Letters to Editor
REFERENCES 1.
Fornage BD, Schernberg FL. Sonographic diagnosis of foreign bodies of the distal extremities. AJR Am J Roentgenol 1986;147:567-9.
2.
Bauer AR Jr, Yutani D. Computed tomographic localization of wooden foreign bodies in children’s extremities. Arch Surg 1983;118:1084-6.
3.
Boyse TD, Fessell DP, Jacobson JA, Lin J, van Holsbeeck MT, Hayes CW. US of soft tissue foreign bodies and associated complications with surgical correlation. Radiographics 2001;21:1251-6.
4.
Yanay O, Vaughan DJ, Diab M, Brownstein D, Brogan TV. Retained wooden foreign body in a child’s thigh complicated by severe necrotizing fasciitis: A case report and discussion of imaging modalities for early diagnosis. Pediatr Emerg Care 2001;17:354-5.
5.
Gulati D, Agarwal A. Wooden foreign body in the forearm — presentation after eight years. Ulus Travma Acil Cerrahi Derg 2010;16:373-5.
6.
Davae KC, Sofka CM, DiCarlo E, Adler RS. Value of power Doppler imaging and the hypoechoic halo in the sonographic detection of foreign bodies: Correlation with histopathologic findings. J Ultrasound Med 2003;22:1309-13.
peritoneal lavage or surgery to assess the diagnostic value of ultrasonography. The Epi Info statistical software version 3.4.1 was used for data analysis. By scanning to detect free fluid, sensitivity, specificity, positive and negative predictive values and the diagnostic accuracy were 96%, 67%, 94%, 75%, and 91% respectively. By scanning to detect the parenchymal injury, sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were 71%, 35%, 62%, 44%, and 56% respectively. In conclusion, ultrasonography has a high diagnostic value in the screening of patients with blunt abdominal trauma. Scanning for the presence of free fluid yields better results than scanning for the visceral parenchymal injury.
Michael I Nnamonu Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria E-mail: [email protected]
Access this article online Quick Response Code: Website: www.onlinejets.org
DOI: 10.4103/0974-2700.120393
Diagnostic value of abdominal ultrasonography in patients with blunt abdominal trauma Sir, Despite the trend to comprehensively investigate the patients with blunt abdominal trauma with a computerized tomography scan, diagnostic ultrasonography remains an important tool more so where computed tomography is not available or condition of the patient precludes transfer to the radiology suite.[1-3] This study assessed the diagnostic value of ultrasonography in blunt abdominal injury. It was a prospective study conducted at the Department of Surgery, Jos University Teaching Hospital from 1 January 2006 to 31 December 2007. Fifty-seven patients who had ultrasonography for blunt abdominal trauma had their sonographic findings compared with findings at diagnostic 308
REFERENCES 1.
Stengel D, Bauwens K, Porzsolt F, Rademacher G, Mutze S, Ekkernkamp A. Emergency ultrasound for blunt abdominal trauma – Meta-analysis update 2003. Zentralbl Chir 2003;128:1027-37.
2.
Breyer B, Bruguera CA, Gharbi HA, Goldberg BB, Tan FE, Wachira MW. Preface. In: Palmer PE, editor. Manual of Diagnostic Ultrasound. Geneva: World Health Organization; 2004. p. vii-viii.
3.
Yoshii H, Sato M, Yamamoto S, Motegi M, Okusawa S, Kitano M, et al. Usefulness and limitations of ultrasonography in the initial evaluation of blunt abdominal trauma. J Trauma 1998;45:45-50. Access this article online Quick Response Code: Website: www.onlinejets.org
DOI: 10.4103/0974-2700.120395
Bilateral luxatio erecta humeri with a unilateral brachial plexus injury Sir, Luxatio erecta is a rare inferior glenohumeral dislocation accounting for only 0.5% of all shoulder dislocations.[1] Bilateral Journal of Emergencies, Trauma, and Shock I 6:4 I Oct - Dec 2013
Letters to Editor
A 19-year-old male front seat passenger was brought to the Emergency Department (ED) subsequent to a RTA. The ambulance crew noted that the patient held both his arms in an abducted position and any movement of the arms were painful. He was immobilized on a spinal board in this unusual position [Figure 1]. He had an obvious right lower limb injury which was immobilized with a splint.
