acil Cerrahi Dergisi yalnızca www.travma.org.tr adresindeki internet sitesinden on-line olarak gönderilen yazıları kabul etmekte, posta yoluyla yollanan yazıları değerlendirmeye almamaktadır. Tüm yazılar ilgili adresteki “Online Makale Gönderme” ikonuna tıklandığında ulaşılan Journal Agent sisteminden yollanmaktadır. Sistem her aşamada kullanıcıyı bilgilendiren özelliktedir.

INFORMATION FOR THE AUTHORS The Turkish Journal of Trauma and Emergency Surgery (TJTES) is an official publication of the Turkish Association of Trauma and Emergency Surgery. It is a peer-reviewed periodical that considers for publication clinical and experimental studies, case reports, technical contributions, and letters to the editor. Six issues are published annually. As from 2001, the journal is indexed in Index Medicus and Medline, as from 2005 in Excerpta Medica and EMBASE, as from 2007 in Science Citation Index Expanded (SCI-E) and Journal Citation Reports / Science Edition, and as from 2008 in Index Copernicus. For the five-year term of 2001-2006, our impact factor in SCI-E indexed journals is 0.5. It is cited as ‘Ulus Travma Acil Cerrahi Derg’ in PUBMED. Submission of a manuscript by electronic means implies: that the work has not been published before (except in the form of an abstract or as part of a published lecture, review, or thesis); that it is not under consideration for publication elsewhere; and that its publication in the Turkish Journal of Trauma and Emergency Surgery is approved by all co-authors. The author(s) transfer(s) the copyright to the Turkish Association of Trauma and Emergency Surgery to be effective if and when the manuscript is accepted for publication. The author(s) guarantee(s) that the manuscript will not be published elsewhere in any other language without the consent of the Association. If the manuscript has been presented at a meeting, this should be stated together with the name of the meeting, date, and the place. Manuscripts may be submitted in Turkish or in English. All submissions are initially reviewed by the editor, and then are sent to reviewers. All manuscripts are subject to editing and, if necessary, will be returned to the authors for answered responses to outstanding questions or for addition of any missing information to be added. For accuracy and clarity, a detailed manuscript editing is undertaken for all manuscripts accepted for publication. Final galley proofs are sent to the authors for approval. Unless specifically indicated otherwise at the time of submission, rejected manuscripts will not be returned to the authors, including accompanying materials. TJTES is indexed in Science Citation Index-Expanded (SCI-E), Index Medicus, Medline, EMBASE, Excerpta Medica, and the Turkish Medical Index of TUBITAK-ULAKBIM. Priority of publications is given to original studies; therefore, selection criteria are more refined for reviews and case reports. Manuscript submission: TJTES accepts only on-line submission via the official web site (please click, www.travma.org.tr/en) and refuses printed manuscript submissions by mail. All submissions are made by the on-line submission system called Journal Agent, by clicking the icon “Online manuscript submission” at the above mentioned web site homepage. The system includes directions at each step but for further information you may visit the web site (http://www.travma.org/en/ journal/). Manuscript preparation: Manuscripts should have double-line spacing, leaving sufficient margin on both sides. The font size (12 points) and style (Times New Roman) of the main text should be uniformly taken into account. All pages of the main text should be numbered consecutively. Cover letter, manuscript title, author names and institutions and correspondence address, abstract in Turkish (for Turkish authors only), and title and abstract in English are uploaded to the Journal Agent system in the relevant steps. The main text includes Introduction, Materials and Methods, Results, Discussion, Acknowledgments, References, Tables and Figure Legends. The cover letter must contain a brief statement that the manuscript has been read and approved by all authors, that it has not been submitted to, or is not under consideration for publication in, another journal. It should contain the names and signatures of all authors. The cover letter is uploaded at the 10th step of the “Submit New Manuscript” section, called “Upload Your Files”.

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ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY C‹LT - VOL. 18

SAYI - NUMBER 3 MAYIS - MAY 2012

İçindekiler - Contents

Klinik Çalışma - Original Articles 195-199 Alpha-1 protease inhibitor and antichymotrypsin levels in acute pancreatitis Akut pankreatitte alfa-1 proteaz inhibitorü ve antikimotripsin düzeyleri Karşıdağ T, Tüzün S, Kemik AS, Purisa S, Ünlü A 200-206 Presence of accompanying head injury in patients with maxillofacial trauma Maksillofasiyal travması bulunan hastalarda eşlik eden kafa travması varlığı Işık D, Gönüllü H, Karadaş S, Koçak ÖF, Keskin S, Garca MF, Eşeoğlu M 207-212 Reconstruction of a distal extremity defect using a temporoparietal fascia flap covered with a split-thickness skin graft harvested from the scalp: a cosmetic consideration in donor site selection Distal ekstremite defektlerinin temporaoparietal fasya ve skalpten alınan kısmi kalınlıklı deri grefti ile rekonstrüksiyonu: Donör saha seçimine kozmetik bir yaklaşım Özkan Ö, Özkan Ö, Bektaş G, Mardini S, Sassu P, Cigna E, Tüzüner S, Chen HC 213-218 Epidemiology of head injury in the United Arab Emirates Birleşik Arap Emirlikleri’ndeki kafa yaralanması epidemiyolojisi Al-Kuwaiti A, Hefny AF, Bellou A, Eid HO, Abu-Zidan FM 219-224 Determinants of mortality in patients with traumatic brain injury Travmatik beyin hasarı olan hastalarda mortalite belirleyicileri Saadat S, Akbari H, Khorramirouz R, Mofid R, Rahimi-Movaghar V 225-230 Role of red blood cell scintigraphy for determining the localization of gastrointestinal bleeding Gastrointestinal kanama odağının saptanmasında işaretli eritrosit sintigrafisinin rolü Şanlı Y, Özkan ZG, Kuyumcu S, Yanar H, Balık E, Tokmak H, Türkmen C, Adalet I 231-238 Effects of decompressive surgery in patients with severe traumatic brain injury and bilateral non-reactive dilated pupils Ağır travmatik beyin yaralanması ve bilateral reaktif olmayan pupil dilatasyonu bulunan hastalarda dekompresif cerrahinin etkileri Göksu E, Uçar T, Akyüz M, Yılmaz M, Kazan S 239-242 Trauma in women of child-bearing age in a high-income developing country Yüksek gelirli gelişmekte olan bir ülkede çocuk doğurma yaşındaki kadınlarda travma Abbas AK, Mirghani H, Eid HO, Abu-Zidan FM 243-249 A newly designed intramedullary nail with distal interlocking system for tibia fractures in adults the clinical results Yetişkinlerdeki tibia kırıkları için yeni dizayn edilmiş bir intramedüller çivi ve distal kilit sistemi, klinik sonuçlarımız Küçükdurmaz F, Akpınar F, Saka G, Sağlam N, Acı C

Cilt - Vol. 18 Sayı - No. 3

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ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY C‹LT - VOL. 18

SAYI - NUMBER 3 MAYIS - MAY 2012

İçindekiler - Contents

250-254 Rectal injury during radical prostatectomy Radikal prostatektomi sırasında rektal yaralanma Yıldırım M, Göktaş C, Horuz R, Çetinel CA, Cangüven Ö, Küçük HF, Albayrak S 255-259 Pellet gunfire injuries among agitated mobs in Kashmir Keşmir’de ayaklanan grupların havalı silah saçmasıyla yaralanmaları Mushtaque M, Mir MF, Bhat M, Parray FQ, Khanday SA, Dar RA, Malik AA 260-264 2011 Van depremi sonrası Van bölgesi Eğitim ve Araştırma Hastanesine başvuran olguların değerlendirilmesi Evaluation of the patients in Van Training and Research Hospital following the 2011 Van earthquake in Turkey Dursun R, Görmeli CA, Görmeli G

Olgu Sunumu - Case Reports 265-267 Penetrating head trauma with four nails: an extremely rare case Dört adet çivi ile çok nadir bir penetran kafa travması olgusu Arıcı L, Akgün B, Kaplan M, Yılmaz İ 268-270 Closed total (pan-talar) dislocation of the talus with delayed presentation: a rare case report and review of the literature Geç bulgu veren kapalı total (pantalar) talus çıkığı: Nadir bir olgu sunumu ve literatür değerlendirmesi Dulani R, Shrivastava S, Dwidmuthe S, Purohit R 271-273 Pyloric atresia associated with epidermolysis bullosa: report of two cases and review of the literature Pilor atrezisi ve epidermolizis bülloza birlikteliği: İki olgu sunumu ve literatür derlemesi Bıçakcı Ü, Tander B, Çakmak Çelik F, Arıtürk E, Rızalar R 274-276 A patient who was burned in the operative field: a case report Ameliyat alanında yanan bir hasta: Olgu sunumu Chung SH, Lee HH, Kim TH, Kim JS 277-279 Isolated hemorrhagic contusion of an incidental meningioma İnsidental menenjiyomda izole hemorajik kontüzyon Eom KS, Kim TY 280-282 Intestinal malrotation in an adult: case report Erişkinlerde intestinal malrotasyon: Olgu sunumu Sözen S, Güzel K

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Mayıs - May 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):195-199

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.99075

Alpha-1 protease inhibitor and antichymotrypsin levels in acute pancreatitis Akut pankreatitte alfa-1 proteaz inhibitorü ve antikimotripsin düzeyleri Tamer KARŞIDAĞ,1 Sefa TÜZÜN,1 Ahu Sarbay KEMİK,2 Sevim PURİSA,3 Aytekin ÜNLÜ4 BACKGROUND

AMAÇ

Acute pancreatitis with high mortality of severe onset is still a major problem in medicine. Early identification of the severity of the disease is critical for effective treatment. Many markers have been tried and are still being tested. The ideal marker should be able to identify the cases and distinguish between mild and severe.

Şiddetli formundaki yüksek mortalite oranı ile akut pankreatit günümüzde halen tıbbın önemli bir sorunudur. Hastalığın şiddetinin erken belirlenmesi etkin tedavi için kritik öneme sahiptir. Çeşitli biyokimyasal belirteçler denenmiştir ve halen denenmektedir. İdeal belirteç olguyu tanıyabilmeli ve pankreatitin hafif ve şiddetli formlarını ayırt edebilmelidir.

METHODS

This prospective study included 34 cases (14 males, 20 females, mean age: 58 years) of acute pancreatitis and 33 cases (17 males, 16 females, mean age: 53 years) as a control group. Mild (n=29) and severe (n=5) cases were compared with respect to serum levels of amylase, C-reactive protein (CRP), alpha-1-protease inhibitor, and antichymotrypsin on admission and 24 and 48 hours (h) after admission.

GEREÇ VE YÖNTEM

RESULTS

Bu prospektif çalışmaya akut pankreatitli 34 olgu (14 erkek, 20 kadın, ort. yaş: 58 yaş) ve kontrol grubundaki 33 olgu (17 erkek, 16 kadın, ort. yaş: 53 yaş) dahil edildi. Hafif (n=29) ve ağır (n=5) olgular başvuru anındaki, başvurudan 24 ve 48 saat sonraki amilaz, C-reaktif protein (CRP), alfa-1 proteaz inhibitörü ve antikimotripsin düzeyleri açısından karşılaştırıldı.

Alpha-1 protease inhibitor and antichymotrypsin levels were significantly elevated in the first 24 h; however, CRP peaked after 48 h in the acute pancreatitis group. While CRP showed significantly higher concentrations in patients with severe pancreatitis, alpha-1-protease inhibitor and antichymotrypsin levels changed slightly, but without significance, in severe cases.

Akut pankreatit grubunda alfa-1 proteaz inhibitörü ve antikimotripsinin serum düzeyleri ilk 24 saatte yükseldi, buna karşın CRP 48 saat sonra pik değere ulaştı. CRP şiddetli pankreatitli hastalarda anlamlı derecede yüksek konsantrasyonlar gösterirken, alfa-1 proteaz inhibitörü ve antikimotripsin düzeylerindeki hafif değişimler anlamlı değildi.

CONCLUSION

SONUÇ

BULGULAR

Alpha-1 protease inhibitor and antichymotrypsin are early events in acute pancreatitis, with high levels on admission. Activation of these variables declines after 24 h. These markers may have early diagnostic value in patients with acute pancreatitis. Because neither of them is good at discrimination of mild and severe cases in the disease, they should not be incorporated into routine clinical investigations.

Başvuru anında yüksek düzeyleri ile alfa-1 proteaz inhibitörü ve antikimotripsin akut pankreatitte erken sonuçlar verir. Bu değişkenlerin aktivasyonları 24 saat sonra düşer. Bu belirteçlerin akut pankreatitli hastalarda erken tanı değeri olabilir. Her ikisi de bu hastalığın hafif ve şiddetli olgularını ayırmada iyi olmadığından, rutin klinik kullanıma dahil edilmemelidir.

Key Words: Alpha-1 protease inhibitor; antichymotrypsin; acute pancreatitis.

Anahtar Sözcükler: Alfa-1 proteaz inhibitor; antikimotripsin; akut pankreatit.

1 2nd Department of Surgery, Haseki Training and Research Hospital, Istanbul; 2Department of Biochemistry, IU Istanbul Faculty of Medicine, Istanbul; 3Department of Biostatistics, IU Cerrahpasa Faculty of Medicine, Istanbul; 4Division of Health, Gendermerie General Headquarters, Ankara, Turkey.

Haseki Eğitim ve Araştırma Hastanesi, 2. Cerrahi Kliniği, İstanbul; 2 İ.Ü., İstanbul Tıp Fakültesi, Biyokimya Anabilim Dalı, İstanbul; 3 İ.Ü. Cerrahpaşa Tıp Fakültesi, Biyoistatistik Anabilim Dalı, İstanbul; 4 Jandarma Genel Komutanlığı, Sağlık Komutanlığı, Ankara. 1

Correspondence (İletişim): Tamer Karşıdağ, M.D. 19 Mayıs Mah., Gazi Berkay Sok., No: 13/9, Şişli 34360 İstanbul, Turkey. Tel: +90 - 212 - 529 44 00 e-mail (e-posta): tamerkarsidag@yahoo.com

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Necrotizing pancreatitis was first described by Nikolaus Tulp, a Dutch physician and anatomist, in 1652.[1] All the descriptions of pancreatitis reflected severe onset of the disease, until 1929, when Elman, a surgical resident working under Professor Evarts Graham, reported the value of blood amylase in acute pancreatitis.[2] After his report, identification and prediction of severe cases emerged as the next problem. Scoring systems such as Ranson, Imrie, Glasgow, and the Acute Physiology and Chronic Health Evaluation (APACHE II) are used for prediction of disease severity, but these scoring systems require up to 48 hours (h). In 1992, the Atlanta Classification on Pancreatitis was announced. Identification of mild and severe cases of the disease was universally accepted.[3] Currently, there is no ideal marker to make this identification early, easy and fast. Interleukin (IL)-6, tumor necrosis factor (TNF)-帢, C-reactive protein (CRP), and procalcitonin are wellknown markers, and have high sensitivity and specificity for early prediction.[4] Medical researchers have also studied some rare markers. Alpha-1 protease inhibitor and antichymotrypsin are promising newly introduced tests in clinical practice; however, controversial results have been reported in the literature. It has been suggested that proteolytic enzymes such as trypsin and elastase play a dominant role in the pathogenesis of acute pancreatitis.[5] The potentially destructive effects of pancreatic enzymes on the pancreas itself are controlled by a number of protease inhibitors (such as alpha-1 protease inhibitor and antichymotrypsin) present in normal plasma.[6] Alpha-1 protease inhibitor is also referred to as alpha-1 antitrypsin. The aim of the present study was to establish whether alpha-1 protease inhibitor and antichymotrypsin were useful in the investigation for the diagnosis of acute pancreatitis and assessment of the disease severity. The validity of the enzymes as a marker for inflammation of the pancreatitis was compared with the amylase value, CRP and the diagnosis of the disease according to the Atlanta Classification.

MATERIALS AND METHODS This prospective study included 34 cases of acute pancreatitis and 33 cases as the control group. Patients were classified according to their clinical outcome into two groups: mild pancreatitis and severe pancreatitis. Mild (n=29) and severe (n=5) cases were compared with respect to serum levels of amylase, CRP, alpha-1 protease inhibitor, and antichymotrypsin on admission and 24 and 48 h after admission. In mild cases, no lifethreatening complications were seen, whereas patients with severe disease manifested respiratory insufficiency, sepsis, shock, and renal failure. Death occurred in 196

one of five patients with severe pancreatitis because of multiorgan failure. The control group was constituted by the patients who admitted for non-pancreatic abdominal pain and without inflammatory process. Antichymotrypsin in serum was determined using particle-enhanced turbidimetric immunoassay method with commercially available specific antibodies (PETIA; Dako, Glostrup, Denmark). Alpha-1 protease inhibitor in serum was determined by nephelometry protein analyzer method (Technicon reagents, Tarrytown, NY, USA). The enzymes were compared among groups using the Mann-Whitney U test. The relation between mild and severe groups was compared by means of the McNemar test. Statistical analyses were performed using the Statistical Package for the Social Sciences for Windows (SPSS Inc., Chicago, IL, USA).

RESULTS A total of 34 patients (14 males, 20 females, mean age: 58 years) were included in the study. Among the patients with acute pancreatitis and those with nonpancreatic abdominal pain, there were no significant differences in age (p=0.129) or sex (p=0.326). Thirty-three patients (17 males, 16 females, mean age: 53 years) who admitted for non-pancreatic abdominal pain and without inflammatory process were accepted as the control group. During the course of the disease, 29 (85%) patients had no complications, while 5 (15%) patients developed local or systemic complications. According to the Atlanta criteria, the first group was classified as mild pancreatitis and the latter group as severe pancreatitis. Severe acute pancreatitis was defined as associated with organ failure and/or local complications, such as necrosis, abscess, or pseudocyst. In the severe group, pseudocyst was seen in two patients, renal failure with creatinine elevation in one patient and pulmonary insufficiency (PaO2 <60 mmHg) in another. One patient (83 years old) with severe pancreatitis died on the third day of hospitalization because of multiorgan failure. As compared with extra pancreatic controls, patients with acute pancreatitis had significantly higher values of amylase, CRP, alpha-1 protease inhibitor, and antichymotrypsin levels in serum on admission (p<0.001) (Table 1, Fig. 1). All patients with acute pancreatitis had serum amylase values above at least 20-fold the upper reference limit (40 U/L). Serum levels of CRP were above the upper reference limit in 20 patients (74%) and serum amylase in 34 patients (100%). Alpha-1 protease inhibitor and antichymotrypsin values were above about May覺s - May 2012

Alpha-1 protease inhibitor and antichymotrypsin levels in acute pancreatitis

Table 1. Mean, minimum and maximum levels in the pancreatitis and control groups on admission and significance of the difference

Acute pancreatitis (n=34)

Control group (n=33)

Serum amylase (U/L) CRP (mg/L) 帢1-protease inhibitor (mg/dl) Antichymotrypsin (mg/dl)

2756 (815-6887) 36.19 (0.5-236) 22.09 (15-30) 44.71 (11-110)

30.42 (16-44) 2.91 (1-5) 10.15 (4-15) 4.79 (2-9)

two-fold and four-fold the upper reference limits (13 mg/dl and 10 mg/dl, respectively). The relation of changes in serum levels of CRP, alpha-1 protease and antichymotrypsin to time and severity are shown in Figures 2 and 3, respectively. Serum CRP values peaked within the third day, 250

200

150

100

p<0.001

CRP (mg/l)

p<0.001

a1-protease inhibitor (mg/dl)

Antichymotrypsin (mg/dl)

Fig. 1. Mean, minimum and maximum levels of CRP in pancreatitis (light bar) and control (dark bar) groups on admission, with significance of difference.

p <0.001 <0.001 <0.001 <0.001

with values considerably higher in the severe pancreatitis group. Serum alpha-1 protease inhibitor and antichymotrypsin values were also in high concentrations on the day of admission, and they decreased periodically without significant difference between mild and severe cases.

DISCUSSION Early diagnosis and prediction of severity are the main targets for improved management of patients with acute pancreatitis. New developments in diagnostic imaging procedures, invasive percutaneous aspiration techniques and a variety of biochemical variables are under investigation to correlate with the development of major complications and severity of acute pancreatitis.[7-10] Need for an ideal marker, which should be simple in test performance, accurate, available under emergency conditions, and cost-effective, is continuing. The usefulness of most markers in the clinic is limited. As an acute phase reactant, CRP is still in use as an ideal biochemical marker, with some disadvantages like late onset for prediction of severity.[11,12] In this prospective clinical trial, alpha-1 protease inhibitor and antichymotrypsin were analyzed for diagnostic value and investigated for prediction of severity in patients with acute pancreatitis.

200 140

123.45

120 100

Admission

180

Mild pancreatitis

24 hour

160

Severe pancreatitis

48 hour 83.83

120

100

60 40

44.71 36.19

34.41 22.09 20.44 14.35

20 0

140

25.68

p<0.001

p<0.722 p<0.303

40 20

CRP (mg/l)

a1-protease inhibitor Antichymotrypsin (mg/dl) (mg/dl)

Fig. 2. Mean values in pancreatitis on admission and at 24 and 48 hours. Cilt - Vol. 18 Say覺 - No. 3

CRP (mg/l)

a1-protease inhibitor Antichymotrypsin (mg/dl) (mg/dl)

Fig. 3. Mean values in mild (light bar) and severe (dark bar) pancreatitis at 24 hours and significance of difference. 197

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This study has shown that alpha-1 protease inhibitor and antichymotrypsin levels increased rapidly in the first hours of the disease, before CRP increased. It is of advantage compared with CRP, especially in diseases with lower inflammatory reaction. This is the most important point of these markers for earlier assessment in clinical laboratories. These findings are compatible with those in the literature.[13-17] Plasma values of CRP, alpha-1 proteinase inhibitor, alpha-2 macroglobulin, and complexed alpha-2 macroglobulin were determined in serial samples from 27 patients with acute pancreatitis by Banks et al.[13] and were reported in 1991. Alpha-1 proteinase inhibitor was raised in both groups (mild and severe). Goodman et al.[14] reported that serum levels of alpha-1 protease inhibitor and antichymotrypsin elevated significantly (p<0.001) from day 0 in mild pancreatitis. They also reported these acute phase proteins become similarly elevated in severe cases, but the rapid rise in levels of alpha-1 protease inhibitor and antichymotrypsin from day 0 in mild pancreatitis seems to be delayed in severe disease. However, they did not mention about the significance of the difference. Hedstorm et al.[15] studied trypsin-alpha-1 protease inhibitor complex. They found it increased in acute pancreatitis. McMahon and Lasson et al.[16,17] reported similar results in elevation of serum levels of alpha-1 protease inhibitor and antichymotrypsin in the early phase of the disease. While CRP showed significantly higher concentrations in patients who developed major complications, multiple organ dysfunction syndrome, or death in the further course of the disease, alpha-1 protease inhibitor and antichymotrypsin levels changed slightly, but not significantly. Several authors studied alpha-1 protease inhibitor and trypsin-alpha-1 protease inhibitor complex in patients with pancreatitis, but only a few have studied the predictive value of alpha-1 protease inhibitor for the severity of pancreatitis. The results are controversial. Banks et al.[13] found no significant difference in concentrations of alpha-1 protease inhibitor between mild and severe groups. Ranson[18] stressed its diagnostic value more than its prognostic power. Viedma et al.[19] pointed out that the concentration of alpha-1 protease inhibitor increased during the pancreatic attack in both groups, and alpha-1 protease inhibitor levels in serum were reported to discriminate severe from mild cases, with significance. In the study of Hedstorm et al.[15] about trypsin-alpha-1 protease inhibitor complex, the difference between mild and severe cases was significant. This study showed no beneficial effect of alpha-1 protease inhibitor and antichymotrypsin in the prediction of severity. However, they are highly valuable as an early marker in patients with acute pancreatitis. 198

In conclusion, alpha-1 protease inhibitor and antichymotrypsin are rapidly produced variables in inflammation of the pancreas and have a faster response than CRP. For this reason, they may be diagnostic variables in patients with acute pancreatitis. Because neither of them is good at discrimination between mild and severe cases in the disease and measurement techniques are not suitable for clinical use, they should not be included in routine investigations. These results require further study in larger patient series including controls.

REFERENCES 1. Tulp N. Observationum medicarum, Editio Nova et Aucta. 2nd ed. Amsterdam, The Netherland; 1652:345. Book 4. Cited by Howard JM, Hess W. History of the pancreas. New York: Kluwer; 2002. 2. Elman R, Arneson N, Graham EA. Value of blood amylase estimations in the diagnosis of pancreatic disease: a clinical study. Arch Surg 1929;19:943-67. 3. Bradley EL 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch Surg 1993;128:586-90. 4. Chen CC. Serum markers in the early assessment of severity of acute pancreatitis: which is the most useful? J Chin Med Assoc 2004;67:439-41. 5. Ohlsson K, Olsson AS. Purification and partial characterization of human pancreatic elastase. Hoppe Seylers Z Physiol Chem 1976;357:1153-61. 6. Adham NF, Dyce B, Haverback BJ. Trypsin-binding -2-macroglobulin in patients with acute pancreatitis. Gastroenterology 1972;62:365-72. 7. Uhl W, Büchler M, Malfertheiner P, Martini M, Beger HG. PMN-elastase in comparison with CRP, antiproteases, and LDH as indicators of necrosis in human acute pancreatitis. Pancreas 1991;6:253-9. 8. Heath DI, Wilson C, Gudgeon AM, Jehanli A, Shenkin A, Imrie CW. Trypsinogen activation peptides (TAP) concentrations in the peritoneal fluid of patients with acute pancreatitis and their relation to the presence of histologically confirmed pancreatic necrosis. Gut 1994;35:1311-5. 9. Rau B, Steinbach G, Gansauge F, Mayer JM, Grünert A, Beger HG. The potential role of procalcitonin and interleukin 8 in the prediction of infected necrosis in acute pancreatitis. Gut 1997;41:832-40. 10. Mayer J, Rau B, Grewe M, Schoenberg MH, Nevalainen TJ, Beger HG. Secretory phospholipase A2 in patients with infected pancreatic necroses in acute pancreatitis. Pancreas 1998;17:272-7. 11. Gross V, Leser HG, Heinisch A, Schölmerich J. Inflammatory mediators and cytokines--new aspects of the pathophysiology and assessment of severity of acute pancreatitis? Hepatogastroenterology 1993;40:522-30. 12. McMahon MJ. Plasma markers of pancreatic necrosis. In: Bradley EL III editor. Acute pancreatitis: diagnosis and therapy. New York: Raven Press; 1994. p. 47-55. 13. Banks RE, Evans SW, Alexander D, Van Leuven F, Whicher JT, McMahon MJ. Alpha 2 macroglobulin state in acute pancreatitis. Raised values of alpha 2 macroglobulinprotease complexes in severe and mild attacks. Gut Mayıs - May 2012

Alpha-1 protease inhibitor and antichymotrypsin levels in acute pancreatitis

1991;32:430-4. 14. Goodman AJ, Bird NC, Johnson AG. Antiprotease capacity in acute pancreatitis. Br J Surg 1986;73:796-8. 15. Hedström J, Sainio V, Kemppainen E, Haapiainen R, Kivilaakso E, Schröder T, et al. Serum complex of trypsin 2 and alpha 1 antitrypsin as diagnostic and prognostic marker of acute pancreatitis: clinical study in consecutive patients. BMJ 1996;313:333-7. 16. McMahon MJ, Bowen M, Mayer AD, Cooper EH. Relation of alpha 2-macroglobulin and other antiproteases to the clini-

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cal features of acute pancreatitis. Am J Surg 1984;147:16470. 17. Lasson A, Ohlsson K. Protease inhibitors in acute human pancreatitis. Correlation between biochemical changes and clinical course. Scand J Gastroenterol 1984;19:779-86. 18. Ranson JH. Diagnostic standards for acute pancreatitis. World J Surg 1997;21:136-42. 19. Viedma JA, Pérez-Mateo M, Agulló J, Domínguez JE, Carballo F. Inflammatory response in the early prediction of severity in human acute pancreatitis. Gut 1994;35:822-7.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):200-206

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.01047

Presence of accompanying head injury in patients with maxillofacial trauma Maksillofasiyal travması bulunan hastalarda eşlik eden kafa travması varlığı Dağhan IŞIK,1 Hayriye GÖNÜLLÜ,2 Sevdegül KARADAŞ,2 Ö. Faruk KOÇAK,1 Sıddık KESKİN,3 M. Fatih GARCA,4 Metehan EŞEOĞLU5

BACKGROUND

AMAÇ

Patients with maxillofacial fractures are at high risk of accompanying traumatic cranial injuries. Prompt determination of head injury in these patients is crucial for improving patient survival and recovery. METHODS

Maksillofasiyal kırığı bulunan hastalar, bu travmaya eşlik eden kafa travması geçirme konusunda yüksek risk altındadırlar. Bu hastalarda kafa travmasının erken anlaşılması hastanın sağkalımı ve iyileşmesi için kritik öneme sahiptir.

The records of 246 patients with maxillofacial fractures referred to the emergency department of our hospital between January 2006 and September 2009 were reviewed in this retrospective study. The patients’ age and gender, cause, type and location of the maxillofacial fracture, and the cranial injuries were analyzed.

GEREÇ VE YÖNTEM

Ocak 2006 ile Eylül 2009 tarihleri arasında hastanemizin acil servisine maksillofasiyal kırık nedeniyle gönderilen 246 hastanın kayıtları geriye dönük olarak tarandı. Hastaların yaş, cinsiyet, maksillofasiyal travmanın nedeni, tipi, yerleşimi ve kafa travması analiz edildi.

RESULTS

BULGULAR

The mean age of the patients was 23.61±16.75 years (83.3% males and 16.7% females). Cranial injury was observed in 38 patients with maxillofacial trauma. While the risk of head injury was found to be 3.44-fold lower among patients with single facial bone fracture (p<0.001), the risk of experiencing head injury significantly increased in patients with multiple facial bone fractures (p<0.001). The risk of head trauma significantly increased in patients with fractures of the nasal bone, maxillary bone, mandibular bone, and with frontal region fractures (p<0.05 in each group).

Hastaların yaşlarının ortalaması 23,61±16,75 idi (%83,3 erkek, %16,7 kadın). Kraniyal yaralanma maksillofasiyal travmalı 38 hastada gözlendi. Hastalar arasında tek yüz kemiği kırığı bulunanlarda kafa travması riski çoklu kırıklı hastalara göre 3,44 kat daha az gözlenirken (p<0,001), yüz kemiği çoklu kırılan hastalarda kafa travması geçirme riski anlamlı derecede artmıştı (p<0,001). İçinde nazal kemik, maksiller kemik, mandibular kemik ve frontal bölge kırığı bulunan hastalarda kafa travması riski önemli derecede artmıştı (p<0,05 her bir grupta).

CONCLUSION

SONUÇ

The patients with multiple facial bone fractures should be investigated with regard to head injury even if they do not have clinical findings.

Çoklu yüz kemik kırığı bulunan hastalarda klinik bulguları olmasa dahi kafa travması yönünden araştırılmaları gerekir.

Key Words: Maxillofacial trauma; head injury; facial bone fracture.

Anahtar Sözcükler: Maksillofasiyal travma; kafa travması; yüz kemik kırığı.

Departments of 1Plastic and Reconstructive Surgery, 2Emergency Medicine, 3 Biostatistics, 4Otorhinolaryngology, 5Neurosurgery, Yuzuncu Yil University, Faculty of Medicine, Van, Turkey.

Yüzüncü Yıl Üniversitesi Tıp Fakültesi, 1Plastik ve Rekonstrüktif Cerrahi ABD, 2Acil Tıp ABD, 3Biyoistatistik ABD, 4Kulak Burun Boğaz Hastalıkları ABD, 5Nöroşirürji ABD, Van.

Correspondence (İletişim): Dağhan Işık, M.D. Yüzüncü Yıl Üniversitesi, Tıp Fakültesi, Plastik Cerrahi ABD, Maraş Cad., 65100 Van, Turkey. Tel: +90 - 432 - 225 10 24 e-mail (e-posta): daghanmd@yahoo.co.uk

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Head injury in patients with maxillofacial trauma

Patients with maxillofacial fractures may have concomitant intracranial, pulmonary, intraabdominal, or extremity injuries.[1-3] A close relationship between maxillofacial fracture and intracranial injury has been reported in many articles.[3-8] In many countries, cranial injury has been found to be the most common accompanying organ injury in patients with maxillofacial trauma.[2-5] This includes head traumas, intracranial hemorrhages, closed head traumas (brain contusion or laceration), or skull fracture. Generally, the presence of emesis, vomiting, loss of consciousness, or a low Glasgow Coma Scale (GCS) score are important findings for suspicion of a cranial injury. However, in patients with maxillofacial trauma, head trauma may be seen without observing these findings suggesting head trauma.[8] Presence of head trauma in patients with maxillofacial trauma is a life-threatening condition increasing the mortality.[5,7] Prompt detection may lead to improved results, as early decompression of an intracranial pressure is crucial in improving the outcome in head injury patients.[9-11] Thus, the healthcare provider who initially assesses the patient should examine the patient in terms of intracranial injury, which increases the morbidity and mortality. Although the relationship between head trauma and facial fractures classified as upper, middle and lower facial fractures has been investigated in the literature, the correlations between the fracture in each facial bone and cranial injury have not been clarified.

facial fractures also accompanying the analyzed bone fracture), and the total of both groups. Among these patients, those who had been diagnosed radiologically with intracranial hemorrhage, cerebral contusion or skull fracture were determined. Cases with subarachnoid hemorrhage, subdural hemorrhage, epidural hemorrhage, and intracranial hemorrhage were classified as the intracranial hemorrhage group. Cases with pneumocephalus, non-displaced skull fractures and open head trauma were classified as the skull fracture group. Cases with cerebral contusion and laceration were classified as the cerebral contusion group. Afterwards, patients with maxillofacial trauma experiencing head trauma were taken as the study group, and patients with maxillofacial trauma but not suffering from head trauma were taken as the control group. Exclusion from the Study Patients with large soft tissue trauma were included in the soft tissue trauma group. Patients with injuries not caused by blunt trauma, but only composed of linear skin lacerations and traumas in the form of a small edematous area or demarcated hematoma were not included in this group. Of the patients with maxil-

In this study, patients with maxillofacial traumas were reviewed retrospectively; those with cranial injury were included in a study group, and those without cranial injury were included in a control group. In this way, it was attempted to determine which facial fractures increased the risk of head injury.

MATERIALS AND METHODS The medical records of the patients with maxillofacial fractures seen in the emergency department of Yuzuncu Yil University Turkey between January 2006 and September 2009 were reviewed. Age, sex, the season in which patients were referred to the hospital, the etiology of the trauma, the fractured bone in the face, accompanying cranial injury, GCS, and data regarding the mortality of the patients were noted. The patients were analyzed in four groups as those aged <16 years, 16-40 years, 41-60 years, and â&#x2030;Ľ61 years. Maxillofacial trauma in the patients was recorded as soft tissue trauma, nasal fracture, maxillary fracture, mandibular fracture, frontal bone fracture (anterior wall of the frontal sinus and the upper orbital rim), lower orbital rim fracture, and zygomatic fracture (Fig. 1), which had been diagnosed by clinical and radiological examination. Facial injuries detected in the patients were analyzed in three categories as isolated cases (each facial bone fracture is isolated), complex cases (other Cilt - Vol. 18 SayÄą - No. 3

Fig. 1. Sites of diagnosed facial fractures in the patients included in the study. 1) Frontal region, 2) zygomatic region, 3) nasal region, 4) lower orbital rim, 5) maxillary region, and 6) mandibular region. (Color figures can be viewed in the online issue, which is available at www.tjtes.org).

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lofacial fractures, those who only had frontal sinus anterior wall fracture and upper orbital rim fracture were included in frontal fracture group. Patients with other frontal fractures were not included in this group. Statistical Analysis Descriptive statistics are presented as numbers and percentages. To test for the relationships between the study and control groups, the Pearson’s chi-square test and the Fisher’s exact test (when the expected counts were less than 5) were used for the categorical variables. p-values <0.05 were considered significant. The risks of head injury for different potential predictors were calculated by the odds ratios (OR) and 95% confidence intervals (CI). These statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) (ver. 13) statistical program. Multiple correspondence analyses were used for the relationship between the selected groups by using Minitab (ver. 15) statistical program. Data from multiple correspondence analyses were given graphically.

RESULTS A total of 246 patients were included in the study (study group: 38 patients, control group: 208 patients). The age and gender of the patients in both groups and

the etiologies of traumas are summarized in Tables 1 and 2. Age, Sex and Season of the Injury Of the 246 patients included in the study, 83.3% (205/246) were males and 16.7% (41/246) were females. While 81.6% of the patients with head injury were males, 18.4% were females. No significant difference was found between gender and experiencing head trauma. The mean age of the patients was 23.61±16.75 years. Of all the patients, 30.1% were aged <16 years of age, 49.2% 16-40 years, 16.2% 41-60 years, and 4.5% ≥61 years. These rates were 26.3%, 36.8%, 31.6%, and 5.3%, respectively, in patients with maxillofacial trauma experiencing head trauma (Table 1). A significant increase was detected between age and experiencing head trauma only in the 41-60 age group (p=0.005). While maxillofacial trauma was most commonly seen in the summer, no significant difference was found between seasons and head injury. Head Injury Of the patients, 15.4% (38/246) experienced head trauma. Of these patients, 15 experienced skull fracture, 14 contusion, and nine intracranial hemorrhage (Table 3).

Table 1. Demographic characteristics, cause and mechanism of injury in 246 patients in a univariate analysis

All patients (%) Study group (%) Control group (%) (n=246) (n=38) (n=208)

Sex Male Female Age 0-15 16-40 41-60 ≥61 Season of injury Summer Autumn Winter Spring Etiology of trauma Gunshot Assault Traffic accident In-vehicle traffic accident Out-of-vehicle traffic accident Accidental falls Animal trauma Others Glasgow coma scale 3-8 9-12 13-15 202

205 (83.3) 41 (16.7) 74 (30.1) 121 (49.2) 40 (16.2) 11 (4.5) 104 (42.3) 71 (28.9) 31 (12.6) 40 (16.2) 9 (3.7) 54 (22.0) 72 (29.3) 49 (19.9) 23 (9.4) 69 (28.0) 18 (7.3) 24 (9.7) 7 (2.8) 19 (7.7) 220 (89.4)

31 (81.6) 7 (18.4) 10 (26.3) 14 (36.8) 12 (31.6) 2 ( 5.3) 15 (39.5) 13 (34.2) 6 (15.8) 4 (10.5) 1 (2.6) 6 (15.9) 15 (39.5) 10 (26.3) 5 (13.2) 11 (28.9) 1 (2.6) 4 (10.5) 7 (18.4) 17 (44.8) 14 (36.8)

174 (83.7) 34 (16.3) 64 (30.8) 107 (51.4) 28 (13.5) 9 (4.3) 89 (42.8) 58 (27.9) 25 (12.0) 36 (17.3) 8 (3.8) 48 (23.1) 57 (27.4) 39 (18.7) 18 (8.7) 58 (27.9) 17 (8.2) 20 (9.6) 0 (0) 2 (0.1) 206 (99.9)

Ns 0.86 Ns 1.15 Ns 0.80 Ns 0.55 0.005 2.96 Ns 1.22 Ns 0.87 Ns 1.34 Ns 1.37 Ns 0.56 Ns 0.67 Ns 0.62 Ns 1.72 Ns 1.54 Ns 1.59 Ns 1.05 Ns 0.30 Ns 1.13 <0.001 0.13 <0.001 83.3 <0.001 0.006

95%CI

0.35-2.12 0.47-2.83 0.36-1.75 0.27-1.12 1.34-6.54 0.25-5.92 0.43-1.76 0.64-2.80 0.52-3.60 0.18-1.68 0.08-5.56 0.24-1.58 0.84-3.54 0.69-3.45 0.55-4.60 0.49-2.26 0.03-2.35 0.30-4.01 0.09-0.18 18.0-385.9 0.001-0.02

Mayıs - May 2012

Head injury in patients with maxillofacial trauma

Mechanism of Injury Patients experienced maxillofacial trauma most frequently due to traffic accidents (20.3%), followed by falls (28.0%), and strikes (22.0%). However, when the patients were analyzed in terms of trauma etiology and risk of head trauma, no causes significantly increasing the risk of head trauma were found. Injury Profile While the risk of head trauma decreased 3.4-fold in cases with only one facial bone fracture compared to those with multiple facial fractures (p=0.002), the risk of head trauma significantly increased in multiple (2 or more) facial bone fractures (p<0.001). When each facial bone was evaluated individually, no significant relationship was found between isolated fracture of the facial bones and risk of head trauma. Nevertheless, the risk of head trauma was found to increase in the presence of an accompanying facial bone fracture for each of the nasal bone, maxilla, mandible, and frontal

Table 3. Description and type of head injury in 38 patients Head injury

Skull fracture Pneumocephalus Cranial fracture Open head trauma Contusion Intracerebral hemorrhage Epidural hemorrhage Subarachnoid hemorrhage Subdural hemorrhage Intracranial hemorrhage

15 7 7 1 14 9 5 2 1 1

6.09 2.84 2.84 0.40 5.69 3.65 2.03 0.81 0.40 0.40

sinus fractures (p=0.004, p=0.022, p<0.001, p<0.001, respectively). When we evaluated all (isolated and complex fractures) of the patients with frontal sinus fracture, the risk of head injury was found to increase significantly (p<0.001). In the multiple correspon-

Table 2. Profile of facial fractures and relationship with head injury

All patients (%) Study group (%) Control group (%) (n=246) (n=38) (n=208)

Type of MFT STT Isolated Total Nasal fr. Isolated Complex with nasal fr. Total Maxillary fr. Isolated Complex with maxillary fr. Total Mandibular fr. Isolated Complex with mandibular fr. Total Zygomatic fr. Isolated Complex with zygomatic fr. Total Frontal bone fr. Isolated Complex with frontal bone fr. Total Lower orbital rim fr. Isolated Complex with orbital lower rim fr. Total Isolated facial bone fr. Multiple facial bone fr. Exitus

18 (7.3) 169 (68.7) 24 (9.7) 74 (30.1) 98 (39.8) 33 (13.4) 89 (36.2) 122 (49.6) 27 (11.0) 34 (13.8) 61 (24.8) 11 (4.5) 58 (23.5) 69 (28.0) 10 (4.1) 21 (8.5) 31 (12.6) 2 (0.8) 59 (23.9) 61 (24.7) 107 (43.5) 121 (49.1) 5 (2.03)

1 (2.6) 29 (76.3) 1 (2.6) 19 (50.0) 20 (52.6) 3 (7.9) 20 (52.6) 23 (60.5) 1 (2.6) 13 (34.2) 14 (36.8) 0 (0) 13 (34.2) 13 (34.2) 2 (5.2) 11 (29.0) 13 (34.2) 1 (2.6) 8 (21.0) 9 (23.6) 8 (21.0) 29 (76.3) 5 (17.8)

17 (8.1) 140 (67.3) 23 (11.1) 55 (26.4) 78 (37.5) 30 (14.4) 69 (33.1) 99 (47.5) 26 (12.5) 21 (10.1) 47 (22.6) 11 (5.3) 45 (21.6) 56 (26.9) 8 (3.8) 10 (4.8) 18 (8.6) 1 (0.5) 51 (24.5) 52 (25.0) 99 (47.6) 92 (44.2) 0 (0)

95%CI

Ns Ns Ns 0.004 Ns Ns 0.022 Ns Ns <0.001 Ns Ns Ns Ns Ns <0.001 <0.001 Ns Ns Ns 0.002 <0.001 <0.001

0.30 1.56 0.21 2.78 1.85 0.50 2.23 1.6 0.18 4.63 1.99 0.83 1.88 1.41 1.38 8.06 5.48 5.59 0.82 0.93 0.29 4.06 0.13

0.03-2.35 0.70-3.49 0.02-1.66 1.37-5.63 0.92-3.71 0.14-1.75 1.11-4.50 0.83-3.41 0.02-1.43 2.06-10.38 0.95-4.16 0.79-0.88 0.89-3.97 0.67-2.94 0.28-6.80 3.13-20.77 2-40-12.51 0.34-91.43 0.35-1.90 0.41-2.09 0.12-0.67 1.83-9.00 0.10-0.18

fr.: Fracture; MFT: Maxillofacial trauma; STT: Soft tissue trauma.

