Refer to: Bovill EG: Orthopedic emergencies (Trauma Rounds). West J Med 122:76-79, Jan 1975
Trauma ounds Chief Discussant... EDWIN. G .BOVILL, M.D Editors DONALD D. TRUNKEY, MD F. WILLIAM BLAISDELL, MD
Orthopedic Emergen c/es
This Is one of a series at Conferences on Trauma at San Francisco General Hfosptal:
CLARK BOREN, MD: * The patient, a 27-year-old woman, was struck by a car and crushed as she walked around the rear of another vehicle. She was brought immediately to Mission Emergency Hospital. On physical examination the patient was seen to be in compensated shock characterized by tachycardia, hypotension and mild agitation. There were no obvious head injuries. However, a cerebral arteriogram made several hours later showed frontal lobe contusion. The chest was clear to auscultation and the abdomen was soft with no guarding. On examination of the lower extremities, compound fractures of both femurs and of both lower extremities including the tibia and fibia were noted. There was a severe degloving injury involving both upper legs to the knees. The skin from the legs was rolled up onto the lower abdomen, which was also partially involved in the degloving injury. There were palpable pedal pulses on the left but no pulses on the right. Capillary filling of the right foot was good. Resuscitation was carried out with the appropriate placement of large bore catheters and the administration of two liters of Ringer's lactate. On exploratory laparotomy, done four hours after admission, no significant intraperitoneal injuries were noted. The fractures were managed by bilateral intramedullary rods to the femur and short *Trauma Service Intern. Sponsored by the American College of Surgeons Northern California Trauma Committee. Supported in part by NIH Grant GM18470. Reprint requests to: D. D. Trunkey, MD, Department of Surgery, San Francisco General Hospital, San Francisco, CA 94110.
76
JANUARY 1975 * 122 * 1
leg casts. The extensive degloving injury was debrided, defatted and replaced as a full-thickness skin graft over the injury. The patient's intraoperative course was very stormy, with extensive bleeding from all wounds and fracture sites. At one point there was no palpable blood pressure, necessitating reopening of the abdomen and clamping the abdominal aorta. Fluid replacement during operation consisted of 20 units of whole blood, 6 liters of colloid and 3 of crystalloid solution. Since the initial operation, five subsequent operations for management of the lower extremity fractures have been required, consisting for the most part of realignment and placement of tibial pins. In addition, multiple skin grafting over the degloving injuries was necessary, particularly on the thigh. At present, however, the patient's wounds are 95 percent covered. Depressed sensorium due to the frontal lobe contusion was treated with dexamethasone (Decadron®) and there has been a complete recovery neurologically. DONALD D. TRUNKEY, MD;t I have two questions in regard to the course of this patient. First, was there a pelvic fracture in addition to the other injuries and second, were there any pulmonary complications? DR. BOREN: Yes, there was a type III pelvic fracturet involving the left pubic ramis. In regard to pulmonary function, the patient did remarkably tChief of Surgery, Mission Emergency Hospital; Assistant Professor of Surgery, University of California, San Francisco.
TRAUMA ROUNDS
well and there were no overt signs of the respiratory distress syndrome. DR. TRUNKEY: Treatment of this patient represents a triumph in regard to resuscitation but more importantly, it was a triumph from an orthopedic standpoint. The management was optimal, in that the lesion was potentially fatal. We have asked Dr. Edwin Bovill to give his concepts of care in the type of case that has been presented today.
EDWIN G. BOVILL, MD:* I would preface my remarks by stating that usually orthopedic injuries are not life threatening. However, there are four situations where the management of a traumatized patient's orthopedic problems assumes a higher priority when accompanying many of the usually more urgent general surgical problems. These include in particular, fractures or dislocations of the spine, compound fractures, fractures associated with vascular compromise and fracture dislocations. It behooves the emergency physician to be aware of the possibility of a spine fracture and to protect the patient to prevent any, or further, neurological damage. In particular the emergencyroom physician must recognize that in multiply injured patients there may be many other more dramatic symptoms and signs than those accompanying a complete or partial spinal cord injury, and that every traumatized patient should have a sufficient preliminary gross neurologic survey to detect such a possibility. Unconscious patients, in particular, represent a clinical situation where paraplegia or quadriplegia or perhaps evidence of partial spinal cord injury can easily be overlooked since the lack of movement of the extremities is attributed to a more central lesion rather than to spinal cord involvement. Flaccid paralysis and the absence of withdrawal from pain stimuli are hallmarks suggesting acute spinal cord injury in comatose patients. Open fractures or dislocations require meticulous debridement and irrigation of the wound,
frequently followed by subsequent secondary closure or grafting to cover the wound. Although compound fractures are not of themselves lifethreatening, in the emergency situation the incidence of residual infection with ultimate chronic osteomyelitis and possible loss of limb increases as the time increases between injury and debride*Chief of Orthopedics, San Francisco General Hospital; Professor of Orthopedic Surgery, University of Califomia, San Francisco.