Figure 1: Photograph of the patient with bilateral inferior shoulder dislocations immobilized on a spinal board. The arms are held in an abducted position with the elbows flexed and forearms pronated. The humeral heads (white arrows) were readily palpable on the lateral chest wall
On clinical examination both arms were abducted, the elbows flexed and forearms pronated. The humeral heads were palpable in the axilla on the lateral chest wall [Figure 1]. Paraesthesia of the left arm along a C6 and C7 dermatomes were present. A right tibial shaft fracture was identified and immobilized appropriately. Computerized tomography scan of the thorax revealed bilateral inferior dislocations associated with avulsion fracture of the greater tuberosity [Figure 2] as well as bilateral pneumothoraxes for which chest drains were sited. Closed reduction of the shoulders was performed with traction and counter traction to the abducted arm under a general anesthetic prior to intramedullary nailing of the tibial fracture. The shoulders reduced easily [Figure 3] and were immobilized in a sling with the arms in adduction and internal rotation. Post-operative examination revealed a left wrist drop and loss of finger extension. However, they began to improve by the third post-operative day with full resolution by 2 weeks.
Figure 2: Three-dimensional reconstruction of the computerized tomography scan of the thorax demonstrating bilateral inferior dislocations with associated with avulsion fracture of the greater tuberosity
Physiotherapy was commenced at 3 weeks and at the 6 months follow-up, the patient had a good range of motion to both shoulders without neurovascular deficits. Luxatio erecta has a high incidence of associated injuries with up to 80% having, either a fracture of the greater tuberosity or a rotator cuff tear, up to 60% having a neurological deficit, however vascular injuries are uncommon.[2] Our patient sustained a transient wrist drop, loss of finger extension and paraesthesia, which likely resulted from stretching of the posterior cord of the brachial plexus during the dislocation. Treatment is generally by closed reduction. Traction to the abducted arm with counter traction is the most commonly used reduction technique.[3,4] Post-reduction, the shoulder is immobilized for at least 2 weeks with the subsequent commencement of physiotherapy. Long-term prognosis is good in most of these patients.[5]
Figure 3: Radiographs demonstrating satisfactory reduction of both shoulder joints
luxatio erecta is rarer still with only a few cases reported. We present a case of successful closed reduction of bilateral luxatio erecta sustained subsequent to a road traffic accident (RTA). Journal of Emergencies, Trauma, and Shock I 6:4 I Oct - Dec 2013
These dislocations add an additional layer of complexity to managing the poly-traumatized patient in the ED. Satisfactory immobilization of the cervical spine can be difficult due to the abducted arms. Log rolling of the patient while performing the initial and subsequent examinations in our case required additional time and personnel. However, the abducted arms made it easier to site the chest drains. 309
Letters to Editor
Prasad Ellanti, Nikolaos Davarinos, Mary J Connolly, Hamid A Khan Department of Trauma Orthopaedics, Adelaide & Meath Incorporating National Children’s Hospital, Tallaght, Dublin 24, Ireland. E-mail: [email protected]
REFERENCES 1.
Laskin RS, Sedlin ED. Luxatio erecta in infancy. Clin Orthop Relat Res 1971;80:126-9.
2.
Mallon WJ, Bassett FH 3rd, Goldner RD. Luxatio erecta: The inferior glenohumeral dislocation. J Orthop Trauma 1990;4:19-24.
3.
Pirrallo RG, Bridges TP. Luxatio erecta: A missed diagnosis. Am J Emerg Med 1990;8:315-7.
4.
Musmeci E, Gaspari D, Sandri A, Regis D, Bartolozzi P. Bilateral luxatio erecta humeri associated with a unilateral brachial plexus and bilateral rotator cuff injuries: A case report. J Orthop Trauma 2008;22:498-500.
5.