Cilt - Vol. 18 Say覺 - No. 3

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dence analysis, while a very close relationship was found between mandible fracture, frontal sinus fracture and head trauma, these categories were in close association with nasal fracture, maxillary fracture and multiple facial bone fracture by taking part in the same component (Fig. 2). Glasgow Coma Scale Head injury was detected in all of the seven patients with GCS score of 3-8. Head injury was observed in 17 of 19 (89.5%) patients with GCS score of 9-12. The risk of head injury increased significantly in both groups (p<0.001 for both). Head injury could not be detected in 93.6% of the patients with GCS score of 13-15 (p<0.001). Mortality Rate Only five (2.03%) of the 246 patients included in the study died. While all of the patients who died had head injury, the GCS scores of all were 3-8. All of the patients who died also had multiple facial fractures. Thoracic injury accompanying maxillofacial trauma was present in two of the five patients.

DISCUSSION Maxillofacial traumas are common traumas encountered in the emergency rooms, and a male predominance is usually seen. The male/female ratio is around 3/1 in the literature.[12-17] Nevertheless, the mean age of the patients exposed to maxillofacial trauma is above 30 years.[3,8,14-19] There is a close relationship between the presence of accompanying head injury in patients with maxillofacial fractures.[2-7] The risk of experiencing head trauma varies between 2.04% and 14%.[2,4-7] Patients with head trauma may be divided into those with intracranial hemorrhage, brain contusion and skull fracture. Hohlrieder et al.[15] and Kanno et al.[18] evaluated only the patients with intracranial hemorrhage among those with maxillofacial trauma, Fig. 2. Interrelation of categories in multiple correspondence analysis graph. While a close relationship was determined between categories 2, 4 and 10 and categories 6, 8 and 12, the categories 2, 4, 6, 8, 10, and 12 are interrelated because of their location in the same area according to the first component (Names of the categories are given in the table next to the graph).

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and found the rates of intracranial hemorrhage as 9.7% and 9.0%, respectively. This rate is 3.65% (9/246) in the current study. However, skull fractures and contusions can be as life-threatening as intracranial hemorrhage. Therefore, the assessment of all head traumas accompanying maxillofacial trauma is crucial in terms of understanding the injury that external powers could create in the face along with facial fracture. Hence, all patients with head injury accompanying maxillofacial trauma were evaluated, and the risk of experiencing head injury was found as 15.44% (38/246) among patients included in the study. This rate is slightly higher than that of similar studies in the literature. The reason for this may be the fact that 61% of the cases were exposed to high-energy traumas like traffic accident, falls or gunshot injury. The etiology of maxillofacial trauma may vary between countries. While motor vehicle accident is the leading etiology in most of the studies in the literature,[1,6,13,14,16,18-21] there are also studies available reporting that sports injuries[8,15] or assaults[2,3] are the most common etiologies in maxillofacial trauma. In many studies, while the risk of head trauma accompanying facial fractures has been reported to increase significantly,[8,16,18,22] Hohlrieder et al.[17] reported that traffic accidents did not increase the risk of intracranial hemorrhage in 2195 patients with facial fractures. Kloss et al.[8] found that assaults also increased the risk of intracranial hemorrhages accompanying maxillofacial trauma as well as traffic accidents. Nevertheless, there were no findings about trauma etiologies that significantly increased the risk of head traumas accompanying maxillofacial fracture. The summer season is risky in terms of maxillofacial trauma frequency.[13,16] In this study, patients with maxillofacial traumas were found to present to the emergency room most frequently in the

Nasal fracture Maxilla fracture Mandibular fracture Frontal fracture Multiple fracture Head injury

No Yes No Yes No Yes No Yes No Yes No Yes

Category no 1 2 3 4 5 6 7 8 9 10 11 12

May覺s - May 2012

Head injury in patients with maxillofacial trauma

summer. However, there is no significant relationship between the seasons and experiencing head trauma. Facial injury should always be of clinical concern with associated brain damage, because it can be a marker for substantial transfer of energy to the brain.[15] GCS is a good marker for determining potential brain injury, clinical conditions and prognosis of the patients following trauma.[10,22] In the current study, the risk of head trauma and mortality rate increased as the GCS decreased. However, this does not mean that there is no risk of head trauma in patients with maxillofacial trauma and high GCS scores. Borzcuk et al.[23] detected abnormal computed tomography (CT) findings in 119 out of 1448 patients who had mild head injury and GCS scores of 13-15, and intracranial hemorrhage required neurosurgical intervention in 11 patients. Kloos et al.[8] reported that intracranial hemorrhage had been detected in 54 (2.8%) out of 1959 patients with maxillofacial fractures and GCS score of 15. In the current study, head injury was detected in 14 (6.36%) out of 220 patients with GCS scores of 13-15. This leads to the question of the exact relationship between the risk of head injury and location of facial bone fractures independent of GCS and the other clinical findings suggesting head injury. While Kanno et al.[18] did not detect an increase in the risk of intracranial hemorrhage in isolated and simple zygomatic, maxillary and mandibular fractures, they found a significant increase in the intracranial hemorrhage risk in isolated maxillary alveolar fractures and panfacial fractures. On the other hand, Hohlrieser et al.[17] detected that the risk of head injury increased with maxillary fractures. On the contrary, Kloss et al.[8] reported that the risk of head injury significantly increased in all facial fractures except maxillary fractures in their study carried out in patients with GCS score of 15. However, they did not classify these fractures as isolated or complex. As a result of analysis of 4786 patients with craniomaxillofacial fractures, Mithani et al.[14] found an increase in the risk of head injury in fractures of the upper third of the face and bilateral mandibular fractures. In our study, while the risk of head injury did not increase in isolated single site fractures, the risk of head injury was found to increase in cases with two or more fractures, multiple facial fractures including nasal, maxillary, frontal sinus, and mandibular bone, and in all facial fractures involving the frontal sinus (isolated and complex frontal sinus fractures). In conclusion, maxillofacial fractures are usually repaired easily by a maxillofacial surgeon, and a lifethreatening risk due to facial fracture alone is usually not present. However, there is a life-threatening condition in cases with head injury accompanying maxillofacial fracture, and making an accurate diagnosis with proper consultations may be life-saving. Among Cilt - Vol. 18 Say覺 - No. 3

these patients, while the risk of head injury increases in those with multiple facial fractures, this risk does not increase in facial fractures isolated to a single region. Furthermore, even with a GCS of 15 and no clinical findings indicating head injury, head injury may be suspected in patients with multiple facial fractures.

REFERENCES 1. Follmar KE, Debruijn M, Baccarani A, Bruno AD, Mukundan S, Erdmann D, et al. Concomitant injuries in patients with panfacial fractures. J Trauma 2007;63:831-5. 2. Lim LH, Lam LK, Moore MH, Trott JA, David DJ. Associated injuries in facial fractures: review of 839 patients. Br J Plast Surg 1993;46:635-8. 3. Alvi A, Doherty T, Lewen G. Facial fractures and concomitant injuries in trauma patients. Laryngoscope 2003;113:1026. 4. Mulligan RP, Friedman JA, Mahabir RC. A nationwide review of the associations among cervical spine injuries, head injuries, and facial fractures. J Trauma 2010;68:58792. 5. Tung TC, Tseng WS, Chen CT, Lai JP, Chen YR. Acute lifethreatening injuries in facial fracture patients: a review of 1,025 patients. J Trauma 2000;49:420-4. 6. Brasileiro BF, Passeri LA. Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:2834. 7. Gwyn PP, Carraway JH, Horton CE, Adamson JE, Mladick RA. Facial fractures--associated injuries and complications. Plast Reconstr Surg 1971;47:225-30. 8. Kloss F, Laimer K, Hohlrieder M, Ulmer H, Hackl W, Benzer A, et al. Traumatic intracranial haemorrhage in conscious patients with facial fractures--a review of 1959 cases. J Craniomaxillofac Surg 2008;36:372-7. 9. Mendelow AD, Karmi MZ, Paul KS, Fuller GA, Gillingham FJ. Extradural haematoma: effect of delayed treatment. Br Med J 1979;1:1240-2. 10. Haug RH, Savage JD, Likavec MJ, Conforti PJ. A review of 100 closed head injuries associated with facial fractures. J Oral Maxillofac Surg 1992;50:218-22. 11. Bouamra O, Wrotchford A, Hollis S, Vail A, Woodford M, Lecky F. Outcome prediction in trauma. Injury 2006;37:10927. 12. Bataineh AB. Etiology and incidence of maxillofacial fractures in the north of Jordan. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:31-5. 13. Ferreira PC, Amarante JM, Silva PN, Rodrigues JM, Choupina MP, Silva AC, et al. Retrospective study of 1251 maxillofacial fractures in children and adolescents. Plast Reconstr Surg 2005;115:1500-8. 14. Mithani SK, St-Hilaire H, Brooke BS, Smith IM, Bluebond-Langner R, Rodriguez ED. Predictable patterns of intracranial and cervical spine injury in craniomaxillofacial trauma: analysis of 4786 patients. Plast Reconstr Surg 2009;123:1293-301. 15. Hohlrieder M, Hinterhoelzl J, Ulmer H, Hackl W, Schmutzhard E, Gassner R. Maxillofacial fractures masking traumatic intracranial hemorrhages. Int J Oral Maxillofac Surg 2004;33:389-95. 16. Hogg NJ, Stewart TC, Armstrong JE, Girotti MJ. Epidemiology of maxillofacial injuries at trauma hospitals in Ontario, Canada, between 1992 and 1997. J Trauma 205

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2000;49:425-32. 17. Hohlrieder M, Hinterhoelzl J, Ulmer H, Lang C, Hackl W, Kampfl A, et al. Traumatic intracranial hemorrhages in facial fracture patients: review of 2,195 patients. Intensive Care Med 2003;29:1095-100. 18. Kanno T, Mitsugi M, Furuki Y, Fujioka M, Katsumata A, Matsumoto Y, et al. Traumatic intracranial hemorrhages in patients with maxillofacial / jaw fractures. JJAAM 2008;19:1023-8. 19. Sinclair D, Schwartz M, Gruss J, McLellan B. A retrospective review of the relationship between facial fractures, head injuries, and cervical spine injuries. J Emerg Med 1988;6:10912.

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20. Imahara SD, Hopper RA, Wang J, Rivara FP, Klein MB. Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank. J Am Coll Surg 2008;207:710-6. 21. Haug RH, Foss J. Maxillofacial injuries in the pediatric patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:126-34. 22. Keenan HT, Brundage SI, Thompson DC, Maier RV, Rivara FP. Does the face protect the brain? A case-control study of traumatic brain injury and facial fractures. Arch Surg 1999;134:14-7. 23. Borczuk P. Predictors of intracranial injury in patients with mild head trauma. Ann Emerg Med 1995;25:731-6.

May覺s - May 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):207-212

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.28003

Reconstruction of a distal extremity defect using a temporoparietal fascia flap covered with a split-thickness skin graft harvested from the scalp: a cosmetic consideration in donor site selection Distal ekstremite defektlerinin temporaoparietal fasya ve skalpten alınan kısmi kalınlıklı deri grefti ile rekonstrüksiyonu: Donör saha seçimine kozmetik bir yaklaşım Özlenen ÖZKAN,1 Ömer ÖZKAN,1 Gamze BEKTAŞ,1 Samir MARDINI,2 Paolo SASSU,2 Emanuele CIGNA,2 Serdar TÜZÜNER,3 Hung-Chi CHEN2

BACKGROUND

AMAÇ

In reconstructive surgery, the ultimate goal in rebuilding a structure is to provide the most similar substitute from both the functional and structural points of view. At the same time, the reconstructive surgeon should focus on minimizing donor area complications.

Rekonstrüktif cerrahide asıl amaç, fonksiyonel ve yapısal açılardan en benzer doku ile yeniden yapılanmanın sağlanmasıdır. Ancak rekonstrüktif cerrah aynı zamanda donör alan komplikasyonlarını en aza indirmeye de odaklanmalıdır.

METHODS

GEREÇ VE YÖNTEM

In this report, we present our experiences with the reconstruction of distal extremity defects using a free temporoparietal fascia flap in five patients. The flap was subsequently covered with a split-thickness skin graft harvested from the same region of the scalp as the flap donor site.

Biz bu çalışmamızda beş hastada distal ekstremite defektlerinde temporoparietal fasya flebi ve deri grefti ile rekonstrüksiyon deneyimlerimizi sunduk. Temporoparietal fasya flebi skalpte aynı bölgeden alınan kısmi kalınlıkta deri grefti ile kaplandı.

RESULTS

BULGULAR

By procuring the skin graft from the scalp, the donor sites of both the flap and the skin graft were concealed by hair. The transferred flaps and skin grafts healed uneventfully in all patients without any complications at the donor or recipient site.

Greftin skalpten alınması ile hem flep hem greft donör alanları saçların arkasında gizlenmiş oldu. Transfer edilen flep ve greftler tüm hastalarda herhangi bir donör alan komplikasyonu görülmeden olaysız şekilde iyileşti.

CONCLUSION

Distal ekstremite defektlerinde temporaparietal fasya kullanmanın sayısız avantajına ek olarak bunu aynı alandan alınan kısmi kalınlıkta deri grefti ile kombine etmenin hem skarı saçlar tarafından gizleyerek donör alan morbiditesini azaltması hem de optimal rekonstrüktif sonuçları sağlaması açısından iyi bir seçenek olduğunu düşünüyoruz.

We conclude that this combination of harvesting a temporoparietal fascia flap, which has many advantages in reconstructing distal extremity defects, along with a skin graft from the same region as the flap, both hidden by hair, can limit donor site morbidity and achieve optimal reconstructive outcomes.

SONUÇ

Key Words: Cosmetic consideration; graft; temporoparietal fascia flap; scalp.

Anahtar Sözcükler: Kozmetik önem; greft; temporaoparietal fasya flebi; skalp.

Departments of 1Plastic and Reconstructive Surgery, Orthopedics and Traumatology, Akdeniz University Faculty of Medicine, Antalya, Turkey; 2Department of Plastic and Reconstructive Surgery, E-Da Hospital / I-Shou University, Kaohsiung County, Taiwan.

Akdeniz Üniversitesi Tıp Fakültesi, 1Plastik ve Rekonstrüktif Cerrahi Anabilim Dalı, 3Ortopedi ve Travmatoloji Anabilim Dalı, Antalya; 2 I-Shou Üniversitesi, E-Da Hastanesi, Plastik ve Rekonstrüktif Cerrahi Bölümü, Kaohsiung, Tayvan.

Correspondence (İletişim): Ömer Özkan, M.D. Akdeniz Üniversitesi Tıp Fakültesi, Plastik ve Rekonstrüktif Cerrahi Anabilim Dalı, B Blok, 2. Kat, Antalya, Turkey. Tel: +90 - 242 - 249 62 08 e-mail (e-posta): omozkan@hotmail.com

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In any kind of tissue defect, the surgeon must consider several factors when selecting the appropriate method of reconstruction. During the reconstruction of a structure, in an otherwise healthy patient, it is obvious that the ultimate goal is to replace like with like. However, this particular principle cannot be achieved in many clinical situations. Thus, the reconstruction is performed with tissue that is similar yet not identical. The reconstructive surgeon must take into consideration the aesthetic outcome at both the donor site and the recipient site. Prior to the era of reconstructive microsurgery, options for coverage of tissue defects consisted of allowing the wound to heal by secondary intention, skin grafting, as well as local and regional flap coverage, many of which were at times insufficient to meet requirements at the recipient site. The advent of free tissue transfer has provided multiple reconstructive options that have allowed for the preservation and maintenance of the functional, structural and aesthetic status of both the recipient and donor sites. The choice of soft tissue for coverage of defects of the upper and lower extremities is dependent on the extent and location of the wound. The aim when treating extremity defects, as is the case with other defects in the body, is to preserve function while achieving a sound aesthetic outcome. Although local fasciocutaneous and muscle flaps may be appropriate and adequate for many defects in the extremities, advances in microsurgical techniques have permitted reliable wound closure and a substantial decrease in patient morbidity with low complication rates while allowing a variety of reconstructive flap options in a single stage. The temporoparietal fascia flap, with its consistent vascular pedicle, is a thin, supple, pliable, and versatile flap that can be used for a variety of complex reconstructive efforts.[1-5] This flap has ample intrinsic blood supply to improve local wound vascularity and allow for excellent wound healing.[1-6] The temporoparietal fascia flap itself is harvested from a region that is inconspicuous, due to its ease of concealment by hair. However, its requirement for skin grafting, in order to complete the reconstruction, necessitates the creation of another donor site for skin grafting. In this report, we present our experiences with distal foot and hand defects reconstructed using a free

temporoparietal fascia flap in five patients. The fascia flap was subsequently covered with a split-thickness skin graft, harvested from the same region of the scalp as the flap. The donor sites for both the flap and the skin graft were prepared simultaneously and were limited to an area that was easily concealed by hair. Structural and aesthetic viewpoints at both the donor site and the reconstructed site were considered and are discussed in this manuscript.

MATERIALS AND METHODS From October 2004 through May 2009, five free temporoparietal fascia flaps were used to reconstruct soft tissue defects of the distal foot and hand defects. There were 4 males and 1 female, aged 9-21 years (Table 1). All patients had crush injury due to traumas. The size of the flaps ranged from 10-13 cm long and 6-8 cm wide. For practical purposes, the right side of the scalp was selected as the donor area for both a fascia flap and a skin graft. This side of the face and scalp were then prepared and draped in the usual sterile fashion after shaving of the hair. Prior to elevation of the flap, in order to increase the skin tension and the surface area of the skin of the scalp, saline was injected into the subgaleal plane. A split-thickness skin graft, measuring approximately 12/1000th of an inch in thickness, was taken from the temporoparietal region utilizing an air-driven dermatome. A preauricular incision starting at the level of the tragus was made and extended superiorly to the superior temporal line, at which point it was converted to a curved Y-shaped incision. The superficial temporal artery and its two concomitant veins were identified, exposed, and isolated. The dissection of the anterior and posterior scalp flaps was carried out in a subcutaneous plane, deep to the hair follicles. Marking of the fascia flap was made and elevated over the level of the deep temporal fascia (in the plane of the loose areolar tissue). The flap was harvested from cephalad to caudad until the flap was fully mobilized and the pedicle length was adequate. The flap was then transferred to the defect and the superficial temporal artery was anastomosed to the recipient artery, and the concomitant veins of the flap were anastomosed to the concomitant deep recipient vein and/or -if it was reliable- to a superficial vein. The skin graft, which

Table 1. Patient summary No

Age (y)

Sex

1* 2 3 4* 5

9 18 21 14 18

F M M M M

Cause Crush injury, right foot Crush injury, right hand Crush injury, left hand Crush injury, right hand Crush injury, left foot

Flap size (cm)

Complication

7 x 12 7 x 13 6 x 10 7 x 11 8 x 13

None None None None None

M: Male; F: Female. *: Presented cases.

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was harvested from the scalp, was cleaned well and all remnant hair shafts were removed. Holes were made in the graft using a no. 11 blade, and the graft was used to cover the fascia flap. The wound of the donor area was closed primarily, and the donor area of the skin graft was covered with Tegaderm (3M Healthcare, St. Paul). Patient 1- A nine-year-old girl had a bicycle accident that resulted in a crush injury and loss of soft tissue in the distal part of the right foot (Fig. 1a). The patient was seen at an outlying hospital where primary repair of the lacerations was performed and dressing

(a)

changes to the dorsal foot wound were instituted. The patient presented to our clinic 20 days later with a soft tissue defect over the dorsum of the foot. The 4th toe and the distal phalanx of the 3rd and 5th toes had been amputated. The dorsal foot defect extended from the 2nd to the 5th metatarsal bones. The distal third of the 3rd metatarsal and the proximal phalanx of the 3rd toe as well as the overlying tendons were exposed. There was necrotic skin over the third web space. The remaining soft and hard tissues of the foot, along with its blood supply, appeared to be intact. The dorsalis pedis and posterior tibial arteries were palpable. X-ray examination identified the level of amputation of the

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

Fig. 1. (a) A crush injury of the foot in a 9-year-old patient. (b) Preoperative preparation for the procedure and marking for the temporoparietal fascia flap. (c) Harvest of the temporoparietal fascia flap based on the superficial temporal vessels. (d) Harvest of a split-thickness skin graft from the scalp. (e) The defect after coverage with the free temporoparietal fascia flap. (f) The surface of the fascia flap was covered with a split-thickness skin graft harvested from the scalp. (g) A postoperative view of the dorsal aspect of the foot at the 4-month follow-up. (h) A postoperative view of the lateral aspect of the foot at the 4-month follow-up. Note the natural contour of the flap and the cosmetic outcome, which was a result of the thinness of the flap. (i) Postoperative view of the donor area. (Color figures can be viewed in the online issue, which is available at www.tjtes.org).

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(a)

The soft tissue defect was closed with a temporoparietal fascia flap measuring 7 x 12 cm (Figs. 1b, 1c, 1d). The superficial temporal artery was anastomosed to the dorsalis pedis artery, and the concomitant veins of the flap were anastomosed to one dorsalis pedis concomitant vein and to the previously exposed superficial dorsal foot vein (Fig. 1e). The proximal part of the fascia flap was used to resurface the dorsal foot defect, and the distal aspect of the flap was used to cover, circumferentially, the degloved 3rd toe. The vascular pedicle of the flap was covered with a proximally based local skin flap from the dorsum of the foot. The skin graft, which was harvested from the scalp, was

(b)

(d)

(c)

(e)

(g)

(f)

(h)

(Color figures can be viewed in the online issue, which is available at www.tjtes.org).

4th toe to be at the metatarsophalangeal joint and of the 3rd and 5th toes to be at the distal interphalangeal joints. The remaining bones of the foot were without fractures. The patient underwent surgical debridement of the wound, at which time it was noted that the proximal interphalangeal joint of the 3rd toe was exposed and dislocated. Because of the strong desire of the family for the preservation of the length of the toes, this was fixed using Kirschner wire. The dorsalis pedis artery along with its concomitant veins and a superficial vein on the dorsum of the foot were prepared as recipient vessels.

Fig. 2. (a) Extensive soft tissue defect in the dorsal aspect of the right hand in a 14-year-old patient. (b) Intraoperative view after debridement of the wound and repair of the tendon with a tendon graft and fixation of the second metacarpal bone fracture. (c) Intraoperative view after harvesting a skin graft from the scalp and marking for the temporoparietal fascia flap. (d) Harvest of the temporoparietal fascia flap based on the superficial temporal vessels. (e) Harvest of a split-thickness skin graft from the scalp. (f) Immediate postoperative view after coverage with the free temporoparietal fascia flap. The surface of the fascia flap was covered with a split-thickness skin graft harvested from the scalp. (g) A postoperative view at the 3-month follow-up. (h) Postoperative view of the donor area. 210

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used to cover the fascia flap (Fig. 1f). Postoperative recovery was uneventful, and the flap survived completely. There was complete take of the split-thickness skin graft (Figs. 1g, 1h, 1i). The Kirschner wire was removed three weeks postoperatively. There was no problem with hair growth in the scalp. The thinness of the flap allowed the patient to wear a shoe at four months postoperatively (Fig. 1h). Patient 2- A 14-year-old male patient was referred to the Plastic Surgery clinic with a crush and avulsion injury to the distal part of the right upper extremity caused by a vehicular accident. Physical examination revealed skin defect and crush injuries in the dorsal aspect of the right hand (Fig. 2a). The circulation of the hand was not affected, and distal pulses were palpable. However, there was severe crush and avulsion injury to the extensor surface of the hand. The second metacarpal bone was exposed with multiple fractures, and the external extensor tendons of the 2nd and 3rd fingers were defective. Under X-ray, multiple fractures of the second metacarpal bone were apparent. Wound debridement of the soft tissues was performed, and tendon defects were repaired with tendon grafts. The metacarpal bone was repaired using a Kirschner wire (Fig. 2b). The superficial radial artery along with its concomitant veins and a superficial vein on the dorsum of the foot were prepared as recipient vessels. The temporoparietal fascia flap measuring 7 x 11 cm and the skin graft were harvested in the same manner (Figs. 2c, 2d, 2e). The flap was then transferred to the defect and the superficial temporal vessels were anastomosed to the superficial radial vessels. The skin graft, which was harvested from the scalp, was used to cover the fascia flap (Fig. 2f). The postoperative recovery was uneventful, and the flap survived completely (Fig. 2g). There was complete take of the splitthickness skin graft. The Kirschner wire was removed six weeks postoperatively. There was no problem with hair growth in the scalp (Fig. 2h).

RESULTS No flap required reoperation due to vascular compromise. All flaps survived completely. No secondary corrections, including debulking procedure and scar revision, were necessary. No infections or hematomas were observed. All flap donor sites that were closed directly healed with minimal scar requiring no correction. None of the cases had postoperative alopecia with hair growth problem in the skin graft donor area. DISCUSSION In reconstructive surgery, the surgeon should focus on preserving and maintaining the natural status of the patient by minimizing complications in the flap donor region, while achieving optimal results in the recipient Cilt - Vol. 18 Say覺 - No. 3

defects. The choice of soft tissue coverage of defects of the lower extremity depends on the extent and location of the wound. While local fasciocutaneous and muscle flaps are sufficient for certain defects of the limbs, they are usually not adequate for coverage of many defects. Advances in microsurgery have provided alternative reconstructive options in which large defects can be reconstructed in one stage using free tissue transfer. At the same time, free tissue transfer allows the preservation of local tissues, thus keeping the functional and cosmetic impairment of an already injured extremity to a minimum. Fascial flaps possess unique advantages related to their tissue quality.[7,8] They have been preferably used in situations where very thin coverage is required, or when a gliding surface is thought to be necessary to facilitate underlying tissue excursion.[1-5] Purely fascial flaps represent a superior choice when the bulk of a fasciocutaneous or myocutaneous flap hinders movement of the extremity or appears aesthetically unacceptable. Of these, the temporoparietal fascia flap, with its consistent vascular pedicle, is a versatile flap that can be used for a variety of complex reconstructive procedures.[1-5] The flap has a good intrinsic blood supply that can improve local wound conditions for superior healing. The temporoparietal fascia flap was first described in the same year by two authors who were working independently: Brown in 18989 for reconstruction of an ear defect and Monks[10] in 1898 for reconstruction of a lower eyelid defect. Despite this relatively early description, this flap has only become popular as either a pedicled or a microvascular free flap over the past three decades.[1-5] Today, the surgical anatomy and blood supply of the flap are well described, and in clinical practice, it has well-defined indications and is well known for its reliable and versatile properties.[1-6] The temporoparietal fascia flap can be harvested from a region that is inconspicuous and easily concealed by hair; however, it usually requires coverage with a skin graft. This necessitates the creation of another donor site, usually in the thigh, which is hard to conceal. In clinical practice, in all cases to date, the skin graft has been harvested from a site distant from the flap donor site, usually from the thigh. The scalp, which is the donor area for the temporoparietal fascia flap, is a useful donor site for split-thickness skin grafts.[11-14] It has been observed that partial thickness defects of the scalp heal quickly. Re-epithelization depends on proliferation and migration of epidermal elements within the dermis, especially those lining the hair follicles, which are present quite densely in the scalp. This donor area is readily hidden by hair. In our cases, the temporoparietal fascia flaps were used to reconstruct the soft tissue defects of the distal 211

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dorsum of the feet and hands, and were then covered with a split-thickness skin graft. The skin grafts were harvested from the same area of the scalp as that from which the flaps were raised. Through this combination of flap and skin graft harvesting from the same side of the scalp, the foot and hand were able to be reconstructed with thin and well-vascularized tissue, and the donor area of both the flap and skin graft was hidden by hair. Although alopecia is considered the main disadvantage of the temporoparietal fascia flap, this is more common if the vascularity of the overlying skin has already been compromised by trauma, irradiation, infection, or previous surgery.[4,5] If the scalp flaps over the fascia were dissected carefully and directly deep to the hair follicles, the rate of alopecia occurrence is extremely low. When alopecia does occur, however, it is usually transient and resolves within a few months; otherwise, the area can be revised in order to improve the aesthetic outcome. In order to decrease the risk of hematoma formation and subsequent increase in tension on the scalp skin, a suction drain is usually inserted. Postoperative alopecia, folliculitis, and visible scar formation are potential complications of harvesting skin grafts from the scalp.[11-15] It has been reported that alopecia can occur as a complication of skin graft harvesting from the scalp in 0 to 10% of the cases. This is mostly related to improper harvesting of the graft.[11,13] The rate of postoperative folliculitis has been reported to be 2%,[11] and when it occurs, it can be treated with local wound care. The rate of postoperative scar formation is extremely low and is usually due to uneven harvesting of the graft, with some areas being too thick. Repeated harvesting of the skin graft from the scalp is not advised since it can be a cause of an increase in complication rates.[13] The use of saline infiltration in the subgaleal plane provides a good contour and appropriate tension for a simpler and more accurate skin graft harvest. Since the size of the skin graft that is harvested for coverage of the flap is relatively small, excessive bleeding is usually not noted, and there is usually no need to provide special applications such as epinephrine or thrombin solutions to the donor site. In conclusion, using the same donor area for both the flap and skin graft can provide optimal outcomes at both the recipient and donor sites. This particular region of the body can be easily concealed by hair and is therefore ideal for this combination of tissues. While the reconstruction provided using a thin fascia flap was appropriate for reconstruction of the dorsum

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of the foot and hand, the patients were also spared an additional donor-site scar. Acknowledgement We thank Akdeniz University Scientific Research Projects Unit for their support of this study. Financial Disclosure and Products None of the authors of this manuscript have any commercial association that might pose or create a conflict of interest with the information presented in the submitted manuscript. This includes: consultancies, stock ownership, or other equity interests, patent licensing arrangements, and payments for conducting or publicizing the study described in the manuscript.

REFERENCES 1. Smith RA. The free fascial scalp flap. Plast Reconstr Surg 1980;66:204-9. 2. Brent B, Byrd HS. Secondary ear reconstruction with cartilage grafts covered by axial, random, and free flaps of temporoparietal fascia. Plast Reconstr Surg 1983;72:14152. 3. Brent B, Upton J, Acland RD, Shaw WW, Finseth FJ, Rogers C, et al. Experience with the temporoparietal fascial free flap. Plast Reconstr Surg 1985;76:177-88. 4. Hing DN, Buncke HJ, Alpert BS. Use of the temporoparietal free fascial flap in the upper extremity. Plast Reconstr Surg 1988;81:534-44. 5. Woods JM 4th, Shack RB, Hagan KF. Free temporoparietal fascia flap in reconstruction of the lower extremity. Ann Plast Surg 1995;34:501-6. 6. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 1986;77:17-28. 7. Chen HC, el-Gammal TA. The lateral arm fascial free flap for resurfacing of the hand and fingers. Plast Reconstr Surg 1997;99:454-9. 8. Meland NB, Weimar R. Microsurgical reconstruction: experience with free fascia flaps. Ann Plast Surg 1991;27:1-8. 9. Brown WJ. Extraordinary case of horse bite: the external ear completely bitten off and successfully replaced. Lancet 1898;1:1533. 10. Monks GH. The restoration of a lower lid by a new method. N Eng J Med 1898;139:385-7. 11. Lesesne CB, Rosenthal R. A review of scalp split-thickness skin grafts and potential complications. Plast Reconstr Surg 1986;77:757-8. 12. Fang K, Stevenson TR. Skin graft from a scalp flap. Plast Reconstr Surg 1987;79:622-4. 13. Martinot V, Mitchell V, Fevrier P, Duhamel A, Pellerin P. Comparative study of split thickness skin grafts taken from the scalp and thigh in children. Burns 1994;20:146-50. 14. Brou J, Vu T, McCauley RL, Herndon DN, Desai MH, Rutan RL, et al. The scalp as a donor site: revisited. J Trauma 1990;30:579-81. 15. Chang LY, Yang JY, Chuang SS, Hsiao CW. Use of the scalp as a donor site for large burn wound coverage: review of 150 patients. World J Surg 1998;22:296-300.

May覺s - May 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):213-218

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.03710

Epidemiology of head injury in the United Arab Emirates Birleşik Arap Emirlikleri’ndeki kafa yaralanması epidemiyolojisi Abdullah AL-KUWAITI,1 Ashraf F HEFNY,2 Abdelouahab BELLOU,3 Hani O EID,2 Fikri M ABU-ZIDAN4

BACKGROUND

AMAÇ

Head injury increases mortality in trauma patients. We aimed to study the epidemiological and clinical features of head injury in Al-Ain city, United Arab Emirates (UAE).

Kafa yaralanması travma hastalarında mortaliteyi artırmaktadır. Bu yazıda, Birleşik Arap Emirlikleri (BAE) Al-Ain kentindeki kafa yaralanmalarının epidemiyolojik ve klinik özellikleri değerlendirildi.

METHODS

GEREÇ VE YÖNTEM

Trauma patients with head injury who were admitted to AlAin Hospital for more than 24 hours and those who died in the hospital were included in the study. Data were prospectively collected from March 2003 - March 2006.

Al-Ain Hastanesi’ne 24 saatten daha uzun süreyle yatırılan ve hastanede ölen kafa yaralanması hastaları çalışmaya dahil edildi. Veri, Mart 2003 ile Mart 2006 tarihleri arasında prospektif olarak derlendi.

RESULTS

BULGULAR

589 patients were studied, and 521 were males (88.3%). The median (range) age was 30 (1-89) years. The most common mechanism of injury was road traffic collision (67.1%) followed by fall from height (11.9%). Head injury was mild in 82.2% of patients, moderate in 5.7%, and severe in 12.1%. 20.9% of patients were admitted to the intensive care unit. 35 patients died (overall mortality 5.9%). Patients who died had significantly higher Injury Severity Score (p<0.0001), lower Glasgow Coma Scale (p<0.0001), and higher Abbreviated Injury Scale of the head (p<0.0001).

589 hasta çalışıldı [521 erkek (%88,3)]. Mediyan (aralık) yaş, 30 (1-89) yıldı. En sık yaralanma mekanizması, karayolu trafik kazası (%67,1) ve daha sonra da yüksekten düşme (%11,9) idi. Kafa yaralanması, hastaların %82,2’sinde hafif, %5,7’sinde orta derece ve %12,1’inde ciddi idi. Hastaların %20,9’u yoğun bakım ünitesine yatırıldı. Otuz beş hasta öldü (genel mortalite %5,9). Ölen hastalar, anlamlı şekilde yüksek yaralanma şiddet skoruna (p<0,0001), daha düşük Glasgow koma skoruna (p<0,0001) ve daha yüksek kısaltılmış yaralanma ölçeğine (p<0,0001) sahipti.

CONCLUSION

Motorlu araç kazası, BAE’deki kafa yaralanması ile ilgili başlıca mekanizma idi ve bunu yüksekten düşme izliyordu. Zorunlu emniyet kemeri kullanımı, bisiklet ve motorsiklet sürücüleri tarafından kask kullanımı ile ilgili mevzuat yasalaştırılmalıdır. İşyerinde güvenli iş ortamı ve koruyucu önlemler sağlanmalıdır.

Motor vehicle collision was the main mechanism of head injury in the UAE followed by fall from height. Legislation for compulsory seatbelt usage and helmet usage by bicyclists and motorcyclists should be adopted. A safe work environment and preventive measures at work should be introduced. Key Words: Head; trauma; motor vehicle collision; United Arab Emirates; seatbelt usage.

Department of Neurosurgery, Tawam Hospital, Al-ain; 2Departments of Surgery (Trauma Group), 3Internal Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University, Al-ain; 4Department of Surgery, Al-ain Hospital, Al-ain, United Arab Emirates. 1

SONUÇ

Anahtar Sözcükler: Kafa; travma; trafik kazası; Birleşik Arap Emirlikleri; emniyet kemeri kullanımı.

1 Tawam Hastanesi, Nöroşirürji Kliniği, Al-ain; Birleşik Arap Emirlikleri Üniversitesi, Tıp ve Sağlık Bilimleri Fakültesi, 2Cerrahi Anabilim Dalı (Travma Grubu), 3İç Hastalıkları Anabilim Dalı, Al-ain; 4Al-ain Hastanesi, Cerrahi Kliniği, Al-ain, Birleşik Arap Emirlikleri.

Correspondence (İletişim): Ashraf F Hefny, M.D. United Arab Emirates University, Faculty of Medicine and Health Sciences, Department of Surgery, Trauma Group, PO Box 17666, Al-Ain, United Arab Emirates. Tel: +0971 - 3 - 7039589 e-mail (e-posta): ahefny@uaeu.ac.ae

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Trauma is a leading cause of death worldwide. Trauma patients with head injury (HI) have a 10-fold higher mortality than in those with no HI.[1] Furthermore, HI accounts for two-thirds of in-hospital trauma deaths.[2] Disability following traumatic brain injury may require a lengthy rehabilitation, which places a great burden on national medical resources.[3,4] The rapid industrialization and tremendous increase in motorized vehicles in developing countries have led to an increase in the incidence of HI. Epidemiological studies are essential for strategic planning for health resources and prevention.[5]

Table 1. Nationality of hospitalized head-injured patients, Al-Ain, United Arab Emirates 20032006 (n=579)* Nationality

Number

UAE Other Arab Pakistani Indian Bangladesh Other Asia Others Total

140 122 129 72 72 38 6 579

24.2 21.1 22.3 12.4 12.4 6.6 1 100

We aimed to study the incidence, mechanisms, types, and outcome of HI in Al-Ain city, United Arab Emirates (UAE) in order to give recommendations on preventive priorities.

UAE: United Arab Emirates; * missing data (10).

MATERIALS AND METHODS All HI trauma patients who were admitted to AlAin Hospital for more than 24 hours or who died in the hospital after arrival were studied. Data of the patients were retrieved from Al-Ain Hospital Trauma Registry. The Local Ethics Committee of Al-Ain Health District area approved data collection for all trauma patients who were admitted to Al-Ain Hospital or who died in the Emergency Department (Ethical approval No: RECA/02/44). Data were prospectively collected over a period of three years (March 2003 - March 2006). The percentages of the population by nationality and gender were retrieved from the general census of the UAE for population, 2005.[6] Demographics, mechanism and types of injury, Glasgow Coma Scale (GCS) on arrival, the need for ventilation, Injury Severity

Mechanism

100

Age (years)

Road traffic collision Fall from height Fall Heavy object Assault Animal-related Others Total

Number

395 70 43 28 28 13 12 589

67.1 11.9 7.3 4.8 4.8 2.2 2.2 100

Score (ISS), Abbreviated Injury Scale (AIS) for the head, hospital stay, and mortality were analyzed. Statistical analysis included Mann-Whitney U test for continuous or ordinal data to compare two independent groups and Spearman’s rank correlation test to study correlations between two variables. A p value of ≤0.05 was considered significant. Data were analyzed with PASW Statistics 18, SPSS Inc, USA.

RESULTS There were 2573 patients included in the Trauma Registry of Al-Ain Hospital, and 589 (22.9%) patients had HI. There were more male patients (521, 88.3%) than female patients (68, 11.5%), with a male: female ratio of 7.7: 1. The median (range) age was 30 (1-89) years (Fig. 1). One hundred and forty patients (24.2%) were UAE nationals (Table 1).

0 0-4

10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 Age (years)

Fig. 1. Hospitalized head injury patients, by age and gender: males (broken line, n=521), females (solid line, n=68), Al-Ain, United Arab Emirates 2003-2006 (n=589). 214

Table 2. Mechanism of injury of hospitalized headinjured patients, Al-Ain, United Arab Emirates 2003-2006 (n=589)

The majority of HI took place on the street (65.1%), followed by the work place (14.1%) and home (12.7%). The most common mechanism of injury was road traffic collision (RTC) (67.1%) followed by fall from height (11.9%) (Table 2). The majority of patients (330, 56.1%) arrived to the hospital by ambulance, while 233 (39.6%) arrived by private cars. The most frequent time for HI was midnight. There was no difference in the occurrence of HI between the days of the week or months of the year (Fig. 2). Mayıs - May 2012

Epidemiology of head injury in the United Arab Emirates

On admission, the median (range) GCS was 15 (315). HI was mild (GCS 13-15) in 474 (82.2%) patients, moderate (GCS 9-12) in 33 (5.7%) patients, and severe (GCS 3-8) in 70 (12.1%) patients. The median (range) ISS was 4 (1-43). Intubation and mechanical ventilation was needed in 82 (13.9%) patients. One hundred

Number (n)

50 40 30

Type of head injury Concussion Fractured skull Subdural hematoma Epidural hematoma Subarachnoid bleeding Intracerebral hemorrhage Brain contusion Others

Number

456 198 44 33 33 13 32 26

77.4 33.6 7.5 5.6 5.6 2.2 5.4 4.4

Table 4. Associated injured body regions of hospitalized head-injured patients, Al-Ain, United Arab Emirates 2003-2006 (n=589)

Region

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 10 21 22 23 24 Hours

Table 3. Types of head injury of hospitalized headinjured patients, Al-Ain, United Arab Emirates 2003-2006 (n=589)

120

Neck Chest Abdomen Spine Upper limbs Lower limbs

Number

18 128 28 32 167 130

3.1 21.7 4.8 5.4 28.4 22.1

Number (n)

100

and seventy-five (29.7%) patients had an isolated HI. The most common HI was concussion (77.4%) (Table 3). The most commonly injured body region in association with HI was the upper limbs (28.4%) (Table 4).

