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ObjectiveField tourniquets are often used for battlefield extremity injuries. Their effectiveness has been documented by a large combat theater trauma center. However, their use and effectiveness by an austere forward surgical team has not been reported. Aims of this study were to determine: Whether field tourniquets: (1) Were placed for appropriate indications; (2) significantly reduced hemorrhage as measured by transfusion requirements; (3) influenced vital signs and injury severity scores; and (4) did they cause limb amputation, changed amputation level, or other complications.MethodsTwenty-five patients with 30 involved extremities presenting to a forward surgical team in Iraq met the inclusion criteria. We prospectively collected data regarding the presence, indications for, and effectiveness of field tourniquets based on the need for blood transfusion. We recorded any complications associated with their use.ResultsTourniquets significantly reduced hemorrhage from penetrating injuries as measured by transfusion requirements. Those having major vascular injuries with effective tourniquets, a total of 12 units of blood were transfused (1.7 units/vascular injury; 2 units/patient). However, 19 units were transfused in patients (3.3 units/vascular injury; 3.8 units/patient) who had an ineffective or no tourniquet (p = 0.0006). Transfusion requirements were related the presence of an effective tourniquet regardless of concomitant injuries. The group with effective tourniquets and compressed hemorrhage presented with higher mean systolic (p = 0.003) and diastolic (p = 0.023) blood pressures than the group with no tourniquets or ineffective ones. Complications included one peroneal nerve palsy and no amputations resulted from tourniquet application.ConclusionField tourniquets applied for penetrating injuries with severe bleeding can significantly reduce transfusion requirements and help maintain adequate blood pressure. Tourniquets were not the proximate cause of amputation and did not determine the choice of immediate amputation level.

Background: Multi-lobed perforator flap was one of popular approaches for one-stage reconstruction of complex soft tissue defects because of its minimal donor-site morbidity. However, the area of skin island that can be harvested on the donor site is limited on the angiosome distribution, Moreover, large defects require more than the conventional skin island provided by a traditional multi-lobed perforator flap. For further extended skin paddles, this study presented a novel design of waveform-arranged skin paddles to elevated a modified multi-lobed perforator flap for the reconstruction of complex soft tissue defects in the extremities.Methods: From March of 2015 to March of 2020, fifteen patients underwent complex soft tissue defects reconstruction with waveform-arranged multi-lobed perforator flaps. According the size, shape and localization of the defects, two strategies were performed to design this modified multi-lobed flap.Results: A total of fifteen waveform-arranged multi-lobed perforator flaps were successfully harvested to reconstruct complex soft tissue defects of the extremities. Among of them, Waveform-arranged dual skin paddles perforator flap were performed in eleven cases, and the waveform-arranged tripaddle perforator flaps were used in four cases. All the flaps survived and no flap related complication was observed postoperatively. The donor sites were closed directly in all cases. The mean follow-up time was 15.6 months. Most of the cases showed satisfactory contour.Conclusion: The waveform design of multi-lobed perforator flap was an alternative approach for reconstruction of complex soft tissue defects; it can maximize the harvested skin area of the donor site to provide extended skin island. [ABSTRACT FROM AUTHOR]