Groh GI, Wirth MA, Rockwood CA Jr. Results of treatment of luxatio erecta (inferior shoulder dislocation). J Shoulder Elbow Surg 2010;19:423-6. Access this article online Quick Response Code: Website: www.onlinejets.org
DOI: 10.4103/0974-2700.120396
Very bad clinical aspect towards diagnosis of deep femoral artery injury: Hypovolemic shock Sir, Isolated profunda femoris artery penetrating injury is rare and has been reported as a consequence of injury, orthopedic procedures, and catheterization.[1] In these patients, delayed diagnosis and treatment may be due to late admission to emergency department, presence of pulses on related lower limb, and also not causing arterial circulatory disorders. In our hospital, 17‑year‑old male patient with penetrating injury on left lateral part of the thigh was brought to the emergency department. After opening the external bandage, a 3 cm long skin incision was observed. In the meantime, there were no significant findings that suggestive of remarkable bleeding or 310
hematoma. On physical examination, the pulses on injured lower limb were observed. On follow‑up, deterioration of the general condition and development of patient confusion, he was urgently taken to the operating room and then lateral thigh incision was enlarged and searched source of hemorrhage. Profunda femoral vein and artery were clamped. By removing the wide injured sections on the vessels, saphenous vein graft was interposed in these segments. After an uneventful recovery, he was discharged on the 8th postoperative day. The most common cause of peripheral arterial injuries was stab and gunshot‑related injuries.[1] The etiologies of vascular injuries especially in young males, in our country, 50-70% are gunshot injury and stab wounds.[2,3] Early diagnosis and appropriate treatment can reduce mortality and morbidity in vascular injuries. In the early period, it is difficult to diagnose profunda femoral artery injuries.[1,2] In our case, the patient had no significant bleeding when he was in the emergency department and before admission to hospital, wound area was bandaged. Hemodynamic parameters were stable but within minutes progressive hypotension and confusion were occurred and then the patient was immediately operated. False‑negative rate was 1.3% in penetrating extremity injuries with only physical examination and a 24 h observation.[4] However, similar results have been reported by arteriography and surgical exploration (3-6%). Therefore, while no significant physical examination findings in the diagnosis of profunda femoral artery injury, clinical observation is more important.[4,5] In the vascular injuries, repair of vessels must be the first treatment option. Significant contribution to the development of collateral vessels and the lower extremity arterial circulation, the profunda femoral artery ligation is not recommended.[1‑3] In peripheral vascular diseases with diabetic and non‑diabetic, profunda femoral artery is the most considerable vessel, limb preservation of the infrapopliteal region through the nutrition with providing of collateral circulation.[4,5] As a result, in the profunda femoral artery injuries, the presence of lower limb palpable pulses, ankle/brachial index levels within normal limits, and efficient distal blood flow may hinder aiding accurate diagnosis. Consequently, performing emergency vascular access and volume replacement to patients if wound is closer to the deep femoral artery anatomy as well as estimating amount of bleeding by a detailed anamnesis, closer monitoring of the patient and we also believe that if stab wound area was bandaged, opening the bandage and establishing the presence of bleeding would be the most appropriate approach.
Faruk Cingoz, Gokhan Arslan, Erkan Kaya, Bilgehan Savas Oz Department of Cardiovascular Surgery, Gulhane Military Medical Academy, Ankara, Turkey. E‑mail: [email protected] Journal of Emergencies, Trauma, and Shock I 6:4 I Oct - Dec 2013
Copyright of Journal of Emergencies, Trauma & Shock is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
REFERENCES 1.
Fornage BD, Schernberg FL. Sonographic diagnosis of foreign bodies of the distal extremities. AJR Am J Roentgenol 1986;147:567-9.
2.
Bauer AR Jr, Yutani D. Computed tomographic localization of wooden foreign bodies in children’s extremities. Arch Surg 1983;118:1084-6.
3.
Boyse TD, Fessell DP, Jacobson JA, Lin J, van Holsbeeck MT, Hayes CW. US of soft tissue foreign bodies and associated complications with surgical correlation. Radiographics 2001;21:1251-6.
4.
Yanay O, Vaughan DJ, Diab M, Brownstein D, Brogan TV. Retained wooden foreign body in a child’s thigh complicated by severe necrotizing fasciitis: A case report and discussion of imaging modalities for early diagnosis. Pediatr Emerg Care 2001;17:354-5.
5.
Gulati D, Agarwal A. Wooden foreign body in the forearm — presentation after eight years. Ulus Travma Acil Cerrahi Derg 2010;16:373-5.
6.
Davae KC, Sofka CM, DiCarlo E, Adler RS. Value of power Doppler imaging and the hypoechoic halo in the sonographic detection of foreign bodies: Correlation with histopathologic findings. J Ultrasound Med 2003;22:1309-13.
peritoneal lavage or surgery to assess the diagnostic value of ultrasonography. The Epi Info statistical software version 3.4.1 was used for data analysis. By scanning to detect free fluid, sensitivity, specificity, positive and negative predictive values and the diagnostic accuracy were 96%, 67%, 94%, 75%, and 91% respectively. By scanning to detect the parenchymal injury, sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were 71%, 35%, 62%, 44%, and 56% respectively. In conclusion, ultrasonography has a high diagnostic value in the screening of patients with blunt abdominal trauma. Scanning for the presence of free fluid yields better results than scanning for the visceral parenchymal injury.