80 60 40

One hundred twenty-three (20.9%) patients were admitted to the intensive care unit (ICU), with a median (range) ICU stay of 2.5 (1-35) days. The mean (range) hospital stay was 8.31 (1-130) days. Two hundred and ten patients (36%) were discharged within 48 hours. Thirty-five patients died (overall mortality 5.9%), while the overall mortality of our Trauma Registry in the same period was 2.2% (56 patients). Twenty-nine (82.9%) patients who died were involved in RTC. 15 died in the Emergency Department, 2 in the Operating Theater, and 18 in the ICU. Patients who died had significantly higher ISS, lower GCS, and higher AIS of the head compared with those who survived (p<0.0001, p<0.0001 and p<0.0001, respectively, Mann-Whitney U-test) (Table 5). GCS was significantly correlated with AIS of the HI (-0.59, p<0.0001, Spearmanâ&#x20AC;&#x2122;s rank correlation).

ay Fr

ay sd Th

sd ne W ed

Tu e

y da

ay nd

Day

Number (n)

6 7 Month

Fig 2. Distribution of hospitalized head-injured patients by time (A), day (B) and month (C), Al-Ain, United Arab Emirates 2003-2006 (n=589). Cilt - Vol. 18 SayÄą - No. 3

DISCUSSION Reports of HI vary widely between different epidemiological studies due to the lack of a common clear definition of head trauma, different study samples, and methodology issues.[4,7] For these reasons, comparison between different studies is difficult. In our study, HI was defined according to the anatomical lesions and 215

Ulus Travma Acil Cerrahi Derg

Table 5. Comparison between patients who died and those who survived after head injury, Al-Ain, United Arab Emirates 2003-2006 (n=589)

Survived (n=554)

Died (n=35)

ISS GCS Highest head AIS

3 (1-41) 15 (3-15) 1 (1-5)

25 (13-43) 4 (3-15) 3 (1-5)

<0.0001 <0.0001 <0.0001

ISS: Injury Severity Score; GCS: Glasgow Coma Scale; AIS: Abbreviated Injury Scale. * p value Mann-Whitney test.

level of consciousness in accordance with the AIS manual.[8] Several factors increase rates of HI in developing countries, including increased population numbers and density and increased vehicular traffic.[9] The UAE is a rapidly developing country. Al-Ain Hospital is one of the two major hospitals in Al-Ain city, which is the largest city in the eastern district of Abu Dhabi, with 463,000 inhabitants.[10] It is a modern city that extends horizontally over a wide area with modern welldesigned roads and short buildings (less than 4 floors in height). This makes the density of the population less compared with other cities in the country. This study has shown that the annual incidence of hospitalized head trauma patients in Al-Ain city was 42 per 100,000 population. If we consider that only 20% of patients presenting to the Emergency Unit were admitted to the hospital,[11] this makes the annual incidence of head trauma patients treated in the hospitals in AlAin city to be 210 per 100,000 inhabitants, which is similar to other studies.[4,9] This incidence is less than that reported by studies including on-scene deaths.[7] Trauma patients having HI constituted more than 20% of all trauma patients admitted to our hospital, which is consistent with other studies.[7] The HI rate for males was higher than for females in all age groups, which is comparable with other studies.[4,12] The male: female ratio in our study was 7.7: 1, which is much higher than in other studies from other regions,[4,7,9,13] but was similar to a study from Qatar, which is located in the same region.[14] This may be explained by the fast economic growth of the Gulf Cooperation Council (GCC) countries requiring the employment of many male foreign workers. In the UAE, there are workers representing 202 different nationalities.[15] Most are male manual laborers working in major infrastructure construction projects and constituting 78% of the population.[6] This can also explain the incidence of HI among the UAE nationals (24%), which is comparable to their percentage in the population. The highest peak of incidence of HI according to age was in young adults (15-34 years). The second peak was below the age of 5 years. This is different from other studies from developed countries, where 216

a third peak occurs at the age of 75 years.[4,7,13] This might be attributed to the fact that only 0.3% of the population in the UAE are over 75 years of age, as many expatriates return to their home country after the age of retirement of 60 years.[6] Similar to other studies, the main mechanism of injury was RTC,[4,5,7,16,17] in contrast to other reports from developed countries, in which fall or assault was the main mechanism.[9,11,18] In Sweden, the incidence of HI due to RTC has changed over time to be replaced by falls as the main mechanism of HI. This was attributed to the success of public safety measures and preventive strategies for RTC.[9] Fall from height was the second cause of HI followed by fall from the same level. Fall from height is the main cause for hospital admission of occupational injuries in the UAE due to lack of proper safety measures in the workplace, especially at construction sites. [19] This can explain the occurrence of the majority of injuries on the street followed by the workplace. RTC is the most common mechanism of injury in young adults, while fall from the same level is common in old ages.[17,20] Our present study has shown that the predominant time for the occurrence of HI was midnight. This may be caused by RTCs involving expatriate laborers returning home after a hard working day, either while walking or using cheap transportation methods like bicycles.[21] In comparison with other studies, our study has shown no increase in the incidence of HI during the weekend days. This was attributed to alcohol consumption in the other studies, which is uncommon in the UAE.[4,22] The GCS was significantly correlated to HI. It is classified according to GCS on arrival at the hospital as severe (GCS <8), moderate (GCS 9-12), or mild (GCS 13-15).[11] Mild HI was recorded in more than 80% of the patients followed by severe HI, which is comparable to other studies.[2,11] Also similar to other studies, only 30% of patients had isolated HI.[7] Concussion was the most common HI, followed by fractured skull and intracranial hemaMay覺s - May 2012

Epidemiology of head injury in the United Arab Emirates

toma.[9] Delayed evacuation of the hematoma is the main cause of preventable deaths in patients with head trauma.[3] The majority of patients had multiple injuries. The most commonly injured body region was the upper limbs.[7] More than one-third of our patients were discharged within 48 hours, which is much less than in other reports.[9,11] This can be attributed to different management protocols and to the fact that most of our injured patients are expatriate laborers living in camps, with no relatives to care for them after discharge. The overall mortality in our study was about 6%, which is similar to other studies.[4] As expected, patients who died had severe HI and had significantly higher ISS than those who survived. HI severity is the most important predictor for mortality in hospitalized trauma patients.[23] Our study has shown that patients with HI account for about two-thirds of hospital trauma deaths, which is consistent with other reports. [2] The severity of HI is related to the mechanism and cause of injury.[11] In our study, RTC was the main mechanism of serious HI, causing more than 80% of deaths, which is higher when compared with other reports.[7,18] This can be attributed to the fact that RTC mortality in the UAE is one of the highest in the world, which has been estimated at 37 per 100,000 population annually.[21,24,25] Patients who survive HI may suffer severe residual disability including epilepsy, speech impairment, personality disturbance, and other irreversible neurologic damages.[4] Residual disability was found in survivors of moderate (54%) and mild (51%) HI.[26] Apparently mild or moderate HI can alter the patientâ&#x20AC;&#x2122;s life by causing persistent headache or memory problems, even leading to unemployment.[11] Treatment and lengthy rehabilitation of HI patients place a heavy burden on health services.[2] Follow-up of our patients is lacking, and it is difficult to study the long-term effects of HI in our study because many of our injured expatriate laborers return to their home countries. Head injury is preventable.[3] Protective equipment that includes seatbelt usage and helmets for motorcyclists and bicyclists can reduce the incidence of HI and must be applied strictly in our community.[27-30] Appropriate safety measures at the workplace should be implemented to safeguard against falls and decrease the incidence of HI at the workplace.[19] One of the success stories of HI prevention in the UAE was the replacement of the camel jockey during camel races by robots. This has led to tremendous decrease in the incidence of HI among those jockeys, who were mostly in the pediatric age group.[31] Motor vehicle collision was determined to be the main mechanism of HI in the UAE followed by fall Cilt - Vol. 18 SayÄą - No. 3

from height. Legislation for compulsory seatbelt usage and helmet usage by bicyclists and motorcyclists should be adopted. Ensuring a safe work environment and other preventive measures including educational programs and the use of protective equipment should be introduced to reduce the morbidity and mortality of HI. Competing interests The authors declare that they have no competing interests. Acknowledgements This study was supported by Individual University Grant (# 01-07-8-11/03), Faculty of Medicine Research Grants (NP/03/11, 2003 and NP/04/28, 2004) and an Interdisciplinary Grant (# 02-07-8-1/4).

REFERENCES 1. Patel HC, Bouamra O, Woodford M, King AT, Yates DW, Lecky FE; Trauma Audit and Research Network. Trends in head injury outcome from 1989 to 2003 and the effect of neurosurgical care: an observational study. Lancet 2005;366:1538-44. 2. Jennett B. Epidemiology of head injury. Arch Dis Child 1998;78:403-6. 3. Jennett B, Carlin J. Preventable mortality and morbidity after head injury. Injury 1978;10:31-9. 4. Jagger J, Levine JI, Jane JA, Rimel RW. Epidemiologic features of head injury in a predominantly rural population. J Trauma 1984;24:40-4. 5. Chiu WT, Hung CC, Shih CJ. Epidemiology of head injury in rural Taiwan -a four year survey. J Clin Neurosci 1995;2:2105. 6. United Arab Emirates Census. Population Preliminary results 2005 by age and nationality. Adapted from: Preliminary Results of the General Census for Population, Housing and Establishments, 2005, United Arab Emirates. Available from URL: http://www.zu.ac.ae/library/html/UAEInfo/documents/CensusResults2005. pdf [Accessed May 27, 2011]. 7. Tiret L, Hausherr E, Thicoipe M, Garros B, Maurette P, Castel JP, et al. The epidemiology of head trauma in Aquitaine (France), 1986: a community-based study of hospital admissions and deaths. Int J Epidemiol 1990;19:133-40. 8. Committee on Injury Scaling: The Abbreviated Injury Scale (AIS), 1980 revision. American Association for Automtive Medicine, Motrton Grove, IL, 1980. 9. Kleiven S, Peloso PM, von Holst H. The epidemiology of head injuries in Sweden from 1987 to 2000. Inj Control Saf Promot 2003;10:173-80. 10. Annual report 2006, Preventive Medicine Sector, Ministry of Health, United Arab Emirates, published on November 2007. 11. Kay A, Teasdale G. Head injury in the United Kingdom. World J Surg 2001;25:1210-20. 12. Klauber MR, Barrett-Connor E, Marshall LF, Bowers SA. The epidemiology of head injury: a prospective study of an entire community-San Diego County, California, 1978. Am J Epidemiol 1981;113:500-9. 13. Whitman S, Coonley-Hoganson R, Desai BT. Comparative head trauma experiences in two socioeconomically different Chicago-area communities: a population study. Am J Epidemiol 1984;119:570-80. 217

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14. Bener A, Omar AO, Ahmad AE, Al-Mulla FH, Abdul Rahman YS. The pattern of traumatic brain injuries: a country undergoing rapid development. Brain Inj 2010;24:74-80. 15. Staff reporter: 202 nationalities in labour market. khaleej times 2006. Website: http://www.khaleejtimes.com/DisplayArticleNew.asp?section=theuae&xfile=data/theuae/2006/ august/theuae_august735.xml. 16. Cadotte DW, Vachhrajani S, Pirouzmand F. The epidemiological trends of head injury in the largest Canadian adult trauma center from 1986 to 2007. J Neurosurg 2011;114:1502-9. 17. Abelson-Mitchell N. Epidemiology and prevention of head injuries: literature review. J Clin Nurs 2008;17:46-57. 18. Swann IJ, MacMillan R, Strong I. Head injuries at an inner city accident and emergency department. Injury 1981;12:2748. 19. Barss P, Addley K, Grivna M, Stanculescu C, Abu-Zidan F. Occupational injury in the United Arab Emirates: epidemiology and prevention. Occup Med (Lond) 2009;59:493-8. 20. Adam SH, Eid HO, Barss P, Lunsjo K, Grivna M, Torab FC, et al. Epidemiology of geriatric trauma in United Arab Emirates. Arch Gerontol Geriatr 2008;47:377-82. 21. World Health Organization, Global status report on road safety: time for action. Geneva, 2009 Available at: htpp:// www.who.int/violence_injury_prevention/road_safety_status/2009 [Accessed on 6 May 2011]. 22. Wilson PJ. The prevention and prognosis of head injury. Practitioner 1983;227:390-7. 23. Lefering R, Paffrath T, Linker R, Bouillon B, Neugebauer EA; Deutsche Gesellschaft für Unfallchirurgie/German

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Society for Trauma Surgery. Head injury and outcome-what influence do concomitant injuries have? J Trauma 2008;65:1036-44. 24. Eid HO, Barss P, Adam SH, Torab FC, Lunsjo K, Grivna M, et al. Factors affecting anatomical region of injury, severity, and mortality for road trauma in a high-income developing country: lessons for prevention. Injury 2009;40:703-7. 25. Eid HO, Abu-Zidan FM. Biomechanics of road traffic collision injuries: a clinician’s perspective. Singapore Med J 2007;48:693-700. 26. Thornhill S, Teasdale GM, Murray GD, McEwen J, Roy CW, Penny KI. Disability in young people and adults one year after head injury: prospective cohort study. BMJ 2000;320:16315. 27. Chiu WT, Hung CC, Le LS, Lin LS, Shih CJ, LaPorte RE. Head and Spinal Cord Injury Research Group ROC (Taiwan). Head injury in urban and rural populations in a developing country. J Clin Neurosci 1997;4:469-72. 28. Hefny AF, Eid HO, Grivna M, Abu-Zidan FM. Bicycle-related injuries requiring hospitalization in the United Arab Emirates. Injury 2011 Jun 9. [Epub ahead of print] 29. Abbas AK, Hefny AF, Abu-Zidan FM. Seatbelts and road traffic collision injuries. World J Emerg Surg 2011;6:18. 30. HefnyAF, Barss P, HaniO.Eid HO, Abu-Zidan FM. Motorcycle-related injuries in the United Arab Emirates. Accid Anal Prev 2011. 31. Nawaz A, Matta H, Hamchou M, Jacobsz A, Al Salem AH. Camel-related injuries in the pediatric age group. J Pediatr Surg 2005;40:1248-51.

Mayıs - May 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):219-224

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.03453

Determinants of mortality in patients with traumatic brain injury Travmatik beyin hasarı olan hastalarda mortalite belirleyicileri Soheil SAADAT, Hesam AKBARI, Reza KHORRAMIROUZ, Roza MOFID, Vafa RAHIMI-MOVAGHAR

BACKGROUND

AMAÇ

We aimed to determine factors associated with mortality rates in patients with traumatic brain injury (TBI).

Travmatik beyin hasarı (TBH) bulunan hastalarda mortalite ile ilişkili faktörleri belirlemeyi amaçladık.

METHODS

GEREÇ VE YÖNTEM

Registered data of a national trauma project conducted in eight major cities in Iran during a five-year period were used. Patients with a TBI were identified and both univariate and multivariate analyses were performed.

İran’da beş yıllık bir periyot boyunca 8 büyük kentte yürütülen ulusal travma projesinin veri kayıtları kullanıldı. TBH’li hastalar belirlendi, tek değişkenli ve çok değişkenli analizler yapıldı.

RESULTS

BULGULAR

2274 brain-injured patients including 1794 males (78.9%) were identified. The mean age of the patients was 30.1 ± 19.11 years. The age of 345 patients was less than 12, while 137 patients were older than 65. 383 patients (16.9%) died as a result of their injury. Univariate analysis showed a significant association between mortality and the following factors: age, sex, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), systolic, diastolic and mean arterial blood pressure (BP), and respiratory rate (RR) (p<0.05). The logistic regression analysis revealed a statistically significant association between death and age (odds ratio [OR]=1.04), GCS (OR=0.59), ISS (OR=1.03), mean arterial BP (OR=0.71), and RR (OR=0.82) one-half hour after hospital arrival.

Beyin yaralanması geçirmiş 2274 hasta kaydına ulaşıldı (1794 erkek, 480 kadın). Hastaların ortalama yaşı 30,1±19,11 yıl idi, 345 hastanın yaşı 12’den küçük, 137 hastanın yaşı 65’den büyüktü. Hastaların 383’ü (%16,9) bir yaralanmaya bağlı ölmüştü. Tek değişkenli analiz; mortalite ile şu faktörler arasında anlamlı bir birliktelik bulunduğunu gösterdi: Yaş, cinsiyet, Glasgow koma skoru (GKS), yaralanma ciddiyeti skoru (YCS), sistolik, diyastolik ve ortalama arteriyel kan basıncı (KB) ve solunum oranı (SO) (p<0,05). Lojistik regresyon analizi, hastaneye varıştan yarım saat sonrasından itibaren ölüm ile aşağıdakiler arasında anlamlı bir ilişki bulunduğunu gösterdi: Yaş (OR=1,04), GKS (OR=0,59), YCS (OR=1,03), ortalama arteriyel KB (OR=0,71) ve SO (OR=0,82).

CONCLUSION

SONUÇ

Our results demonstrated that age, GCS, ISS, BP, and RR as prognostic factors in patients with TBI indicate those that need special care during the initial management in the emergency department.

Bizim sonuçlarımız, acil servis bölümünün ilk tedavisi süresince özel bakım gerektiren TBH’li hastalarda prognostik faktörlerin yaş, GKÖ, YCS, KB ve SO olduğunu göstermiştir.

Key Words: Mortality; outcome; prognosis; traumatic brain injury.

Anahtar Sözcükler: Mortalite; sonuç; prognoz; travmatik beyin hasarı.

Sina Trauma and Surgery Research Center, Student’s Scientific Research Center (SSRC) Tehran University Medical Sciences, Tehran, Iran.

Tahran Üniversitesi Tıp Bilimleri, Öğrenci Bilimsel Araştırma Merkezi (ÖBAM) Sina Travma ve Cerrahi Araştırma Merkezi, Tahran, İran.

Correspondence (İletişim): Vafa Rahimi-Movaghar, M.D. Tehran University Medical Sciences, Sina Trauma and Surgery Research Center, Sina Hospital, Hassan-Abad Square, Imam Khomeini Ave., Tehran, 11365-3876, Iran. Tel: (+98) 915 342 2682 e-mail (e-posta): v_rahimi@sina.tums.ac.ir

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Traumatic brain injury (TBI) is a complex injury with a broad spectrum of symptoms and disabilities caused by a sudden trauma to the brain or an object piercing the brain tissue. Each year, 1.5 million Americans suffer from TBI. Fifty thousand people die as a result of these injuries.[1] The rate of TBI incidence is higher in children and the elderly, but the mortality rate is higher in people older than 60 years.[2] The incidence of TBI is higher in males, but in the same condition of severity, poorer prognosis has been reported for females.[3] These figures/statistics show the importance of understanding the determining factors of TBI outcome. According to several studies, some factors, including older age, female gender, low Glasgow Coma Scale (GCS), high Injury Severity Score (ISS), lower respiratory rate (RR), pulse rate (PR), hypotension, hypoxia, hyperthermia, and alcohol consumption, have an association with TBI outcome. In this study, the factors determinant of the Glasgow Outcome Scale (GOS) in patients with TBI admitted to the emergency department have been evaluated.

MATERIALS AND METHODS This is a retrospective cross-sectional study performed using the data from Iran’s national trauma registry database from August 1999 to February 2004. The data were collected from the target hospitals in eight major cities of Iran. The data of every patient admitted in these hospitals due to mild, moderate or severe trauma and who had a hospital stay of more than 24 hours were registered in the database. The data extracted from the original database included the general characteristics of the patients, like age, sex, GCS, vital signs including systolic (SBP), diastolic (DBP) and mean arterial blood pressure (MBP), RR, PR, ISS, presence of TBI, Abbreviated Injury Scale (AIS), and final disposition/outcome. These parameters were evaluated one-half hour after the patient’s arrival to the emergency room by a general physician or a trained

nurse. The data were gathered by the general physicians. Further data collection was made and reported by the same doctors. The type of TBI and the mechanism of accidents were coded according to the International Classification of Diseases, 9th revision (ICD-9). AIS scores were used to classify injury severity and were assigned to all injuries (ICD-9-CM 800-904 and 910-959) noted in the diagnostic record of cases hospitalized with TBI. ISS was calculated from the sum of squares of the highest AIS score in the three most severely injured body regions. The statistical analyses included Student’s t test to compare means and chi-square testing of frequency data, where appropriate. The significance level was set at 0.05. The statistical analyses of the data were done using SPSS 15.0 (SPSS Inc, Illinois, USA). The logistic regression model for prediction of death in patients with TBI was based on their age, sex, ISS, GCS, MBP, PR, and RR at the time of admission into the emergency department.

RESULTS Of 2274 patients with a TBI, 480 (21.1%) were females and 1794 (78.9%) were males. The mean age of the patients was 30.1± 19.11 years and it was similar between genders (Table 1). The ISS and GCS of the male patients were higher and lower, respectively, than in females, and the difference was statistically significant (Table 1). The GCS score of the patients ranged from 3 (4%) to 14 (30%) (Fig. 1). 383 patients (16.9%) died as a result of their injury. Mortality was higher in males (18.2%) compared to females (12.2%), and the difference was statistically significant (p<0.01). The age and ISS of the patients who died due to injury was higher, while their GCS, SBP, DBP, and RR were lower than the patients discharged alive from the hospital (Table 2). The relationship between the death rates of the patients with a TBI and their vital signs in the emergen-

Table 1. Characteristics of the patients according to gender

Total

Mean

Age GCS SBP DBP MBP RR PR ISS n (%)

30.1 19.11 11.0 3.38 110.8 19.92 68.9 12.48 82.9 14.16 18.2 4.34 86.2 14.30 17.1 16.02 2274 (100%)

Male Mean

Female SD

29.9 18.29 10.8 3.44 111.2 19.29 69.3 12.05 83.3 13.66 18.3 4.35 85.7 14.28 17.8 16.57 1794 (78.9%)

Mean

30.8 21.90 11.6 3.06 109.2 22.10 67.4 13.88 81.3 15.83 18.0 4.29 87.8 14.28 14.2 13.34 480 (21.1%)

p >0.05 <0.001 >0.05 <0.01 <0.05 >0.05 <0.01 <0.001

GCS: Glasgow Coma Scale; SBP, DBP, MBP: Systolic, diastolic and mean arterial blood pressure; RR: Respiratory rate; PR: Pulse rate; ISS: Injury Severity Score.

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Determinants of mortality in patients with traumatic brain injury

cy department are displayed in Figures 2-5. Figure 2 demonstrates that BPs higher than 135 and lower than 90 were associated with a poor prognosis in patients with TBI. DBP of less than 50 was associated with

The logistic regression analysis revealed a statistically significant association between death and age, GCS, ISS, MBP, and RR (Table 3).

Relative frequency (%)

GCS

Fig. 1. Distribution of Glasgow Coma Scale (GCS) in headinjured patients.

Death rate (%)

higher death rates (Fig. 3). RRs higher than 25 and lower than 10 increased mortality rates (Fig. 4). PRs lower than 70 and higher than 120 had a significant effect on mortality in patients with TBI (Fig. 5). However, the mean PR in both alive and exitus patients was almost equal (Table 2). The death rates were inversely associated with GCS at admission (Figure 6).

60 >1

16 0-

14 013

-1

012

11 0 0-

11 0

00 -1 90

-9 80

-8

-7

Systolic blood pressure (mmHg)

DISCUSSION Our study demonstrated that there was a statistically significant association between death and older age, lower RR, hypotension, low GCS, and high ISS levels in patients with TBI. Thus, most of the data from the western literature concerning TBI are confirmed by this work. Trauma and TBI are more common in males than females. This study also included more males than females. Male patients arrived in worse conditions with lower GCS and higher ISS levels. When both genders were evaluated in similar conditions, the logistic regression model did not show a significant difference in mortality between males and females. There are controversies in the literature about the role of gender differences in outcome after TBI. It has been shown that a better outcome in females might be due to the neuroprotective effect of progesterone.[4] However, several other studies pointed out that females have a lower six-month survival and a poorer prognosis than males.[3,5] Another study showed that females have a poorer prognosis in similar injury severity.[6] Similar to our study, it has been shown that TBI is associated with poorer prognosis in the elderly, es-

Fig. 2. Death rate according to systolic blood pressure (SBP) of head -injured patients. 80 70

Death rate (%)

60 50 40

30 20

Diastolic blood pressure (mmHg)

Fig. 3. Death rate according to diastolic blood pressure (DBP). Cilt - Vol. 18 Say覺 - No. 3

>3 0

0 25 -3

5 20 -2

0 15 -2

5 10 -1

0 <1

>9 0

0 80 -9

0 70 -8

0 60 -7

0 50 -6

0 40 -5

Respiratory rate (per minute)

Fig. 4. Death rate according to respiratory rate (RR). 221

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Table 2. Comparison of age, Glasgow Coma Scale (GCS) and vital signs in alive and exitus headinjured patients

Alive

Exitus

Mean

Age GCS SBP DBP MBP RR PR ISS

28.7 12.0 112.4 70.1 84.2 18.5 86.3 13.7

18.46 2.46 17.75 11.46 12.76 3.95 12.72 11.96

36.8 6.2 102.7 63.0 76.2 16.7 85.6 33.0

20.62 3.08 26.87 15.33 18.25 5.73 20.47 21.96

<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 >0.05 <0.001

SBP, DBP, MBP: Systolic, diastolic and mean arterial blood pressure; RR: Respiratory rate; PR: Pulse rate; ISS: Injury Severity Score.

pecially in those above 60. The age of patients is somewhat different, particularly regarding the very low incidence of TBI in the older age group (only 6% are older than 65 years). This low percentage of elderly patients might be due to the younger aged population in developing countries. Moreover, recent data suggest that among the 250,000 hospitalized for TBI in the United States, around 22% die. Notwithstanding the greater number of American hospitals, in this Iranian population, the mortality is less, at only 17% (p<0.001). This might have something to do either with the cause of the TBI or with a major selection of patients (i.e., a larger group of patients die before reaching the hospital). On the other hand, there is no association between TBI outcome and age lower than 40 years.[10] [7-9]

As far as we found in the literature, all authors agree with a reverse association between GCS and TBI outcome.[8,11] ISS is another factor that has a direct

Table 3. Logistic regression model for prediction of death in patients with a traumatic brain injury based on their age, ISS, GCS, mean blood pressure, and RR at admission into the emergency department (Nagelkerke R Square: 0.63) Variable Age ISS GCS MBP RR Model constant

S.E.

Sig.

.040 .030 -.520 -.335 -.197 3.075

.005 .005 .030 .072 .095 .452

.000 .000 .000 .000 .038 .000

1.041 1.031 .595 .716 .821 21.647

ISS: Injury Severity Score; GCS: Glasgow Coma Scale; MBP: Mean blood pressure; RR: Respiratory rate.

relation with TBI. High ISS levels increase mortality rates in patients with TBI. The effects of GCS and ISS have been considered for a better prediction in TBI.[12] Hypotension following TBI is known as a significant secondary insult that is associated with adverse outcome. There is a U-shaped relationship between SBP and TBI outcome.[13] The best outcomes were observed for values of SBP between 135 and 90 mmHg. Both lower and higher levels of SBP were associated with poorer outcome. The present guidelines for the management of BP in TBI focus on the prevention of SBP <90 mmHg. Traumatic brain injury (TBI) causes dysautonomia that is manifested as fluctuations in PR and RR.[14,15] Dysautonomia arises in about 10% of patients surviving severe TBI, which is more likely to have poorer outcome.[14] Both increase and decrease in RR out of the normal range is associated with a poor outcome in patients with TBI. There are similar findings about the association between PR and mortality in patients with 100

Death rate (%)

20 20

14 0

13 0

13 0-

12 0-

20 11 01

11 0 10 0-

-1 0 90

80 -

80 70 -

70 60 -

60 -

GCS

Pulse rate (per minute)

Fig. 5. Death rate according to pulse rate (PR). 222

Fig. 6. Death rate according to Glasgow Coma Scale (GCS). May覺s - May 2012

Determinants of mortality in patients with traumatic brain injury

TBI.[15,16] Heart rate variability might be a predictor of pending brain death and a useful addition for predicting the outcome of patients with severe head injury[15] even at 12 hours.[16] Causes of TBI were not mentioned, because there was no association between these factors and mortality in patients with TBI in our study. However, the most common mechanism of trauma was motor-vehicle crash (62.5%), followed by fall (23.8%).[17] Limitations of the Study Hypoxia, hyperthermia and alcohol consumption were significant risk factors in other studies.[1823] However, we did not point to these factors in our study. Although it has been shown that bradypnea had an unfavorable prognosis in TBI, considering arterial blood gases could add valuable information in analyzing respiratory function. Concerning the unfavorable outcome in the elderly, the study does not indicate the cause of the outcome as being due to accompanying pathologies or secondary factors of brain damage during intensive therapy. The patients underwent different management before arrival to the emergency department. The interval before admission was also different in the injured patients. Patients hospitalized for less than 24 hours were not considered in our study. A brain computed tomography (CT) scan was performed in all patients. There were some operative procedures performed, but the effects on outcome were not registered. Intracranial pressure measurement was not performed in the patients. While we know the number of patients who died, we do not have GOS of the patients at six months after injury. Finally, there were diverse associated injuries in the study. The injury severity was only evaluated by the ISS. Although all the cases referred to the emergency department at any hour were included in the study, follow-up was not complete in those patients who were transferred to private hospitals. In conclusion, our results emphasize the role of the following prognostic factors in patients with TBI: bradypnea, systemic hypotension, ISS, GCS, and old age, which are independent risk factors and predictors of mortality. Special care is recommended for patients with these risk factors during the initial management in the emergency department. Acknowledgement The database was provided by Sina Trauma and Surgery Research Center. The authors thank Mrs. Bita Pourmand for her careful editing of the manuscript. Disclaimer The authors received no funding for this clinical research. Cilt - Vol. 18 Say覺 - No. 3

REFERENCES 1. Thurman DJ, Alverson C, Dunn KA, Guerrero J, Sniezek JE. Traumatic brain injury in the United States: A public health perspective. J Head Trauma Rehabil 1999;14:602-15. 2. Harris C, DiRusso S, Sullivan T, Benzil DL. Mortality risk after head injury increases at 30 years. J Am Coll Surg 2003;197:711-6. 3. Farace E, Alves WM. Do women fare worse? A metaanalysis of gender differences in outcome after traumatic brain injury. Neurosurg Focus 2000;8:6. 4. Groswasser Z, Cohen M, Keren O. Female TBI patients recover better than males. Brain Inj 1998;12:805-8. 5. Ponsford JL, Myles PS, Cooper DJ, Mcdermott FT, Murray LJ, Laidlaw J, et al. Gender differences in outcome in patients with hypotension and severe traumatic brain injury. Injury 2008;39:67-76. 6. Moppett IK. Traumatic brain injury: assessment, resuscitation and early management. Br J Anaesth 2007;99:18-31. 7. Hukkelhoven CW, Steyerberg EW, Rampen AJ, Farace E, Habbema JD, Marshall LF, et al. Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients. J Neurosurg 2003;99:666-73. 8. Jiang JY, Gao GY, Li WP, Yu MK, Zhu C. Early indicators of prognosis in 846 cases of severe traumatic brain injury. J Neurotrauma. 2002;19:869-74. 9. Mosenthal AC, Lavery RF, Addis M, Kaul S, Ross S, Marburger R, et al. Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome. J Trauma 2002;52:907-11. 10. MRC CRASH Trial Collaborators, Perel P, Arango M, Clayton T, Edwards P, Komolafe E, et al. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 2008;336:425-9. 11. McNett M. A review of the predictive ability of Glasgow Coma Scale scores in head-injured patients. J Neurosci Nurs 2007;39:68-75. 12. Foreman BP, Caesar RR, Parks J, Madden C, Gentilello LM, Shafi S, et al. Usefulness of the abbreviated injury score and the injury severity score in comparison to the Glasgow Coma Scale in predicting outcome after traumatic brain injury. J Trauma 2007;62:946-50. 13. Butcher I, Maas AI, Lu J, Marmarou A, Murray GD, Mushkudiani NA, et al. Prognostic value of admission blood pressure in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007;24:294-302. 14. Hendricks HT, Heeren AH, Vos PE. Dysautonomia after severe traumatic brain injury. Eur J Neurol 2010;17:11727. 15. Rapenne T, Moreau D, Lenfant F, Vernet M, Boggio V, Cottin Y, et al. Could heart rate variability predict outcome in patients with severe head injury? A pilot study. J Neurosurg Anesthesiol 2001;13:260-8. 16. Norris PR, Morris JA Jr, Ozdas A, Grogan EL, Williams AE. Heart rate variability predicts trauma patient outcome as early as 12 h: implications for military and civilian triage. J Surg Res 2005;129:122-8. 17. Saadat S, Rashidi-Ranjbar N, Rasouli MR, RahimiMovaghar V. Pattern of skull fracture in Iran: report of the Iran National Trauma Project. Ulus Travma Acil Cerrahi Derg 2011;17:149-51. 18. De Guise E, Leblanc J, Dagher J, Lamoureux J, Jishi AA, Maleki M, Early outcome in patients with traumatic brain injury, pre-injury alcohol abuse and intoxication at time of 223

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injury. Brain Inj 2009;23:853-65. 19. Marion DW, Penrod LE, Kelsey SF, Obrist WD, Kochanek PM, Palmer AM, et al. Treatment of traumatic brain injury with moderate hypothermia. N Engl J Med 1997;336:5406. 20. McHugh GS, Engel DC, Butcher I, Steyerberg EW, Lu J, Mushkudiani N, et al. Prognostic value of secondary insults in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007;24:287-93. 21. Shandro JR, Rivara FP, Wang J, Jurkovich GJ, Nathens AB,

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MacKenzie EJ. Alcohol and risk of mortality in patients with traumatic brain injury. J Trauma 2009;66:1584-90. 22. Stiefel MF, Spiotta A, Gracias VH, Garuffe AM, Guillamondegui O, Maloney-Wilensky E, et al. Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring. J Neurosurg 2005;103:80511. 23. Thompson HJ, Tkacs NC, Saatman KE, Raghupathi R, McIntosh TK. Hyperthermia following traumatic brain injury: a critical evaluation. Neurobiol Dis 2003;12:163-73.

May覺s - May 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):225-230

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.55553

Role of red blood cell scintigraphy for determining the localization of gastrointestinal bleeding Gastrointestinal kanama odağının saptanmasında işaretli eritrosit sintigrafisinin rolü Yasemin ŞANLI,1 Zeynep Gözde ÖZKAN,1 Serkan KUYUMCU,1 Hakan YANAR,2 Emre BALIK,2 Handan TOKMAK,1 Cüneyt TÜRKMEN,1 Işık ADALET1 BACKGROUND

AMAÇ

We aimed to evaluate the role of Tc-99m labeled red blood cell (RBC) scintigraphy for determination of localization of gastrointestinal system (GIS) bleeding.

Gastrointestinal sistem (GİS) kanamalarında kanama odağının saptanmasında, Tc-99m ile işaretli eritrosit (RBC) sintigrafisinin rolü klinik deneyimlerimiz ışığında değerlendirildi.

METHODS

GEREÇ VE YÖNTEM

Fifty-seven cases (27 females, 30 males; mean age 43.9±24; range 1 to 91 years) who referred to our clinic between 1995-2010 were evaluated for determination of localization of GIS bleeding with RBC scintigraphy. Prior to scintigraphy, gastroscopy in 51, colonoscopy in 45, and angiography in 9 patients were performed.

1995-2010 yılları arasında GİS kanaması odağının belirlenmesi amacıyla kliniğimize gönderilen 57 hasta (27 kadın, 30 erkek; ortalama yaş 43.9±24; dağılım 1-91 yıl) geriye dönük olarak çalışmaya alındı. Sintigrafi öncesi hastaların 51’ine gastroskopi, 45’ine kolonoskopi, 9’una anjiyografi yapılmıştı.

RESULTS

BULGULAR

RBC scintigraphies were positive and negative in 31 and 26 patients, respectively. Positive scintigraphic findings were obtained within the 1st hour of dynamic imaging in 19 patients, within the 1st-4th hour static images in 7, and within the 4th-24th hour images in 5 patients. Fourteen patients underwent surgical exploration. In 13 patients, the surgery confirmed the diagnosis by RBC scintigraphy (accuracy: 92.8%). Of 43 patients without surgical exploration, 12 had anemia due to iron deficiency and their scintigraphic evaluation were negative. Four patients died and in 27 patients, GIS bleeding ceased spontaneously or with conservative measures.

RBC sintigrafisi hastaların 31’inde pozitif ve 26’sında negatifti. Pozitif sintigrafik bulgular, 19 hastada ilk bir saatlik dinamik imajlarda, 7 hastada 1-4. saatler arası statik imajlarda, 5 hastada ise 4-24. saatler arasında alınan statik imajlarda kaydedildi. Toplam 14 hasta GİS kanaması nedeniyle ameliyat edildi. On üç hastada kanama yeri RBC sintigrafisi tanısıyla doğrulandı (doğruluk: %92,8). Ameliyat edilmeyen 43 hastanın 12’sinde nedeni bilinmeyen demir eksikliği anemisi vardı ki bu hastaların tümünde sintigrafi negatif olarak sonuçlandı. Yoğun kanama bulguları olan 4 hasta medikal takip sürecinde kaybedildi, geri kalan 27 hastanın kanamaları kendiliğinden ya da konservatif tedavilerle durdu.

CONCLUSION

SONUÇ

Scintigraphy should be the primary tool for accurate diagnosis of patients with active GIS bleeding. Positive dynamic images obtained within the first hour of imaging may be more accurate for demonstrating bleeding localization and a good predictor of requirement of surgical exploration.

Çalışmamız aktif GİS kanamalarında kanama odağının belirlenmesinde sintigrafinin primer yöntem olması gerekliliğini göstermektedir. Özellikle ilk 1 saatlik dinamik görüntüleme esnasında saptanan pozitif imajlar, kanama odağının doğru yerinin saptanmasında ve cerrahi gerekliliğin belirlenmesinde yol göstericidir.

Key Words: Gastrointestinal bleeding; red blood cell scintigraphy; endoscopic intervention.

Anahtar Sözcükler: Gastrointestinal kanama; işaretli eritrosit sintigrafisi; endoskopik girişimler.

Departments of 1Nuclear Medicine, 2General Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey.

İstanbul Üniversitesi, İstanbul Tıp Fakültesi, 1Nükleer Tıp Anabilim Dalı, 2 Genel Cerrahi Anabilim Dalı, İstanbul.

Correspondence (İletişim): Zeynep Gözde Özkan, M.D. İÜ İstanbul Tıp Fakültesi Nükleer Tıp Anabilim Dalı Sekreterliği, Çapa-Fatih 34390 İstanbul, Turkey. Tel: +90 - 212 - 414 20 00 / 32963 e-mail (e-posta): zgozdeozkan@yahoo.com

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Gastrointestinal hemorrhage is a common indication for hospital admission. While the great majority of the bleedings are observed to be from the upper gastrointestinal system (GIS), about 20% of them originate from the lower GIS.[1] In the upper GIS bleedings, the source of bleeding can be localized in 80-97% with endoscopy and 75% of these will either stop spontaneously or will respond to the medical therapy, while 10% of them will require urgent operation.[2] In the case of lower GIS bleedings, 80% will cease spontaneously without further intervention, about 25% of them will start to bleed again, and about 10-15% will require urgent operation.[3] It is essential to locate the site of bleeding before any intervention. The current methods for this purpose are endoscopy, angiography, and scintigraphic techniques. Among these, as a major advantage, scintigraphic methods permit the rendering of the visual image of the whole abdomen at the same time.[4] For this reason, some authors advocate the evaluation of patients with scintigraphic methods before undergoing endoscopy or angiography.[3,5-8] The aim of this retrospective study is to report our clinical experience with red blood cell (RBC) scintigraphy and to discuss the role of this method in light of the contemporary literature.

MATERIALS AND METHODS Scintigraphic findings of a total of 57 cases (27 females, 30 males), with a mean age of 43.9±24 (1-91) years, who were referred to our clinic between 1995 and 2010 were evaluated retrospectively. The patients who were referred to our clinic had at least one diagnostic examination, such as gastroscopy, colonoscopy or angiography, and the results of the examinations were interpreted as either “normal” or as “no bleeding focus could be found”. Red Blood Cell Labeling Technique: In this study, in vivo and the modified in vitro erythrocyte labeling techniques were used. Briefly, in the in vivo technique, 20 minutes (min) after the injection of stannous agent, 20 millicurie (mCi) (in children 0.2 mCi/kg) Tc-99m injection was performed.[8] On the other hand, in the modified in vitro technique, 10-15 min after the injection of stannous agent, 3-5 ml of blood was drawn from the patient into a heparin-washed injector and transferred to a sterile tube containing 20 mCi (in children 0.2 mCi/kg) Tc-99m. The sample was then incubated either at 37ºC for 10 min or at room temperature for 20 min before its reinjection to the patient.[9] Imaging Procedures: The images were obtained by using low-energy all-purpose collimators (ADAC Vertex Plus, Milpitas, CA). The images obtained after the injection were taken from the anterior position in 226

which the camera’s area of focus included the entire abdominal region. The images of the first hour were recorded as dynamic images in 60 frames, each with a duration of 60 seconds (s). In the following hours (first 4-6 hours), images were obtained at the beginning of each hour as static images of 300 s. When necessary, a late image was obtained up to the 24th hour. Interpretation: In the images obtained, the detection of an abnormal activity pattern in the abdominal region was evaluated as positive. Changes in localization of activity in static images were accepted as due to intraintestinal activities. If focal activity remained fixed and did not change in configuration over time, then it was not interpreted as representing a bleeding site. The scintigraphic results as well as endoscopic, colonoscopic, angiographic, and operational findings were evaluated together with the available follow-up of the patients.

RESULTS Twenty-three of the patients had a complaint of hematochezia, while 34 complained of melena. The mean hemoglobin level of the patients with GIS bleeding was found to be 7.3±1.2 (4.1-9.6) mg/dl. In their histories, 10 patients were on steroids, 6 were on non-steroid anti-inflammatory drugs, 2 were on acetylsalicylic acid, and 1 patient was on oral anticoagulants. Prior to scintigraphy, gastroscopy in 51 (89.4%), colonoscopy in 45 (78.9%) and angiography in 9 (15.7%) patients were performed. Of the 57 scintigraphies, 31 (54.4%) were found to be positive, while 26 (45.6%) were found to be negative. Fourteen of 31 patients underwent urgent surgical exploration due to lower GIS bleeding primarily based on the scintigraphic findings. Operational findings of 13 patients confirmed the diagnosis of the scintigraphic findings, giving an accuracy of 92.8% for the scintigraphic technique. The result of the scintigraphy of one case was interpreted as a bleeding of the small intestine; however, the site of bleeding was found to be her hemorrhoids (Table 1). Scintigraphies of 19 patients were positive in the 1st hour dynamic images. Scintigraphies were positive in the initial 1st-4th hour static images in 7 patients and in the 4th-24th hour static images in 5 patients. Of 19 patients with positive scintigraphies within the 1st hour dynamic images, 10 were operated and 9 were treated medically (Fig. 1). Unfortunately, 3 patients died after obtaining positive scintigraphic findings. Of the 7 patients with positive scintigraphic findings in the 1st-4th hour static images, 2 were operated and 5 received medical treatment. Two of 5 patients with positive scintigraphic findings in the 4th-24th hour static images were operated, and the remaining 3 patients were treated mediMayıs - May 2012

Role of red blood cell scintigraphy for determining the localization of gastrointestinal bleeding

Table 1. Features of patients who underwent surgery for gastrointestinal system bleeding No Age/Sex

Scan localization

Operation

Pathologic finding

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Small intestine Small intestine Rectum Small intestine Diffuse colon Small intestine Small intestine Ascending colon Small intestine Small intestine Small intestine Small intestine Small intestine Small intestine

Partial ileal resection Partial ileal resection Hemorrhoid Internal hemorrhoid Right hemicolectomy Partial ileal resection Partial ileal resection Right hemicolectomy Diverticulectomy + Partial ileal resection Partial ileal resection Partial ileal resection Partial ileal resection Partial ileal resection Partial ileal resection

Primary non-Hodgkin lymphoma Metastases of lung carcinoma Hyperplastic polyps Hyperplastic polyps Hemorrhagic diverticulosis Jejunal diverticulosis Small intestinal segment with focal hemorrhagic necrosis Hemorrhagic diverticulosis

60/F 62/M 34/M 42/F 63/M 63/M 72/F 75/F 10/F 53/M 14/M 44/M 12/M 5/F

Meckelâ&#x20AC;&#x2122;s diverticulum Gastrointestinal stromal tumor Hemangioma Small intestinal segment with focal hemorrhagic necrosis Hemangioma Small intestinal segment with focal hemorrhagic necrosis

Table 2. Scintigraphy timing and requirement of urgent surgical exploration

1st hour dynamic images (n)

1st - 4th hour static images (n)

4th - 24th hour static images (n)

10 9*

2 5

2 3

Requirement of surgical exploration Conservative therapy

* Three patients died while under conservative treatment without surgical intervention.

cally (Table 2). As a result, of 31 cases who had positive scintigraphic findings, 14 were operated, and in 13 (92.8%) of the patients, it was noted that the correct foci of the bleeding was determined with RBC scintigraphy. From another aspect, among patients whose sites of bleeding were localized with scintigraphic methods, 48.1% required surgical intervention (Table 3).