Introduction: There is conflicting data regarding if patients with vascular extremity trauma who undergo surgical treatment need to be systematically anticoagulated. We hypothesized that intraoperative systemic anticoagulation (ISA) decreased the risk of repair thrombosis or limb amputation after traumatic vascular injury of the extremities.Methods: We analyzed a composite risk of repair thrombosis and/or limb amputation (RTLA) between patients who did and did not undergo ISA during arterial injury repair. Patient data was collected in the American Association for the Surgery of Trauma PROspective Vascular Injury Treatment (PROOVIT) registry. This registry contains demographic, diagnostic, treatment, and outcome data.Results: Between February 2013 and August 2015, 193 patients with upper or lower extremity arterial injuries who underwent open operative repair were entered into the PROOVIT registry. The majority were male (87%) with a mean age of 32.6 years (range 4-91) and 74% injured by penetrating mechanism. 63% of the injuries were described as arterial transection and 37% had concomitant venous injury. 62% of patients underwent ISA. RTLA occurred in 22 patients (11%) overall, with no significant difference in these outcomes between patients who received ISA and those that did not (10% vs. 14%, p=0.6). There was, however, significantly higher total blood product use noted among patients treated with ISA versus those that did not receive ISA (median 3 units vs. 1 unit, p=0.002). Patients treated with ISA also stayed longer in the ICU (median 3days vs. 1day, p=0.001) and hospital (median 9.5days vs. 6days, p=0.01).Discussion: In this multicenter prospective cohort, intraoperative systemic anticoagulation was not associated with a difference in rate of repair thrombosis or limb loss; but was associated with an increase in blood product requirements and prolonged hospital stay. Our data suggest there is no significant difference in outcome to support use of ISA for repair of traumatic arterial injuries. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the impact on health related quality of life (HRQL) during the first year after minor extremity injury and to determine whether there is a difference in recovery patterns and return to work between upper extremity injuries (UEI) and lower extremity injuries (LEI).Method: A total of 181 adults' age 18 years or older randomly selected from patients admitted to an emergency department with minor injuries were studied. HRQL was measured using the Functional Status Questionnaire (FSQ) at 1-2 weeks, 3, 6, and 12-months post-injury. Pre-injury FSQ scores were measured retrospectively at admission. A quasi-least square (QLS) model was constructed to examine differences of FSQ scores at each measuring point for UEI and LEI.Results: Fractures of the knee/lower leg (25%) were the most frequently injured body area. Slips or falls (57%) and traffic-related events (22%) were the most common injury causes. The mean ISS was 4.2 (SD 0.86). Both groups had significant declines in the FSQ scores physical and social functioning at 1-2 weeks after injury. Patients with UEI made larger improvements in the first 3 months post-injury versus patients with LEI whose improvements extended over the first 6 months. None of the groups reached the pre-injury FSQ scores during the first post-injury year except in the subscale work performance where UEI exceeded the pre-injury scores. At 12 months post-injury, significant lower FSQ scores remained in the LEI group compared to the UEI group in intermediate activities of daily living (p=0.036, d 0.4) and work performance (p=0.004, d 0.7). The return to work at 3 months and 12 months were 76% and 88% for UEI and 58% and 77% for LEI. No significant differences were found between groups in the FSQ scale mental health and social interaction.Conclusions: LEI had the highest impact on HRQL and return to work during the first year which exceeded the consequences of UEI. These findings contribute to the information about the consequences of injury in order to give sufficient prognostic information to patients and different stakeholders. Future investigations should aim to investigate specific minor extremity injuries and identify factors that facilitate recovery and return to work. [ABSTRACT FROM AUTHOR]

Prevention of extremity war wound infection remains a clinical challenge. Staphylococcus aureus is the most common pathogen in delayed infection. We hypothesised that choice of wound dressings may affect bacterial burden over 7 days reflecting the current practice of delayed primary closure of wounds within this timeframe. A randomised controlled trial of 3 commercially available dressings (Inadine® (Johnson & Johnson, NJ, USA), Acticoat® (Smith & Nephew, Hull, UK), Activon Tulle (Advancis Medical, Nottingham, UK)) was conducted in a rabbit model of contaminated forelimb muscle injury. A positive control group treated with antibiotics was included. Groups were compared to a saline soaked gauze control. The primary outcome was a statistically significant reduction (p <0.05) in tissue S. aureus at 7 days post-injury. Secondary outcome measurements included bacteraemias, observational data, whole blood determination, ELISA for plasma biomarkers, PCR array analysis of wound healing gene expression and muscle/lymph node histopathology. Antibiotic, Inadine and Acticoat groups had statistically significant lower bacterial counts (mean 7.13 [95% CI 0.00–96.31]×102; 1.66 [0.94–2.58]×105; 8.86 [0.00–53.35]×104 cfu/g, respectively) and Activon Tulle group had significantly higher counts (2.82 [0.98–5.61]×106 cfu/g) than saline soaked gauze control (7.58 [1.65–17.83]×105 cfu/g). There were no bacteraemias or significant differences in observational data or whole blood determination. There were no significant differences in muscle/loss or pathology and lymph node cross-sectional area or morphology. There were some significant differences between treatment groups in the plasma cytokines IL-4, TNFα and MCP-1 in comparison to the control. PCR array data demonstrated more general changes in gene expression in the muscle tissue from the Activon Tulle group than the Inadine or Acticoat dressings with a limited number of genes showing significantly altered expression compared to control. This study has demonstrated that both Acticoat® and Inadine® dressings can reduce the bacteria burden in a heavily contaminated soft tissue wound and so they may offer utility in the clinical setting particularly where surgical treatment is delayed. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: The incidence of acute deep venous thrombosis as a result of penetrating proximity extremity trauma (PPET) to the thigh has been demonstrated to be 16% in a single report. The purpose of the current study is to demonstrate the incidence and clinical significance of venous injury as a result of proximity trauma to the thigh in a large cohort screened with colour flow duplex (CFD) ultrasound and to identify factors predictive of defining a wound in proximity to a major vascular structure. Patients and methods: A prospective observational study was conducted from January 1st, 2010 to January 1st, 2012 on all patients presenting with penetrating extremity trauma. Data on injury location, mechanism, associated extremity and non-extremity injuries, use and results of CFD, as well as the admitting trauma surgeon were recorded and analysed. Results: 220 thigh wounds with a normal physical examination were identified, of which 167 (75.9%) underwent CFD due to proximity. The incidence of acute venous injury was 4.8% (8/167). 37.5% (3/8) of these injuries resulted in morbidity. Injury mechanism and which attending physician was on call were predictive of a wound being defined as in proximity, whereas an injury with an associated fracture was a negative predictor. Conclusions: Occult venous injuries as a result of PPET occur in 4.8% of patients with thigh wounds in proximity to a major vascular structure. The designation of a wound as being in “proximity” was influenced by injury mechanism, associated fractures, and the judgement of the on-call attending. Colour flow duplex is a valuable tool with the ability to identify not only occult arterial injuries, but also venous injuries with the potential to cause significant morbidity as well. [Copyright &y& Elsevier]

