J Trauma
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Nineteen patients with displaced four-part fracture or fracture-dislocation of the proximal humerus were retrospectively studied to investigate the incidence of avascular necrosis and its clinical importance. The average followup duration was 23.6 months. ⋯ The treatment of choice for displaced four-part fracture or fracture-dislocation of the proximal humeral is early adequate open reduction and internal fixation rather than primary prosthetic replacement. The authors believe that a majority of the humeral heads in this injury develop avascular necrosis, but most of the humeral heads are quickly revascularized with creeping substitution.
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As part of an incidence study of external cause-specific trauma, the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS) are being used to measure the severity of the anatomic injuries. Problems identified in the study pilot phase by medical record specialists, after training in AIS procedures, include noteworthy variations in the interpretation of scaling procedures in the AIS dictionary. The AIS dictionary was replaced by a newly designed single page (SP) precoded abstracting form. ⋯ Abstractors are instructed to code all injuries for an episode. A computer algorithm has been developed and implemented to assign the AIS severity codes. Accuracy and precision improved markedly by eliminating the need to make severity scoring decisions during the AIS coding process.
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Experiments were conducted using non-enzymatic chemical agents (with emphasis on certain mercaptans), alone, in conjunction with enzymatic agents and/or other nonenzymatic chemicals for debridement of burns. Both in vitro (rats, pigs, humans) and in vivo (rats, pigs) tests were carried out. N-acetylcysteine, penicillamine and cysteine ethyl ester in low to moderate concentrations accelerate the debriding action of bromelain (an enzymatic preparation from pineapple stems) and in higher concentrations, N-acetylcysteine and penicillamine (cysteine ethyl ester was not tested) cause ready separation of the burn eschar from the underlying tissue before solubilization of the eschar is complete (rat) or has occurred (pig). ⋯ The use of a keratolytic agent prior to the application of N-acetylcysteine hastens the latter's action. Sulfamylon and sulfadiazine can be used with N-acetylcysteine without interfering with its debriding action. The effects of the mercaptans are likely due largely to their ability to depolymerize connective tissue proteoglycans and proteins, especially at the interface between living and dead tissue.
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Management of acutely burned patients requires intense but meticulous fluid therapy. Indicators of satisfactory resuscitation include: intravascular and arterial pressures and urine output. The usefulness of these parameters as a predictor of cardiac index (CI) has not been tested. ⋯ Mean PA pressure, wedge pressure, RV end-diastolic pressure, and urine output correlated poorly with CI (r = 0.36, 0.32, 0.27, and 0.26, respectively). Unlike atrial pressures the RVEDV and RVEF are unaffected by malpositioning of transducers, airway pressure, and compliance changes of the ventricle. The measurement of RVEDV is a useful clinical tool for the assessment of preload and when used in combination with RVEF may indicate the need for inotropy.
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Bullets may embolize against normal blood flow into distal veins because of gravity or the Valsalva maneuver. A case is described in which a bullet was fluoroscopically repositioned from the popliteal vein into the area of a lacerated iliac vein and trapped with a balloon catheter obviating popliteal exploration.