Of the 43 patients who were not operated, 2 patients died due to abundant bleeding, 1 patient died due to pneumonia, and 1 patient who was evaluated as negative died due to hemolytic uremia syndrome. The GIS bleeding of the remaining 39 patients ceased spontaneously or with conservative measures (i.e., blood transfusion, vitamin K injection, iron supplements, suppositories for internal hemorrhoids).

Fig. 1. A 58-year-old patient was admitted to the emergency room with the complaint of hematochezia. Tc-99m labeled RBC scintigraphy was performed to detect a possible lower gastrointestinal bleeding. In the early dynamic images, bleeding was detected on the right side of the iliac bifurcation (small arrow) with significant increased activity in the following frames (arrow). The localization of the bleeding was interpreted in the region of the small intestine. Based on the scintigraphic findings, the patient was operated. In the surgical exploration, a bleeding jejunal diverticulum was seen and resected, with the confirmation of a negative surgical margin (Table 1, patient number 6).

Cilt - Vol. 18 SayÄą - No. 3

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Table 3. Proportion of positive scan results: surgical versus non-operative cases Scan results Positive / localizing (27) Positive / non-localizing (4) Negative (26) Total (57)

Operative [no. (%)]

Non-operative [no. (%)]

13 (92.8 %) 1 (7.2%) â&#x20AC;&#x201C; 14 (100%)

14 (32.5%) 3 (7%) 26 (60.5%) 43 (100%)

DISCUSSION In the determination of the localization of bleedings in the GIS, scintigraphic methods have been used over the last 20 years. Some studies have recommended scintigraphic evaluation as the first method to be employed.[3,5-8] In the present study, RBC scintigraphy was not the initial diagnostic method, since all patients had received at least one radiological examination prior to their referral to our clinic. However, no positive result was obtained in any of these examinations for the foci of the bleeding. At this point, the question is whether the scintigraphic techniques for GIS bleeding should be an initial step for the diagnosis or an assisting technique to the other diagnostic tools such as endoscopy and angiography. Although for most centers, RBC scintigraphy is an assisting technique, clinicians should keep in mind that a significant portion of the patients with GIS bleeding are diagnosed with scintigraphy. For this reason, it may be rational to carry this minimally invasive technique to one of the first steps of the algorithm for the management of a bleeding patient. In the literature, the ratio of detection of lower GIS bleedings with scintigraphy has been reported as between 75-92%.[6] In our study, 31 of the 57 patients (54.3%) with GIS bleedings were found to be positive with scintigraphy. Gunderman et al.[10] reported that, of the 249 cases evaluated with GIS bleeding scans, 115 (51.3%) were found to be positive, and of them, 37 positive cases underwent surgical exploration. In 36 patients (97.3%), an accurate bleeding localization was determined through scintigraphy. The requirement for surgical treatment was determined to be 5 times greater for the patients who were positive on scintigraphic evaluation. In our study, of the 31 cases with positive scintigraphic findings, 14 were operated, and in 13 (92.8%) of them, it was noted that the correct foci of the bleeding was determined with RBC scintigraphy. From another aspect, among patients whose sites of bleeding were localized with scintigraphic methods, 48.1% required surgical intervention. Many investigators claim that the first method of choice in the determination of lower GIS bleedings should be colonoscopy, since it facilitates not only the diagnosis but also effective treatments with electrocautery and similar interventions.[11,12] However, 228

% Requiring surgery 48.1 25 â&#x20AC;&#x201C; 24.5

in acute bleedings requiring urgent management, since colon cleaning cannot be done, colonoscopy may not localize the focus of the bleeding. Vernava et al.[13] reported the ratio of determining the localization of bleeding in patients with severe hematochezia as between 74-82%. In the present study, of 51 and 45 patients with initial gastroscopic and colonoscopic evaluations, respectively, who were referred to our department, none had a demonstrable bleeding site with these techniques. Mesenteric angiography is capable of providing high resolution images and showing the vascular anatomy in the definitive localization of the focus point of the bleeding, and hence is far superior to scintigraphy. During the procedure, therapeutic interventions can also be done. While bleedings over 0.05 ml/min can be determined with scintigraphic methods, bleedings over 0.5 ml/min can be determined with angiography.[14,15] Therefore, if the scintigraphy proves to be negative, there is no practical benefit in performing an angiography.[16-18] In addition, RBC scintigraphy may be helpful in establishing the correct timing of the angiography.[19] In the present study, angiography was performed in nine patients with negative results before referral to our center. In all of these patients, RBC scintigraphies were found to be positive, and three patients underwent surgical exploration. Conservative measures were applied in the remaining patients. Endoscopy and angiography are generally unsuccessful for demonstrating intermittent bleedings. However, scintigraphy is quiet helpful due to its ability to demonstrate intermittent bleedings. Moreover, compared with the above-mentioned diagnostic methods, scintigraphy has the advantage of high tolerability due to its minimally invasive nature. 2-3 ml of extravasated blood is sufficient for detection.[20,21] Another advantage brought about by this technique is the capability of long-term imaging (up to 24 hours) due to circulation of radioactively marked erythrocytes in the blood pool.[22-24] Timing for scintigraphy is important for determining bleeding localization correctly. Ten of 19 (52.6%) patients with positive scintigrams in the first hour underwent surgical exploration. In all patients, bleeding sites had been demonstrated with scintigraphic methMayÄąs - May 2012

Role of red blood cell scintigraphy for determining the localization of gastrointestinal bleeding

ods accurately. The single case of an incorrect positive scan, in which an internal hemorrhoid was interpreted as a small intestine bleeding, was observed in the 4th-24th hour static images. In addition, other nonlocalizing scans were found in the same time interval. Although Jacobson et al.[25] reported that patients with late positive scans had a higher rate of surgery than late negative patients, according to the present study, a positive dynamic image obtained within the first hour is a mainstay for accurate localization of the bleeding and higher rate of requirement of surgery. The use of RBC scintigraphy as a tool for risk stratification may assist an algorithmic approach to management and may also help to prevent an overaggressive surgical approach to management, which may reduce both morbidity and mortality.[19] A negative scintigraphic study is predictive of a good outcome and may be a very useful means of risk stratification in patients who do not need to be put at an unnecessary risk of emergency surgery.[26] Consistent with the above-mentioned opinion, in the present study, no patient with negative RBC scintigraphy underwent urgent surgical exploration. Schillaci et al.[27] performed a study with Tc-99m RBC scintigraphy using a single- photon emission computed tomography (SPECT)/CT hybrid imaging system in patients with lower GI bleeding. This system was used only for patients with positive planar scintigraphy and the authors found that SPECT/CT images may yield a better localization of GI bleeding in comparison with the standard planar scan. Glucagon can be used in conjunction with RBC scintigraphy for improving detection and localization of the bleeding site. Further, the use of subtraction scintigraphy during RBC imaging may improve the contrast.[28] In conclusion, the present study addresses the importance of RBC scintigraphy in determination of the correct localization of GIS bleedings. For this reason, RBC scintigraphy could be the primary tool for the diagnosis of patients with GIS bleeding, especially in centers without immediate availability to angiographic intervention. Moreover, positive dynamic images obtained within the first hours of the imaging are probably more accurate for demonstrating the bleeding localization and are a good predictor of the requirement of surgical exploration.

REFERENCES 1. Friedman LS, Martin P. The problem of gastrointestinal bleeding. Gastroenterol Clin North Am 1993;22:717-21. 2. Fuad H, Sleiman N, Al-Enizi E. Gastrointestinal bleeding. In: Elgazzar A, editor. The pathophysiologic basis of nuclear medicine. Berlin: Springer Verlag; 2001. p. 289-290. 3. Al Qahtani AR, Satin R, Stern J, Gordon PH. InvestigaCilt - Vol. 18 Say覺 - No. 3

tive modalities for massive lower gastrointestinal bleeding. World J Surg 2002;26:620-5. 4. Alavi A, Worsley D, Zhuang H. Scintigraphic detection and localization of gastrointestinal bleeding sites. In: Sandler MP, editor. Diagnostic nuclear medicine. 4th ed., Philadelphia: Lippincott Williams & Wilkins; 2003. p. 531-51. 5. Winzelberg GG, McKusick KA, Froelich JW, Callahan RJ, Strauss HW. Detection of gastrointestinal bleeding with 99mTc-labeled red blood cells. Semin Nucl Med 1982;12:139-46. 6. Orecchia PM, Hensley EK, McDonald PT, Lull RJ. Localization of lower gastrointestinal hemorrhage. Experience with red blood cells labeled in vitro with technetium Tc 99m. Arch Surg 1985;120:621-4. 7. Treves ST, Grand RJ. Gastrointestinal bleeding. In: Treves ST, editor. Pediatric nuclear medicine. 2nd ed., New York: Springer-Verlag; 1994. p. 453-462. 8. Kostamo KL. Evaluation of gastrointestinal bleeding by nuclear medicine techniques. In: Henkin RE, Boles MA, Dillehay GL, editors. Nuclear medicine. Vol II, St. Louis: Mosby, Inc., 1996. p. 1016-1022. 9. Suzman MS, Talmor M, Jennis R, Binkert B, Barie PS. Accurate localization and surgical management of active lower gastrointestinal hemorrhage with technetium-labeled erythrocyte scintigraphy. Ann Surg 1996;224:29-36. 10. Gunderman R, Leef J, Ong K, Reba R, Metz C. Scintigraphic screening prior to visceral arteriography in acute lower gastrointestinal bleeding. J Nucl Med 1998;39:1081-3. 11. Richter JM, Christensen MR, Kaplan LM, Nishioka NS. Effectiveness of current technology in the diagnosis and management of lower gastrointestinal hemorrhage. Gastrointest Endosc 1995;41:93-8. 12. Chaudhry V, Hyser MJ, Gracias VH, Gau FC. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg 1998;64:723-8. 13. Vernava AM 3rd, Moore BA, Longo WE, Johnson FE. Lower gastrointestinal bleeding. Dis Colon Rectum 1997;40:84658. 14. Tada M, Shimizu S, Kawai K. Emergency colonoscopy for the diagnosis of lower intestinal bleeding. Gastroenterol Jpn 1991;26:121-4. 15. Fiorito JJ, Brandt LJ, Kozicky O, Grosman IM, Sprayragen S. The diagnostic yield of superior mesenteric angiography: correlation with the pattern of gastrointestinal bleeding. Am J Gastroenterol 1989;84:878-81. 16. Nicholson ML, Neoptolemos JP, Sharp JF, Watkin EM, Fossard DP. Localization of lower gastrointestinal bleeding using in vivo technetium-99m-labelled red blood cell scintigraphy. Br J Surg 1989;76:358-61. 17. Zuckerman GR, Prakash C. Acute lower intestinal bleeding: part I: clinical presentation and diagnosis. Gastrointest Endosc 1998;48:606-17. 18. Baum S. Angiography and the gastrointestinal bleeder. Radiology 1982;143:569-72. 19. Howarth DM. The role of nuclear medicine in the detection of acute gastrointestinal bleeding. Semin Nucl Med 2006;36:133-46. 20. Thrall JH, Ziessman HA. Gastrointestinal system. In: Thrall JH, Ziessman HA, editors. Nuclear medicine. The Requisites. 2nd ed., St Louis: Mosby, Inc., 2001. p. 280-91. 21. Hoedema RE, Luchtefeld MA. The management of lower gastrointestinal hemorrhage. Dis Colon Rectum 2005;48:201024. 229

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22. Winzelberg GG, Froelich JW, McKusick KA, Waltman AC, Greenfield AJ, Athanasoulis CA, et al. Radionuclide localization of lower gastrointestinal hemorrhage. Radiology 1981;139:465-9. 23. Ponzo F, Zhuang H, Liu FM, Lacorte LB, Moussavian B, Wang S, et al. Tc-99m sulfur colloid and Tc-99m tagged red blood cell methods are comparable for detecting lower gastrointestinal bleeding in clinical practice. Clin Nucl Med 2002;27:405-9. 24. Nwakanma L, Meyerrose G, Kennedy S, Rakvit A, Bohannon T, Silva M. Recurrent gastrointestinal bleeding diagnosed by delayed scintigraphy with Tc-99m-labeled red blood cells. Clin Nucl Med 2003;28:691-3. 25. Jacobson AF, Cerqueira MD. Prognostic significance of late

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imaging results in technetium-99m-labeled red blood cell gastrointestinal bleeding studies with early negative images. J Nucl Med 1992;33:202-7. 26. Zettinig G, Staudenherz A, Leitha T. The importance of delayed images in gastrointestinal bleeding scintigraphy. Nucl Med Commun 2002;23:803-8. 27. Schillaci O, Spanu A, Tagliabue L, Filippi L, Danieli R, Palumbo B, et al. SPECT/CT with a hybrid imaging system in the study of lower gastrointestinal bleeding with technetium-99m red blood cells. Q J Nucl Med Mol Imaging 2009;53:281-9. 28. Currie GM, Kiat H, Wheat JM. Scintigraphic evaluation of acute lower gastrointestinal hemorrhage: current status and future directions. J Clin Gastroenterol 2011;45:92-9.

May覺s - May 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):231-238

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.79059

Effects of decompressive surgery in patients with severe traumatic brain injury and bilateral non-reactive dilated pupils Ağır travmatik beyin yaralanması ve bilateral reaktif olmayan pupil dilatasyonu bulunan hastalarda dekompresif cerrahinin etkileri Ethem GÖKSU,1 Tanju UÇAR,1 Mahmut AKYÜZ,1 Murat YILMAZ,2 Saim KAZAN1

BACKGROUND

AMAÇ

We investigated Glasgow Coma Scale (GCS) scores, intracranial pressure (ICP) and cerebral perfusion pressure (CPP) changes, and long-term clinical outcomes in patients with severe traumatic brain injury (STBI) associated with bilateral non-reactive dilated pupils (BNDP) who underwent decompressive surgery (DS).

Ağır travmatik beyin yaralanmalı (ATBY) ve bilateral reaktif olmayan pupil dilatasyonu (BRPD) olup, dekompresif cerrahi (DC) uygulanmış hastalarda Glasgow koma skalası (GKS), kafa içi basınç (KİB), serebral perfüzyon basıncı (SPP) değişiklikleri ve uzun dönem klinik sonuçları değerlendirildi.

METHODS

GEREÇ VE YÖNTEM

The study group consisted of 28 patients (11 females, 17 males) with BNDP from among 147 patients who underwent DS due to STBI in our department.

Çalışma gurubu, bölümümüzde ATBY nedeniyle DC uygulanan 147 hasta içerisinden BRPD’li 28 hastayı (11 kadın, 17 erkek) içerdi.

RESULTS

BULGULAR

The mean GCS score was 4.96±1.20 at admission and 4 preoperatively. Mean ICP in non-surviving patients after DS was higher (p<0.05). ICP decrease after DS was also higher in surviving patients than in non-surviving patients (p<0.05). The overall mortality rate was 61.02%. A GCS motor score >2 at admission was associated with lower mortality (p<0.05). Four of the surviving patients (14.28%) had a functional outcome (Glasgow Outcome Score: 4 and 5) at one year after hospital discharge. CONCLUSION

Outcome in patients with BNDP after STBI may not always be fatal or poor. Rapid DS may increase the chance of functional survival, especially in patients with admission GCS score of 6 or 7.

Ortalama GKS skoru, başvuruda 4,96±1,20, ameliyat öncesi dönemde 4 idi. Ölen hastalarda, DC sonrası ortalama KİB değerleri hayatta kalanlara göre anlamlı ölçüde yüksekti (p<0,05). Ayrıca, DC sonrası KİB azalması, yaşayan hastalarda yine anlamlı olarak yüksekti (p<0,05). Tümden mortalite oranı %61,02 bulundu. Başvuruda ikinin üzeri GKS motor skoru anlamlı olarak düşük mortalite ile ilişkili idi (p<0,05). Yaşayan 4 hasta taburcu sonrası birinci yılda (%14,28) işlevsel sonuç skoru (Glasgow sonuç skoru 4 ve 5) gösterdi. SONUÇ

ATBY sonrası BRPD’li hastalarda sonuçlar her zaman ölümcül ya da olumsuz olmayabilir. Hızlı DC, özellikle başvuru GKS skoru 6, 7 olan hastalarda işlevsel sağkalım şansını artırabilir.

Key Words: Decompressive surgery; traumatic brain injury; nonreactive dilated pupil.

Anahtar Sözcükler: Dekompresif cerrahi; travmatik beyin yaralanması; reaktif olmayan dilate pupil.

Departments of 1Neurosurgery, 2Anaesthesiology and Reanimation, Akdeniz University Faculty of Medicine, Antalya, Turkey.

Akdeniz Üniversitesi Tıp Fakültesi, 1Nöroşirurji Anabilim Dalı, 2 Anesteziyoloji ve Reanimasyon Anabilim Dalı, Antalya.

Correspondence (İletişim): Ethem Göksu, M.D. Akdeniz Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, 07070 Antalya, Turkey. Tel: +90 - 242 - 249 61 98 e-mail (e-posta): ethemgoksu@mynet.com

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Non-reactive fixed and dilated pupils have been well known as the most unwanted and an ill-omened event in neurosurgery. Despite our advances in understanding, monitoring and treating cerebral traumatic pathologies, the outcome for patients with dilated pupils in severe traumatic brain edema remains significantly poor.[1-5] However, there are not many reports in the literature that definitively and quantitatively document about the effect of decompressive craniectomy (DC) on intracranial pressure (ICP), cerebral perfusion pressure (CPP) and prognosis in patients with severe head injury (SHI) associated with bilateral nonreactive dilated pupils (BNDP). In patients with severe traumatic brain edema, uncontrollable ICP ends uncal or central transtentorial herniation showing uni- or bilateral pupil dilation. When the patient develops neurological pons signs with BNDP, irreversible ischemic damage to the brain exists with no chance of recovery. Medical treatment is frequently ineffective in such severe brain trauma.[6] When the patient demonstrates compression signs of the upper brainstem in the early period of uncal or central transtentorial herniation due to uncontrollable ICP, despite the modern management protocols (intubation, artificial ventilation, ventricular drainage of cerebrospinal fluid (CSF), and osmotherapy with mannitol), DC has been recommended as a last treatment option. [7-11] However, the criteria for the use of DC in such patients with severe traumatic brain injury (STBI) have not been standardized. There are not many reports in the current literature about the necessity of decompressive surgery (DS) in patients with BNDP due to STBI or cerebrovascular accidents (CVA). For these reasons, there is an uncertainty about what should be done when it is confronted early in a patient with SHI associated with herniation syndrome and BNDP, but with spontaneous respiration and motor responses. In our study, we reviewed 28 consecutive cases during a five-year period to identify the results after DS in patients with SHI associated with BNDP.

MATERIALS AND METHODS Patient Population The study group consisted of 28 patients with BNDP taken from among 147 patients who had undergone DS due to SHI in our department between September 1997 and July 2009. Admission details were taken by the emergency room (ER) for patients brought directly from the scene of the accident or another institution. Data included cause and nature of injury, patient’s age, Glasgow Coma Scale (GCS) score on arrival at the hospital and after resuscitation and preoperatively, pupillary size and pupillary response to light pre- and postoperatively, results of computed tomography (CT) scans, values of ICP and CPP as the 232

difference between mean arterial blood pressure and mean ICP and their response to medical and surgical treatment, and the hospitalization period. Patients with GCS scores of ≤8 on admission and after resuscitation were accepted as SHI. Pupillary size was classified as <4 mm or ≥4 mm, and pupils ≥4 mm were considered dilated, associated with very sluggish or absent light responses. Pupillary improvement was identified as partial or full pupillary constriction of at least 1 mm, toward the normal diameter. Patients with major direct ocular trauma were not initially considered for inclusion in the study, because a major component of early neurological evaluation was based on accurate inspection of both pupils when they were not affected by direct trauma to the eyes and/or the eyelids. Patients with early arterial hypotension (systolic arterial blood pressure of <90 mmHg associated with major extracranial injuries) that was documented in the ER were initially excluded from the study. Any patient fitting the clinical criteria for brain death on admission and patients with open head injury such as gunshot wounds or other penetrating injuries were also excluded. Initial Stabilization and Study Protocol After admission to the hospital, primary resuscitation and stabilization were performed according to the European Brain Injury Consortium (EBIC) guidelines for SHI.[12] Standard management included completion of CT scanning as rapidly as possible at the time of presentation to the ER. CT scans were classified according to the Marshall CT classification system.[13] As standardized treatment, sedation, muscle relaxation, normoventilation or sometimes mild hyperventilation, normothermia, normoglycemia, and 30 degree head elevation were provided for all patients. ICP measurement via ventricular catheter was done in all study patients. ICP values were measured and recorded hourly. According to our surgical decompression protocol, DS was performed in the patients who showed neurological deterioration and/or were not responding to standardized treatment methods for decreasing ICP. Also, as a part of our surgical decompression protocol in patients with SHI, DS was immediately performed on patients with BNDP unless brain death, severe arterial hypotension with major extracranial injuries or GCS scores of ≤8 with no obvious CT scan findings were present. In all of the cases having high ICP values, mannitol was given in the form of fractionated bolus, and CSF was drained via the ventricular catheter if necessary. Postoperatively, routine CT scans were taken. No course of barbiturate medication was applied to the patients. The outcome of each living patient was assessed at one year after hospital discharge according to the Glasgow Outcome Scale (GOS). Surgery The type of surgery was chosen according to neuroMayıs - May 2012

Effects of DS in patients with severe traumatic brain injury and bilateral non-reactive dilated pupils

logical and/or neuroradiological conditions. Unilateral or bilateral large frontotemporoparietal DC combined with duraplasty with temporalis muscle fascia and galea graft were performed. Bilateral DC was performed in all patients with Marshall CT grade 3. Bilateral DC was also performed in patients with Marshall CT grade 4 and unilateral mass lesion when rapidly pulsatile brain swelling was observed after unilateral DC. In order to avoid complications related with sagittal sinus, a bone rim is left on the sinus in bilateral DS operations. A bone flap was inserted under the abdominal fat tissue or preserved in a cold storage at -80°C temperature and replaced 1-4 months after surgery in surviving patients. Statistical Analysis All data are presented as the mean ± standard deviation. Comparisons between data groups were computed from the Statistical Package for the Social Sciences (SPSS) 12.0 for Windows. Nonparametric Mann-Whitney U tests were used for independent samples and Wilcoxon signed-rank tests were used for related samples. Statistical significance was defined as a probability value of less than 0.05.

RESULTS Patient Population All 28 patients (11 females, 17 males) had BNDP with a GCS motor score of 2 due to STBI in the preoperative period. Cause of injury was traffic accident in all cases. The mean age was 27.60±9.08 years (range: 17-54). The mean GCS score was 4.96±1.20 on admission (after initial resuscitation) and 4.0±0.0 preoperatively. Extracranial injury was found in four cases and all these injuries were in the extremities. All patients were taken for potentially life-saving DS. The mean time span between the accident and surgical decompression was 219±340 minutes. Characteristics at presentation in patients with SHI and the prognosis are shown in Table 1. Ventricular ICP and CPP Changes The initial ventricular ICP after the ventricular puncture varied from 25 to 40 mmHg. In the intensive care unit (ICU) after uni- or bilateral DS, ICP values decreased, ranging from -4 to -16 mmHg in all patients. In surviving patients, ICP decreased to 26.54±8.16% of the initial values (p<0.05), whereas in non-surviving patients, ventricular pressures de-

Table 1. Characteristics at presentation in patients with severe head injury associated with bilateral pupillary dilation and the prognosis No

Age/Sex

GCS score PR

GCS score PrO

ECI

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

25/F 35/M 42/M 49/M 24/M 32/M 24/F 30/F 28/M 25/F 54/F 22/F 29/M 28/M 18/F 19/M 21/M 19/M 21/F 33/M 23/F 30/M 17/F 33/M 19/F 27/M 17/M 29/M

4 7 4 4 4 7 5 7 7 4 7 5 5 4 5 4 4 4 5 4 4 5 5 7 4 4 6 4

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

- - - - + - - - - - - - - - - + - - - - + + - - - - - -

Pupillary light response PrO R/L PO R/L -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/- -/-

-/- +/+ -/- -/- -/- +/+ -/- +/+ +/- -/- +/+ -/- -/- +/- +/+ -/- -/- -/- +/+ -/- -/- +/+ -/- +/+ -/- -/- +/+ -/-

Mannitol/ HV in ER

CT category

Operation type

HP (days)

GOS

Time Span (min)

+/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+

3 3 3 3 4 +L SDH 4+L SDH 4 4 +R SDH 4 +L SDH 4 4 +L SDH 4 +L SDH 4 +L SDH 4 +R SDH 4 +L SDH 4 4 +L SDH 3 4 +L SDH 4 +L SDH 4 +R SDH 3 3 3 3 3 4 + ICH 3

Bilateral DC Bilateral DC Bilateral DC Bilateral DC Unilateral DC Bilateral DC Bilateral DC Bilateral DC Unilateral DC Unilateral DC Unilateral DC Unilateral DC Unilateral DC Bilateral DC Unilateral DC Bilateral DC Unilateral DC Bilateral DC Unilateral DC Unilateral DC Unilateral DC Bilateral DC Bilateral DC Bilateral DC Bilateral DC Bilateral DC Bilateral DC Bilateral DC

- 46 - - - 35 - 47 103 - 42 - - 58 54 - - - 35 - - 48 - 124 - - 50 -

1 4 1 1 1 5 1 4 2 1 5 1 1 2 3 1 1 1 3 1 1 2 1 2 1 1 5 1

100 130 180 150 170 240 135 105 160 245 90 230 105 125 165 80 70 110 260 320 280 240 115 95 135 80 1920 105

GCS: Glasgow Coma Scale; PR: Post-resuscitation; PrO: Preoperatively; PO: Postoperatively; HV: Hyperventilation; ER: Emergency room; CT: Computed tomography; HP: Hospitalization period; GOS: Glasgow Outcome Scale; DC: Decompressive craniectomy; SDH: Subdural hematoma; ICH: Intracerebral hematoma.

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Table 2. Comparisons of mean GCS scores, ICP and CPP measurements initially and in ICU after DS and time interval in non-surviving and surviving patients

Non-surviving patients

Surviving patients

4.27 ± 0.46 34.05 ± 4.15 28.66 ± 4.10 81.33 ± 11.46 74.77 ± 9.59 153.5 ± 74

6.00± 1.15 27.90 ± 2.60 20.02 ± 2.25 81.6 ± 4.50 80.8 ± 4.77 320.9 ± 533

<0.05 <0.05 <0.05 NS* NS NS

Mean initial GCS score Mean initial ICP (mmHg) Mean ICP in ICU (mmHg) Mean initial CPP (mmHg) Mean CPP in ICU (mmHg) Mean time interval between accident and surgery

NS: Not statistically significant; GCS: Glasgow Coma Scale; ICP: Intracranial pressure; CPP: Cerebral perfusion pressure; ICU: Intensive care unit.

creased to 16.05±10.07% of the initial ICP (p<0.05). There was no significant difference for CPP changes initially and after DS between surviving and non-surviving patients (Table 2). Prognosis The overall survival rate was 39.28% (11/28). Seventeen patients (60.71%) died as a result of elevated ICP. These 17 patients had ventricular ICP readings >25 mmHg after DS despite conventional ICP controlling measures such as infusion of hyperosmotic solution, hyperventilation, and CSF drainage. Seven (25%) surviving patients had a poor outcome (GOS score 2 or 3), whereas four (14.28%) surviving patients had a good outcome (GOS score: 4 and 5) (Table 1). In surviving patients, GCS scores at admission were higher than in non-surviving patients (p<0.05). In all surviving patients, the mean hospitalization period was 58 ± 28 days.

(a)

Illustrative Cases (Case No. 11) This 54-year-old female patient was admitted to the ER after a motor vehicle accident with a GCS score of 7. In the ER, she suddenly deteriorated and showed decerebrate posturing with BNDP. CT scans showed a left frontoparietal subdural hemorrhage, contusions on the right frontal and left parietal lobes with 10 mm midline shift to right side and diffuse cerebral swelling (Fig. 1a). Left unilateral DC with external ventricular drainage (EVD) was performed urgently and the hematoma was evacuated. Postoperatively, pupils were isocoric and reactive. CT scan obtained one month after the initial procedure demonstrated enlarged ventricles with left frontoparietal subdural hygroma (Fig. 1b). After 42 days of hospitalization, she was discharged with GOS of 3 and the first year GOS was 5. (Case No. 27) This 17-year-old male patient was

(b)

Fig. 1. Brain CT scans of Case no. 11. (a) Initial CT scan demonstrates a left frontoparietal subdural hemorrhage, contusions on the right frontal and left parietal lobes with 10 mm midline shift to the right side and diffuse cerebral swelling. (b) CT scan obtained one month after the initial procedure demonstrates enlarged ventricles with left frontoparietal subdural hygroma. 234

Mayıs - May 2012

Effects of DS in patients with severe traumatic brain injury and bilateral non-reactive dilated pupils

(a)

(b)

(c)

Fig. 2. Brain CT scans of Case no. 27. (a) Initial CT scan demonstrates contusions on both frontal lobes and 13 mm midline shift to the left side. (b) Postoperatively, 45th day CT scan shows hypodense areas on both frontal lobes and enlarged ventricles. (c) CT scan obtained after cranioplasty and left subduroperitoneal shunt operations demonstrates hypodense area on right frontal lobe, enlarged ventricles and left frontal subdural shunt catheter.

admitted to an external hospital after motor vehicle accident with GCS score of 6. He was referred to our institution because of neurological deterioration. On admission, he was found in decerebrate posturing with BNDP. CT scans showed large contusions on both frontal lobes and a 13 mm midline shift to the left side (Fig. 2a). Urgent bilateral DC with EVD was performed and the hematoma was evacuated. Postoperatively, pupils were isocoric and reactive. The 45th day CT scans showed resorbed contusions and enlarged ventricles (Fig. 2b). At the 46th day of hospitalization, he was discharged with a GOS of 3. The first year GOS was 5 and CT scan obtained at this time was demonstrated in Fig. 2c.

DISCUSSION Causes of Pupillary Dilation in Patients with Severe Head Injury Acute pupillary dilation without major direct ocular trauma in patients with STBI is known as a neurosurgical emergency. Pupil dilation is thought to be the result of uncal herniation causing mechanical compression of the third cranial nerve at the tentorial edge. Continued compression of the medial temporal lobe into the brainstem results in loss of consciousness, decerebrate posturing, and cardiovascular collapse. Also, compromise of brainstem circulation is a major contributing factor to pupillary dilation.[4] This could be the result of either a consequent deformation of the perforating brainstem arteries arising from the basilar artery due to brainstem displacement, or global reduction in whole-brain cerebral blood flow (CBF) that occurred because of raised ICP in the head-injured patient. As a result, the presence of BNDP in patients with SHI may be interpreted as indicative of abnormally high ICP and associated with cerebral hypoperfusion. Additional concern may be raised over ultimately diagnosCilt - Vol. 18 Sayı - No. 3

ing clinically significant primary brainstem injury on magnetic resonance imaging (MRI) studies. It would be preferable to diagnose such a potentially grim prognostic feature before undertaking aggressive surgical measures.[7] However, it could be fatal in patients in a coma with severe traumatic brain edema in the shortterm because the time window for extensive studies such as clinical, radiologic, laboratory investigations, and interventional factors such as elucidation and collation can require hours and days. Another cause for a patient’s low GCS score or non-reactive pupils may be due to alcohol or drugs (or both) rather than symptoms of brain damage.[14] Decompressive Surgery in Patients with Severe Head Injury: Which Patient and When? According to the EBIC and the American Brain Injury Consortium (ABIC) guidelines for SHI,[12,15] DS is one therapeutic option for brain edema that does not respond to conventional therapeutic measures such as hyperventilation, osmotherapy with mannitol, ventricular drainage of CSF, and metabolic suppression therapy.[12,16-20] However, specific indications and timing for this intervention have not been standardized as yet. It has been reported that the indications for DS in patients with SHI are the appearance of diffuse unilateral or bilateral brain swelling with correlating clinical deterioration; worsening of GCS score and/or dilation of pupils unresponsive to light; therapy-resistant increase in ICP to >30 mmHg and/or a reduction in CPP to <45 mmHg; and initial GCS score of ≥4 and a GCS score of at least 4 on the 1st posttraumatic day.[6,7,9-11] Guerra et al.[6] and Yoo et al.[11] reported that patients with primary fatal brainstem lesions, that is, an initial and persisting GCS score of 3 and/or bilaterally fixed and dilated pupils, did not undergo DS. Additionally, other authors reported that exclusion criteria for DS are patients over 40 years of age with hypertonic extensor 235

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posturing (GCS motor score of 2); bilateral unreactive pupil ≥4 mm in diameter; bilateral intracranial lesions, and life-threatening concomitant medical disease.[7,9,10] In this study, our patients were the worst subgroup of patients with SHI, associated with bilateral pupillary dilation and extensor motor responses (GCS score: 4); in an unavoidable form and without intervention, the next step would be the progression to brain death. There is no reported definite documentation in the current literature regarding the results of DS for such patients, except case reports including the patients with head injury or CVA.[21-24] Nevertheless, the question may be raised whether the lack of demonstrable efficacy of DS in our patient study group was due to the small sample size. Difficulties arise because of timing (early compared with ‘last option’) of the DS, which may well change the pathophysiological responses. It is reported that the right time for DS is determined by clinical follow-up, repeated CT scans, and continuous ICP and CPP monitoring.[6] It is also suggested that if further evidence is found for the assumed relationships, the B wave will be a new parameter to control brainstem function.[6] Thus, deterioration in neurological status while the patient is sedated could be detected before pupillary dilation. In our previous study, we compared 40 STBI patients who underwent early bilateral DC as a first-tier treatment with 36 patients in whom surgical treatment was considered as a second step.[25] In the early bilateral DC group, especially in patients <40 years and with an initial GCS score of ≥6, the favorable outcome rate was significantly higher. However, treatment is not clear in patients who suddenly develop bilateral pupillary dilation in the early posttraumatic period. It is reported that a slowly developing deterioration seems to carry a better prognosis than a rapid one.[6,26] It is widely accepted that DS should not be postponed so long that irreversible brainstem changes, such as Duret hemorrhages, occur.[17] However, the optimal time at which DS should be performed remains debatable. GCS Score, ICP and CPP Changes and Prognosis There is also confusion in the current literature regarding prognostic features of patients that have undergone DS. In general, the use of simple clinical data findings to determine outcomes after head injury has been widely employed. Indeed, a number of authors have found that age, GCS score (or motor score), pupillary abnormalities, elevated ICP and the presence of hypotension, shift in CT scans, and abnormal somatosensory evoked potential tracings are regarded as reliable indicators of outcome.[2-4,14,27,28] The adverse effect of increased age after head injury among the adult population has been verified in numerous series.[1,29] It 236

has been reported that admission GCS score is closely associated with patient outcome.[1,14,23,28,30,31] According to the Traumatic Coma Data Bank,[28] mortality rates progressively decrease with increases in GCS scores; a GCS score of 3 resulted in 78.4% mortality; a score of 4 in 55.9%; 5 in 40.2%; 6 in 21.2%; 7 in 17.6%; and a score of 8 in 11.3% mortality. In another study, Waxman et al.[5] noted a poor correlation between admission GCS score and outcome, and 10 of 117 patients scoring a GCS of 3 had a good recovery. The current literature has concluded that initial therapy should be aggressive for patients with SHI regardless of the initial neurologic status, because accurate prediction of outcome within six hours of admission is impossible. However, neither of these studies assessed the results of DS with the presence of bilateral pupillary dilation in patients with SHI. Choi et al.[1] evaluated 21 indicators present at admission to the ER to determine whether any could be correlated with outcome. These authors noted that no patients recording a motor score <4 with no pupillary responses bilaterally had a functional survival. Quigley et al.[3] reported that the overall functional survival was low (12.5%) in patients with GCS of 3, 4 or 5, and that it was the worst among patients presenting pupillary abnormalities (6.6%). Lieberman et al.[31] reviewed data from 137 patients with a GCS of 3; 104 had fixed and dilated pupils and 33 did not. The authors concluded that patients with a GCS of 3 as well as fixed and dilated pupils have no reasonable chance of recovery. Similarly, in a retrospective study of Tien et al.,[32] they found that patients with an initial GCS of 3 and bilateral fixed and dilated pupils had a 100% in-hospital mortality rate. Despite the hopeless results of these reports, Chamoun et al.[33] presented a survival rate of 21.3% and a good outcome rate of 1.5% in this patient group in a recent study. They explained their results as related with young age, initially aggressive treatment and the epidural hematoma (EDH) subgroup, and they emphasized that patients who suffered TBI and presented with a GCS score of 3 should be treated aggressively initially, since a good functional outcome could be obtained in some cases. Cruz et al.[8] reported that among patients with SHI and BNDP who were treated with ultra-early high-dose mannitol, 43.5% had a favorable outcome at six months. They also reported that patients with abnormal pupillary widening documented at the scene of the injury did not benefit from ultra-early high-dose mannitol treatment, in contrast to those whose bilateral widened pupils were first seen in the ER.[34] We used mannitol in conventional doses as a way to gain a few minutes of valuable time while patients were transferred to an operating theater for DS. It is also necessary to ask which is worse, a GCS score 3 or 4? Andrews et al.[14] reported that a patient with a GCS motor score of 2 and an extension response Mayıs - May 2012

Effects of DS in patients with severe traumatic brain injury and bilateral non-reactive dilated pupils

of the limbs may be more severely brain damaged than a patient with a score of 1 because of possible external factors such as alcohol or drugs. Because this score is a constituent part of the GCS, it could explain why a patient with a total score of 3 (the lowest possible score on the scale) may have a better outcome than a patient with a score of 4. In our study, the GCS motor score of >2 at admission was associated with lower mortality. All surviving patients with a good outcome were associated with initial GCS scores of 6 and 7. In our previous report, we already proposed that this group of patients were the best candidates for DS.[35] They also presented with neurological deterioration (GCS score of 4 and BNDP) due to mass effect from a hematoma (subdural hematoma in 4 and intracerebral hematoma in 2 patients). Those patients might have a higher chance of survival and functional recovery than patients whose neurological status is mainly caused by diffuse cerebral swelling. The overall mortality rate in our patients who underwent DS with a GCS score of 4 associated with BNDP in the preoperative period was 61.02%. Another important issue in SHI is management of CPP.[36-39] CPP is a physiological parameter intimately linked with ICP and mean arterial blood pressure, and it is the greatest determinant of cerebral hemodynamic responses and effects. CPP management directs therapy to the pressure gradient across the brain rather than isolated ICP. However, recent, emphasis has moved again to ICP because episodes of ‘neuro-worsening’ have been shown to be associated with ICP increases and not changes in CPP.[10,38,40] In our patient study group, CPP changes were not found significantly important before and after DS. However, ICP was significantly decreased in surviving patients compared to non-surviving patients. In conclusion, the accurate prediction of outcome in patients with BNDP after SHI remains elusive, and the outcome may not always be fatal or poor. Rapid DS may increase the chance of functional survival, especially in patients with admission GCS score of 6 or 7 and neurological deterioration due to mass effect from a hematoma. In addition, this study raises high concerns regarding the possibility of saving a patient from death, only for them to survive with severe disability in spite of current methods of reducing ICP.

