Injury
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We critically evaluated several diagnostic modalities (clinical criteria, subxiphoid pericardial window (SPW) and laparoscopy) used in the detection of occult cardiac injury in haemodynamically stable patients at high risk of cardiac injury. Over 5 years, 122 patients were admitted to a Level I trauma centre with such an injury. They sustained 69 stab wounds, and 53 gunshot wounds. ⋯ SPW remains the standard means of diagnosing occult cardiac injury in high-risk patients. Since the incidence of occult cardiac injury in haemodynamically stable patients is 20 per cent, SPW should be used liberally. Laparoscopy may have a role in evaluating the pericardium in the subgroup of patients with lower chest wounds, and it facilitates inspection of intra-abdominal viscera and diaphragm at the same time.
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The change in knowledge resulting from formal training in trauma management on two different courses was examined. Seventy-four doctors and a control group were included in this prospective study over a 2-year period. They represented participants on two Advanced Trauma Life Support (ATLS) courses and four induction courses for junior doctors in Accident and Emergency (A&E) departments. ⋯ Standardization of approach is recommended. Assessment and audit of training in trauma management is feasible with limited resources. It may eventually be possible to measure individual clinician's proficiency against a standard scale.
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With increasing violence in our society, the number of gunshot fractures is likely to increase. Fourteen femoral fractures caused by gunshot injuries were treated with statically locked intramedullary nailing within 8 h of injury. Three patients had concomitant femoral arterial injuries. ⋯ One fracture was graded as a poor outcome because of a non-union which was treated with an exchange nailing procedure and progressed to bony union. Our experience of immediate intramedullary nailing of gunshot femoral fractures has yielded results which approximate to those observed in treating closed femoral fractures. We would therefore recommend this as the treatment of choice in fractures of the femoral shaft caused by gunshots.
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Comparative Study
Effects of method of internal fixation of symphyseal disruptions on stability of the pelvic ring.
This study tested different methods of internal fixation of a symphyseal disruption, in comparison with the mechanics of the intact pelvis. Unembalmed cadaveric pelves were tested in simulated bilateral stance in a servohydraulic materials-testing machine. Motion of the superior and inferior pubic symphysis, and at two levels of the posterior sacroiliac complex, was measured using high resolution displacement transducers. ⋯ There was no significant difference in sacral fracture motion between the three methods. The results indicate that in osteoporotic bone, as used in this study, symphyseal wiring is best able to oppose the tensile loads in the inferior symphysis that are associated with bilateral stance loading. These biomechanical findings must be interpreted within the broader context of surgical management of these complex injuries.