Injury
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Among the 1274 patients admitted to a Pakistan border hospital from 1985 to 1987, the distribution and outcome of musculoskeletal war injuries differed from those seen in other conflicts. Serious complications from injuries were found in approximately 50 per cent of patients, of which most were wound infections, chronic osteomyelitis, and restriction of joint motion. Guerrillas in the Afghan war had no access to acute medical treatment in the field. ⋯ Although some complications, such as soft tissue infection and foreign body retention are not site specific, other complications such as contracture, non-union, loss of range of motion, and chronic osteomyelitis are highly related to the region injured. Early surgical management and evacuation of those with musculoskeletal war injuries can greatly improve the outcome from war trauma and reduce the subsequent disability. However, the increasing use of hand-held anti-aircraft missiles may prevent the rapid evacuation of the wounded in future conflicts, and may make the situation seen in Afghanistan more common.
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We have retrospectively reviewed our experience of 153 consecutive patients who underwent emergency laparotomy for suspected intraabdominal injury over a 10-year period. The commonest cause of injury was road traffic accidents (61 per cent), and the commonest indication for operation was signs of peritoneal irritation (35 per cent). Peritoneal lavage was performed in 62 patients (41 per cent). ⋯ The negative laparotomy rate was 16 per cent. Forty-five patients died (29 per cent) and five of these had negative laparotomies. The Injury Severity Score (ISS) of all patients who died was > 16.
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Comparative Study
Variation in trauma resuscitation and its effect on patient outcome.
There were significant differences in the time taken to resuscitate 257 trauma patients from four internationally recognized trauma centres. The fastest unit completed resuscitation in 15 min while the slowest took 105 min. This variation was not explained by differences in the type of patient dealt with, seniority of the team leader, or the number of personnel in the trauma team. ⋯ Although the slowest unit had the smallest trauma team (two people), larger numbers of personnel did not shorten resuscitation times. The time taken to carry out the ABC of the primary survey was significantly correlated with patient's physiological change in the resuscitation room (R = -0.63, P less than 0.0001 with systolic blood pressure; R = -0.68, P less than 0.01 with the revised trauma score). A multiple regression with survival as the dependent variable revealed that this time was also a predictor of the patient's eventual outcome (t = 3.18, P less than 0.005).
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In the treatment of either acute severe open tibial fractures or their sequelae, a convenient external fixator is desirable. The conventional transosseous fixation with pins entering the medullary cavity is associated with problems such as pin loosening and pin track infection. Due to the bacterial contamination of the medullary space via the pin track the change of treatment from primary external fixation to secondary medullary nailing is an infection risk. In order to minimize these problems an external clamp fixator, the Pinless, was created. Medullary penetration is avoided by substitution of the conventional pins with clamps. The latter are inserted by hand (removable handles) and anchored only in the bone cortex. The medullary cavity stays intact. But is this clamp fixation stable enough for clinical use? ⋯ The Pinless was not as stiff as the conventional AO-tubular device but stiffer than the clinically used Ultra-X, especially in sagittal bending, the main load on a tibial fracture in the first weeks after trauma.(ABSTRACT TRUNCATED AT 400 WORDS)