REFERENCES 1. Choi SC, Narayan RK, Anderson RL, Ward JD. Enhanced specificity of prognosis in severe head injury. J Neurosurg 1988;69:381-5. 2. Pasquale MD, Rhodes M, Cipolle MD, Hanley T, Wasser T. Defining “dead on arrival”: impact on a level I trauma center. J Trauma 1996;41:726-30. 3. Quigley MR, Vidovich D, Cantella D, Wilberger JE, Maroon JC, Diamond D. Defining the limits of survivorship after very severe head injury. J Trauma 1997;42:7-10. Cilt - Vol. 18 Sayı - No. 3

4. Ritter AM, Muizelaar JP, Barnes T, Choi S, Fatouros P, Ward J, et al. Brain stem blood flow, pupillary response, and outcome in patients with severe head injuries. Neurosurgery 1999;44:941-8. 5. Waxman K, Sundine MJ, Young RF. Is early prediction of outcome in severe head injury possible? Arch Surg 1991;126:1237-42. 6. Guerra WK, Gaab MR, Dietz H, Mueller JU, Piek J, Fritsch MJ. Surgical decompression for traumatic brain swelling: indications and results. J Neurosurg 1999;90:187-96. 7. Coplin WM, Cullen NK, Policherla PN, Vinas FC, Wilseck JM, Zafonte RD, et al. Safety and feasibility of craniectomy with duraplasty as the initial surgical intervention for severe traumatic brain injury. J Trauma 2001;50:1050-9. 8. Cruz J, Minoja G, Okuchi K, Facco E. Successful use of the new high-dose mannitol treatment in patients with Glasgow Coma Scale scores of 3 and bilateral abnormal pupillary widening: a randomized trial. J Neurosurg 2004;100:376-83. 9. Münch E, Horn P, Schürer L, Piepgras A, Paul T, Schmiedek P. Management of severe traumatic brain injury by decompressive craniectomy. Neurosurgery 2000;47:315-23. 10. Polin RS, Shaffrey ME, Bogaev CA, Tisdale N, Germanson T, Bocchicchio B, et al. Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema. Neurosurgery 1997;41:84-94. 11. Yoo DS, Kim DS, Cho KS, Huh PW, Park CK, Kang JK. Et al. Ventricular pressure monitoring during bilateral decompression with dural expansion. J Neurosurg 1999;91:953-9. 12. Maas AI, Dearden M, Teasdale GM, Braakman R, Cohadon F, Iannotti F, et al. EBIC-guidelines for management of severe head injury in adults. European Brain Injury Consortium. Acta Neurochir (Wien) 1997;139:286-94. 13. Marshall LF, Marshall SB, Klauber MR, Van Berkum Clark M, Eisenberg H, Jane JA, et al. The diagnosis of head injury requires a classification based on computed axial tomography. J Neurotrauma 1992;9:287-92. 14. Andrews PJ, Sleeman DH, Statham PF, McQuatt A, Corruble V, Jones PA, et al. Predicting recovery in patients suffering from traumatic brain injury by using admission variables and physiological data: a comparison between decision tree analysis and logistic regression. J Neurosurg 2002;97:326-36. 15. Marmarou A. Conduct of head injury trials in the United States: the American Brain Injury Consortium (ABIC). Acta Neurochir Suppl 1996;66:118-21. 16. Diringer MN, Videen TO, Yundt K, Zazulia AR, Aiyagari V, Dacey RG Jr, et al. Regional cerebrovascular and metabolic effects of hyperventilation after severe traumatic brain injury. J Neurosurg 2002;96:103-8. 17. Doerfler A, Forsting M, Reith W, Staff C, Heiland S, Schäbitz WR, et al. Decompressive craniectomy in a rat model of “malignant” cerebral hemispheric stroke: experimental support for an aggressive therapeutic approach. J Neurosurg 1996;85:853-9. 18. Marshall LF. Head injury: recent past, present, and future. Neurosurgery 2000;47:546-61. 19. Oertel M, Kelly DF, Lee JH, McArthur DL, Glenn TC, Vespa P, et al. Efficacy of hyperventilation, blood pressure elevation, and metabolic suppression therapy in controlling intracranial pressure after head injury. J Neurosurg 2002;97:104553. 20. Piek J. Decompressive surgery in the treatment of traumatic brain injury. Curr Opin Crit Care 2002;8:134-8. 21. Fisher CM, Ojemann RG. Bilateral decompressive craniectomy for worsening coma in acute subarachnoid hemor237

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rhage. Observations in support of the procedure. Surg Neurol 1994;41:65-74. 22. Jaeger M, Soehle M, Meixensberger J. Effects of decompressive craniectomy on brain tissue oxygen in patients with intracranial hypertension. J Neurol Neurosurg Psychiatry 2003;74:513-5. 23. Jourdan C, Convert J, Mottolese C, Bachour E, Gharbi S, Artru F. Hemicraniectomy and intracranial hypertension. Neurochirurgie 1993;39:304-10. 24. Koh MS, Goh KY, Tung MY, Chan C. Is decompressive craniectomy for acute cerebral infarction of any benefit? Surg Neurol 2000;53:225-30. 25. Akyuz M, Ucar T, Acikbas C, Kazan S, Yilmaz M, Tuncer R. Effect of early bilateral decompressive craniectomy on outcome for severe traumatic brain injury. Turk Neurosurg 2010;20:382-9. 26. Gerl A, Tavan S. Bilateral craniectomy in the treatment of severe traumatic brain edema. [Article in German] Zentralbl Neurochir 1980;41:125-38. 27. Kazan S, Tuncer R, Karasoy M, Rahat O, Saveren M. Posttraumatic bilateral diffuse cerebral swelling. Acta Neurochir (Wien) 1997;139:295-302. 28. Marshall LF, Gautille T, Klauber MR, Eisenberg HM, Jane JA, Luerssen TG, et al. Report on the traumatic coma data bank: The outcome of severe closed head injury. J Neurosurg 1991;75(Suppl):28-36. 29. Luerssen TG, Klauber MR, Marshall LF. Outcome from head injury related to patientâ&#x20AC;&#x2122;s age. A longitudinal prospective study of adult and pediatric head injury. J Neurosurg 1988;68:409-16. 30. Demetriades D, Kuncir E, Velmahos GC, Rhee P, Alo K, Chan LS. Outcome and prognostic factors in head injuries with an admission Glasgow Coma Scale score of 3. Arch Surg 2004;139:1066-8.

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31. Lieberman JD, Pasquale MD, Garcia R, Cipolle MD, Mark Li P, Wasser TE. Use of admission Glasgow Coma Score, pupil size, and pupil reactivity to determine outcome for trauma patients. J Trauma 2003;55:437-43. 32. Tien HC, Cunha JR, Wu SN, Chughtai T, Tremblay LN, Brenneman FD, et al. Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival? J Trauma 2006;60:274-8. 33. Chamoun RB, Robertson CS, Gopinath SP. Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation. J Neurosurg 2009;111:683-7. 34. Cruz J, Minoja G, Okuchi K. Major clinical and physiological benefits of early high doses of mannitol for intraparenchymal temporal lobe hemorrhages with abnormal pupillary widening: a randomized trial. Neurosurgery 2002;51:62838. 35. Ucar T, Akyuz M, Kazan S, Tuncer R. Role of decompressive surgery in the management of severe head injuries: prognostic factors and patient selection. J Neurotrauma 2005;22:1311-8. 36. Hatashita S, Hoff JT. The effect of craniectomy on the biomechanics of normal brain. J Neurosurg 1987;67:573-8. 37. Juul N, Morris GF, Marshall SB, Marshall LF. Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury. The Executive Committee of the International Selfotel Trial. J Neurosurg 2000;92:1-6. 38. Rosner MJ, Rosner SD, Johnson AH. Cerebral perfusion pressure: management protocol and clinical results. J Neurosurg 1995;83:949-62. 39. Young JS. Cerebral perfusion pressure or intracranial pressure? J Neurosurg 2000;92:191-2. 40. McKinley BA, Parmley CL, Tonneson AS. Standardized management of intracranial pressure: a preliminary clinical trial. J Trauma 1999;46:271-9.

MayÄąs - May 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):239-242

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.45578

Trauma in women of child-bearing age in a high-income developing country Yüksek gelirli gelişmekte olan bir ülkede çocuk doğurma yaşındaki kadınlarda travma Alaa K. ABBAS,1 Hisham MIRGHANI,2 Hani O. EID,3 Fikri M. ABU-ZIDAN1

BACKGROUND

AMAÇ

We aimed to study the distribution and causes of trauma in women of child-bearing age.

Çocuk doğurma çağında bulunan kadınlardaki travma ile ilgili dağılım ve nedenler araştırıldı.

METHODS

GEREÇ VE YÖNTEM

Data were collected from Al-Ain Hospital (United Arab Emirates-UAE) Trauma Registry. Females aged 16 to 45 years (child–bearing age) who were admitted with trauma between March 2003 and March 2006 were included in the study.

Bu çalışmadaki veriler, Al-Ain Hastanesi (Birleşik Arap Emirlikleri-BAE) Travma Kayıtlarından derlendi. 16 ile 45 arası (çocuk doğurma çağı) bir yaşa sahip olan ve 15 Mart 2003 ile Mart 2006 tarihleri arasındaki periyotta travma nedeniyle hastaneye yatırılan kadınlar çalışmaya dahil edildi.

RESULTS

BULGULAR

Females represented 9% (n=171) of all trauma patients (n=1809) of the same age group, of which 29% were UAE nationals. The mean age for females was 30.5 years. Road traffic collision (RTC) was the main mechanism of injury (n=78, 46%). Burns were significantly higher in females than males (p=0.001). Cervical fractures were significantly higher in females (p=0.04), while lumbar fractures were significantly higher in males (p=0.03). In females, pelvic fractures were diagnosed in 6.4%, spinal fractures in 7%, and both injuries in 1.2%. Three females died (1.7%), and all were due to RTC.

Kadınlar (n=171) aynı yaş grubundaki bütün travma hastalarının (n=1809) %9’unu kapsadı ve bunların %29’u BAE ulusundandı. Kadınlar için ortalama yaş 30,5 yıl idi. Karayolu araç kazası (KAK), başlıca yaralanma nedeniydi (n=78, %46). Yanıklar, erkeklere göre kadınlarda anlamlı olarak daha yüksek bulundu (p=0,001). Lomber kırıklar anlamlı şekilde erkeklerde daha yüksekti (p=0,03), servikal kırıklar anlamlı şekilde kadınlarda daha yüksekti (p=0,04). Kadınlarda pelvik kırıklar %6,4, spinal kırıkları %7 ve her iki yaralanmanın var olduğu %1,2 oranında ki hastaya tanı konuldu, 3 kadın öldü (%1,7); ölümlerin tümü KAK nedeniyle idi.

CONCLUSION

SONUÇ

The majority of females involved in trauma were aged 2034 years. RTC is the main mechanism of injury and fatality. Female trauma is associated with a high incidence of pelvic fractures. A higher rate of cervical injuries was observed in females in contrast to lumbar injuries in males.

Travmaya uğrayan kadınların çoğunluğu 20 ile 34 yaş arasındaydı. KAK, yaralanma ve ölümle ile ilgili başlıca nedendi. Kadınlarda travma, yüksek bir pelvik kırık insidansı ile birliktedir. Erkeklerdeki lomber yaralanmaların tersine, kadınlarda daha yüksek servikal yaralanma oranı gözlendi.

Key Words: Women; child-bearing age; trauma.

Anahtar Sözcükler: Kadın; çocuk doğurma çağı; travma.

Departments of 1Surgery, 2Obstetrics & Gynecology, Faculty of Medicine and Health Sciences, United Arab Emirates (UAE) University, Al-Ain District, Abu Dhabi, UAE; 3Department of Emergency Medicine, Tawam Hospital, Al-Ain, UAE.

Birleşik Arap Emirlikleri (BAE) Üniversitesi, Tıp ve Sağlık Bilimleri Fakültesi, 1Cerrahi Anabilim Dalı, 2Kadın Hastalıkları ve Doğum Anabilim Dalı, Al-Ain, Abu Dhabi, BAE; 3 Tawam Hastanesi, Acil Tıp Kliniği, Al-Ain, BAE.

Correspondence (İletişim): Hisham Mirghani, M.D. Department of Obstetrics & Gynecology, Faculty of Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates. Tel: +00971 3 7137562 e-mail (e-posta): hmirghani@uaeu.ac.ae

239

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Trauma is a leading cause of death and disability worldwide.[1] Females represent approximately onethird of the trauma patients presenting to the Emergency Department.[2] Furthermore, road traffic collisions (RTCs) are one of the leading causes of trauma deaths in developing countries.[3] More than half of all road traffic deaths occur among young adults aged 15-44 years.[3] In the United Arab Emirates (UAE), RTC is the second cause of death in the nation.[4] Female disability and death resulting from trauma have grave effects on the family and community. Few studies have been done on female trauma, and the majority were on pregnant women. Furthermore, trauma in females may involve the vertebrae and pelvis, with long-term morbidity, including urinary incontinence, pelvic organ prolapse, dyspareunia, infertility, and increased risk for operative delivery.[5,6] Table 1. Profile of female trauma patients by nationality compared with males UAE Arabs Indian subcontinent Others Total

Female Number (%)

Male Number (%)

50 (29.2) 48 (28.1) 39 (22.8) 34 (19.9) 171 (100)

198 (12.1)* 316 (19.3)** 1058 (64.6)*** 66 (4)*** 1638 (100)

*p<0.0001; **p<0.008; ***p<0.0001; Fisher’s exact test.

Table 2. Mechanism of injury of female trauma patients compared with males RTC Fall Fall from height Burn Assault Motorcycle/bicycle Others Total

Female Number (%)

Male Number (%)

78 (45.6) 42 (24.6) 13 (7.6) 18 (10.5) 9 (5.3) 3 (1.7) 8 (4.7) 171 (100)

613 (37.4) 138 (8.4)** 358 (21.9)** 69 (4.2)** 45 (2.7) 101 (6.2)*** 314 (19.2) 1638 (100) *

*p<0.04, **p<0.001, ***p<0.01; Fisher’s exact test.

Table 3. The level of spinal injury in female trauma patients compared to male patients Cervical Thoracic Lumbar Multiple Total

Female (n=171) Male (n=1638) Number (%) Number (%) 5 (2.9) 3 (1.8) 3 (1.8) 2 (1.2) 13 (7.6)

*p<0.04; **p<0.03; Fisher’s exact test.

240

16 (1.0)* 26 (1.6) 93 (5.7)** 20 (1.2) 155 (9.5)

We aimed to study the incidence and nature of trauma in women of child-bearing age in the UAE.

MATERIALS AND METHODS Data were collected from the Trauma Registry of Al-Ain Hospital.[7] Al-Ain is the 4th largest city in the UAE, with a population of 463,000, and females represent 34.3% (n=160,000) of the population.[8] Al-Ain Hospital, a highly specialized acute care and emergency hospital with 412 beds and 30 medical departments and divisions, is one of the two major hospitals in the Al-Ain District, Abu Dhabi. The Emergency Medicine and Trauma Centre handles 136,000 patients per year.[9] The registry includes all patients hospitalized more than 24 hours in the hospital and those who died after arrival to the hospital. Females between 16-45 years (child-bearing age) admitted with trauma between 15 March 2003 and 15 March 2006 were selected. Data variables related to the patients’ age, marital status, cause of injury, nature of injury, type of pelvic fracture, spinal injury, injury severity score (ISS), duration of stay, and outcome were recorded. The Local Ethics Committee of Al-Ain Health District Area approved the data collection for all trauma patients who were admitted to Al-Ain Hospital or who died in the Emergency Department (Ethical approval NO: RECA/02/44). Statistics Unpaired t-test was used to compare continuous data between two independent groups and Fisher’s exact test to compare categorical data between two independent groups.

RESULTS A total number of 1809 patients were studied, of which 171/1809 (9%) were females. The mean age for females was 30.5 (±SD 7.8) years compared with 31 (±SD 7.7) years in males. More than half (53%, n=92) were in the age group of 20-34 years, while 23% (n=39) were in the age group 35-39 years. 95/171 (55%) were married. Nearly one-third, 50/171 (29%), were UAE nationals compared with 12.1% UAE nationals among males (Table 1). In females, RTC was the cause of trauma in 78/171 (46%) compared with 37.4% in males (Table 2). However, females were involved in 11.2% of all RTCs. The ambulance was the method of arrival in 65/171(38%) patients. Of those, 86% were involved in RTC. Pelvic fracture was present in 11/171 (6.4%) patients and spinal injury in 12 (7%) patients, and two (1.2%) had both pelvic fracture and spinal injury. 2.9% of the patients had cervical spine fractures, which was significantly higher than in males (Table 3). There was a total of 13/171 (7.6%) patients with pelvic fractures: Mayıs - May 2012

Trauma in women of child-bearing age in a high-income developing country

four (2.3%) had unilateral pelvic fracture, two (1.2%) had bilateral pelvic fracture and four (2.3%) had open pelvic fracture. None was reported to have bladder or vaginal injury. There was no statistical difference in the ISS between males and females (median [range] ISS was 4 [1-41] for both groups). The mean hospital stay was 9.2 (ÂąSD 12.4) days. There were three (1.7%) deaths in the female group compared to 34 (2.1%) deaths in the male group. This difference was not statistically significant. All deaths among females were due to RTCs, causing severe head injury with a low Glasgow Coma Scale â&#x2030;¤6. The first patient was a 34-year-old woman who was admitted to the intensive care unit (ICU) with severe head injury associated with depressed skull fracture. She died six days after admission. The second patient was a 43-year-old woman who was admitted to the ICU with subdural hematoma, subarachnoid hemorrhage, brain stem contusion, and lower limb fractures. She died 14 days after admission to the ICU. The third patient was a 21-year-old woman who presented with a head injury, multiple rib fractures, retroperitoneal bleeding, open pelvic fracture, and fracture of the left femur. She died on the day of admission.

DISCUSSION In our study, females aged 16-45 years represented 9% of the trauma patients. This is nearly half of that reported in other countries.[2,10] Furthermore, it is higher than that observed in some of the neighboring countries with a similar socioeconomic pattern.[11] Messahel et al.[12] reported a ratio of 6.3:1 in Saudi Arabia. This can be explained by the demographic distribution of the Abu Dhabi Emirate, as females represent only one-third of the population.[4] Trauma represented 21% of the annual mortality in Abu Dhabi Emirate in 2008.[4] Interestingly, trauma among UAE national females was the highest (29.2%) compared with other nationalities. In contrast, trauma among UAE males was the lowest (12.1%) among the male patients. National females represent 72.3% of all females resident in the UAE, while male nationals represent 27.7% of the male population, which may explain these findings.[13] In our study, the ratio of male to female was exceptionally high among patients from the Indian subcontinent. The reason for this might be that the majority of the labor workforce is mainly males from the Indian subcontinent. Male patients represent 98% of occupational-related injuries in Al-Ain, of which 74% are from the Indian subcontinent.[14] Trauma was highest among females in the age group of 20-34 years. This is expected, as females in this age group are in their most active period.[15] In our study, RTC was the main mechanism of inCilt - Vol. 18 SayÄą - No. 3

jury in both females (45.6%) and males (37.4%). This high percentage reflects its magnitude in the UAE, as it is the main cause of death of all injuries in the UAE. Bener and Crandall[16] have attributed this to careless driving and excessive speed. Furthermore, Barrs et al.[17] showed a low compliance rate (11%) for using seatbelts in Al-Ain city. Females represented 11.2% of all RTC patients in our study (Table 2). In comparison, Hamza et al.[18] observed a similar percentage (14%) among Bahraini females. Nevertheless, these figures are lower than those observed in other developing countries. This might be due to the low number of licensed female drivers.[18] Most (86%) of the RTC patients were transported by ambulance, which mainly reflects the severity of the injury. Cervical spine fractures were significantly higher in females, while lumbar fractures were significantly higher in males. This might be due to the significantly higher incidence of cervical spine fractures with RTCs, while lumbar spine fractures were more common in accidental falls.[19] There were no reported cases of vaginal or urinary tract injury (UTI) in the 13 cases of pelvic fracture. This might be due to the small number of patients with pelvic fractures. Another explanation might be that most were unilateral (stable) fractures of the pubic rami, which are unlikely to be associated with UTI. [20] Furthermore, the reported incidence of UTI is generally low, ranging from 0.15% to 1.5%.[21] However, pelvic trauma may have serious and long-term effects on the female reproductive life. It seems that the longterm consequences of pelvic fracture are more common and severe. This is mainly due to the damage to the muscle, connective tissue, nerves, and blood supply of the pelvis resulting in neuropathy, pelvic floor dysfunction, and urogenital pain in nearly half of the females with pelvic fracture.[5] Furthermore, about one-third of females suffer from sexual dysfunction. Sacral fractures are commonly associated with pelvic ring fractures and are associated with sacral root injuries. This might lead to bowel and bladder incontinence and sexual dysfunction.[22] Trauma to the back and pelvis are associated with pelvic girdle pain.[23] Unfortunately, we were unable to obtain long-term follow-up for these patients. Surprisingly, there were no reported suicide attempts in our study. Haukka et al.[24] reported the risk of suicide in Finland to be as high as 10%, with a risk of repeated attempts of 30%. The reported suicide rate in neighboring countries that are similar to the UAE is very low. Elfawal et al.[25] reported a suicide rate of 1.1/100,000 population per annum, with a male to female ratio of 4.5:1. Underreporting might be another cause for this low suicide rate. Furthermore, this study only included patients with trauma who were hospi241

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talized for more than 24 hours. Hence, patients with suicide attempts not requiring admission or who were discharged within 24 hours were not included in the results. Road traffic collision (RTC) was the main cause of fatality in this study. The associated severe head injury and low Glasgow Coma Scale was an indicator of a significant increased risk of mortality.[26] Therefore, it is unlikely that alternative management would have altered the outcome. In conclusion, the majority of females involved in trauma were 20-34 years old. RTC is the main mechanism for injury and fatality. Female trauma is associated with a high incidence of pelvic fractures. Pelvic fractures are not necessarily associated with bladder or vaginal injuries. A higher rate of cervical injuries was observed in females in contrast to lumbar injuries in males.

REFERENCES 1. Sasser SM, Varghese M, Joshipura M, Kellermann A. Preventing death and disability through the timely provision of prehospital trauma care. Bull World Health Organ 2006;84:507. 2. Chan KC, Seow K, Lau G, Chan SP, Tham KY. Female trauma patients in the emergency department: should their injury prevention programme be different? Hong Kong J Emerg Med 2003;10:13-8. 3. Peden M, Scurfield R, Sleet D, Mohan D, Hayder AA, Jarwan E, et al. World report on road traffic injury prevention. Geneva: World Health Organization; 2004. 4. Health Authority Abu Dhabi (HAAD). Health Statistics 2008 Quarter 2. 2009. Available at http://bit.ly/K7y8QK. Accessed on 10 April 2012. 5. Baessler K, Bircher MD, Stanton SL. Pelvic floor dysfunction in women after pelvic trauma. BJOG 2004;111:499-502. 6. Kammerer-Doak D. Assessment of sexual function in women with pelvic floor dysfunction. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:45-50. 7. Shaban S, Ashour M, Bashir M, El-Ashaal Y, Branicki F, Abu-Zidan FM. The long term effects of early analysis of a trauma registry. World J Emerg Surg 2009;4:42. 8. Annual Report. Preventive Medicine Sector, Ministry of Health, United Arab Emirates, 2006. Published on November 2007. 9. Alain hospital website. Available at http://bit.ly/IPAQOn. Accessed on 10 April 2012. 10. Laflamme L, Eilert-Petersson E. Injury risks and socioeconomic groups in different settings. Differences in morbidity

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between men and between women at working ages. Eur J Public Health 2001;11:309-13. 11. Karbakhsh M, Zandi NS, Rouzrokh M, Zarei MR. Injury epidemiology in Kermanshah: the National Trauma Project in Islamic Republic of Iran. East Mediterr Health J 2009;15:5764. 12. Messahel F, Seraj M, al-Qasabi Q, el-Bakry AK. Trauma cases admitted to the surgical intensive care unit--progress and outcome. Middle East J Anesthesiol 1996;13:585-91. 13. Emiratesfreezones, UAE population, http://www.emiratesfreezone.com. Accessed on 10 April 2012. 14. Barss P, Addley K, Grivna M, Stanculescu C, Abu-Zidan F. Occupational injury in the United Arab Emirates: epidemiology and prevention. Occup Med (Lond) 2009;59:493-8. 15. Nilambar J, Agrawal SC. Epidemiological study of road traffic accident cases: a study from Eastern Nepal, Regional Health Forum WHO South-East Asia Region 2004;8:15-22. 16. Bener A, Crandall D. Road traffic accidents in the United Arab Emirates compared to western countries. Adv Transport Stud Int J 2005;6:5-12. 17. Barss P, Al-Obthani M, Al-Hammadi A, Al-Shamsi H, El-Sadig M, Grivna M. Prevalence and issues in non-use of safety belts and child restraints in a high-income developing country: lessons for the future. Traffic Inj Prev 2008;9:256-63. 18. Hamza AY, Al-Mousawi FR, Husel-Pincock A. Road Traffic Accidents in Bahrain. Bahrain Medical Bulletin 2003; 25 Available at: http://bit.ly/JHsbtJ. Accessed on 10 April 2012. 19. Heidari P, Zarei MR, Rasouli MR, Vaccaro AR, RahimiMovaghar V. Spinal fractures resulting from traumatic injuries. Chin J Traumatol 2010;13:3-9. 20. Koraitim MM, Marzouk ME, Atta MA, Orabi SS. Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol 1996;77:876-80. 21. Bariol SV, Stewart GD, Smith RD, McKeown DW, Tolley DA. An analysis of urinary tract trauma in Scotland: imnpact on management and resource needs. Surgeon 2005;3:27-30. 22. Russell GV, Jarrett CA, Routt MC. 2009. Pelvic Fractures. Website: http://bit.ly/K57HNW. Accessed on: 10 April 2012. 23. Albert HB, Godskesen M, Korsholm L, Westergaard JG. Risk factors in developing pregnancy-related pelvic girdle pain. Acta Obstet Gynecol Scand 2006;85:539-44. 24. Haukka J, Suominen K, Partonen T, L繹nnqvist J. Determinants and outcomes of serious attempted suicide: a nationwide study in Finland, 1996-2003. Am J Epidemiol 2008;167:1155-63. 25. Elfawal MA. Cultural influence on the incidence and choice of method of suicide in Saudi Arabia. Am J Forensic Med Pathol 1999;20:163-8. 26. Eid HO, Barss P, Adam SH, Torab FC, Lunsjo K, Grivna M, et al. Factors affecting anatomical region of injury, severity, and mortality for road trauma in a high-income developing country: lessons for prevention. Injury 2009;40:703-7.

May覺s - May 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):243-249

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.08466

A newly designed intramedullary nail with distal interlocking system for tibia fractures in adults - the clinical results Yetişkinlerdeki tibia kırıkları için yeni dizayn edilmiş bir intramedüller çivi ve distal kilit sistemi, klinik sonuçlarımız Fatih KÜÇÜKDURMAZ,1 Fuat AKPINAR,2 Gürsel SAKA,2 Necdet SAĞLAM,2 Cihan ACI2

BACKGROUND

AMAÇ

The surgical treatment of fractures of the tibia includes reamed and unreamed options. Reamed nails have mechanical advantages but they significantly harm the endosteal circulation. Unreamed nails spare the endosteal circulation, but provide a less stable fixation. In both systems, immediate full weight-bearing is not possible due to instability related to distal interlocking (DI). Further, DI is responsible for the majority of the fluoroscopy requirement and a significant loss of surgical time.  In our study, we present the clinical results of a new intramedullary (IM) nail and system, which allows stable fixation with an unreamed technique that permits immediate full weight-bearing, with a minimum fluoroscopy requirement for DI.

Tibia kırıklarının cerrahi tedavisinde oymalı ve oymasız seçenekler vardır. Oymalı çivilerin biyomekanik üstünlükleri vardır ancak endosteal dolaşıma önemli ölçüde zarar verir. Oymasız çiviler ise endosteal dolaşımı korur fakat daha az stabil bir sabitleme sağlar. Her iki sistemde de distal kilit vidası kaynaklı instabilite nedeniyle hemen tam ağırlık vermek mümkün değildir. Ayrıca, distal kilit vidası, skopi kullanma ihtiyacının ve cerrahi sürenin uzamasından sorumludur. Bu çalışmada, yeni intramedüller çivi ve oymasız sistemle stabil bir sabitleme sağlayıp hemen tam ağırlık vermeye izin veren distal kilit vidası sisteminin klinik sonuçları sunuldu.

METHODS

2008 ile 2010 yılları arasında yeni intramedüller sistemle ameliyat edilmiş 50 tibia kırığı (49 hasta) geriye dönük olarak değerlendirildi. Ameliyattan hemen sonraki 1. gün tam ağırlığa izin verildi. Hastalar ameliyat sonrası en az 10 ay takip edildi.

Fifty tibia fractures (49 patients) operated using our new IM system between 2008 and 2010 were evaluated retrospectively. They were allowed full weight-bearing the day after surgery. The patients were followed at least 10 months postoperatively. RESULTS

Mean fluoroscopy time was 18 seconds (min: 10, max: 30) for DI. Mean union time was 9 weeks (min: 6, max: 12). There was no neurovascular injury, deep infection, malunion, delayed union, or nonunion.

GEREÇ VE YÖNTEM

BULGULAR

Distal kilitleme için ortalama skopi süresi 18 saniye (min: 10, maks: 30) idi. Ortalama kaynama süresi 9 hafta (min: 6, maks: 12). Nörovasküler yaralanma, derin enfeksiyon, yanlış veya gecikmiş kaynama ve kaynamama yoktu. SONUÇ

We demonstrated that our newly developed IM nail and new DI system may be an option to solve the stability problems sourced from the DI screw. It also significantly decreases the requirement of fluoroscopy.

Biz bu çalışmamızla yeni geliştirdiğimiz intramedüller çivinin ve distal kilit vidası sisteminin distal kilit vidasından kaynaklanan stabilite problemlerinin çözülmesinde bir seçenek olabileceğini gösterdik. Ayrıca sistemimiz ameliyatta gereken skopi ihtiyacını da önemli ölçüde azaltmaktadır.

Key Words: Distal interlocking; fluoroscopy; immediate full weight-bearing; stability; tibia fracture.

Anahtar Sözcükler: Distal kilit vidası; skopi; hemen tam ağırlık verme; stabilite; tibia kırığı.

CONCLUSION

1 Department of Orthopedics and Traumatology, Bezmialem Vakıf University, Istanbul; 2Department of Orthopedics and Traumatology, Umraniye Training and Research Hospital, Istanbul, Turkey.

Bezmialem Vakıf Üniversitesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul; Ümraniye Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul.

Correspondence (İletişim): Fatih Küçükdurmaz, M.D. Bezmialem Vakıf Üniversitesi, Adnan Menderes Bulvarı Vatan Cad., Fatih 34093 İstanbul, Turkey. Tel: +090 - 212 - 523 37 19 e-mail (e-posta): fatihmfk@hotmail.com

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Intramedullary (IM) nailing has been the gold standard treatment for tibia fractures.[1-3] However, there is a debate on the superiority of reamed versus unreamed IM nailing systems. IM nailing with reaming has mechanical advantages with its larger possible diameters and larger surface-area contact between the bone and nail.[4,5] On the other hand, reaming of the medulla significantly increases the IM pressure and heat.[6] Unreamed nails are smaller in diameter and preserve the endosteal blood supply, which allows more biological fixation with a cost of less stable fixation.[7] Consequently, the biological advantages of unreamed tibial nailing are associated with specific disadvantages. In case of limited nail-bone contact as when unreamed nails are used, the interlocking screw-nail interface becomes an important contributor to the construct stability.[8] Disparity between the distal interlocking (DI) screw hole and nail would inevitably reduce the stability and cause increased interfragmentary movements.[9] This stress to the screws can also cause screw loosening or screw failure.[10] In addition to these mechanical problems, DI is also responsible for the majority of radiation exposure and a significant investment of surgical time in the entire procedure.[11,12] In order to overcome the problems regarding DI, various techniques and devices have been developed.[1319] Despite their developments, no system has gained common acceptance and popularity; thus, DI remains a problem.

Table 1. Fracture types according to the AO classification system Type of fracture

Number of patients

42 43 Total

A B C A

1 2 3 1 2 3 1 2 3 1 2 3

6 2 3 2 3 3 â&#x20AC;&#x201C; 2 1 12 6 8 48

standard in diameter, 8 mm, but had different lengths, ranging from 34-42 mm. The distal end of the IM nail was designed to be engaged to the DSBLS (Fig. 2). The DSBLS was positioned to leave the larger end of the funnel-like hole

In this study, we present the clinical results of a newly developed unreamed IM nail with a new DI system, the Distal Bolt Locking Screw (DSBLS), which allows full weight- bearing (FWB) the day after surgery. It also allows easy DI, which requires significantly less fluoroscopy.

MATERIALS AND METHODS Patients The results of 50 surgically treated tibia fractures in 49 adult patients between May 2008 and May 2010 were evaluated retrospectively. There were 4 isolated tibia and 46 lower leg fractures. Twenty-two of the fractures were shaft and 28 were distal tibia fractures (Table 1). The mean age was 39 (min: 17, max: 80). One patient had bilateral tibia fractures, with a tibia shaft and tibia plateau fracture on one side and distal tibia fracture on the other side. One patient had Gustilo-Andersen type 1 open fracture. One patient had an acetabulum fracture on the same side as the distal tibia fracture. Intramedullary Nail Set The IM nails may be used either reamed or unreamed. The nail is available in diameters from 7 to 12 mm and in lengths from 280 to 400 mm. The DSBLS was cannulated for a set screw (Fig. 1) and was 244

Fig. 1. The DSBLS, set screw and the hole for the set screw are seen.

Fig. 2. The distal end of the intramedullary nail has a special design that makes engagement to the DSBLS possible. (Color figures can be viewed in the online issue, which is available at www.tjtes.org).

MayÄąs - May 2012

A newly designed intramedullary nail with distal interlocking system for tibia fractures in adults

Fig. 3. The design allows rigid fixation of the nail within the DSBLS with a set screw after the engagement. (Color figures can be viewed in the online issue, which is available at www.tjtes.org).

facing in the superior direction, which is indicated by a mark on the DSBLS. The design allows rigid fixation of the nail within the DSBLS with a set screw after the engagement (Fig. 3). Operation The operations were performed by 10 surgeons. A standard point of application for the DSBLS was determined as at the intersection point of approximately 3 cm proximal to the distal tip of the medial malleolus and the middle of the tibia in the sagittal plane. Then, the DSBLS was inserted from the medial to lateral aspect in the distal tibia in a predrilled channel. This step was followed by inserting the selected unreamed nail from the standard point of insertion in the proximal tibia. The insertion of the nail through the medulla was advanced until the engagement of the nail with the DSBLS. The success of the engagement may be confirmed with fluoroscopy (Fig. 4). The nail does not have to approach the DI screw precisely (Figs. 4, 5). Another method of confirmation without using fluo-

Fig. 5. The nail and distal interlocking screw (DSBLS) is drawn from the lateral aspect. The guiding effect is seen even if the nail drops anteriorly (A) or posteriorly (B) within a certain range. If the nail drops more anteriorly (C), the DSBLS is turned anteriorly and the nail is thusly caught by the DSBLS, and it returns to normal position by moving the nail further (D). Cilt - Vol. 18 Say覺 - No. 3

Fig. 4. The progress (A) and success (B) of the engagement may be confirmed with fluoroscopy.

roscopy was made using a Kirschner wire. If the nail is successfully engaged, it is not possible to advance the wire more than 5 mm in the set screw hole (Fig. 6).

Fig. 6. Confirmation of the engagement with a Kirschner wire and without using fluoroscopy is seen. The nail is successfully engaged so it is not possible to advance the wire more than 5 mm in the set screw hole (A). If the engagement is not successful, however, the wire advances through the whole length of the set screw hole (B). (Color figures can be viewed in the online issue, which is available at www.tjtes.org).

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The proximal interlocking was done with a proximal guide, as attached to the nail, and two screws were used in all patients. Another method for DI was to insert the nail to a few centimeters above the localization of the DSBLS and then place the screw precisely below the tip of the nail, after which, the nail was inserted further into its final position. Follow-Up We took standard anteroposterior (AP) and lateral (Lat) views weekly for the first four weeks, and then at the 6th, 9th and 12th weeks. Radiological callus formation was recorded for each view, and union was assumed if there was callus in both views, without pain on palpation and weight-bearing at the fracture site. We recorded the fluoroscopy time for DI. For all patients, FWB was allowed immediately postoperatively and range of motion the day after surgery without any type of external support except for the one patient who had an acetabular fracture.

RESULTS Mean fluoroscopy time was 18 seconds (min: 10, max: 30) for DI. The patients were followed for at least 10 months (min: 10 months, max: 3 years). The mean radiological union time was 9 weeks (min: 6, max: 12). There were no malunion, delayed union or nonunion. During weight-bearing, none of the patients expressed pain interference with their daily activities. None of the patients had complications of deep infection, regional dystrophic syndrome or neurovascular injury. DISCUSSION Intramedullary (IM) nailing of fractures of the tibia is the most commonly accepted surgical treatment in adults. Despite the advantages of IM nailing,

immediate FWB is not possible, especially if the fracture extends distally or proximally and when unreamed IM nailing is performed using the currently available systems. The interfragmentary movements at the fracture site are found to be increased when unreamed nailing is performed.[20] When interfragmentary movement is increased, complications like nonunions, delayed unions or malunions are significantly increased. [9] Attempts have been made for reducing movements and increasing stability at the fracture site following IM nailing.[21] Nevertheless, none of the currently available unreamed nailing systems provides enough stability to allow FWB the day after surgery. In our IM nail system, all patients are allowed FWB the day after surgery and none of them experienced a complication that could be related to instability of the fracture site. It is clearly demonstrated that limited axial interfragmentary movement provides an effective stimulus for periosteal callus formation and thereby accelerates healing.[21-23] On the other hand, the shearing forces affecting the fracture site are detrimental to fracture repair. Thus, the newly developed systems are targeting angular stability by modifying DI options [10,21,24,25] and early weight-bearing.[26,27] The rationale for this is, if the nail is an angular stable construct, weight-bearing acts as cyclic axial loading on the fracture site, which enhances periosteal callus formation. However, in these circumstances, the IM nails act as load-sharing devices and transmit vertical forces on the transverse interlocking screws until the bony union, especially if unreamed nailing is performed. This fatigue stress to screws may cause failure or produce metal splinters on their surface.[8,25,28] In our series, we used our newly designed unreamed IM nail and allowed FWB the day after surgery. We had no implant failure even in unstable and distal tibia fractures. To our knowledge, in the current

Fig. 7. The preoperative (A), postoperative 1st day (B) and postoperative 6th month (C) follow-up X-rays of a segmental tibia fracture are seen. 246

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A newly designed intramedullary nail with distal interlocking system for tibia fractures in adults

English literature, there is no series allowing immediate FWB following unreamed IM nailing of the tibia. Unreamed nails are biologically more advantageous, because they partially preserve the endosteal blood supply and spare the cortical blood supply.[29-31] The IM pressure and heat generated by the insertion of a tibial nail without reaming are significantly smaller than those resulting from reamed tibial nailing.[32-36] These advantages contribute to a favorable bone healing. On the other hand, when unreamed nails are used, nail-bone contact decreases, which causes mechanical insufficiency, and as a result, the interfragmentary movement is more apparent.[20,21] The literature confirms higher nonunion rates with unreamed IM nails in the clinical setting.[37] Although we used unreamed IM nails in this study, no nonunion or delayed union was seen even in the distal and unstable fractures (Fig. 7). Our IM nail system has the biological advantages of unreamed systems, while at the same time providing superior stability features according to currently available reamed IM nail systems. The DI step usually lengthens the operation time and causes prolonged radiation exposure of the surgical team.[38,39] The importance of minimizing ionizing radiation during the surgery is well-known,[40,41] and this risk has been the impetus for many clinicians to develop surgical techniques and/or recommendations that would limit the need for fluoroscopy.[42] The devices developed for reducing fluoroscopy time in DI are either nail or image-intensifier mounted targeting devices[43,44] as well as computer-based navigation systems.[45-47] Image-intensifier mounted systems do not allow micro movements[38] and may be difficult to adapt to all image intensifiers. The nail-mounted systems have some disadvantages that make them unpopular: The weight of these devices declines their distal ends slightly towards the floor when used in the supine position,[47] and deformation of the nail secondary to insertion-related bending[48] and displacement due to the force applied to the device during the drilling have been observed. Computer-based systems are complex, expensive and not radiation-free. Setting up these systems is also time-consuming.[49,50] The results of this study demonstrate that our newly designed IM nail system is superior to the currently available IM nail systems. Our system is completely different in its conception. In contrast to the currently available devices, the first step is to place the DI screw and then the nail is engaged to the screw, instead of using the DI screws at the last step of the procedure. The funnel-like canal in the DSBLS allows for easy engagement of the sharp end of the nail. This makes interlocking easier and dramatically decreases fluoroscopy time. In order to be able to perform a precise interlocking with our system, one has to make preoperaCilt - Vol. 18 Sayı - No. 3

tive planning and determine the most suitable length of the nail. If the selected nail remains short, the nail may be extended with proximal end cups in different lengths within the set. If the nail remains long then the only option is to replace it with a suitable one. Precise matching of the DSBLS and the distal end of the nail is not always necessary. Even if the nail mismatches in the sagittal or coronal plane (Fig. 4) at a certain range, moving the nail further or manipulation of the distal tibial fragment is enough to oppose the nail and the DSBLS hole. Because the DSBLS has a funnel-like hole with a wider upper end, it provides a guiding effect for the distal end of the nail (Fig. 5). The operations were performed in one clinic by 10 different surgeons. Even with the range of surgeons, the outcome among patients was quite similar between surgeons. The learning curve regarding this new system is short. In conclusion, although stability features should be supported by biomechanical studies, the rigid fixation of the nail with a DI screw, the DSBLS, provides superior stability properties in the clinical setting.