Michael I Nnamonu Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria E-mail: [email protected]
Access this article online Quick Response Code: Website: www.onlinejets.org
DOI: 10.4103/0974-2700.120393
Diagnostic value of abdominal ultrasonography in patients with blunt abdominal trauma Sir, Despite the trend to comprehensively investigate the patients with blunt abdominal trauma with a computerized tomography scan, diagnostic ultrasonography remains an important tool more so where computed tomography is not available or condition of the patient precludes transfer to the radiology suite.[1-3] This study assessed the diagnostic value of ultrasonography in blunt abdominal injury. It was a prospective study conducted at the Department of Surgery, Jos University Teaching Hospital from 1 January 2006 to 31 December 2007. Fifty-seven patients who had ultrasonography for blunt abdominal trauma had their sonographic findings compared with findings at diagnostic 308
REFERENCES 1.
Stengel D, Bauwens K, Porzsolt F, Rademacher G, Mutze S, Ekkernkamp A. Emergency ultrasound for blunt abdominal trauma – Meta-analysis update 2003. Zentralbl Chir 2003;128:1027-37.
2.
Breyer B, Bruguera CA, Gharbi HA, Goldberg BB, Tan FE, Wachira MW. Preface. In: Palmer PE, editor. Manual of Diagnostic Ultrasound. Geneva: World Health Organization; 2004. p. vii-viii.
3.
Yoshii H, Sato M, Yamamoto S, Motegi M, Okusawa S, Kitano M, et al. Usefulness and limitations of ultrasonography in the initial evaluation of blunt abdominal trauma. J Trauma 1998;45:45-50. Access this article online Quick Response Code: Website: www.onlinejets.org
DOI: 10.4103/0974-2700.120395
Bilateral luxatio erecta humeri with a unilateral brachial plexus injury Sir, Luxatio erecta is a rare inferior glenohumeral dislocation accounting for only 0.5% of all shoulder dislocations.[1] Bilateral Journal of Emergencies, Trauma, and Shock I 6:4 I Oct - Dec 2013
Letters to Editor
A 19-year-old male front seat passenger was brought to the Emergency Department (ED) subsequent to a RTA. The ambulance crew noted that the patient held both his arms in an abducted position and any movement of the arms were painful. He was immobilized on a spinal board in this unusual position [Figure 1]. He had an obvious right lower limb injury which was immobilized with a splint.
Figure 1: Photograph of the patient with bilateral inferior shoulder dislocations immobilized on a spinal board. The arms are held in an abducted position with the elbows flexed and forearms pronated. The humeral heads (white arrows) were readily palpable on the lateral chest wall
On clinical examination both arms were abducted, the elbows flexed and forearms pronated. The humeral heads were palpable in the axilla on the lateral chest wall [Figure 1]. Paraesthesia of the left arm along a C6 and C7 dermatomes were present. A right tibial shaft fracture was identified and immobilized appropriately. Computerized tomography scan of the thorax revealed bilateral inferior dislocations associated with avulsion fracture of the greater tuberosity [Figure 2] as well as bilateral pneumothoraxes for which chest drains were sited. Closed reduction of the shoulders was performed with traction and counter traction to the abducted arm under a general anesthetic prior to intramedullary nailing of the tibial fracture. The shoulders reduced easily [Figure 3] and were immobilized in a sling with the arms in adduction and internal rotation. Post-operative examination revealed a left wrist drop and loss of finger extension. However, they began to improve by the third post-operative day with full resolution by 2 weeks.
Figure 2: Three-dimensional reconstruction of the computerized tomography scan of the thorax demonstrating bilateral inferior dislocations with associated with avulsion fracture of the greater tuberosity
Physiotherapy was commenced at 3 weeks and at the 6 months follow-up, the patient had a good range of motion to both shoulders without neurovascular deficits. Luxatio erecta has a high incidence of associated injuries with up to 80% having, either a fracture of the greater tuberosity or a rotator cuff tear, up to 60% having a neurological deficit, however vascular injuries are uncommon.[2] Our patient sustained a transient wrist drop, loss of finger extension and paraesthesia, which likely resulted from stretching of the posterior cord of the brachial plexus during the dislocation. Treatment is generally by closed reduction. Traction to the abducted arm with counter traction is the most commonly used reduction technique.[3,4] Post-reduction, the shoulder is immobilized for at least 2 weeks with the subsequent commencement of physiotherapy. Long-term prognosis is good in most of these patients.[5]
Figure 3: Radiographs demonstrating satisfactory reduction of both shoulder joints
luxatio erecta is rarer still with only a few cases reported. We present a case of successful closed reduction of bilateral luxatio erecta sustained subsequent to a road traffic accident (RTA). Journal of Emergencies, Trauma, and Shock I 6:4 I Oct - Dec 2013
These dislocations add an additional layer of complexity to managing the poly-traumatized patient in the ED. Satisfactory immobilization of the cervical spine can be difficult due to the abducted arms. Log rolling of the patient while performing the initial and subsequent examinations in our case required additional time and personnel. However, the abducted arms made it easier to site the chest drains. 309
Letters to Editor
Prasad Ellanti, Nikolaos Davarinos, Mary J Connolly, Hamid A Khan Department of Trauma Orthopaedics, Adelaide & Meath Incorporating National Children’s Hospital, Tallaght, Dublin 24, Ireland. E-mail: [email protected]
REFERENCES 1.