Abstract: Introduction: Paediatric extremity vascular injuries are infrequent, and management protocols draw significantly from adult vascular trauma experience necessitating a continuous review of evidence. Materials and methods: A retrospective registry review of all consecutive patients younger than 18 years age treated for extremity vascular trauma from 2007 to 2012 was carried out. Diagnostic algorithm relied little on measurement of pressure indices. Data was collected about demographics, time since injury, pattern of injury, ISS, initial GCS and presence of shock, results of diagnostic modality and treatment given with associated complications. Patients completing 2 years follow up were assessed for functional disability and vascular patency. A multivariable regression model was used to evaluate effects of – ISS, presence of orthopaedic injury, soft tissue injury, neural injury and arterial patency at the end of 2 years – on outcome of functional disability. Results: Paediatric extremity vascular injuries accounted for 0.68% hospital admissions with a median delay of 8h from injury. 82 patients were included with 50 cases examined for long term outcome. Patient cohort was overwhelmingly male, with ‘fall’, ‘road traffic injury’ and ‘glass cut’ being most common injury mechanisms. CT angiography and duplex scan based diagnostic algorithm performed satisfactorily further identifying missed injuries and aiding complex orthopaedic reconstruction. Brachial and femoral vessels were most commonly injured. Lower extremity vascular injury was found associated with significantly higher ISS and requirement for fasciotomy. Upper extremity vascular injury was associated with higher odds of neural injury. Younger children were at higher risk of combined radial and ulnar vessel injury. No patient satisfactorily complied with post-operative anticoagulant/antithrombotic prophylaxis. 28 patients had good functional outcome with unsatisfactory functional outcome found associated with significantly higher ISS, presence of orthopaedic and neural injury, along with absence of arterial patency. Conclusion: The epidemiology of paediatric peripheral vascular injury differs in India compared to west. Certain traditional management principles of extremity vascular trauma may stand uniquely challenged in the paediatric population. [Copyright &y& Elsevier]

Summary: Background: Nail guns have been employed since 1959 to speed construction work, but with the increased productivity came an increasing number of injuries associated with the device. The majority of reported cases occur to the extremities. Methods: Our study retrospectively examines 88 cases of nail gun injuries to the extremities collected from a 4-year period. Radiographs and charts were used to collect data on anatomic site, type of treatment, type and duration of antibiotic treatment, and outcomes. Results: We found that infections associated with nail gun injuries were relatively rare (n =3) and in our study were limited to those patients who presented later than the day of injury. The majority of injuries were to the hand and knee (38.6% and 28.1%, respectively). No significant vascular or neurological injuries were encountered. Conclusions: It appears that simple emergency room removal of the nail with local debridement and a short course of antibiotics is appropriate in most cases. The exception to this is where there is intra-articular or neurovascular involvement, then operative debridement is recommended. [Copyright &y& Elsevier]

Objectives To review fracture rates in patients who had X-rays of either the ankle or foot or both in the Emergency Department of a district hospital. Method A retrospective review of 2589 Emergency Department patients who had X-rays of the ankle or foot or both over a 12-month period. Results There were 1199 ankle X-rays taken of which 193 (16%) showed a significant fracture. There were 1081 patients who had a foot X-rayed of which 165 (15%) showed a significant fracture. Younger patients had more X-rays but older patients were more likely to have a fracture. There were 309 patients who had an ipsilateral ankle and foot X-rayed at the same time, and of these 42 (14%) showed one fracture and just two (0.6%) showed a significant fracture of both ankle and foot. Conclusions The approach to X-raying ankle and feet in this study is probably widespread, and Ottawa Ankle Rules still seem to be of limited use in diagnosing fractures. This low yield of positive X-ray could be accepted or a more sophisticated ankle rule introduced. [ABSTRACT FROM AUTHOR]