REFERENCES 1. Im GI, Tae SK. Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation. J Trauma 2005;59:1219-23. 2. Janssen KW, Biert J, van Kampen A. Treatment of distal tibial fractures: plate versus nail: a retrospective outcome analysis of matched pairs of patients. Int Orthop 2007;31:709-14. 3. Goldhahn S, Moser R, Bigler R, Matter P. Treatment methods and outcomes of tibial shaft fractures in Switzerland. A prospective multicenter study of the Swiss AO. Swiss Surg 2000;6:315-22. [Abstract] 4. Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF. A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma 2000;14:187-93. 5. Bonnevialle P, Bellumore Y, Foucras L, Hézard L, Mansat M. Tibial fracture with intact fibula treated by reamed nailing. Rev Chir Orthop Reparatrice Appar Mot 2000;86:29-37. [Abstract] 6. Heim D, Schlegel U, Perren SM. Intramedullary pressure in intramedullary nailing of the femur and tibia. Helv Chir Acta 1994;60:605-10. 7. Klein MP, Rahn BA, Frigg R, Kessler S, Perren SM. Reaming versus non-reaming in medullary nailing: interference with cortical circulation of the canine tibia. Arch Orthop Trauma Surg 1990;109:314-6. 8. Schüller M, Weninger P, Tschegg E, Jamek M, Redl H, Stanzl-Tschegg S. Micromotion at the fracture site after tibial nailing with four unreamed small-diameter nails--a biomechanical study using a distal tibia fracture model. J Trauma 2009;66:1391-7. 9. Horn J, Linke B, Höntzsch D, Gueorguiev B, Schwieger K. Angle stable interlocking screws improve construct stability of intramedullary nailing of distal tibia fractures: a biome247

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chanical study. Injury 2009;40:767-71. 10. Forster MC, Bruce AS, Aster AS. Should the tibia be reamed when nailing? Injury 2005;36:439-44. 11. Lee MY, Kuo CH, Hung SS. A new fluoroscopy-free navigation device for distal interlocking screw placement. J Med Eng Technol 2008;32:284-95. 12. Krettek C, Könemann B, Farouk O, Miclau T, Kromm A, Tscherne H. Experimental study of distal interlocking of a solid tibial nail: radiation-independent distal aiming device (DAD) versus freehand technique (FHT). J Orthop Trauma 1998;12:373-8. 13. Whatling GM, Nokes LD. Literature review of current techniques for the insertion of distal screws into intramedullary locking nails. Injury 2006;37:109-19. 14. Gugala Z, Nana A, Lindsey RW. Tibial intramedullary nail distal interlocking screw placement: comparison of the freehand versus distally-based targeting device techniques. Injury 2001;32:21-5. 15. Abdlslam KM, Bonnaire F. Experimental model for a new distal locking aiming device for solid intramedullary tibia nails. Injury 2003;34:363-6. 16. Madan S, Blakeway C. Radiation exposure to surgeon and patient in intramedullary nailing of the lower limb. Injury 2002;33:723-7. 17. Pardiwala D, Prabhu V, Dudhniwala G, Katre R. The AO distal locking aiming device: an evaluation of efficacy and learning curve. Injury 2001;32:713-8. 18. Riley SA. Exposure of the orthopaedic surgeon to radiation. J Bone Joint Surg Am 1994;76:952-3. 19. Levin PE, Schoen RW Jr, Browner BD. Radiation exposure to the surgeon during closed interlocking intramedullary nailing. J Bone Joint Surg Am 1987;69:761-6. 20. Augat P, Penzkofer R, Nolte A, Maier M, Panzer S, v Oldenburg G, et al. Interfragmentary movement in diaphyseal tibia fractures fixed with locked intramedullary nails. J Orthop Trauma 2008;22:30-6. 21. Penzkofer R, Maier M, Nolte A, von Oldenburg G, Püschel K, Bühren V, et al. Influence of intramedullary nail diameter and locking mode on the stability of tibial shaft fracture fixation. Arch Orthop Trauma Surg 2009;129:525-31. 22. Bhandari M, Tornetta P 3rd, Sprague S, Najibi S, Petrisor B, Griffith L, et al. Predictors of reoperation following operative management of fractures of the tibial shaft. J Orthop Trauma 2003;17:353-61. 23. Hou T, Li Q, Luo F, Xu J, Xie Z, Wu X, Zhu C. Controlled dynamization to enhance reconstruction capacity of tissueengineered bone in healing critically sized bone defects: an in vivo study in goats. Tissue Eng Part A 2010;16:201-12. 24. Wehner T, Penzkofer R, Augat P, Claes L, Simon U. Improvement of the shear fixation stability of intramedullary nailing. Clin Biomech (Bristol, Avon) 2011;26:147-51. 25. Gueorguiev B, Wähnert D, Albrecht D, Ockert B, Windolf M, Schwieger K. Effect on dynamic mechanical stability and interfragmentary movement of angle-stable locking of intramedullary nails in unstable distal tibia fractures: a biomechanical study. J Trauma 2011;70:358-65. 26. Hente R, Füchtmeier B, Schlegel U, Ernstberger A, Perren SM. The influence of cyclic compression and distraction on the healing of experimental tibial fractures. J Orthop Res 2004;22:709-15. 27. Weaver AS, Su YP, Begun DL, Miller JD, Alford AI, Goldstein SA. The effects of axial displacement on fracture callus morphology and MSC homing depend on the timing of application. Bone 2010;47:41-8. 248

28. Kaspar K, Schell H, Seebeck P, Thompson MS, Schütz M, Haas NP, et al. Angle stable locking reduces interfragmentary movements and promotes healing after unreamed nailing. Study of a displaced osteotomy model in sheep tibiae. J Bone Joint Surg Am 2005;87:2028-37. 29. Hupel TM, Weinberg JA, Aksenov SA, Schemitsch EH. Effect of unreamed, limited reamed, and standard reamed intramedullary nailing on cortical bone porosity and new bone formation. J Orthop Trauma 2001;15:18-27. 30. Shepherd LE, Shean CJ, Gelalis ID, Lee J, Carter VS. Prospective randomized study of reamed versus unreamed femoral intramedullary nailing: an assessment of procedures. J Orthop Trauma 2001;15:28-33. 31. Ruchholtz S, Nast-Kolb D, Schweiberer L. Intramedullary nailing of lower leg fractures with minimal soft tissue injuries. Orthopade 1996;25:197-206. [Abstract] 32. Saldua NS, Kuhn KM, Mazurek MT. Thermal necrosis complicating reamed intramedullary nailing of a closed tibial diaphysis fracture: a case report. J Orthop Trauma 2008;22:737-41. 33. Leunig M, Hertel R. Thermal necrosis after tibial reaming for intramedullary nail fixation. A report of three cases. J Bone Joint Surg Br 1996;78:584-7. 34. Mawhinney IN, Maginn P, McCoy GF. Tibial compartment syndromes after tibial nailing. J Orthop Trauma 1994;8:2124. 35. Karunakar MA, Frankenburg EP, Le TT, Hall J. The thermal effects of intramedullary reaming. J Orthop Trauma 2004;18:674-9. 36. García OG, Mombiela FL, De La Fuente CJ, Aránguez MG, Escribano DV, Martín JV. The influence of the size and condition of the reamers on bone temperature during intramedullary reaming. J Bone Joint Surg Am 2004;86-A:994-9. 37. Larsen LB, Madsen JE, Høiness PR, Øvre S. Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years’ follow-up. J Orthop Trauma 2004;18:144-9. 38. Whatling GM, Nokes LD. Literature review of current techniques for the insertion of distal screws into intramedullary locking nails. Injury 2006;37:109-19. 39. Fan CY, Chiang CC, Chuang TY, Chiu FY, Chen TH. Interlocking nails for displaced metaphyseal fractures of the distal tibia. Injury 2005;36:669-74. 40. Barry TP. Radiation exposure to an orthopedic surgeon. Clin Orthop Relat Res 1984;182:160-4. 41. Sugarman ID, Adam I, Bunker TD. Radiation dosage during AO locking femoral nailing. Injury 1988;19:336-8. 42. Babis GC, Benetos IS, Zoubos AB, Soucacos PN. The effectiveness of the external distal aiming device in intramedullary fixation of tibial shaft fractures. Arch Orthop Trauma Surg 2007;127:905-8. 43. Gugala Z, Nana A, Lindsey RW. Tibial intramedullary nail distal interlocking screw placement: comparison of the freehand versus distally-based targeting device techniques. Injury 2001;32:21-5. 44. Tyropoulos S, Garnavos C. A new distal targeting device for closed interlocking nailing. Injury 2001;32:732-5. 45. Slomczykowski MA, Hofstetter R, Sati M, Krettek C, Nolte LP. Novel computer-assisted fluoroscopy system for intraoperative guidance: feasibility study for distal locking of femoral nails. J Orthop Trauma 2001;15:122-31. 46. Hofstetter R, Slomczykowski M, Sati M, Nolte LP. Fluoroscopy as an imaging means for computer-assisted surgical navigation. Comput Aided Surg 1999;4:65-76. Mayıs - May 2012

A newly designed intramedullary nail with distal interlocking system for tibia fractures in adults

47. Zheng G, Zhang X, Haschtmann D, G矇det P, Langlotz F, Nolte LP. Accurate and reliable pose recovery of distal locking holes in computer-assisted intra-medullary nailing of femoral shaft fractures: a preliminary study. Comput Aided Surg 2007;12:138-51. 48. Krettek C, Mannss J, Miclau T, Schandelmaier P, Linnemann I, Tscherne H. Deformation of femoral nails with intramedullary insertion. J Orthop Res 1998;16:572-5.

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49. Suhm N, Jacob AL, Nolte LP, Regazzoni P, Messmer P. Surgical navigation based on fluoroscopy--clinical application for computer-assisted distal locking of intramedullary implants. Comput Aided Surg 2000;5:391-400. 50. Suhm N, Messmer P, Zuna I, Jacob LA, Regazzoni P. Fluoroscopic guidance versus surgical navigation for distal locking of intramedullary implants. A prospective, controlled clinical study. Injury 2004;35:567-74.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):250-254

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.04379

Rectal injury during radical prostatectomy Radikal prostatektomi sırasında rektal yaralanma Mehmet YILDIRIM,1 Cemal GÖKTAŞ,2 Rahim HORUZ,2 Cihangir A. ÇETİNEL,2 Önder CANGÜVEN,2 Hasan Fehmi KÜÇÜK,1 Selami ALBAYRAK2

BACKGROUND

AMAÇ

We evaluated the data of our patients who experienced rectal injury during radical prostatectomy (RP).

Radikal prostatektomi (RP) sırasında iyatrojenik rektal yaralanma gelişen hastaların verileri değerlendirildi.

METHODS

GEREÇ VE YÖNTEM

We analyzed the data for the 7 patients (6 perineal, 1 retropubic) with iatrogenic rectal injury who were selected from 451 patients with RP (218 retropubic, 233 perineal) operated in our clinic between 2003 and 2011.

2003 ile 2011 yılları arasında ameliyat edilen 451 RP (218 retropubik, 233 perineal RP) olgusu arasında, ameliyat sırasında rektal yaralanma gelişen 7 hastanın (6 perineal, 1 retropubik RP) pre-, intra- ve post-operatif döneme ait klinik verileri geriye dönük olarak incelendi.

RESULTS

The mean age of the 7 patients was 64.4 years. Rectal injury occurred during prostatic apical dissection in 4 patients, during dissection of Denonvilliers fascia in 1 patient, during transection of the rectourethral muscles in 1 patient, and during dissection of the rectal region proximal to the anal sphincter in 1 patient. The mean size of the lesions was 2 (1-4) cm. All of the rectal injuries were recognized during the operation, and double-layered sutures were used for the primary repair. None of the cases required colostomy procedure. No postoperative complications were encountered in 6 of the patients; however, 1 patient underwent a second operation on the following day due to detachment at the injury site. None of the patients displayed urethrorectal fistula, urinary incontinence or urethral stricture.

BULGULAR

CONCLUSION

SONUÇ

Primary repair with double-layered suturing is sufficient for the treatment of rectal injuries that occur during RP if they are recognized intraoperatively. Key Words: Cancers; injuries; prostatectomy; rectal; urologic.

Departments of 1General Surgery, 2Urology, Dr. Lutfi Kirdar Kartal Training and Research Hospital, Istanbul, Turkey.

Yedi hastanın ortalama yaşı 64,4 yıl idi. Rektal yaralanmanın, 4 hastada prostatın apikal diseksiyonu sırasında, 1 hastada Denonvillier fasyasının diseksiyonu sırasında, 1 hastada rektoüretral kasların kesilmesi sırasında, 1 hastada ise anal sfinkterin hemen yakınındaki seviyede rektum diseksiyonu yapılırken geliştiği tespit edildi. Rektal yaralanmanın ortalama ebatı 2 (1-4) cm idi. Tüm olgularda yaralanan bölge anında fark edilerek çift-tabaka dikiş ile primer olarak perioperatif onarıldı, hiçbir olguda kolostomi uygulanmadı. Altı olguda ameliyat sonrası dönemde herhangi bir komplikasyonla karşılaşılmadı. Bir olguda ise yaralanan ve onarılan rektum duvarında gelişen detaşman nedeniyle ameliyattan sonra 1. günde cerrahi gerekti ve hasta sorunsuz iyileşti. Ameliyat sonrası takipte hiçbir hastada üretrorektal fistül, idrar inkontinansı veya üretral darlık ile karşılaşılmadı. Radikal prostatektomi sırasında fark edilmesi durumunda, rektum yaralanmalarının tedavisinde çift-tabaka dikiş ile primer onarım uygulanması yeterli olmaktadır. Anahtar Sözcükler: Kanser; yaralanma; prostatektomi; rektal; ürolojik.

Dr. Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi, 1 Genel Cerrahi Kliniği, 2Üroloji Kliniği, İstanbul.

Correspondence (İletişim): Rahim Horuz, M.D. Dr. Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi, 2. Üroloji Kliniği, Cevizli, Kartal, İstanbul, Turkey. Tel: +090 - 216 - 441 39 00 / 1921 e-mail (e-posta): rahimhoruz@yahoo.com

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Rectal injury during radical prostatectomy

Radical prostatectomy is the most effective method for the treatment of localized prostate cancer. The first technique that was described for prostatectomy was radical perineal prostatectomy, but retropubic radical prostatectomy has been the preferred surgical technique in the treatment of patients with localized prostate cancer disease since its introduction in the 1980s. More recently, laparoscopic and robotic retropubic techniques have been developed. Regardless of the surgical technique used, iatrogenic rectal trauma remains an important potential complication during prostatectomy. In this study, we evaluated the data from patients in whom iatrogenic rectal injury occurred during radical prostatectomy.

MATERIALS AND METHODS Seven patients who encountered iatrogenic rectal injury during radical prostatectomy were selected for this study from a population of 451 patients with localized prostate cancer (218 retropubic, 233 perineal radical prostatectomies) who were operated in our clinic between May 2003 and May 2011. We recorded the clinical, operative and pathological data. In addition, preoperative (i.e., age, medical history, particular history of previous operations related to the rectum and/or prostate, body mass index (BMI), findings of digital rectal examinations (DREs), prostate-specific antigen (PSA) levels, biopsy findings, time between biopsy and the operation, and the clinical stage), intraoperative (i.e., the weight of the prostate and seminal vesicles as determined by measurements of the surgical specimens, the exact localization and size of the rectal injury, and the treatment of the injury), and postoperative (i.e., the Gleason score and the surgical margin status of the tumor, the time that oral alimentation was initiated, the time with a transurethral catheter, the treatment outcomes, and related complications) data were comparatively analyzed.

RESULTS Among 7 patients with a mean age of 64.4 (56-70) years, radical perineal prostatectomy was performed in 6 patients, and retropubic prostatectomy was performed in 1 patient. None of the patients had a history of prostate or rectal surgery or radiotherapy. In 1 of the patients, there was a history of hospitalization with a diagnosis of acute prostatitis 30 years ago, which was treated with medication. Four patients had a normal DRE, but we detected regional hardness in 2 patients and palpable nodules in 1 patient. The mean BMI was 27.4 (23.8-30.3). The mean PSA value was 9.2 (5.2-21.7) ng/ml. The Cilt - Vol. 18 Say覺 - No. 3

mean ratio of positive cores in the biopsies was 29.4% (10-66%), and the mean duration between the date of the biopsy and the operation was 36 (16-52) days. All of the patients fasted for 8-12 hours (h) before the operation and were given 1 g of cefazolin intravenously for prophylaxis. One patient had an American Society of Anesthesiology (ASA) score of 3, 2 patients had an ASA score of 2, and 2 patients had an ASA score of 1. The mean operation time was 138 (115-165) minutes (min). The mean weight of the surgical specimens (i.e., prostate and seminal vesicles) was 57.4 (40-74) g. Rectal injury occurred during prostatic apical dissection in 4 patients, during dissection of Denonvilliers fascia in 1 patient, during transection of the rectourethral muscles in 1 patient, and during dissection of the rectal region proximal to the anal sphincter in 1 patient. The mean size of the lesions was 2 (1-4) cm. In 2 of the 4 patients with rectal injury during apical dissection, the pathology report revealed surgical margin positivity in the apical region of the prostate. The surgical margins were negative in the other 5 patients. When the patients were evaluated according to the TNM classifications of prostate cancer that were published in 2009, the pathological stage was pT2a (the tumor involves one- half of 1 lobe or less) in 2 patients, pT2c (the tumor involves both lobes) in 2 patients, and pT3a (extracapsular extension including microscopic bladder neck involvement) in 3 of the patients. All of the rectal injuries were recognized during the operation, and double-layered sutures were used for the primary repair. Patients were placed on a liquid diet 24 h after the operation and given broad-spectrum antibiotic therapy (1 g cefazolin, 160 mg gentamicin, 500 mg metronidazole, all intravenously). In 6 of the patients, no complications were encountered during the postoperative period, and a normal diet was started on the 5th postoperative day. Interestingly, suspicious fecal drainage through the perineal incision was observed in 1 patient. He immediately underwent another operation, and a detachment was identified on the sutured rectal wall, which was previously injured and had been repaired. This site was repaired again with double-layered sutures, and the patient was able to tolerate a normal diet on the 5th postoperative day without any complications. No urethrorectal fistula was observed in any of the patients. In addition, urological follow-up of our cases did not reveal any instances of urinary incontinence or urethral stricture. The data of the patients are given in Table 1.

DISCUSSION Radical prostatectomy is the most commonly used treatment method in localized prostate cancer because of its high oncological success. In addition to 251

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Table 1. Patient data No

Hardness 5.3 on the left side Normal 6.1 Hard21.7 ness on the right side 10.2 Normal Basal 5.2 nodule on the right side Normal 5.2 Normal 9.5

2 3 4 5

6 7

H I

38 1/10 (10%) pT2a 3+3

Negative

Dissection of Denonvilliers fascia 6

16 Primary repair

Cure

37 2/10 (20%) pT2a 4+3 26 4/6 (66%) pT2c 3+4

Negative Negative

63 56

1 1

Level of rectourethral muscles Proximal to the anal sphincter

6 9

19 Primary repair 16 Primary repair

Cure Cure

41 3/12 (25%) pT3a 3+3 52 4/10 (40%) pT3a 3+3

Positive Negative

61 41

2 2

Apical dissection Apical dissection

13 7

30 Primary repair 20 Primary repair

* Cure

42 2/10 (20%) pT3a 3+3 16 3/12 (25%) pT2c 3+3

Positive Negative

40 67

2 4

Apical dissection Apical dissection

6 6

14 Primary repair 16 Primary repair

Cure Cure

A: DRE (Findings obtained upon digital rectal examination of the prostate); B: PSA (Ng/ml); C: Time between biopsy and the operation (days); D: Ratio of positive cores obtained from the biopsy; E: Pathological stage (TNM) and Gleason score; F: Surgical margin positivity; G: Prostate weight (g); H: Size of the injury (cm); I: Time / localization of the injury; J: Hospitalization (days); K: Duration of transurethral catheter insertion (days); L: Treatment; M: Outcome; *: Re-repair on the 1st postoperative day and cure.

the open surgical methods, laparoscopic and robotic radical prostatectomy techniques are currently being performed with increasing frequency, and technical improvements are constantly being made.

jury was more frequent among perineal patients. Although the difference was not found statistically significant (p=0.071), out of a total of seven patients with rectal injury, six were perineal and one was retropubic.

One of the most important intraoperative complications in radical prostatectomy is rectal injury because of the anatomic relationship between the prostate and the rectum. Although the frequency of rectal injury in radical prostatectomy varies from 0% to 11% in the literature,[1,2] it was reported to be as high as 28% in a review of the studies of cases of salvage prostatectomy. [3] Importantly, there has been a decrease in the rate of rectal injury during radical prostatectomy operations in recent years, which may be due to the more refined surgical techniques and increasing anatomical knowledge of the male pelvis.[4] Previous studies have suggested that the rates of rectal injury are higher when the surgeon is unfamiliar with radical prostatectomy. Indeed, Heinzer et al.[5] reported a rectal injury rate of 2% among patients who were operated upon later in the study compared with 7.8% in the group of patients who were operated upon at the beginning of the study. Similarly, Castello et al.[6] reported an 8% rectal injury rate in patients operated upon during the period when surgeons were still familiarizing themselves with the technique of radical prostatectomy.

McLaren et al.[9] found that a history of radiotherapy or prostatic or rectal surgery predisposed patients to rectal injury, whereas the local stage of the disease did not. In contrast, several studies failed to find an increased risk in cases with a history of open prostatic adenomectomy or transurethral resection.[10,11] A novel technique was reported in a study by Albayrak et al.,[12] and they recommended a circular incision of the bladder neck by endoscopic means to make the dissection of the bladder neck easier during perineal radical prostatectomy in cases with a previous history of prostatic surgery. Since none of our seven cases had a history of prostatic surgery, we did not use this technique; however, it may be helpful in decreasing the risk of rectal injury during radical prostatectomy in those cases with a history of prostatic surgery.

It is difficult to conclude whether the rates of rectal injury vary from one technique to another in radical prostatectomy. In a comparative study, open retropubic radical prostatectomy and laparoscopic radical prostatectomy were found to have similar rectal injury rates (i.e., approximately 2.8%).[7] Another study that compared retropubic and perineal radical prostatectomy reported that rectal injury was more likely with the perineal approach.[8] Similarly, the present study, which had a similar number of patients in each group (218 retropubic vs. 231 perineal), found that rectal in252

Iatrogenic rectal injuries may occur more frequently during salvage radical prostatectomy performed for a PSA recurrence after primary radiotherapy, brachytherapy, high-intensity focused ultrasound (HIFU), or cryotherapy. The increased incidence of iatrogenic rectal injuries in salvage radical prostatectomy cases is correlated with the local stage of the disease and associated with severe periprostatic fibrotic changes, which result from previous therapeutic procedures.[13-15] Because the diagnosis of prostate cancer requires a transrectal biopsy, it is thought that a time interval of at least one month between the biopsy and the prostatectomy may have positive effects on the operation by enhancing the chances of resolving inflammation of the rectal wall and the prostatic/periprostatic tissues. A one-month waiting period between the biopsy and the operation might result in an easier dissection on May覺s - May 2012

Rectal injury during radical prostatectomy

the plane between the prostate and the rectum, which would decrease the risk of rectal injury. In the present study, the mean interval between the biopsy and the operation was 36 days, and the minimum interval was 16 days (1 case). In the 1990s, preoperative bowel preparation was widely used before radical prostatectomy operations to obviate the need for colostomy in the case of rectal injury.[9] Today, preoperative bowel preparation is generally not preferred. We did not require any gastrointestinal preparation other than a routine 8-12-h preoperative fast, and this did not increase the need for colostomy. Double-layered suturing is usually sufficient for the successful repair of rectal injuries occurring during radical prostatectomy. In most cases, the addition of a colostomy procedure would not be necessary after primary repair of the rectal wall. In general, colostomy may be necessary in certain cases with larger defects, intraoperatively unrecognized defects, fistula development, or in salvage radical prostatectomy procedures.

[1,6,13,16,17]

There is a consensus among most authors about the importance of recognizing rectal injuries during the operation. The presence of a defect in the rectal wall may be tested by checking for a loss of gas through the rectal wall. This can be done by filling the operation area with isotonic saline and observing the saline after the injection of normal room air through the anus into the rectal lumen with a syringe. This test is only performed when rectal trauma is suspected. In all of our cases, the rectal trauma was recognized at the moment of the trauma and appropriately repaired during the same operative session. Simultaneous primary repair with double-layered suturing was sufficient in six cases, and no complications were encountered during the postoperative period of these six patients. In the remaining patient, however, a second operation was required after the development of fecal drainage from the operation site despite the primary repair. In the secondary operation, which was performed via the perineal approach on the first postoperative day, a 2-cm detachment of the sutures on the rectal wall was closed with double-layered suturing, and no additional measure was needed. Drainage was resolved after the operation, and no complications were encountered. None of the patients required a colostomy procedure. We believe that the perineal approach has an advantage with respect to surgical exposure in the repair of rectal traumas. Patients who experience a rectal injury during laparoscopic radical prostatectomy may require open surgery and colostomy when it is not possible to repair the injury laparoscopically.[18,19] In cases of iatrogenic rectal injury during radiCilt - Vol. 18 Say覺 - No. 3

cal prostatectomy, complications can be observed postoperatively if the injury is not recognized during the operation. The most important complications are urorectal fistulas, peritonitis, infections related to the operation site, anastomotic strictures, and urinary incontinence.[6,9,20] Previous studies have shown that unrecognized traumas resulting from the use of thermal energy, electrical energy or cautery, especially in laparoscopic surgery, are particularly vulnerable to fistula development.[6] McLaren et al.[9] reported the development of rectourethral fistulas in four out of 27 cases of rectal injury in which rectal trauma had been recognized and repaired intraoperatively. In addition, Fichtner et al.[20] reported the development of fistulas in four out of 22 cases of intraoperatively recognized and repaired rectal trauma, and three patients required a colostomy procedure. Interestingly, Castillo et al.[6] followed three patients with intraoperatively unrecognized trauma for one month using an indwelling transurethral catheter. Although the fistula disappeared in one of the cases, surgical repair of the fistula was necessary in the remaining two patients. The majority of the published reports suggest that there is no need to limit the oral alimentation of patients if an effective primary repair is performed on the injured rectal wall. In the present study, the patients were permitted to start a liquid diet 24 h after the operation, and they tolerated a normal diet on the 5th postoperative day. In conclusion, primary repair with double-layered suturing is sufficient for the treatment of rectal injury that occurs during radical prostatectomy operations if it is recognized intraoperatively. Because radical prostatectomy operations might be complicated by fistulas and peritonitis, however, iatrogenic rectal injuries should always be considered as a potential complication of every radical prostatectomy operation.

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A, et al. Is laparoscopic radical prostatectomy better than traditional retropubic radical prostatectomy? An analysis of peri-operative morbidity in two contemporary series in Italy. Eur Urol 2003;44:401-6. 8. Lance RS, Freidrichs PA, Kane C, Powell CR, Pulos E, Moul JW, et al. A comparison of radical retropubic with perineal prostatectomy for localized prostate cancer within the Uniformed Services Urology Research Group. BJU Int 2001;87:61-5. 9. McLaren RH, Barrett DM, Zincke H. Rectal injury occurring at radical retropubic prostatectomy for prostate cancer: etiology and treatment. Urology 1993;42:401-5. 10. Elder JS, Gibbons RP, Correa RJ Jr, Brannen GE. Morbidity of radical perineal prostatectomy following transurethral resection of the prostate. J Urol 1984;132:55-7. 11. Ramon J, Rossignol G, Leandri P, Gautier JR. Morbidity of radical retropubic prostatectomy following previous prostate resection. J Surg Oncol 1994;55:14-9. 12. Albayrak S, Canguven O, Aydemir H, Goktas C, Cetinel C, Akca O. Endoscope-assisted radical perineal prostatectomy. J Endourol 2010;24:527-30. 13. Ahallal Y, Shariat SF, Chade DC, Mazzola C, Reuter VE, Sandhu JS, et al. Pilot study of salvage laparoscopic prostatectomy for the treatment of recurrent prostate cancer. BJU Int 2011;108:724-8.

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14. Gotto GT, Yunis LH, Vora K, Eastham JA, Scardino PT, Rabbani F. Impact of prior prostate radiation on complications after radical prostatectomy. J Urol 2010;184:136-42. 15. Lawrentschuk N, Finelli A, Van der Kwast TH, Ryan P, Bolton DM, Fleshner NE, et al. Salvage radical prostatectomy following primary high intensity focused ultrasound for treatment of prostate cancer. J Urol 2011;185:862-8. 16. Borland RN, Walsh PC. The management of rectal injury during radical retropubic prostatectomy. J Urol 1992;147:905-7. 17. Guillonneau B, Gupta R, El Fettouh H, Cathelineau X, Baumert H, Vallancien G. Laparoscopic [correction of laproscopic] management of rectal injury during laparoscopic [correction of laproscopic] radical prostatectomy. J Urol 2003;169:1694-6. 18. Ou YC, Yang CR, Wang J, Yang CK, Cheng CL, Patel VR, et al. The learning curve for reducing complications of roboticassisted laparoscopic radical prostatectomy by a single surgeon. BJU Int 2011;108:420-5. 19. Chun L, Abbas MA. Rectourethral fistula following laparoscopic radical prostatectomy. Tech Coloproctol 2011;15:297300. 20. Fichtner J, Gillitzer R, Melchior SW, Hohenfellner M, Th羹roff JW. Perineal complications following radical perineal prostatectomy. Aktuelle Urol 2003;34:223-5.

May覺s - May 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):255-259

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.47639

Pellet gunfire injuries among agitated mobs in Kashmir Keşmir’de ayaklanan grupların havalı silah saçmasıyla yaralanmaları Majid MUSHTAQUE,1 Mohammad F. MIR,2 Muneer BHAT,3 Fazl Q. PARRAY,1 Samina A KHANDAY,2 Rayees A. DAR,1 Ajaz A. MALIK1

BACKGROUND

AMAÇ

Pellet gunfire injuries inflicted while controlling agitated mobs has been studied.

Ayaklanan grupların kontrol edilirken uğradıkları saçma ile silah yaralanmaları incelendi.

METHODS

GEREÇ VE YÖNTEM

A total of 198 patients admitted to the Accident and Emergency Department with pellet gun injuries were studied in terms of anatomic site, severity and type of injury, treatment, and outcomes.

Saçma tanesi ile gerçekleşen silah yaralanmaları nedeniyle kaza ve acil servis bölümüne yatırılan toplam 198 hasta, anatomik bölge, ciddiyet ile yaralanma tipi, tedavi ve sonuçlar bakımından değerlendirildi.

RESULTS

BULGULAR

72.7% of patients were aged 16-25 years. The most common sites of injury were the extremities (47.9%), abdomen (36.3%) and chest (31.3%). 59.5% of patients were found to have minor injuries. Of the 80 patients admitted to the hospital for their injuries, 43 (53.7%) required an operative procedure. Six deaths (3.03%) were observed.

Hastaların %72,7’si, 16 ile 25 yaş arasında idi. En sık yaralanma bölgeleri ekstremiteler (%47,9), karın (%36,3) ve göğüs (%31,3) idi. Hastaların %59,5’inde minör yaralanma vardı. Yaralanmaları nedeniyle hastaneye yatırılan 80 hastanın 43’ü (%53,7) ameliyat edildi. Altı adet ölüm (%3,03) gözlemlendi.

CONCLUSION

SONUÇ

While the pellet wound itself may seem trivial, if not appreciated for the potential for tissue disruption and injuries to the head, chest, and abdomen, there can be catastrophic results. Patients should be evaluated and managed in the same way as those sustaining bullet injuries.

Kendi başına saçma yaraları önemsiz gibi görünebilir, ancak, kafaya, göğüse ve karına yönelik potansiyel doku hasarına neden olabilecek yaralanmaların değerlendirilmemesi durumunda ölümcül sonuçlar ortaya çıkabilir. Hastalar, genel kurşun yaralanmaları ile aynı şekilde değerlendirilmeli ve tedavi edilmelidir.

Key Words: Pellet wounds; non-powdered guns.

Anahtar Sözcükler: Saçma yaraları, barutsuz silahlar.

An estimated 32,000 injuries attributable to nonpowder firearms (i.e., BB gun, pellet gun, and air rifle) occur each year in the United States, most of which are seen in the pediatric population.[1] Many case reports of serious and even fatal non-powder firearm injuries have been published describing ocular, intracranial, abdominal, and thoracic wounds,[2-9] but there

is no single data regarding the pattern, severity and outcome of pellet injuries inflicted while controlling agitated crowds in a defined population. A persisting problem is the lack of medical recognition of the severity of injuries that can result from these guns, including penetration of the eye, skin, internal organs, and bone. Injuries associated with non-powder guns

Departments of 1General Surgery, 2Radiodiagnosis & Imaging, 3Hospital Administration, Sher-I Kashmir Institute of Medical Sciences, Srinagar, J & K, India.

Sher-i Kashmir Tıp Bilimleri Enstitüsü, 1Genel Cerrahi Kliniği, Radyodiyagnostik ve Görüntüleme Bölümü, 3Hastane Yönetimi, Srinagar, Hindistan.

Correspondence (İletişim): Majid Mushtaque, M.S. Sher-I Kashmir Institute of Medical Sciences, Department of General Surgery, Srinagar, J & K, India. Tel: +09419018445 e-mail (e-posta): drmajidmushtaque@gmail.com

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should receive prompt medical management similar to that administered for firearm-related injuries.[9]

MATERIALS AND METHODS This study was conducted at Sher-I Kashmir Institute of Medical Sciences. The data were obtained during the period of social unrest from June 2010 to September 2010. A total of 634 patients were received in Emergency Reception (ER). Three hundred and twenty-five people sustained firearm injuries (88 bullet injuries, 39 tear gas shell injuries and 198 pellet gunfire injuries), Ninety-eight were injured by stone pelting and another 211 by alleged beating by the security forces. Our study included only those sustaining pellet gunfire injuries. The weapon is a pump action shotgun or pellet gun (Fig. 1), and its single shot fires numerous pellets that can hit multiple targets at once. Abstraction of information included the following: patient age, gender, anatomic location, severity of injury, diagnostic studies, treatment, and outcome including morbidity and mortality. Upon arrival to the ER, patients were examined, primarily treated with intravenous (iv) fluids, a dose of anti-tetanus toxin, and prophylactic iv antibiotic. They also underwent the obligatory scans including X-rays [cervical spine, abdominal, pelvic and chest] and focused assessment with sonography in trauma (FAST) ultrasound scan. They were then sent either directly to the operating room, observation/disaster ward, or for additional studies such as non-contrast computed tomography (NCCT), Doppler scan, or extremity Xrays, according to their condition assessment and diagnosis (Figs. 2-6). Patients diagnosed to have minor injuries were discharged within 12 hours.

RESULTS During the study period of four months, 198 patients were identified as having sustained pellet gunfire injury. Patientsâ&#x20AC;&#x2122; ages ranged between 6-54 years Table 1. Age distribution Age in years 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 â&#x2030;Ľ51 Total 256

Number of patients (n)

Percentage (%)

2 14 85 59 22 6 4 2 3 1 198

1.01% 7.07% 42.92% 29.79% 11.11% 3.03% 2.02% 1.01% 1.51% 0.50% 100%

Fig 1. Pump action shotgun or pellet gun used to control agitated mobs.

(Table 1). The highest prevalence of injury was observed in the 16-25 year age group (72.7%). The youngest patient was a six-year-old boy and the oldest was 54 years old, with pellet wounds in the face and abdomen, respectively. There were 192 males and six females. Most patients sustained multiple wounds, with up to 70 small wounds reported in one of them. The most common sites of injury were the extremities (47.9%), abdomen (36.3%) and chest (31.3%). Injuries to any of these sites were associated with a significant number of injuries involving other parts of the body (Table 2). All patients were thoroughly examined and primarily treated with iv fluids, a dose of anti-tetanus toxin and prophylactic iv antibiotic. Obligatory scans including X-rays, FAST ultrasound scan, and additional studies including NCCT, Doppler scan or extremity X-rays were done according to the site of injury. A total of 118 (59.5%) patients were found to have minor injuries and were discharged from the emergency department after antiseptic dressing or removal of the foreign bodies. Of the remaining 80 (40.4%) patients admitted to the hospital for their injuries, 43 (53.7%) required an operative procedure. The viscera damaged/injured site and the surgical procedures done are shown in Table 3. The most common sites of injuries requiring either hospitalization or operative intervention were the abdomen, chest and eyes. Operative procedures included exploratory laparotomy (20), intercostal chest tube (ICCT) drainage (9), thoracotomy (2), vascular repair/grafting (3), ophthalmic procedures (7), and exploration of neck wounds (2). At exploratory laparotomy, the findings included isolated small gut perforations in four patients. Small gut perforation(s) were associated with large gut perforation(s) in two patients, retroperitoneal hematoMayÄąs - May 2012

Pellet gunfire injuries among agitated mobs in Kashmir

ma in two patients, and mesenteric hematoma, urinary bladder perforation, liver laceration, and splenic hilar injury in one patient each. Two patients had isolated colonic perforations, while another two had isolated mesenteric hematoma and gastric perforation, respectively. The operative procedures for small gut injuries included primary closure/repair in seven, resection anastomosis in four, and ileostomy in one patient. Large gut perforations were managed with repair in two, colostomy in one, and resection anastomosis in one patient. Two patients with mesenteric laceration were treated by repair in one and resection anastomosis in another. Splenic hilar injury seen in one of the patients was treated by splenectomy. Gastric perforations and liver laceration present in one each of the patients were managed by primary repair, while the urinary bladder injury was treated by primary repair with suprapubic cystostomy (SPC). No retroperitoneal hematoma was explored in our series. Four patients in our study had a negative laparotomy. One of these patients had postoperative fecal drainage via the pelvic drain on the 2nd day. Reexploration revealed a per-

foration in the posterior wall of the rectum above the peritoneal reflection, which was managed with closure and proximal diversion colostomy. Eleven patients were treated with ICCT drainage for hemothorax/pneumothorax/ hemo-pneumothorax, of which two required thoracotomy for their persistent drainage. Seven of 11 patients with injuries to the eyes required operative intervention. A total of five patients were blinded in the involved eye. One patient had pellet injuries in both eyes, rendering him completely blind. Three patients required vascular repair of femoral or popliteal vessels, and another two were subjected to exploration of neck hematoma revealing injury to the trachea and one of the carotids. Mortality occurred in six patients (3.03%). Five of these patients died either in the emergency OT or in the immediate postoperative period. One died of sepsis on the 7th day. Wound infection was seen in eight

Fig. 2. Views of multiple pellets in different areas of the body.

Cilt - Vol. 18 Say覺 - No. 3

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Ulus Travma Acil Cerrahi Derg

Table 2. Anatomical site of injuries Site of injury

Number of patients Isolated to the site Associated with injury to (single or multiple wounds) other sites

Head and neck Face and eyes Chest Abdomen Extremities

31 21 35 38 73

11 2 27 34 22

Total

Percentage (%)

42 23 62 72 95

21.21 11.61 31.31 36.36 47.97

Percentage does not correlate to 100% because of multiple injuries present in majority of the patients (n=198).

of the operated patients (18.6%). Two patients had adhesion obstruction that was managed conservatively.

DISCUSSION A number of firearms have been used to disperse/ control violent mobs in Kashmir over the last 20 years. These include conventional bullets, rubber bullets, and tear gas shells. Pellet firearms have been introduced as the latest modality for crowd control, assuming to have lower mortality. There are two injury patterns that result from pellets: minor, requiring local care in the emergency department with subsequent discharge, and serious, requiring admission to the hospital and frequently operative intervention. Serious injuries occasionally cause long-term functional deficit. Nonpowder firearms can generate muzzle velocities of 200 to 900 foot-pounds per second;[7] skin penetration requires only 120 foot-pounds per second,[4] while ocular penetration can occur at velocities as low as 130 ft/second.[9] Fortunately, the majority of these injuries are minor (59.5% in this series). There is a potential for serious injury, which mandates that all non-powder firearm wounds be thoroughly

evaluated to avoid missing underlying severe injury. This should include localization of the foreign body, if present, in three dimensions using imaging techniques (typically roentgenograms), determination of the trajectory to postulate the potential organs injured, and assessment of the need for operative intervention. Wounds determined to be minor should receive local wound care (irrigation, removal of foreign body if superficial), and tetanus prophylaxis. Antibiotics are not required routinely, but their use should be at the discretion of the treating physician. Antibiotics are typically reserved for patients with additional risk factors for wound infection (i.e., tissue devitalization, delay in treatment, or gross contamination).[5] All the patients in our series received prophylactic antibiotics, as most of them had contamination. Patients with potentially serious wounds should be admitted for observation, and if indicated, operative intervention. In our series, the extremities were the most common site involved (47.9%), and only three patients required admission and operative intervention for vascular injuries. The majority of the extremity wounds required only local wound care, careful neurovascular

Table 3. Showing various viscera damaged and surgical procedure done Viscera damaged/Injured site

258

Number of patients

Small gut perforation

Large gut perforation

Mesenteric laceration Splenic hilar injury Urinary bladder laceration Gastric perforation Liver laceration Negative laparotomy Re-exploration Thoracic wounds Vascular injuries in extremities

2 1 1 1 1 4 1 11 3

Ophthalmic procedures Neck wounds

7 2

Surgical procedure Repair in 7, resection anastamosis in 4, and ileostomy in 1 patient. Repair in 2, colostomy in 1 and resection anastamosis in 1 patient Repair in 1 and resection-anastamosis in 1 patient Splenectomy Repair with SPC Primary repair Primary repair Missed rectal perforation ICCT drainage only in 9, and thoracotomy in 2 patients End to end anastamosis in 2 and vascular grafting in 1 patient Carotid a repair in 1, and tracheal repair in 1 patient May覺s - May 2012

Pellet gunfire injuries among agitated mobs in Kashmir

evaluation, and tetanus prophylaxis. This is in accordance with the consequences of non-powder firearm injuries reported previously.[7] Abdominal injury occurred in 72 patients, of whom 20 (27.7%) required laparotomy for signs of peritonitis and/or hemoperitoneum. The small gut was the most common viscera injured. Four patients had a negative laparotomy. One of these patients had postoperative fecal drainage requiring reexploration. We stress the importance of a thorough inspection of all the abdominal viscera in patients sustaining pellet wounds to the abdomen, as small perforations may be missed easily and present with complications. Bond et al.[10] also described in their study that abdominal wounds were frequently associated with visceral injury and multiple perforations, usually of the small bowel, and peritoneal penetration was associated with a more than 80% chance of visceral injury. Thoracic injury occurred in 62 (31.3%) patients, of whom operative intervention was required in 11 (17.7%). Most of these patients were managed with ICCT drainage, while two required a thoracotomy for persistent drainage. No patient in our series had cardiac injury, which could be rapidly fatal. The potential lethal nature of these wounds is reported by Scribano et al.,[7] who evidenced a child sustaining right ventricular penetration and presenting with pericardial tamponade. Others reported similar experiences including cardiac penetration with pellet embolization and aortic penetration with delayed cardiac arrest and death.[11] Although 42 (21.2%) patients in our study had pellet wounds in the head and neck region, only two (4.7%) required operative intervention. None of the patients had intracranial penetration of the pellet, which is also a possibility, with its attendant risk of morbidity and mortality.[12] Ocular and facial injuries, in contrast, occur less frequently, but were seen in 23 (11.6%) patients. Eleven of these patients had penetrating ocular injury, seven required operative intervention, and six (54.5%) had residual functional deficits. This is in accordance with the consequences of non-powder firearm ocular injuries reported previously.[3,6] Deaths attributable to non-powder firearms have been reported in previous case reports. Most of these studies have been done in the pediatric population[4,7,8-12] and are the result of unintentional/sports-related non-powder firearms injuries. The lethal poten-

Cilt - Vol. 18 Say覺 - No. 3

tial of these wounds is difficult to quantify due to the paucity of large reported series; however, this should not diminish the concern in the evaluation of these patients.[7] There were six deaths in this series. Pellet gun (pump action short gun), though considered as a new benign modality (non-lethal weapon) for controlling agitated crowds, is not really benign. It can cause serious injuries with morbidity and mortality. Pellet guns either should not be used to disperse agitated mobs unless extremely necessary, or the personnel using them might be better trained so that the people do not receive close hits. While the pellet wound itself may seem trivial, if not appreciated for the potential for tissue disruption and injuries to the head, chest, and abdomen, there can be catastrophic results. Patients should be evaluated and managed in the same way as those sustaining bullet injuries.

REFERENCES 1. McNeill AM, Annest JL. The ongoing hazard of BB and pellet gun-related injuries in the United States. Ann Emerg Med 1995;26:187-94. 2. Annest JL, Mercy JA, Gibson DR, Ryan GW. National estimates of nonfatal firearm-related injuries. Beyond the tip of the iceberg. JAMA 1995;273:1749-54. 3. Smith D, Wrenn K, Stack LB. The epidemiology and diagnosis of penetrating eye injuries. Acad Emerg Med 2002;9:20913. 4. Fernandez LG, Radhakrishnan J, Gordon RT, Shah MR, Lain KY, Messersmith RN, et al. Thoracic BB injuries in pediatric patients. J Trauma 1995;38:384-9. 5. Wascher RA, Gwinn BC 2nd. Air rifle pellet injury to the heart with retrograde caval migration. J Trauma 1995;38:379-81. 6. Girdler NM. Facial airgun wound. J Trauma 1995;38:3901. 7. Scribano PV, Nance M, Reilly P, Sing RF, Selbst SB.Pediatric nonpowder firearm injuries: outcomes in an urban pediatric setting. Pediatrics 1997;100;e5. 8. Powell EC, Sheehan KM, Christoffel KK. Firearm violence among youth: public health strategies for prevention. Ann Emerg Med 1996;28:204-12. 9. Laraque D; American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Injury risk of nonpowder guns. Pediatrics 2004;114:1357-61. 10. Bond SJ, Schnier GC, Miller FB. Air-powered guns: too much firepower to be a toy. J Trauma 1996;41:674-8. 11. Suchedina AA, Watson DC, Alpert BS, Di Sessa TG. Cardiac injury from an air gun pellet: a case report. Am J Dis Child 1993;147:262-3. 12. Myre LE, Black RE. Serious air gun injuries in children: update of injury statistics and presentation of five cases. Pediatr Emerg Care 1987;3:168-70.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):260-264

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.05863

2011 Van depremi sonrası Van bölgesi Eğitim ve Araştırma Hastanesine başvuran olguların değerlendirilmesi Evaluation of the patients in Van Training and Research Hospital following the 2011 Van earthquake in Turkey Recep DURSUN,1 Cemile Ayşe GÖRMELİ,2 Gökay GÖRMELİ3

AMAÇ

BACKGROUND

23 Ekim 2011 tarihinde Van ilinde deprem meydana geldi. Bu deprem çok büyük yıkıcı bir felaketti ve kitlesel yaralanmalara neden oldu. Burada sunulan tanımlayıcı analizin, yanlız bu çalışma için değil, aynı zamanda daha sonra yaşanabilecek afetler için de bir kaynak olarak kullanılması amaçlanmıştır.