Laskin RS, Sedlin ED. Luxatio erecta in infancy. Clin Orthop Relat Res 1971;80:126-9.
2.
Mallon WJ, Bassett FH 3rd, Goldner RD. Luxatio erecta: The inferior glenohumeral dislocation. J Orthop Trauma 1990;4:19-24.
3.
Pirrallo RG, Bridges TP. Luxatio erecta: A missed diagnosis. Am J Emerg Med 1990;8:315-7.
4.
Musmeci E, Gaspari D, Sandri A, Regis D, Bartolozzi P. Bilateral luxatio erecta humeri associated with a unilateral brachial plexus and bilateral rotator cuff injuries: A case report. J Orthop Trauma 2008;22:498-500.
5.
Groh GI, Wirth MA, Rockwood CA Jr. Results of treatment of luxatio erecta (inferior shoulder dislocation). J Shoulder Elbow Surg 2010;19:423-6. Access this article online Quick Response Code: Website: www.onlinejets.org
DOI: 10.4103/0974-2700.120396
Very bad clinical aspect towards diagnosis of deep femoral artery injury: Hypovolemic shock Sir, Isolated profunda femoris artery penetrating injury is rare and has been reported as a consequence of injury, orthopedic procedures, and catheterization.[1] In these patients, delayed diagnosis and treatment may be due to late admission to emergency department, presence of pulses on related lower limb, and also not causing arterial circulatory disorders. In our hospital, 17‑year‑old male patient with penetrating injury on left lateral part of the thigh was brought to the emergency department. After opening the external bandage, a 3 cm long skin incision was observed. In the meantime, there were no significant findings that suggestive of remarkable bleeding or 310
hematoma. On physical examination, the pulses on injured lower limb were observed. On follow‑up, deterioration of the general condition and development of patient confusion, he was urgently taken to the operating room and then lateral thigh incision was enlarged and searched source of hemorrhage. Profunda femoral vein and artery were clamped. By removing the wide injured sections on the vessels, saphenous vein graft was interposed in these segments. After an uneventful recovery, he was discharged on the 8th postoperative day. The most common cause of peripheral arterial injuries was stab and gunshot‑related injuries.[1] The etiologies of vascular injuries especially in young males, in our country, 50-70% are gunshot injury and stab wounds.[2,3] Early diagnosis and appropriate treatment can reduce mortality and morbidity in vascular injuries. In the early period, it is difficult to diagnose profunda femoral artery injuries.[1,2] In our case, the patient had no significant bleeding when he was in the emergency department and before admission to hospital, wound area was bandaged. Hemodynamic parameters were stable but within minutes progressive hypotension and confusion were occurred and then the patient was immediately operated. False‑negative rate was 1.3% in penetrating extremity injuries with only physical examination and a 24 h observation.[4] However, similar results have been reported by arteriography and surgical exploration (3-6%). Therefore, while no significant physical examination findings in the diagnosis of profunda femoral artery injury, clinical observation is more important.[4,5] In the vascular injuries, repair of vessels must be the first treatment option. Significant contribution to the development of collateral vessels and the lower extremity arterial circulation, the profunda femoral artery ligation is not recommended.[1‑3] In peripheral vascular diseases with diabetic and non‑diabetic, profunda femoral artery is the most considerable vessel, limb preservation of the infrapopliteal region through the nutrition with providing of collateral circulation.[4,5] As a result, in the profunda femoral artery injuries, the presence of lower limb palpable pulses, ankle/brachial index levels within normal limits, and efficient distal blood flow may hinder aiding accurate diagnosis. Consequently, performing emergency vascular access and volume replacement to patients if wound is closer to the deep femoral artery anatomy as well as estimating amount of bleeding by a detailed anamnesis, closer monitoring of the patient and we also believe that if stab wound area was bandaged, opening the bandage and establishing the presence of bleeding would be the most appropriate approach.
Faruk Cingoz, Gokhan Arslan, Erkan Kaya, Bilgehan Savas Oz Department of Cardiovascular Surgery, Gulhane Military Medical Academy, Ankara, Turkey. E‑mail: [email protected] Journal of Emergencies, Trauma, and Shock I 6:4 I Oct - Dec 2013
Copyright of Journal of Emergencies, Trauma & Shock is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