On 23 October 2011, an earthquake occurred in the city of Van, Turkey. This earthquake was an enormous devastating disaster and caused mass casualties. The descriptive analysis presented here serves as a reference not only for the present injury profile but also for future disaster response.

GEREÇ VE YÖNTEM

This is a retrospective study based on the medical records of earthquake victims admitted to Van Training and Research Hospital. The results were compared with the current literature.

Deprem nedeniyle Van Bölge Eğitim ve Araştırma Hastanesine başvuran hastaların ilk 7 günlük kayıtları geriye dönük olarak incelendi. Sonuçlar mevcut literatür ile karşılaştırıldı.  BULGULAR

METHODS

RESULTS

Depremzede 1582 hasta (806 erkek, 776 kadın; ort. yaş 36,9) acil servise başvurdu. Hastaların 301’i yatarak tedavi gördü. Hastaların 84’ü (%28) ortopedi ve travmatoloji, 40’ı (%13) genel cerrahi ve çocuk cerrahisi, 26’sı (%9) göğüs cerrahisi, 34’ü (%11) beyin cerrahisi, 56’sı (%19) iç hastalıkları, 39’u (%13) yoğun bakım, 22’si (%7) ise diğer servislere yatırıldı. Ölenlerin sayısı 60 idi.

1582 earthquake victims (806 male, 776 female, mean age 36.9 years) were admitted to emergency service. 301 of the patients were treated with hospital care in different departments: 84 (27.9%) in orthopedics surgery, 40 (13.2%) in general and pediatric surgery, 26 (9%) in thorax surgery, 34 (11%) in neurosurgery, 56 (19%) in internal medicine, 39 (13%) in the intensive care unit, and 22 (7%) in other departments. The total number of deceased was 60.

SONUÇ

CONCLUSION

Deprem felaketi sonrası mortalite ve morbidite oranını azaltmak için erken ve etkili triyaja önem verilmelidir. Hastalar hastaneye nakledildikten sonra klinik özelliklerine göre tedavi uygulanmalı ve birçok kliniğin birbiriyle uyumlu ve işbirliği içerisinde çalışmaları sağlanmalıdır.

To minimize mortality and morbidity after earthquake disaster, immediate and effective triage should be done, and after the patients are transported to the hospital, individualized treatment should be planned according to the patients’ respective clinical features. Coherent collaboration between many departments is vital.

Anahtar Sözcükler: Deprem, travma, yaralanma profili

Key Words: Earthquake; trauma; injury profile.

Van Bölge Eğitim ve Araştırma Hastanesi, 1Acil Servis Bölümü, 2 Radyoloji Kliniği, 3Ortopedi ve Travmatoloji Kliniği, Van.

Departments of 1Emergency Service, 2Radiology, 3Orthopedics and Traumatology, Van Training and Research Hospital, Van, Turkey.

İletişim (Correspondence): Dr. Gökay Görmeli. Koru Mah., 2580. Sok., Vadikent Sitesi Vahdet Apt. 7/35 Çayyolu, Ankara, Turkey. Tel: +90 - 312 - 240 35 98 e-posta (e-mail): ggormeli@yahoo.com

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2011 Van depremi sonrası Van bölgesi eğitim ve araştırma hastanesine başvuran olguların değerlendirilmesi

Burada sunulan tanımlayıcı analiz, yalnızca mevcut çalışma için değil aynı zamanda daha sonraki deprem felaketi yanıtı için de bir kaynak olarak hizmet etmektedir.

GEREÇ VE YÖNTEM 23 Ekim 2011 yerel saat ile 13:41’de Van’ın 27 km kuzeyinde merkez üssü Tabanlı köyü olan Richter ölçeğine göre 7.2Mw şiddetinde deprem meydana geldi. Resmi rakamlara göre merkezde 61, merkeze bağlı köylerde 66, Erciş ilçesinde ise 477 kişi olmak üzere toplam 604 kişi hayatını kaybetti. Bunun yanında muhtelif yapılarda da farklı derecelerde hasar oluştu. 23 Ekim 2011’de Van’da meydana gelen deprem nedeniyle Van Bölge Eğitim ve Araştırma Hastanesi’ne başvuran hastaların 23-30 Ekim 2011’e kadar olan 7 günlük kayıtları geriye dönük olarak incelendi. Acil servis, ameliyathane, diğer servisler ve morg kayıtları ve Van deprem kriz masasının verileri incelendi. Hastaların yaş, cinsiyet, başvuru zamanları, hastaların yattığı servisler ve bu hastalara yapılan girişim kayıtları incelenerek günlere göre dağılımı yapıldı. BULGULAR Van Bölge Eğitim ve Araştırma Hastanesi’ne 7 gün boyunca 4280 hasta başvurdu. Hastaların 1582’si (%36,9) depreme bağlı yaralanmalarla 2698’i (%64,1) ise deprem dışı nedenlerle başvurdu. Hastaların 1994’ü (%46,5) kadın, 2286’sı (%53,5) erkekti. Orta-

800 Depreme bağlı 700

Deprem dışı nedenlere bağlı

600 500 Sayı

Kitlesel felaketler ani bir olay sonucunda insanların yaralanması ve ölmesi, mal ve mülkün zarar görmesi, bu sırada yerel ilk yardım ve kurtarma kaynaklarının yetersiz kalması, organize toplumsal düzeneklerin yıkılmasıdır.[1,2] Kitlesel felaketler içinde karşımıza en sık çıkan ise depremlerdir. Deprem ülkemizde ve dünyada en çok ölüme neden olan ve sakat bırakan doğal afettir.[3,4] Ülkemizin büyük bölümü 1. derece deprem bölgesinde yer almaktadır. Ancak, pek çok deprem bölgesinde özellikle hareketli fay hatları üzerinde periyodik olarak depremler meydana gelmesine karşın ölüm ve yaralanma oranları değişmemekte, hatta çarpık kentleşme ve depreme dayanıksız binalar, uygunsuz ilk müdahale gibi nedenlerle daha da artmaktadır. [5,6] Bu nedenle de deprem konusundaki bütün verilerin, üzerinde tartışmak ve projeler üretmek üzere toplanması ve yayınlanması gereklidir.

400 300 200 100 0 1

Günler

Şekil 1. Hastaların başvuru günlerine göre dağılımı.

lama yaş 29,6 olarak hesaplandı (Tablo 1). Deprem sonrası ilk 7 gün incelendiğinde depreme nedeniyle 1582, deprem dışı nedenlerle 2698 hasta olmak üzere toplam 4280 hasta başvurusu oldu. Deprem nedeni ile 1. gün 754, 2. gün 492, 3. gün 272, 4. gün 48, 5. gün 10, 6. gün 4 ve 7. gün ise 2 kişi başvurdu. Deprem dışı nedenlerle 1. gün 46, 2. gün 133, 3. gün 340, 4. gün 430, 5. gün 554, 6. gün 580 ve 7. gün 615 kişi başvurdu (Şekil 1). Depremzede hastalar incelendiğinde; 290 hasta acil gözlemde izlendi, 842 hasta gerekli tedavileri yapılarak taburcu edildi. Hastaların 149’u il dışı hastanelere sevk edildi, 301’i ise servislere yatırıldı (Tablo 2). Hastane servislerine yatırılan 301 hastanın 84’ü (%28) ortopedi ve travmatoloji, 40’ı (%13) genel cerrahi ve çocuk cerrahisi, 26’sı (%9) göğüs cerrahisi 34’ü (%11) beyin cerrahisi, 56’sı (%19) dahiliye, 39’u (%13) yoğun bakım ve 22’si (%7) diğer servislere yatırıldı (Şekil 2). Hastanemiz acil servis ve ameliyathanesinde deprem nedeni ile başvuran hastaların 58’ine santral venöz kateterizasyon, 7’sine ezilme sendromu nedeni ile amputasyon ve 81’ine ekstremite travması nedeni ile cerrahi tedavi uygulandı. Hastaların 155’i alçı ve

Tablo 1. Hastanemize başvuran hasta sayıları ve cinsiyet ile ilişkisi Cinsiyet Erkek Kadın

Depreme bağlı yaralanma (Grup1) n (%)

Diğer yaralanmalar (Grup2) n (%)

Toplam

Yaş ortalaması (29,6) 28,8 30,4

1582 (36,9) 806 (50,9) 776 (49,1)

2698 (64,1) 1188 (44) 1510 (56)

4280 (100) 1994 (46,5) 2286 (53,5)

Cilt - Vol. 18 Sayı - No. 3

n (%)

261

Ulus Travma Acil Cerrahi Derg

Tablo 2. Deprem nedeniyle başvuran hastaların acil gözlem, yatış ve sevk durumu

1. gün

2. gün

3. gün

4. gün

5. gün

6. gün

7. gün

Toplam

121 95 355 179

83 35 256 82

33 14 178 26

34 5 36 12

11 0 9 2

5 0 5 0

3 0 3 0

290 149 842 301

Acil gözlem Sevk Taburcu Yatış

atel ile takip edildi. Ezilme sendromu olan hastaların 21’ine, gelişen kompartman sendromu nedeni ile fasyotomi uygulandı (17’sine alt ekstremite fasyotomi, 2’sine üst ekstremite fasyotomi, 2’sine üst ve alt ekstremite fasyotomi). Hemotoraks ve hemopnömotoraks nedeniyle 7 hastaya torakotomi, 25 hastaya da tüp torakostomi uygulandı. İntrakranyal kanama nedeniyle 6 hastaya kraniyotomi, 21 hastaya karın travması nedeniyle laparotomi uygulandı. Hastaların 42’si ezilme yaralanması sonrası bozulan böbrek fonksiyonları nedeniyle diyaliz programına alındı (Tablo 3). Deprem sonrasında Van Bölge Eğitim ve Araştırma Hastanesi’ne ölü olarak gelen veya hastanede yapılan girişimlere rağmen ölenlerin 60 kişi olduğu belirlendi. Ölenlerin 26’sı erkek, 34’ü kadındı. Ölenlerin yalnızca 4’ü (%6,7) 60 yaş üstü, 8’i (%13,3) 10 yaş altı, 7’si (%11,7) 10-19 yaş arası iken, 30’u (%50) 20-40 yaşları arasındaydı. Yaşanan depremler sonrası Van ilinde 33016 bina, 28532 konut, 2240 işyeri ve 8254 ahır olmak üzere toplam 72242 mekan yıkık ve ağır hasarlı olarak tespit edilmiştir. Deprem sonrasında Türkiye’nin birçok ilinden gerek gönüllü gerekse görevlendirme ile gelen sağlık personeli dönüşümlü olarak sağlık hizmetlerini yerine getirmiştir. Yoğun Bakım (%13) Diğer (%7) Ortopedi ve Travmatoloji (%28)

Genel - Çocuk Cerrahisi (%13)

İç Hastalıkları (%19)

Göğüs Cerrahisi (%9) Beyin Cerrahisi (%11)

Şekil 2. Hastanemize yatırılan hastaların servislere göre dağılımı. 262

TARTIŞMA Doğal felaketler son 20 yılda 3 milyondan fazla kişinin ölümüne veya sekel bırakan yaralanmaya, 800 milyondan fazla insanın da hayat şartlarının değişmesine neden olmuştur.[7,8] Yaşam kayıpları ve ekonomik zarar değerlendirildiği zaman deprem bu felaketlerin içinde en yıkıcı felaket olarak ön plana çıkmaktadır. [9,10] Ülkemiz deprem açısından riskli bir bölgedir ancak buna rağmen fay hatları üzerine kurulu kentler, çarpık kentleşme ve depreme dayanıksız ve denetimsiz yapılan binalar ölü ve yaralı sayısını artırmaktadır. 1908-1995 yılları arasında 100,000 kişi deprem nedeni ile hayatını kaybetmiştir. Deprem felaketine eklenen kötü felaket organizasyonu da depreme bağlı kayıpları artırmaktadır.[6,11] 23 Ekim 2011’de Van’da meydana gelen 7,2 şiddetindeki deprem 604 kişinin ölümüne neden olmuştur. 72242 mekan ise yıkık ve ağır hasarlı olarak tespit edilmiştir. Hasarlı ve yıkık bina sayısının fazla oluşu binaların depreme dayanıklı olarak inşa edilmediğini ve bu nedenle can kaybının fazla olduğunu düşündürmektedir. Deprem sonrası hasta başvurusunun artması ile oluşan triyaj ve hasta kayıt problemi, hastalara müdahale edilebilecek alan yetersizliği, iletişim sorunları, depremzede olmayan hastaların artmış müracaatı, hasta transportundaki problemler acil servislerde ilk 24-48 saatte yaşanan sorunların başında gelmektedir.[12-17] Hastanemizin acil servisinde de benzer sorunlar ile karşılaşılmış, özellikle ilk saatlerde artan hasta yükü nedeni ile triyaj problemi yaşanmıştır. Hastaneye depremzede olmayan hastaların artmış başvuruları da triyaj probleminin yaşanmasında önemli bir nedendir. Ancak hızla organize olan ekipler ile bu sorun kısa sürede aşılmıştır. Hastanemize başvuran hastalarda kayıt problemi yaşanmamıştır. Deprem sonrası servislere yatışlar incelendiğinde Ortopedi ve Travmatoloji Kliniği ilk sıradadır (%28). Marmara depremi sonrası Uludağ Üniversitesi’nde takip edilen 330 yaralının 147’si Ortopedi ve Travmatoloji Kliniği’ne yatırılırken diğer hastalar genel cerrahi, plastik cerrahi ve göğüs kalp damar cerrahisi servisine yatırılmıştır.[18] Marmara depremi sonrası Kartal Eğitim ve Araştırma Hastanesi’nde yatan hastaların büyük çoğunluğunun ortopedi ve travmatoloji servisinde yattığı ve 160 ameliyatın 96’sının ortopedik nedenMayıs - May 2012

2011 Van depremi sonrası Van bölgesi eğitim ve araştırma hastanesine başvuran olguların değerlendirilmesi

Tablo 3. Hastanemizin acil servisi ve ameliyathanesinde yapılan girişim ve ameliyatlar

Günler 1., 2., 3.

4., 5.

6., 7.

Toplam

17 4 47 5 85 16 1 15 10

38 2 30 12 54 11 3 4 26

3 1 4 4 16 5 2 2 6

58 7 81 21 155 32 6 21 42

Santral venöz kateterizasyon Amputasyon Redüksiyon - Fiksasyon Fasyotomi Alçı - Atel Tüp torakostomi - Torakotomi Kraniyotomi Laparatomi Hemodiyaliz

lerle yapıldığı, diğer ameliyatların ise laparotomi, tüp torakostomi, kafa ve yüz kemikleri fiksasyonu olduğu gözlenmiştir.[12] Hindistandaki Gujarat depreminde de 534 yaralının 234’ünde (%51) ortopedik yaralanmalar ön plandadır.[19] Literatürle uyumlu olarak Van depreminde de olguların çoğunu Ortopedi ve Travmatoloji ile ilgili hastalar oluşturmaktadır.

önemlidir. Hastalara mevcut medikal tedavinin yapılması, yakın dolaşım takibi, gelişebilecek rabdomiyoliz ve akut böbrek yetersizliği açısından gözlem önemlidir. Gelişebilecek kompartman sendromu açısından dikkatli olunmalı ve gerekli cerrahi tedaviler (fasyotomi veya amputasyon) yapıldıktan sonra da medikal tedavide dikkatli olunmalıdır.

Deprem sonrası ölümler incelendiğinde ölümlerin %50 sinin 20-40 yaşları arasındaki genç nüfustan olduğu dikkati çekmektedir. Sultandağı depreminde ölümlerin çoğu 65 yaş üzeri gruptadır.[20] 65 yaş üzerindeki insanların deprem sonrası ölüm riskinin 2,9 kat daha fazla olduğu belirtilmiştir.[21] Yaşanan Van depreminde 20-40 yaş arası olguların fazlalığı yaşlı nüfusun daha çok köylerde yaşaması ancak genç nüfusun ise özellikle yıkılmış olan çok katlı binalarda ikamet etmesine bağlı olabilir. Kaldıkları binaların yıkılması sonucu ölen öğretmenler de bu yaş grubunda yer almaktadır. Ayrıca depremin hafta sonu olması ve gece olmaması nedeni ile binaların içinde olan insanların daha az sayıda olması olası can kayıplarının daha az olmasına neden olmuştur.

Sonuç olarak; dileğimiz bu tür felaketlerin hiç yaşanmamasıdır ancak 1. derece deprem kuşağındaki ülkemizde Van depremi yaşadığımız son deprem olmayacaktır. Bu nedenle uygun bir ön hazırlık mutlaka yapılmalı, felaket sonrası saha ile hastane, hastane içi ve hastaneler arası iletişim ve etkili triyaja önem verilmeli, tüm sağlık personellerinin bu tür felaketlere hazırlıklı olması için gerekli tatbikatlar yapılmalı ve hasta kayıtları her türlü zorluğa rağmen mutlaka eksiksiz tutulmalıdır. Etkili sağlık organizasyonu felaketin zararlarının en alt düzeyde tutulmasında yardımcı olacaktır.

Deprem sonrası karşılaşılan önemli sorunlardan biri de ezilme yaralanması ve sonucunda gelişen kompartman sendromudur. 1988 Ermenistan depreminde 600, 1995 Hanshin-Awaji depreminde 372, 1999 Marmara depreminde Uludağ Üniversitesi’ne başvuran hastalardan 110 ve 2008’de Çin Wenchuan’da meydana gelen depremde ise 202 kişi ezilme yaralanması ile acil servise getirilmiştir.[18,22-25] Hastanemize başvuran hastalardan ezilme yaralanması nedeni ile başvuranların sayısı 46’dır. Bunlardan 21’ine gelişen kompartman sendromu nedeni ile fasyotomi uygulanmış, 7 sine amputasyon uygulanmıştır. Diğer 18 hasta ise medikal tedavi ile takip edilmiştir. Yaralanma bölgesi alt ekstremitede olan hasta sayısı 35, üst ekstremitede olan hasta sayısı 6, alt ve üst ekstremitede olan olgu sayısı ise 6’dır. Mevcut ezilme yaralanması olan hastalara multidisipliner yaklaşım çok Cilt - Vol. 18 Sayı - No. 3

KAYNAKLAR 1. al-Madhari AF, Keller AZ. Review of disaster definitions. Prehosp Disaster Med 1997;12:17-21. 2. Schwab MT, Noji EK. Disaster planning and operation in the emergency department. In: Scwartz GR, editor. Principles and practise of emergency medicine. Baltimore: Williams and Wilkins; 1999. p. 1804-21. 3. Taviloğlu K. Felaketlerde yaralılara yaklaşım ve hekimlik hizmetleri. İçinde: Depremlerde uzmanlık hizmetleri. İstanbul Tabip Odası Yayınları, İstanbul: Ekspres Ofset; 2000. s. 1-36. 4. Çakmakçı M. Felakette sağlık düzeni. Bilim Teknik Dergisi 1999;31:11-7. 5. Atasoy S, Ziyalar N, Alsancak B. Earthquake epidemiology in Turkey: 1900-1995. (Poster) American Academy of Forensic Sciences 51. Annual Meeting. Orlando, Florida, USA, February 15-20, 1999. 6. Taviloğlu K. 17 Ağustos 1999 Marmara depreminin ardından: Felaket organizasyonunda neredeyiz? Ulusal Cerrahi Derg 1999;15:333-42. 7. Schultz CH, Koenig KL, Noji EK. A medical disaster response to reduce immediate mortality after an earthquake. N Engl J Med 1996;334:438-44. 8. Peek-Asa C, Kraus JF, Bourque LB, Vimalachandra D, Yu J, 263

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Abrams J. Fatal and hospitalized injuries resulting from the 1994 Northridge earthquake. Int J Epidemiol 1998;27:45965. 9. Mahoney LE, Reutershan TP. Catastrophic disasters and the design of disaster medical care systems. Ann Emerg Med 1987;16:1085-91. 10. Building Seismic Safety Council. Seismic considerations: Health care facilities. Washington DC: Federal Emergency Management Agency Publication, FEMA 150; 1990. 11. Atasoy S, Ziyalar N, Alsancak B. Earthquake epidemiology in Turkey: 1900-1995. (Poster) American Academy of Forensic Sciences 51. Annual Meeting. Orlando, Florida, USA, 1999 February: 15-20. 12. Kurt N, Küçük HF, Celik G, Demirhan R, Gül O, Altaca G. Evaluation of patients wounded in the 17 August 1999 Marmara earthquake. Ulus Travma Derg 2001;7:49-51. 13. Alkan N, Elmas I, Karakuş M, Akkay E. Problems encountered during natural disasters: a questionnaire study. Ulus Travma Derg 2001;7:195-9. 14. Ishii N, Nakayama S. Emergency medical care following the great Hanshin-Awaji earthquake: practices and proposals (a report from a university hospital located in the damaged region). Kobe J Med Sci 1996;42:173-86. 15. Yamauchi K, Mizuno S, Xu Z. Disaster-readiness of medical facilities in Aichi Prefecture. Nagoya J Med Sci 1996;59:1218. 16. Haynes BE, Freeman C, Rubin JL, Koehler GA, Enriquez SM, Smiley DR. Medical response to catastrophic events: California’s planning and the Loma Prieta earthquake. Ann Emerg Med 1992;21:368-74. 17. Bugrov SA, Litovchenko VV, Golovchits VN. The use of aviation transport in providing medical care to the victims in

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an earthquake focus. Voen Med Zh 1991;9:54-7. 18. Bulut M, Turanoğlu G, Armağan E, Akköse S, Ozgüç H, Tokyay R. The analysis of traumatized patients who were admitted to the Uludag University Medical School Hospital after the Marmara earthquake. Ulus Travma Derg 2001;7:262-6. 19. Phalkey R, Reinhardt JD, Marx M. Injury epidemiology after the 2001 Gujarat earthquake in India: a retrospective analysis of injuries treated at a rural hospital in the Kutch district immediately after the disaster. Glob Health Action 2011;4:7196. 20. Akbulut G, Yilmaz S, Polat C, Sözen M, Leblebicioğlu M, Dilek ON. Afyon Sultandagi earthquake. Ulus Travma Acil Cerrahi Derg 2003;9:189-93. 21. Peek-Asa C, Ramirez M, Seligson H, Shoaf K. Seismic, structural, and individual factors associated with earthquake related injury. Inj Prev 2003;9:62-6. 22. Oda J, Tanaka H, Yoshioka T, Iwai A, Yamamura H, Ishikawa K, et al. Analysis of 372 patients with Crush syndrome caused by the Hanshin-Awaji earthquake. J Trauma 1997;42:470-6. 23. Shimazu T, Yoshioka T, Nakata Y, Ishikawa K, Mizushima Y, Morimoto F, et al. Fluid resuscitation and systemic complications in crush syndrome: 14 Hanshin-Awaji earthquake patients. J Trauma 1997;42:641-6. 24. Oda Y, Shindoh M, Yukioka H, Nishi S, Fujimori M, Asada A. Crush syndrome sustained in the 1995 Kobe, Japan, earthquake; treatment and outcome. Ann Emerg Med 1997;30:507-12. 25. Quan Y, Pan X, Deng S, Lu S, Tao S, Zhou J, et al. Features of crush injury in Wenchuan earthquake and the corresponding operational methods. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2009;23:549-51.

Mayıs - May 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):265-267

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.47587

Penetrating head trauma with four nails: an extremely rare case Dört adet çivi ile çok nadir bir penetran kafa travması olgusu Lutfü ARICI,1 Bekir AKGÜN,1 Metin KAPLAN,1 İlhan YILMAZ2

We present a rare case of self-inflicted penetrating head trauma by a 34-year-old male who hammered four nails into his own head; he had been diagnosed with schizophrenia seven years before.  On the physical examination, four nails were observed in the hairy scalp that had been driven into the cranium in the right temporal and parietal areas of the head. No cerebrospinal fluid fistulas were present. On the neurological examination, no motor or sensory deficits were present. The Glasgow Coma Scale was 15. On direct skull X-ray and cranial computerized tomography (CT), the nails were seen to be approximately 10 cm long and extending in various directions. No injury was observed in the main vasculature on CT angiography. Under general anesthesia, two nails in the right temporal area were removed by extraction, and the other two nails in the right parietal area were removed through a mini craniotomy. In areas such as the temporal area where the bone is thin, nails can be removed by extraction. However, in areas like the parietal bone where the bone is thick, removal of the nails using this method may not always be possible.

Yedi yıl önce şizofreni tanısı almış, 34 yaşındaki erkek hastanın kendi kafasına 4 adet çivi çakmasıyla gelişen nadir bir penetran kafa travması olgusu sunuldu. Fiziksel incelemede kafasının sağ temporal ve paryetal bölgesinde saçlı deri içerisinde kraniyuma çakılı 4 adet çivi vardı. Beyin omurilik sıvısı fistülü yoktu. Hastanın nörolojik incelemesinde motor ve duyu defisiti yoktu. Glasgow koma skoru 15 idi. Direkt kafa grafisinde ve beyin bilgisayarlı tomografisinde (BT) çivilerin yaklaşık 10 cm uzunluğunda olduğu ve değişik yönlere uzandığı görüldü. BT anjiyografisinde büyük vasküler yapılarda yaralanma yoktu. Genel anestezi altında sağ temporal bölgede olan 2 çivi direkt çekilerek, sağ paryetal bölgede olan 2 çivi ise mini kraniyotomiler ile çıkarıldı. Temporal bölge gibi kemiğin ince olduğu alanlarda çivi direkt çekilip çıkarılabilir. Ancak paryetal kemik gibi kemiğin kalın olduğu bölgelerde bu yöntemle çivilerin çıkarılması her zaman mümkün olmayabilir.

Key Words: Nail; penetrating head trauma; schizophrenia.

Anahtar Sözcükler: Çivi; penetran kafa travması; şizofreni

The great majority of penetrating head traumas due to misuse of nails are observed in schizophrenic patients and patients with major depression. The risk of death due to these injuries is 40%. The major causes of death are injuries of the main vasculature and infections.[1-5] Penetrating head traumas caused by nails are usually inflicted upon others.[6] Our case is interesting since the penetrating head trauma with nails was selfinflicted.

examined in the emergency room. He had been diagnosed with schizophrenia seven years before. It was ascertained that he had not received regular treatment in the last few years.

CASE REPORT A 34-year-old male patient, who was presented after having hammered four nails into his own head, was

Optimal evaluation could not be performed on the cerebral computerized tomography (CT) due to the presence of artefacts caused by the nails. However,

Department of Neurosurgery, Firat University Hospital, Elazig; Department of Neurosurgery, Mus State Hospital, Mus, Turkey.

1 2

On the neurological examination, there was no loss of consciousness or lateralization findings, and his relatives did not report seizures. The Glasgow Coma Scale was 15. Four nails were observed on the skull X-ray (Fig. 1a).

Fırat Üniversitesi Hastanesi, Nöroşirürji Kliniği, Elazığ; 2 Muş Devlet Hastanesi, Nöroşirürji Kliniği, Muş.

Correspondence (İletişim): Lutfü Arici, M.D. Fırat Universitesi Hastanesi, Nöroşirurji Kliniği, 23100 Elazığ, Turkey. Tel: +90 - 424 - 233 3 555 / 2651 e-mail (e-posta): lutfuarici@ymail.com

265

Ulus Travma Acil Cerrahi Derg

according to the observations, no serious parenchymal lesion was detected (Fig. 1b). Three-dimensional cranial CT imaging demonstrated that the nails had penetrated into the cranium (Fig. 1c). No vascular injury was observed on the preoperative cerebral CT angiography (Fig. 1d). The patient was operated under general anesthesia. The two nails in the right temporal area were pulled

out directly after a mini scalp incision. The nails on the right parietal area could not be extracted, so a mini craniotomy was performed around the nails. The defect in the dura mater in the region where the nails were extracted directly was too small for surgical repair; these regions were covered by Spongostan. In the mini craniotomy regions, we performed primary duraplasty before covering with Spongostan. In all of

(b) (a)

(d)

(c)

(e)

Fig. 1. (a) Four nails penetrating the cranium are observed on direct skull X-ray. (b) Dense artefact caused by the nails can be observed on cerebral CT. (c) Nails penetrating into the cranium can be observed on three-dimensional (3D) cranial CT. (d) No vascular injury is observed on the preoperative cerebral CT angiography. (e) No serious pathological lesions other than millimetric pneumocephaly are observed on the follow-up cerebral CT. 266

May覺s - May 2012

Penetrating head trauma with four nails

the surgical areas, skin and subcutaneous tissues were sutured tightly, so no cerebrospinal fistulas were observed. No pathological lesions other than millimetric areas of pneumocephaly were observed on the followup cerebral CTs in the postoperative period (Fig. 1e). We followed the patient postoperatively for five days in the neurosurgery clinic. After this management and in view of the patientâ&#x20AC;&#x2122;s good general condition, no abnormal findings detected on the neurological examination, and the cleanness of the wounds, his psychiatric disease was followed in a psychiatry clinic for continuation of his required treatment. A specially equipped mental health hospital was recommended during the follow-up in light of the risk of injury to himself or his relatives. Unfortunately, despite all attempts, he did not present for late postoperative follow-ups. Thus, long-term imagings (CT, magnetic resonance [MR] or MR-angiography) were not performed. No complaints were conveyed by the patient or his relatives by telephone.

DISCUSSION Nails are an easily accessible material with highly penetrant and powerful drilling properties.[1,4] Penetrating skull and brain injuries are observed rarely, constituting 0.4% of all head traumas.[7] Injuries with nails constitute 33.3% of this group. Injuries that occur in psychiatric disorders constitute 66.7%, and are usually inflicted upon another individual by the person with the psychiatric disorder.[6] This condition has been observed frequently especially in schizophrenia and major depressive disorder.[1-5] Intracerebral hematoma is one of the most important causes of mortality in strongly penetrant head traumas such as those caused by nails. These are usually rare and constitute less than 1% of wide intracranial aneurysm series and can be multiple.[8] Traumatic pseudoaneurysms usually rupture in the third week of the post-traumatic period and are mortal in 50%.[9,10] Pseudoaneurysms can develop in hours to years after penetrating traumas, with an average time to development of two to three weeks.[9] Pseudoaneurysms due to trauma can be demonstrated in the early preoperative period and between the fourth and seventh postoperative days.[2,3,11] No vascular injury was detected on the preoperative cerebral CT angiography in our patient. Intracranial abscess,[12] meningitis[1-3,5] and seizures[13] are among complications that have been reported in the literature to occur following penetrating head traumas. No such complications developed in the postoperative follow-up of our patient. There are two known methods in the surgical treatment. These include the application of emergency cra-

Cilt - Vol. 18 SayÄą - No. 3

niotomy under general anesthesia,[14] and direct extraction of the nails from the skull under local anesthesia. [3] In our patient, the nails in the temporal area were extracted under general anesthesia. Mini craniotomy was performed for removal of the nails in the parietal area. Since the parietal bone is thick, extraction of the nails is not as easy as in the temporal area. Powerful manipulations and manipulations in various directions can injure the cerebral parenchyme and augment the existing injury. Mini craniotomy should therefore be chosen in such cases. In multiple penetrant injuries with nails extending in various directions, a single craniotomy to manipulate all of the nails can increase the extent of the parenchymal injury. For this reason, separate mini craniotomies should be performed and the nail should be pulled out together with the bone in accordance with the penetration angle of the nail.

REFERENCES 1. Musa BS, Simpson BA, Hatfield RH. Recurrent self-inflicted craniocerebral injury: case report and review of the literature. Br J Neurosurg 1997;11:564-9. 2. Rezai AR, Lee M, Kite C, Smyth D, Jafar JJ. Traumatic posterior cerebral artery aneurysm secondary to an intracranial nail: case report. Surg Neurol 1994;42:312-5. 3. Sakuta Y, Arai S. Penetrating brain injury and traumatic aneurysm caused by a nail gun. No Shinkei Geka 1997;25:35762. [Abstract] 4. Shenoy SN, Raja A. Unusual self-inflicted penetrating craniocerebral injury by a nail. Neurol India 2003;51:4113. 5. Viswanathan R, MacArthur DC, Whittle IR. Nail gun injury to the brain: an unusual case of suicide. Scott Med J 1994;39:83. 6. Litvack ZN, Hunt MA, Weinstein JS, West GA. Self-inflicted nail-gun injury with 12 cranial penetrations and associated cerebral trauma. Case report and review of the literature. J Neurosurg 2006;104:828-34. 7. Gennarelli TA, Champion HR, Sacco WJ, Copes WS, Alves WM. Mortality of patients with head injury and extracranial injury treated in trauma centers. J Trauma 1989;29:1193202. 8. Haddad FS, Haddad GF, Taha J. Traumatic intracranial aneurysms caused by missiles: their presentation and management. Neurosurgery 1991;28:1-7. 9. Holmes B, Harbaugh RE. Traumatic intracranial aneurysms: a contemporary review. J Trauma 1993;35:855-60. 10. Voelker JL, Ortiz O. Delayed deterioration after head trauma due to traumatic aneurysm. W V Med J 1997;93:317-9. 11. Larson PS, Reisner A, Morassutti DJ, Abdulhadi B, Harpring JE. Traumatic intracranial aneurysms. Neurosurg Focus 2000;8:4. 12. Horner FA, Berry RG, Frantz M: Broken pencil points as a cause of brain abscess. N Engl J Med 1964;271:342-45. 13. Aulino JM, Gyure KA, Morton A, Cole JW. Temporal lobe intraparenchymal retained foreign body from remote orbital trauma. AJNR Am J Neuroradiol 2005;26:1855-7. 14. Rahman NU, Jamjoom A, Jamjoom ZA, Abu el-Asrar A. Orbito-cranial injury caused by penetrating metallic foreign bodies: report of two cases. Int Ophthalmol 1997;21:13-7.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):268-270

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.69376

Closed total (pan-talar) dislocation of the talus with delayed presentation: a rare case report and review of the literature Geç bulgu veren kapalı total (pantalar) talus çıkığı: Nadir bir olgu sunumu ve literatür değerlendirmesi Rajesh DULANI, Sandeep SHRIVASTAVA, Sameer DWIDMUTHE, Ravi PUROHIT Major fractures and dislocation of the talus and peritalar joint are uncommon. We present here a very rare case of injury with delayed presentation of closed total talus dislocation with fractured medial malleolus and posterior talar tubercle fracture. This report analyzes previous reports in the literature and the proposed treatment.

Talus ve peritalar eklemin majör kırık ve çıkıkları nadirdir. Bu yazıda, gecikmeli başvuran, kapalı total talus çıkığı, mediyal malleol kırığı ve posterior talar tüberkül kırığı yaralanmalı, nadir görülen olgu sunuldu. Bu yazıda, literatürdeki daha önceki sunum ve önerilen tedavi değerlendirildi.

Key Words: Total talus dislocation; delayed presentation; closed injury.

Anahtar Sözcükler: Total talus çıkığı; gecikmeli başvuru; kapalı yaralanma.

Major fractures and dislocation of the talus and peritalar joint are uncommon. The incidence of fracture of the talus ranges from 0.1% to 0.85% of all fractures,[1] and 6% of injuries affect the ankle and foot. [2] Total dislocation of the talus is an extremely rare injury. There are few reports of total dislocation of the talus in the literature, with the majority being an open injury. There are two major series of nine cases each by Detenbeck et al.[3] and Coltart[2] of total talar dislocation, with the majority being open type.

ing over the left foot and ankle and varus deformity of the forefoot (Fig. 1). There was no breach in the skin above the ankle and foot. There was no associated injury. On palpation, bony swelling was present below the lateral malleolus with hollowness below the medial malleolus. The dorsalis-pedis and posterior tibial pulsations were palpated as normal. There was no hypoesthesia over the foot or ankle. There was no sign of hyper- laxity of other joints. On radiographic examination of the ankle and foot (Figs. 2a-c), the talus was found completely dislocated from the ankle and subtalar and talonavicular joints. The talus lay horizontally just below the lateral malleolus, and there was associated fracture of the medial malleolus and posterior tubercle of the talus.

We present here a very rare case of injury with delayed presentation of closed total talus dislocation with fractured medial malleolus and posterior talar tubercle fracture. This report analyzes previous reports in the literature and the proposed treatment.

CASE REPORT A 19-year-old healthy male, with height of 1.75 m and weight of 80 kg, presented in our outpatient department with pain, swelling and deformity of his left ankle for three days after a fall from a height of about 4.57 m. The physical examination revealed swell-

The patient was taken to emergency for reduction of the dislocation. Medial exposure was used. The talus was approached through the window of the fractured medial malleolus, and was found beneath the lateral malleolus with no soft tissue attachment. Reduction was achieved by traction through a temporary transverse Steinman pin placed through the calcane-

Department of Orthopaedics J N Medical College, Datta Meghe Institute of Medical Science Deemed University, Sawangi(m), Wardha, Maharastra, India.

Deemed Üniversitesi Datta Meghe Tıp Bilimleri Enstitüsü, J N Tıp Koleji, Sawangi(m), Wardha, Maharastra, Hindistan.

Correspondence (İletişim): Rajesh Dulani, M.D. M2 Ga Meghdhootam Jnmc Sawangi(m) Wardha, India. Tel: +091 - 7152 - 287763 e-mail (e-posta): rajeshkdulani@rediffmail.com

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Closed total (pan-talar) dislocation of the talus with delayed presentation

(a) Fig. 1. Preoperative clinical photograph of the foot showing slight forefoot varus and edema. (Color figures can be viewed in the online issue, which is available at www.tjtes.org).

um. The medial malleolus was fixed with a Kirschner (K)-wire. A percutaneous K-wire from the heel was used to stabilize the subtalar and ankle joints. Similarly, a percutaneous K-wire was used to stabilize the talonavicular joint (Fig. 3). After removing the sutures, a non-weight-bearing below-knee cast was applied for six weeks. After six weeks, the cast and percutaneous K-wires were removed. The patient’s left ankle was kept in non-weight-bearing with gradual mobilization for another six weeks. The patient was reviewed after six months and one year, and was found to have 10º and 40º of pain-free ankle dorsiflexion and plantarflexion, respectively. Radiographic examination showed no sign of avascular necrosis of the talus (Fig. 4).

DISCUSSION Total dislocation of the talus has been reported as 0.06% of all dislocations and 2% of all talar fractures.[4]

(b)

(c) Fig. 2. (a) Anteroposterior X-ray of the ankle showing the talus below the lateral malleolus. The lateral X-ray of the ankle shows complete dislocation of the talus from the ankle and subtalar joint and the talus anterior to the lateral malleolus. (b) Anteroposterior (right) and (c) oblique (left) X-ray of the foot of the same patient showing complete dislocation of the talonavicular joint.

Fig. 3. Postoperative lateral X-ray showing the reduced ankle with percutaneous K-wire fixed for the talonavicular joint and subtalar and ankle joints. Cilt - Vol. 18 Sayı - No. 3

Fabricus first described complete dislocation of the talus treated by talectomy in 1608.[5] One of the largest series of 228 talus injuries was published by Coltart,[2] who was the first to propose a concise classification of talus injury as fractures, fracture - dislocations, dislocation, miscellaneous injuries, and subtalar dislocation. In this series, nine cases of total dislocation of the talus were reported and most were open type. In the report by Detenbeck et al.,[3] seven of nine cases of total dislocation of the talus were of open type. One of 269

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ankle, and forceful adduction and inversion of the foot then leads the talus to rotate 90° on its vertical and longitudinal axes. The foot itself the recoils below tibia but the talus is let displaced in its rotated position outside and front ankle joint.[2] In a review of 42 cases of total dislocation of the talus by Leitner,[8] subtalar dislocation was considered as a preliminary stage in total dislocation of the talus. Total dislocation of the talus results from excessive supination or excessive pronation, and accordingly, the dislocated talus lies either laterally or medially. A first-degree supination injury results in medial subtalar dislocation, a second-degree supination results in medial subtalar dislocation with talocrural subluxation, and a third-degree supination injury results in total lateral dislocation of the talus.

Fig. 4. One year after reduction, lateral X-ray of the ankle shows well-maintained density of the talus.

the closed total dislocations was with fracture of the neck and body of the talus and another was with comminuted fracture of the body of the talus. In a review of 58 major injuries of the talus by Kenwright et al.,[5] there were two cases of total dislocation of the talus. The authors reported that in both cases, the talus was displaced on to the dorsolateral aspect of the foot, but there is no report as to whether total dislocation was of closed or open type. In a report by Newcomb et al.,[6] a 45-year-old man with head injury had complete dislocation of the talus of closed type. He was treated within one hour of injury. Closed reduction was possible with traction by means of a K-wire through the calcaneum and countertraction with a Steinman pin through the proximal portion of the tibia. In a report by Segal et al.,[7] a 50-year-old man was shown on initial roentgenogram to have a dislocation of the ankle with the talus displaced anteriorly. Stress roentgenogram revealed unrecognized talonavicular and talocalcaneal subluxation when the foot was in internal rotation with varus stress applied to its fore part. There was no frank dislocation of the talonavicular or subtalar joint in this case. Normally, the talus is held in the ankle mortise by its own shape assisted by attachment of the neck and head, the talocalcaneal ligament, the strong posterior talofibular ligament, and the posterior and deep fibers of the medial ligament of the ankle.[2] The mechanism for total dislocation of the talus as suggested by Clotart is extreme plantar flexion and inversion of the foot. He suggested that extreme plantar flexion first leads to complete forward dislocation of the whole foot at the 270

The majority of total talar dislocations are open injuries[2,3,4,9] because of the severity of trauma. In the majority of cases, the talus has dislocated forward and laterally so that it lies in front of the lateral malleolus and is rotated 90° in both its vertical and longitudinal axis. [2,3,5,6,8] In our case, the talus lay in front of the lateral malleolus but was not rotated on any axis; moreover, the patient presented three days after the injury. Treatment recommendations in the case of total dislocation of the talus vary. Some authors recommend, because of possible infection, damage to the talar vascularity and consequent avascular necrosis, primary talectomy with tibiocalcaneal arthrodesis, even in the case of a closed talar dislocation.[3] However, primary talectomy affects hindfoot function and limits subsequent reconstructive options.[9,10] In our opinion, relocation of the talus should be recommended in closed total dislocation of the talus, even in the case of delayed presentation, as in our case.

REFERENCES 1. Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg 2001;9:114-27. 2. Coltart WD. Aviator’s astragalus. J Bone Joint Surg Br 1952;34-B:545-66. 3. Detenbeck LC, Kelly PJ. Total dislocation of the talus. J Bone Joint Surg Am 1969;51:283-8. 4. Gulan G, Sestan B, Jotanovic Z, Madarevic T, Mikacevic M, Ravlic-Gulan J, et al. Open total talar dislocation with extrusion (missing talus). Coll Antropol 2009;33:669-72. 5. Kenwright J, Taylor RG. Major injuries of the talus. J Bone Joint Surg Br 1970;52:36-48. 6. Newcomb WJ, Brav EA. Complete dislocation of the talus. J Bone Joint Surg Am 1948;30A:872-4. 7. Segal D, Wasilewski S. Total dislocation of the talus. Case report. J Bone Joint Surg Am 1980;62:1370-2. 8. Leitner B. The mechanism of total dislocation of the talus. J Bone Joint Surg Am 1955;37-A:89-95. 9. Assal M, Stern R. Total extrusion of the talus. A case report. J Bone Joint Surg Am 2004;86-A:2726-31. 10. Smith CS, Nork SE, Sangeorzan BJ. The extruded talus: results of reimplantation. J Bone Joint Surg Am 2006;88:241824. Mayıs - May 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):271-273

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.13284

Pyloric atresia associated with epidermolysis bullosa: report of two cases and review of the literature Pilor atrezisi ve epidermolizis bülloza birlikteliği: İki olgu sunumu ve literatür derlemesi Ünal BIÇAKCI,1 Burak TANDER,1 Fatma ÇAKMAK ÇELİK,2 Ender ARITÜRK,1 Rıza RIZALAR1

The coexistence of pyloric atresia (PA) and epidermolysis bullosa (EB) is a rare but well-known surgical emergency in neonates. PA/EB is described by the association of atresia of the pylorus and bullous lesions on the skin. Ninetyone cases have been reported in the literature to date. We present two new cases and evaluate the association of PA/ EB, its etiopathogenesis and the clinical properties. Case 1:  A three-day-old female presented with nonbilious vomiting and bullous lesions 2-3 cm in diameter on the extremities. Abdominal X-ray showed a single air-fluid level in the left upper quadrant. At laparotomy, we found PA and performed a pyloro-pylorostomy. The patient died due to sepsis complication of EB two months after surgery. Case 2:  A two-day-old male presented with severe dermal bullous lesions on the trunk, neck and extremities. His stomach was dilated and there was no gas distally. We found PA and performed gastroduodenostomy. Initially, he tolerated the feeding well, but he died due to severe sepsis on the postoperative 23rd day. Almost all neonates born with the PA/EB result in a fatal outcome in the first few years. The complications related to EB are usually the cause of death. Even after successful repair of PA, skin lesions lead to death due to infection.

Pilorik atrezi (PA) ve epidermolizis bülloza (EB) birlikteliği genetik etyolojisi iyi bilinen fakat ender rastlanılan yenidoğanın acil cerrahi hastalığıdır. PA/EB, pilor atrezisi ile cilt ve mukozalardaki bülloz lezyonların beraberliği olarak tariflenir. Literatürde bugüne dek toplam 91 olgu bildirilmiştir. Bu yazıda iki yeni olgu sunuldu, literatür taraması yapıldı. Olgu 1: Üç günlük hasta safrasız kusma ve ekstremitelerde 2-3 cm çapında bülloz lezyonlarla başvurdu. Karın grafisinide sol üst kadranda hava-sıvı seviyesi vardı. Laparotomide pilor atrezisi saptanarak piloropilorostomi uygulandı. Sorunsuz taburcu edilen hasta iki ay EB’ye bağlı ağır sepsisten kaybedildi. Olgu 2:  İki günlük hasta, boyunda, diz altında, ön yüzde, el sırtında ve sol dirsek üstünde yaygın cilt lezyonları mevcuttu. Karın grafisinde, dilate mide ve distalinde gaz yokluğu dikkati çekti. Pilor atrezisi ön tanısı ile ameliyat edilerek gastroduodenostomi uygulandı. Başlangıçta oral beslenmeyi iyi tolere eden hasta ameliyat sonrası 23’üncü cilt lezyonlarına bağlı ağır sepsis nedeniyle kaybedildi. PA/EB tanısı alan hastaların hemen hemen hepsi ilk birkaç yıl içinde kaybedilmektedir. EB’den kaynaklanan komplikasyonlar ölümlerin en yaygın nedenidir. Başarılı PA ameliyatlarından sonra bile, EB’ye bağlı cilt lezyonları, enfeksiyon ve metabolik problemlere yol açarak, ölümleri neredeyse kaçınılmaz hale getirmektedir.

Key Words: Epidermolysis bullosa; Carmi syndrome; pyloric atresia.

Anahtar Sözcükler: Epidermolizis bülloza; Carmi sendromu; pilor atrezisi.

The association of pyloric atresia (PA) and epidermolysis bullosa (EB) is very rare, but is a life-threatening emergency in neonates. Its genetic background is well defined.[1,2] Surgical intervention for PA is effective only for short-term survival. Long-term outcome of PA/EB is almost always poor and most patients are

lost due to complications related to EB. Ninety-one cases of this rare syndrome have been reported in the literature thus far.[3,4]

Departments of 1Pediatric Surgery, 2Neonatology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey.

Ondokuz Mayıs Üniversitesi, Tıp Fakültesi, 1Çocuk Cerrahisi Anabilim Dalı, 2Neonatoloji Bilim Dalı, Samsun.

We report here two additional cases of PA/EB and review the related literature.

Correspondence (İletişim): Burak Tander, M.D. Ondokuz Mayıs Üniversitesi, Çocuk Cerrahisi Anabilim Dalı, Kurupelit 55139 Samsun, Turkey. Tel: +90 - 362 - 312 19 19 / 3510 e-mail (e-posta): btander@omu.edu.tr

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CASE REPORTS Case 1- A three-day-old female was admitted to the emergency department with nonbilious vomiting on her third day of life (33 weeks gestation, 2000 g, spontaneous vaginal delivery). She had bullous lesions 2-3 cm in diameter on her extremities and peeling dermal lesions on her right arm and left wrist. Abdominal Xray depicted prominent gastric air and lack of air distally. No intraabdominal calcifications were identified (Fig. 1). PA was found at laparotomy. A pyloro-pylorostomy described by Dessanti et al.[5] was performed, which provides the preservation of the pyloric sphincter. She was fed by trans-anastomotic tube on the second day of surgery. The postoperative course was uneventful, and she was discharged on the ninth day after operation. In the follow-up studies, feeding was well tolerated and bullous lesions had improved. After two months, however, she was admitted to our emergency department with increased bullous lesions of the skin in number and size, electrolyte imbalance (Na: 119 mmol/dl, K: 7.5 mmol/dl), findings of sepsis (tachypnea, tachycardia, hypotension, WBC: 23,000, body temperature: 38.7ºC), and dehydration. Some of the lesions of the skin contained purulent material. There were numerous bullous lesions 1-2 cm in diameter on the trunk and extremities and peeling dermal lesions covering the body. She had no feeding problem. Abdominal radiographic examination revealed no specific finding. Her clinical status deteriorated within a few hours and despite all medical efforts, the patient died of severe sepsis induced by EB. Case 2- A two-day-old male was admitted to our newborn intensive care unit due to extensive dermal lesions (35 weeks gestation, 2200 g, cesarean section). Dermal lesions were severe bullous type on the trunk, neck, and extremities (Fig. 2). He had nonbilious vomiting and was dehydrated. On X-ray examination,

Fig. 1. Abdominal X-ray of Case 1 shows large gastric airfluid with lack of air distally. 272

his stomach was dilated and there was no gas distally. The oral contrast X-ray study revealed dilated stomach and no distal passage. At laparotomy, we found PA and performed gastroduodenostomy. Oral feeding was started on the seventh day postoperatively and was well tolerated. Within the first two weeks after surgery, the dermal lesions were prone to healing, but they became aggravated thereafter. The general condition of the patient deteriorated progressively, and he died of severe sepsis on the postoperative 23rd day.

DISCUSSION Pyloric atresia (PA) is a rare surgical emergency in newborns with obscure etiology, and its incidence has been reported as 1 per 100,000 live births.[6] Anatomic subgroups consist of (a) pyloric membrane alone, (b) obstructed pyloric canal by a solid cord and (c) atrophic pylorus with a gap between the stomach and duodenum.[7] PA is also associated with EB and/or aplasia cutis congenitalis, as seen in our patient.[8] The coexistence of PA and EB was first described by Swinburne and Kohler in 1968.[1,9] Carmi suggested the pathophysiology of the disorder; therefore, it is also referred to as ‘Carmi syndrome’.[2] Both PA and EB are very rare and autosomal recessive entities. The combination of these pathologies appears more than coincidental and is not the result of chance association. [10,11] Chang et al.[12] proposed that PA occurs secondary to an intrauterine complication of EB where sloughing pyloric mucosa leads to fibrosis and obstruction of the pyloric canal. Indeed, any epithelial-lined structure may be affected by EB, such as the uroepithelium.[13] EB is divided into three main categories: (a) EB simplex occurs within the epidermis, (b) junctional EB occurs within the lamina lucida of the basement membrane, and (c) dystrophic EB occurs within the lamina densa of the basement membrane.[14]

Fig. 2. Dermal lesion of Case 2 on the extremities. Mayıs - May 2012

Pyloric atresia associated with epidermolysis bullosa

Neonates with PA usually present with nonbilious vomiting soon after birth. Plain radiographs of the abdomen confirm the diagnosis of PA, with the stomach distended by air and an otherwise gasless abdomen.[7] Skin lesions may not appear until as late as 48 hours after birth. Disruption of the intestinal mucosa leads to malabsorption, increased antigenic sensitivity, bloody diarrhea, and protein losing enteropathy. Patients with PA/EB may have many associated disorders including gastrointestinal, urinary, pulmonary, and eye problems.[15] The surgical treatment of PA depends on the anatomic variety. The recommended treatment for a pyloric web is excision of the web in combination with a pyloroplasty.[16] For solid PA, the treatment of choice is Heineke-Mikulicz pyloroplasty if the atresia is short. Excision of the atretic segment with gastroduodenostomy is the choice of treatment if the solid cord is long. Gastroduodenostomy is required in cases of PA with gap.[17] Dessanti et al.[5] described a new mode of surgical treatment. A longitudinal incision on the gap and dissection of two stumps of atresia are the essentials of their technique. We performed this technique in one patient with a good postoperative outcome. In the other patient, we performed a gastroduodenostomy. He also tolerated the oral feeding well. Pyloric atresia (PA)/EB is a highly lethal combination, and death is almost a universal result. Hayashi et al.[10] reported four patients who had a survival between 17 months to 16 years, but they might have had alleles with lesser likelihood of lethality. Many infants die from extensive denudation of skin leading to septicemia, electrolyte imbalance, protein loss, and dehydration. Chronic blood and protein loss from denuded skin and mucosa causes anemia and hypoalbuminemia. Very few patients with limited and manageable skin blisters had long survival. As in our patient, most of the PA/EB infants die within the first few weeks or months of life despite successful surgical correction of PA.[3] Our cases developed aggravated skin lesions following minor trauma, and had severe sepsis induced by infected skin lesions of EB. In conclusion, PA/EB combination is rare and a lethal pathology. Surgical intervention for PA is effective only for short-term survival, and the long-term outcome is almost always poor.

REFERENCES 1. Birnbaum RY, Landau D, Elbedour K, Ofir R, Birk OS, Carmi R. Deletion of the first pair of fibronectin type III re-

Cilt - Vol. 18 Sayı - No. 3

peats of the integrin beta-4 gene is associated with epidermolysis bullosa, pyloric atresia and aplasia cutis congenita in the original Carmi syndrome patients. Am J Med Genet A 2008;146:1063-6. 2. Carmi R, Sofer S, Karplus M, Ben-Yakar Y, Mahler D, Zirkin H, et al. Aplasia cutis congenita in two sibs discordant for pyloric atresia. Am J Med Genet 1982;11:319-28. 3. Dank JP, Kim S, Parisi MA, Brown T, Smith LT, Waldhausen J, et al. Outcome after surgical repair of junctional epidermolysis bullosa-pyloric atresia syndrome: a report of 3 cases and review of the literature. Arch Dermatol 1999;135:12437. 4. Samad L, Siddiqui EF, Arain MA, Atif M, Parkash J, Ahmed S, et al. Pyloric atresia associated with epidermolysis bullosa--three cases presenting in three months. J Pediatr Surg 2004;39:1267-9. 5. Dessanti A, Iannuccelli M, Dore A, Meloni GB, Niolu P. Pyloric atresia: an attempt at anatomic pyloric sphincter reconstruction. J Pediatr Surg 2000;35:1372-4. 6. Muller M, Morger R, Engbert J. Pyloric atresia: A report of four cases and review of the literature. Pediatr Surg Int 1990;5:276-9. 7. Okoye BO, Parikh DH, Buick RG, Lander AD. Pyloric atresia: five new cases, a new association, and a review of the literature with guidelines. J Pediatr Surg 2000;35:1242-5. 8. Sencan A, Mir E, Karaca I, Günşar C, Sencan A, Topçu K. Pyloric atresia associated with multiple intestinal atresias and pylorocholedochal fistula. J Pediatr Surg 2002;37:12234. 9. Sarin YK, Nagdeve NG. Carmi syndrome complicated by pharyngo-esophageal perforation. Indian Pediatr 2006;43:614. 10. Hayashi AH, Galliani CA, Gillis DA. Congenital pyloric atresia and junctional epidermolysis bullosa: a report of longterm survival and a review of the literature. J Pediatr Surg 1991;26:1341-5. 11. Maman E, Maor E, Kachko L, Carmi R. Epidermolysis bullosa, pyloric atresia, aplasia cutis congenita: histopathological delineation of an autosomal recessive disease. Am J Med Genet 1998;78:127-33. 12. Chang CH, Perrin EV, Bove KE. Pyloric atresia associated with epidermolysis bullosa: special reference to pathogenesis. Pediatr Pathol 1983;1:449-57. 13. Reitelman C, Burbige KA, Mitchell ME, Hensle TW. The urological manifestations of epidermolysis bullosa. J Urol 1986;136:1320-2. 14. Shaw DW, Fine JD, Piacquadio DJ, Greenberg MJ, WangRodriguez J, Eichenfield LF. Gastric outlet obstruction and epidermolysis bullosa. J Am Acad Dermatol 1997;36:30410. 15. Lestringant GG, Akel SR, Qayed KI. The pyloric atresiajunctional epidermolysis bullosa syndrome. Report of a case and review of the literature. Arch Dermatol 1992;128:10836. 16. Moore CM. Congenital gastric outlet obstruction. J Pediatr Surg 1998;24:1241-6. 17. Al-Salem A, Nawaz A, Matta H, Jacobsz A. Congenital pyloric atresia: the spectrum. Int Surg 2002;87:147-51.

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Ulus Travma Acil Cerrahi Derg 2012;18 (3):274-276

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.49225

A patient who was burned in the operative field: a case report Ameliyat alanında yanan bir hasta: Olgu sunumu Soo-Ho CHUNG, Hae-Hyeog LEE, Tae-Hee KIM, Jeong-Sig KIM

Operating room fires occur very rarely. Nevertheless, a disaster can complicate almost any kind of surgery. The majority of operating room fires result from the use of alcohol-based surgical preparation solutions, electro-surgical equipment, or flammable drapes in an oxygen-rich environment. We report a patient with an ovarian cyst and uterine myomas who suffered a flame burn while undergoing gynecological surgery.

Ameliyat alanı yangınları oldukça nadirdir. Yine de, bir felaket, hemen hemen her türlü cerrahiyi güçleştirebilir. Ameliyat alanı yangınlarının çoğunluğu, oksijenden zengin bir ortamda alkol bazlı cerrahiye hazırlama solüsyonlarının, elektrikli cerrahi ekipmanın veya kolay tutuşan kumaşların kullanılmasından kaynaklanmaktadır. Biz, over kisti ve uterin miyomları nedeniyle jinekolojik cerrahi geçirirken alev yanığına maruz kalan hastayı sunuyoruz.

Key Words: Fire; flame burn; operating room; alcohol-based surgical preparation solutions; electro-surgical equipment.

Anahtar Sözcükler: Alev; alev yanığı; ameliyathane; alkol bazlı cerrahi hazırlık solüsyonları; elektrikli cerrahi ekipman.

Fires in the operating room may start in a number of ways, although nonflammable anesthetics are thought to prevent fires in medical institutions.[1] Operating room fires and burns are relatively rare, but such disasters can complicate almost any surgical procedure. In the United States, approximately 100 operating room fires are reported each year, although burns to the patient are not counted.[2,3] When ignition sources such as alcohol-based surgical preparation solutions, electrosurgical equipment, and flammable drapes are used in an oxygen-rich environment, the risk of an operating room fire increases, and any burn is more severe in such conditions. Most burns in the operative field are chemical burns, which are difficult to extinguish.

had no previous surgery. She was referred to our department from a local clinic for evaluation and surgical management of a pelvic mass. The right ovary had a thick-walled cyst with a surrounding hematoma (a probable hemorrhagic corpus luteal cyst). There was a thin, egg-shell like calcified cystic mass in the posterior pelvic cavity. Laparoscopy was performed. At the time of surgery, a 6x5-cm cyst was noted in the right ovary and a 5x5-cm myoma-like mass was identified on the posterior uterus. A laparoscopic right ovarian cystectomy and myomectomy were performed.

CASE REPORT A 47-year-old woman presented with a 10-month history of amenorrhea and a four-day history of uterine bleeding. Her medical history was benign, and she

The patient’s surgeon commonly used a large amount of alcohol to clean and disinfect the operating field. While cleaning and preparing the skin, there was some bleeding from the trocar insertion site in the skin. When electro-surgical equipment was used by mistake, the alcohol on the patient’s abdomen ignited. The drapes were used in an attempt to smother the fire, but the fire spread to the drapes (Fig. 1a) and triggered the fire alarm. It was difficult to extinguish the chemical fire, which required the use of fire extinguishers. The patient suffered a deep second-degree burn (Fig.

Department of Obstetrics and Gynecology, College of Medicine, Soonchunhyang University, Bucheon, Republic of Korea.

Soonchunhyang Üniversitesi, Tıp Fakültesi, Kadın Hastalıkları ve Doğum Anabilim Dalı, Bucheon, Kore Cumhuriyeti.

We report herein a patient who suffered a burn during gynecological surgery for an ovarian cyst and uterine myomas.

Correspondence (İletişim): Hae-Hyeog Lee, M.D. Soonchunhyang University Bucheon Hospital, Department of Obstetrics and Gynecology, 1174 Jung-1-dong, Wonmi-gu, Bucheon-si, Gyunggi-do, 420-767, Republic of Korea. Tel: +82 - 32 - 621 - 5078 e-mail (e-posta): hhl22@chol.com

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A patient who was burned in the operative field

(a)

(b)

Fig. 1. Burn wound of the skin on the abdomen and burned drapery. (a) Burned drapery. (b) Wound with packed laparoscopy wound surrounded by deep second-degree burns.

Fig. 2. Burn wound of the skin on the abdomen at postoperative 1 week.

1b). This was treated with daily burn dressings by plastic surgeons. Postoperatively, we prepared a risk management report. The patient was discharged one week after surgery (Fig. 2) and was followed at weekly intervals without other complications.

DISCUSSION A few operating room fires have been reported. In the United States, the reported frequency is approximately 100 cases, 60 injuries, and two deaths per year.[2,4] However, patient burns are not counted. Nearly 70% of these fires were related to the use of electro-surgical equipment; the oxygen-rich environment contributed to the fire and most of the burns were chemical burns.[5] There is a significant risk of fire when alcohol-based surgical skin preparation solutions are used. Three conditions are needed for a fire outbreak: heat, fuel and an oxidizer. In operating room fires, the electro-surgical equipment most often ignites a flammable substance. The fuel is the alcoholbased surgical preparation solution and drapes. In an oxygen-rich environment, the presence of all three Cilt - Vol. 18 Say覺 - No. 3

conditions can cause an object to burst into flames and burn intensely.[2,5,6] It has been suggested that fires may be initiated by the ignition of the vapor generated from an antiseptic solution. The heat of the skin ensures that this is at high concentration near the operating site. The

Fig. 3. Carbon dioxide fire extinguisher. 275

Ulus Travma Acil Cerrahi Derg

Table 1. Fire safety protocol for the operating room 1. Be aware of the risk of ignition of volatile fluids, such as alcohol 2. Immediately pour cold water 3. Use a fire extinguisher 4. Examine the ignition point and other electrical equipment 5. Treat the patient’s burns and prepare a risk management report

potential for fire is increased when the alcohol-based skin antiseptic is applied in ways that allow the solution to run off and collect into a pool on the skin or surgical drapes.[7] As soon as the electro-cauterization instrument is activated, these vapors can ignite. Attention to these details demands increasing the required solution drying time.[8] Operating room fires are uncommon, but have the potential to complicate surgical procedures disastrously. The risk of surgical fires can be minimized by avoiding situations in which all three conditions for a fire are present and by educating and training operating room personnel in fire hazards. The speed of progression of a fire ignited by alcohol is faster compared with general fires. Dousing the fire site with water may be of help in diluting the concentrated alcohol. A carbon dioxide fire extinguisher (Fig. 3) can be used safely in the operative field, including a sterile field and the abdominal cavity. There are five teaching points regarding fire prevention, which involve removing fuel and avoiding a fueloxidizer combination. First, it has been recommended that[1] 10% povidone-iodine in alcohol solution,[2] thimerosal in 50% alcohol solution,[3] 70% chlorhexidine hand rub, and[4] methanol or ethanol should not be used for skin cleaning in the operative field. Second, when

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using electro-surgical equipment, minimize the time it is used and use non-flammable equipment instead of flammable equipment. Third, when alcohol-based skin preparations have to be used, wait for at least 3 minutes for the solution to dry and wipe the skin with a cotton swab before draping the operative field.[9] Fourth, shave the skin and drape the patient with a clear plastic adhesive drape to prevent the collection of flammable vapors beneath the drapes. Fifth, when a fire breaks out, extinguish it using fire extinguishers. Surgeons must know the location of a fire extinguisher and how to use it properly. All surgeons and members of the operating team should be well informed regarding the fire safety protocol (Table 1).

REFERENCES 1. Macdonald AG. A brief historical review of non-anaesthetic causes of fires and explosions in the operating room. Br J Anaesth 1994;73:847-56. 2. Rinder CS. Fire safety in the operating room. Curr Opin Anaesthesiol 2008;21:790-5. 3. A clinician’s guide to surgical fires. How they occur, how to prevent them, how to put them out. Health Devices 2003;32:5-24. 4. United States Fire Administration. Medical facility fires. Topical Fire Res Ser 2001;2. 5. Batra S, Gupta R. Alcohol based surgical prep solution and the risk of fire in the operating room: a case report. Patient Saf Surg 2008;2:10. 6. Spigelman AD, Swan JR. Skin antiseptics and the risk of operating theatre fires. ANZ J Surg 2005;75:556-8. 7. Prasad R, Quezado Z, St Andre A, O’Grady NP. Fires in the operating room and intensive care unit: awareness is the key to prevention. Anesth Analg 2006;102:172-4. 8. Tooher R, Maddern GJ, Simpson J. Surgical fires and alcohol-based skin preparations. ANZ J Surg 2004;74:382-5. 9. Patel R, Chavda KD, Hukkeri S. Surgical field fire and skin burns caused by alcohol-based skin preparation. J Emerg Trauma Shock 2010;3:305.

Mayıs - May 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):277-279

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.32392

Isolated hemorrhagic contusion of an incidental meningioma İnsidental menenjiyomda izole hemorajik kontüzyon Ki Seong EOM, Tae Young KIM The authors present an unusual case of isolated hemorrhagic contusion of an incidental meningioma showing radiological findings similar to those of a hemorrhagic cerebral contusion on computed tomography (CT) in a female patient who presented to our hospital for head trauma. This case has two characteristics. First, although the meningioma had a hemorrhagic contusion due to head trauma, most of the brain tissue was intact. Second, there was a possibility that the hemorrhagic contusion of the incidental meningioma on CT was misdiagnosed as a cerebral hemorrhagic contusion. In this case, we propose a possible mechanism to explain this rare phenomenon.

Bu yazıda, kafa travması nedeniyle hastanemize başvuran bir kadın hastanın bilgisayarlı tomografisinde (BT) hemorajik serebral kontüzyon benzeri radyolojik bulgular gösteren, insidental menenjiyoma eşlik eden nadir bir izole hemorajik kontüzyon olgusu sunuldu. Olgunun iki özelliği vardı. Birincisi, menenjiyom kafa travmasına bağlı hemorajik kontüzyona neden olmakla birlikte beyin dokusunun bütünlüğü bozulmamıştı. İkincisi, BT’de rastlantı sonucu fark edilen menenjiyomaya ilişkin hemorajik kontüzyonun serebral bir hemorajik kontüzyon olarak yanlış tanı konulmuş olması söz konusuydu. Bu olguda, bu nadir fenomeni açıklamaya yönelik olası bir mekanizma önerdik.

Key Words: Head injury; hemorrhagic contusion; incidental meningioma.

Anahtar Sözcükler: Kafa yaralanması; hemorajik kontüzyon; rastlantısal menenjiyom.

Head injuries can occur as a result of specific types of mechanical forces. Observation of the characteristics of the mechanical force, such as its amplitude, velocity, contact duration, direction, and application rate, can help to determine the type, range, and severity of the head injury.[1]

swelling in the left frontal area suggesting scalp contusion, and a closed fracture in the left proximal tibia. Her medical and surgical histories were unremarkable. A non-enhanced CT scan of the head revealed a 4.5 x 5.3 x 5.2-cm round, relatively well-defined lesion in the left frontal lobe that appeared as multiple diffuse high-signal intensities with a broad base on the frontal convexity.

Here, we present a unique case of isolated hemorrhagic contusion of an incidental meningioma showing radiological findings similar to those of a hemorrhagic cerebral contusion on computed tomography (CT) in a female patient who presented to our hospital for head trauma. We also propose a possible mechanism to explain this rare phenomenon.

CASE REPORT A 75-year-old woman was admitted to our emergency room after having suffered blunt trauma associated with a pedestrian traffic accident. On presentation, the patient was in a stuporous mental state and had a Glasgow Coma Scale score of 6 (E3, V1, M2). Physical examination revealed scalp bruising and a

There was a midline shift to the right, a small acute subdural hematoma at the margin of the lesion, and an intraventricular hematoma in the right lateral ventricle. There was no definitive edema around the lesion or any bone changes. After contrast injection, partial minimal enhancement was observed (Fig. 1). The authors considered two possible diagnoses, i.e., an extraaxial mass or hemorrhagic contusion of the left frontal lobe. Because of the patient’s serious condition (she was in a state of mental stupor) and the marked mass effect on the CT images, we performed an emergency decompressive surgery. After frontoparietal craniotomy, we confirmed the extra-axial tumor base on the

Department of Neurosurgery, Wonkwang University School of Medicine, Iksan, South Korea.

Wonkwang Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Iksan, Güney Kore.

Correspondence (İletişim): Tae Young Kim, M.D. 344–2 Shinyong-dong, Iksan, South Korea. Tel: +082 63 859 1462 e-mail (e-posta): tykim@wonkwang.ac.kr

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(a)

(b)

(c)

Fig. 1. (a) A non-enhanced CT scan of the head showing a round, relatively well-defined lesion in the left frontal lobe appearing as multiple diffuse high-signal intensities with a broad base on the frontal convexity with moderate mass effect; there is a small acute subdural hematoma at the margin of the lesion and an intraventricular hematoma in the right lateral ventricle. (b) A CT scan with bone window settings showing no bone changes. (c) An enhanced CT scan showing partial minimal enhancement.

dura mater. The mass was relatively hard, well circumscribed, and bloody due to severe contusion (Fig. 2a). Although there were multiple small hematomas around the tumor, the brain cortex was intact (Fig. 2b). The tumor was completely removed microscopically. The histological diagnosis was meningothelial meningioma associated with multiple hemorrhages and an acute inflammatory reaction (Fig. 3). On postoperative day 2, the patientâ&#x20AC;&#x2122;s consciousness had not improved, and she was still in a stuporous mental state. Cranial magnetic resonance images (MRI) with susceptibilityweighted imaging (SWI) on postoperative day 2 revealed multiple small hemorrhagic shearing injuries in the midbrain, corpus callosum, and right subcortical white matter, a typical finding of diffuse axonal injury (Fig. 4). The patientâ&#x20AC;&#x2122;s level of consciousness showed

(a)

no improvement, and she was referred to another hospital at one month after surgery.

DISCUSSION The type, direction, intensity, and duration of mechanical forces collectively contribute to the characteristics and severity of the head injury caused by them.[1] The mechanisms of traumatic head injury can be classified as dynamic loading and static loading.[1,2] The precise duration of the loading force is a critical factor that determines the type of head injury produced. Static loading refers to a force that is applied to the head slowly, typically over periods >200 ms, whereas dynamic loading, the more common type, is characterized by a force that is applied to the head rapidly, typically over durations <50 ms.[1,3] Dynamic

(b)

Fig. 2. (a) Intraoperative photograph showing the extra-axial tumor base on the dura mater. The mass is relatively well circumscribed and bloody due to severe contusion. (b) After complete removal of the tumor, intact brain cortex can be seen. (Color figures can be viewed in the online issue, which is available at www.tjtes.org).

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Isolated hemorrhagic contusion of an incidental meningioma

considerably in their tolerances to compression, tension, and shear.[1,2]

Fig. 3. Histological examination of the surgical specimen showing a meningothelial meningioma associated with multiple hemorrhages and an acute inflammatory reaction (H&E, x100). (Color figure can be viewed in the online issue, which is available at www.tjtes.org).

Fig. 4. Cranial magnetic resonance images (MRI) with susceptibility-weighted imaging (SWI) on postoperative day 2 showing multiple small hemorrhagic shearing injuries in the midbrain, corpus callosum, and right subcortical white matter, a typical finding of diffuse axonal injury.

its being struck or impacted. Therefore, there is no impact to the cranium, and thus no contact phenomena occur. The resulting head injuries are caused solely by the inertial load that is produced by the way in which the head moves. Impact loading is the more frequent type of dynamic loading and generally results in a combination of contact phenomena and inertial load that eventually contribute to damaging the skull and brain by distorting or straining the bony or soft tissues beyond functional or structural tolerance.[2] In general, strain can be considered as the extent of deformation that a tissue undergoes as a result of an applied mechanical force. Strain, considered the primary cause of tissue damage, can be compressive, tensile, or shear in nature. The three principal tissues involved in head injury (bone, vascular structures, and brain tissue) vary Cilt - Vol. 18 SayÄą - No. 3

This case has two characteristics. First, although the meningioma had a hemorrhagic contusion due to head trauma, most of the brain tissue was intact. The dynamic load (duration, <50 ms) caused by the pedestrian traffic accident damaged the patientâ&#x20AC;&#x2122;s head. The left frontal scalp contusion indicated the point of impact, and an incidental meningioma that lay just below the scalp contusion appeared to have suffered a combination injury of contact phenomena and inertial load due to coup injury. Since meningiomas are relatively hard, their density differentiates them from the soft brain tissue; in our case, the meningioma appeared to strongly protect the brain tissue from the impact load, which finally caused strain to the meningioma itself. After the meningioma had absorbed most of the impact load, only impulsive loading occurred in the brain tissue, and this appears to have caused diffuse axonal injury. Second, there was a possibility that the hemorrhagic contusion of the incidental meningioma on CT was misdiagnosed as a cerebral hemorrhagic contusion. Generally, 25% of meningiomas are observed as isodense lesions on non-contrast CT, and the enhancement sometimes is only modest.[4] In this case, ascertaining the origin of the enhancement on CT as the isolated hemorrhagic contusion of the incidental meningioma was difficult. Since there is no peritumoral edema or bone changes around the meningioma, such cases may be misdiagnosed as cases of hemorrhagic cerebral contusion. Although the exact pathogenic mechanism of isolated hemorrhagic contusion of an incidental meningioma remains unclear, this report is worthwhile, considering the possibility of misdiagnosis of this condition as a hemorrhagic cerebral contusion on CT. Such misdiagnosis can lead to inadequacies in the investigations and preparation required before tumor surgery. Surgeons should always pay close attention to the radiographic findings and the patientâ&#x20AC;&#x2122;s clinical symptoms, despite the critical state of the patient in such emergencies. Acknowledgements This paper was supported by Wonkwang University in 2012.

REFERENCES 1. Gennarelli TA, Meany DF. Mechanisms of primary brain injury. In: Wilkins RH, Rengachery SS, editors. Neurosurgery. New York: McGraw-Hill; 1996. p. 2611-21. 2. Ommaya AK, Gennarelli TA. Cerebral concussion and traumatic unconsciousness. Correlation of experimental and clinical observations of blunt head injuries. Brain 1974;97:63354. 3. Demann D, Leisman G. Biomechanics of head injury. Int J Neurosci 1990;54:101-17. 4. Ginsberg LE. Radiology of meningiomas. J Neurooncol 1996;29:229-38. 279

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (3):280-282

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.60973

Intestinal malrotation in an adult: case report Erişkinlerde intestinal malrotasyon: Olgu sunumu Selim SÖZEN,1 Kerim GÜZEL2

Intestinal malrotation is a developmental anomaly of the midgut in which the normal fetal rotation of intestines around the superior mesenteric artery and their fixation in the peritoneal cavity fail. Rotational anomalies of the midgut are rare in adults. Operative intervention is required generally when they are symptomatic. While difficult to diagnose, prompt recognition and surgical treatment usually lead to a successful outcome. Intestinal malrotation is rarely asymptomatic and generally diagnosed incidentally in adults. In the present report, a case of incidental intestinal malrotation with clinical findings of small bowel obstruction is discussed with a literature review.

İntestinal malrotasyon, orta bağırsak (midgut) bölümünün peritoneal kavitede arteria mesenterica superior etrafında normal fetal rotasyonunu yapamaması ve fiksasyon bozukluğu ile seyreden bir gelişimsel anomalidir. Midgut rotasyon anomalilerine erişkinlerde nadir rastlanır. Bunlar, genellikle, klinik bulgulara sebep olduklarında cerrahi girişimi gerektirirler. Tanısını koymak güç olsa da erken tanı ve tedavi başarılı sonuç verir. İntestinal malrotasyon nadir olarak asemptomatik seyredip tanısı genellikle insidental olarak konur. Bu yazıda, kliniğimize ince bağırsak tıkanıklığı bulguları ile başvuran bir insidental intestinal malrotasyon olgusu literatür eşliğinde irdelendi.

Key Words: Embryology; intestine; ischemia; malrotation;

Anahtar Sözcükler: Embriyoloji; intestine; iskemi; malrotasyon.

Congenital midgut malrotation, a rare anatomic anomaly that can lead to duodenal or small bowel obstruction, is observed rarely beyond the first year of life. Symptomatic patients present with either acute bowel obstruction/intestinal ischemia with a midgut or cecal volvulus or with chronic vague abdominal pain.[1]

tinal loops predominantly on the right side. Chest radiography did not reveal any signs of perforation of a hollow viscus. At surgery, the small bowel was found to be twisted several times around the superior mesenteric artery. Surgical examination showed a duodenum crossing the spine and entering the jejunum in the left upper quadrant. The fourth duodenal segment and the normal duodenojejunal junction were not developed. All colon segments with the cecum were found to the left of the spine (Fig. 1a).

CASE REPORT A 60-year-old man presented with acute epigastric pain and bilious vomiting. He had a long history of constipation, opening his bowels 2-3 times a week with laxatives. On physical examination, his vital signs were pulse 90, blood pressure 126/67, and respiratory rate 16. The abdomen was not distended; however, he had a palpable, tender mid-epigastric mass. His rectal examination was normal. Hemoglobin, white blood cell count, basic biochemistry panel, and arterial blood gases were all within normal values. Plain radiographs suggested bowel obstruction with the localization of small intes-

Department of General Surgery, Elazığ Training and Reserach Hospital, Elazig; 2Department of General Surgery, Çarşamba State Hospital, Samsun, Turkey.

The small intestine lay on the right side of the abdomen and the large intestine on the left side. The duodenum ran caudally in a straight line from its first part onwards. The cecum lay on the left side of the abdomen and the ileum entered it from the right. The mobile mesentery was fixed. At laparotomy, midgut volvulus in a clockwise direction was found. The volvulus was untwisted completely in a counter-clockwise direction and then the viability of the bowel was assessed. Segmented massive gangrene of the small bowel was

Elazığ Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Elazığ; 2 Çarşamba Devlet Hastanesi, Genel Cerrahi Kliniği, Samsun.

Correspondence (İletişim): Selim Sözen, M.D. Adana Numune Eğitim ve Araştırma Hastanesi Genel Cerrahi Kliniği, Seyhan, Adana, Turkey. Tel: +90 - 322 - 355 01 01 e-mail (e-posta): selimsozen63@yahoo.com

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Intestinal malrotation in an adult

(a)

(b)

Fig. 1. (a) The cecum were found to the left of the spine. (b) An area of gangrenous small

intestine was resected.

present. An area of gangrenous small intestine (30 cm of necrotic small bowel) was resected and the abdomen was then closed (Fig. 1b). After a difficult postoperative period, the patient recovered satisfactorily.

DISCUSSION Malrotation of the midgut is an abnormality in the embryological development of the gastrointestinal tract. By the 4th intrauterine week, the gastrointestinal tract is in the form of an endoderm-lined tube. Approximately during the 5th week, a vascular pedicle develops and the gut can be divided into foregut, midgut and hindgut. The superior mesenteric artery supplies blood to the midgut. Intestinal rotation primarily involves the midgut. The rotation of intestinal development has been divided into three stages. Stage 1 occurs in weeks 5-10. It includes extrusion of the midgut into the extra-embryonic cavity, a 90° counterclockwise rotation, and return of the midgut into the fetal abdomen. Stage 2 occurs in week 11 and involves further counter-clockwise rotation within the abdominal cavity, completing a 270° rotation. This rotation brings the duodenal “C” loop behind the superior mesenteric artery with the ascending colon to the right, the transverse colon above, and descending colon to the left. Stage 3 involves fusion and anchoring of the mesentery. The cecum descends, and the ascending and descending colon attach to the posterior abdominal wall. According to this concept, cases of failure of rotation will involve the entire midgut, and a classical and severe malposition will result, with the small bowel located on the right side and the colon on the left side of the peritoneal cavity. Stage 1 anomalies include omphaloceles caused by failure of the gut to return to the abdomen. Stage 2 anomalies include nonrotation, malrotation, and reversed rotation. Stage 3 anomalies include an unattached duodenum, mobile cecum, and an unattached small bowel mesentery.[2-4] Midgut mal- and nonrotation refers to a failure in the counter-clockwise rotation of the midgut, which Cilt - Vol. 18 Sayı - No. 3

results in the misplacement of the duodenojejunal junction to the right of midline. Midgut volvulus is rare in adults.[5] Most acute presentations occur in the first month of life. In the adult with malrotation, midgut volvulus is the most common cause of bowel obstruction.[6] Acute presentation is with volvulus of the midgut or ileocecum occurring most frequently in the neonate, with the likelihood decreasing with age.[7,8] The chronic presentation is more challenging, with symptoms including chronic abdominal pain, bloating, vomiting, constipation, and diarrhea all being reported.[9] The volvulus occurs around the primitive dorsal mesentery, and thus constricts and compresses the superior mesenteric vessels. This process will particularly affect the venous drainage and the involved bowel will become filled with blood. The infarcted bowel will bleed into its lumen, and if the volvulus is then relieved spontaneously, the patient will pass blood-stained diarrhea signifying the end of the attack. At operation, the entire mass of the small bowel must be delivered through the wound, the volvulus completely untwisted in an counter-clockwise direction, and then the viability of the bowel assessed. If gangrene is evident, the affected gut is resected and the bowel continuity restored. When the viability of the gut is uncertain, reoperation is carried out 24 to 48 hours later, during which time adequate resuscitation is continued.[10] Limited resection may then be possible. In conclusion, at operation, the mesentery must be sutured to the posterior abdominal wall to prevent further episodes of volvulus. Emergency exploration with resection of the gangrenous bowel is vital for the patient’s survival.

REFERENCES 1. Hsu SD, Yu JC, Chou SJ, Hsieh HF, Chang TH, Liu YC. Midgut volvulus in an adult with congenital malrotation. Am J Surg 2008;195:705-7. 2. Mallick IH, Iqbal R, Davies JB. Situs inversus abdominus and 281

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3. 4. 5. 6.

malrotation in an adult with Ladd’s band formation leading to intestinal ischaemia. World J Gastroenterol 2006;12:40935. Stringer DA. Small bowel. In: Stringer DA, editor. Pediatric gastrointestinal imaging. Philadelphia: BC Decker; 1989. p. 235-9. Sadler TW, Langman J. Langman’s medical embryology. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004. p. 60-110. Pelucio M, Haywood Y. Midgut volvulus: an unusual case of adolescent abdominal pain. Am J Emerg Med 1994;12:16771. Gohl ML, DeMeester TR. Midgut nonrotation in adults. An

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aggressive approach. Am J Surg 1975;129:319-23. 7. Prasil P, Flageole H, Shaw KS, Nguyen LT, Youssef S, Laberge JM. Should malrotation in children be treated differently according to age? J Pediatr Surg 2000;35:7568. 8. Spigland N, Brandt ML, Yazbeck S. Malrotation presenting beyond the neonatal period. J Pediatr Surg 1990;25:1139-42. 9. Seymour NE, Andersen DK. Laparoscopic treatment of intestinal malrotation in adults. JSLS 2005;9:298-301. 10. Krasna IH, Becker JM, Schwartz D, Schneider K. Low molecular weight dextran and reexploration in the management of ischemic midgut-volvulus. J Pediatr Surg 1978;13:480-3.

Mayıs - May 2012

Değerli Meslektaşlarım, Sizileri 19-23 Nisan 2013 tarihleri arasında Antalya’da gerçekleşecek olan 9. Ulusal Travma ve Acil Cerrahi Kongresi’ne davet etmekten mutluluk duyuyoruz. Bu kongre ile, Travma, Acil Cerrahi ve Acil Tıp alanında en üst düzeyde bilgi birikimi ve yoğun deneyimle elde edilebilecek, tanı, tedavi, organizasyon ve hasta bakımı alanındaki tüm gelişmeler bilgilerinize sunulacaktır. Kongre programı kongre öncesi kursları, uzman oturumları, video sunumları, interaktif paneller, tartışma oturumları, uzlaşma toplantıları, konferanslar ve uzmanlık alanında gerçekleşen yenilikleri içermektedir. Hedefimiz değerli görüşlerinizle bilimsel programımızı zenginleştirip, herkesin birbirinden bir şeyler öğrenebileceği bir platform yaratmaktır. Antalya tarih boyunca kültürün, sanatın, mimarinin ve mitolojinin merkezi olmuştur. Muhteşem doğası, açık maviden laciverte uzanan denizi, şelaleleri, Toros dağları ve palmiye ağaçları ile bu gölgenin büyüsüne kapılacaksınız. Bu özellikleri ile de Antalya, Travma ve Acil Cerrahideki son gelişmeleri tartışabileceğimiz en uygun yer. Sizi Antalya’da ağırlamaktan büyük memnuniyet duyacağız. Saygılarımızla, Recep Güloğlu

Salih Pekmezci

Ulusal Travma ve Acil Cerrahi Derneği Başkanı

Kongre Başkanı

DÜZENLEME KURULU Kongre Başkanı Salih PEKMEZCİ Kongre Eş Başkanı Tayfun YÜCEL Genel Sekreter M. Mahir ÖZMEN Bilimsel Sekreterya Kaya SARIBEYOĞLU Hakan YANAR Üyeler Ediz ALTINLI Acar AREN Gürhan ÇELİK Cemalettin ERTEKIN Recep GÜLOĞLU Ahmet Nuray TURHAN