ment. Optimally, a compound fracture should be treated within six to eight hours of injury, since contamination usually remains superficial up to this point. From this time on, progressive bacterial invasion of the soft tissues takes place and local treatment may not be as effective in removing contamination. The third area that requires urgent definitive treatment is the fracture associated with vascular impairment due either to a large artery laceration or compartmental vascular compression. The initial evaluation of the fractures should include a careful evaluation of the circulatory status of the limb. A warm extremity with good pulses is reassurance that vascular compromise is negligible. On the other extreme, a cool pulseless extremity, without sensation or with impaired muscle function is a nonviable limb. A cool limb with impaired pulses but intact sensation is a marginal limb. If reduction of the fracture does not result in immediate improvement of circulation, arteriographic studies are indicated and can usually be done on the operating table without the need to resort to special equipment. Arterial repair should be made for any injury detected-preferably within four to six hours of injury to avoid the development of ischemic damage, muscle swelling and secondary vascular compression due to the development of one of the compartmental compression syndromes. Immediate decompression of the compartmental syndrome, unaccompanied by major artery injury, by fasciotomy can salvage muscle compartments or limbs. However, this must be begun early if it is to be of significant benefit. It is particularly important that following repair of a major arterial injury, skeletal fixation be achieved when possible to protect the arterial repair from reinjury from adjacent fracture fragments. Another injury that requires immediate treatment is joint dislocation. The most important areas are the hip and knee. It is well documented that leaving a hip dislocated for periods longer than six to eight hours is associated with a high incidence of avascular necrosis of the femoral head with residual permanent disability. Most dislocations in the extremities are readily apparent to the emergency-room physician and are relatively easy to reduce. The knee presents somewhat of a special problem since it has a higher incidence of major vascular damage and associated potential loss of limb due to the close relationships of the popliteal vessels to the dislocated parts. We THE WESTERN JOURNAL OF MEDICINE
77
TRAUMA ROUNDS
consider it good judgment to do arteriographic studies in all knee dislocations as part of the initial assessment. Repair of any vascular injury detected assumes priority in the patient's management. The last area that I wish to call your attention to is particularly poignant in regards to this patient. This is the treatment of fractures associated with severe soft tissue injury. In this patient, there not only was massive soft tissue injury but also multiple associated injuries. This puts the patient at risk for fat embolism or the disseminated intravascular clotting syndrome. This syndrome results from a combination of extensive soft tissue injury and shock. Internal fixation helped to reduce the likelihood of further soft tissue injury. In addition, it permitted early mobilization, which is so essential in these patients to prevent the pulmonary complications so frequently seen following multiple injuries of this severity. In this patient, bilateral intramedullary rods were placed, making it much easier for the nurse to move the patient and obtain optimal ventilation of all lung segments. The full-thickness skin loss involving all of both thighs in this particular patient created bilateral circumferential massive soft tissue wounds, interlaced with varying degrees of crush injury to the musculature. This could only have been managed in traction with any semblance of efficiency by placing the hips at 90 degrees and confining the patient to bed with little attention to fracture position. The internal fixation of this patient afforded stable fixation, not only for the femoral fracture, but also "splinted" the soft parts with the associated benefit in the later attempts to secure skin cover. I would now like to turn the discussion over to Dr. Kevin Harrington, who was the orthopedic surgeon in charge of this patient. KEVIN HARRINGTON, MD:* My comments will be confined to the management of this patient. The case represents the classic dilemma that the orthopedic surgeon is faced with in regard to immediate management. Although abdominal problems and cerebral problems in this patient were managed quickly, there still was a problem of volume loss due to continued loss of blood into the soft tissues around the fracture sites. In addition, I thought that the continuous soft tissue blood loss was ag*Staff Surgeon, San Francisco General Hospital; Assistant Professor of Orthopedic Surgery, University of California, San Francisco.
78
JANUARY 1975 * 122 * 1
gravated by the flail nature of the fractures. This in itself was an indication for internal fixation. Certainly nonoperative management would have led to necrosis of the flaps and infection. Another comment I would make about the management of this patient was the need for especially meticulous debridement and hemostasis for treatment of the soft tissue injuries. I think that this is another very important adjunct in preventing infection and further blood loss, and minimizing the amount of postoperative pulmonary complications. The degloving injury most certainly would have become necrotic and infected, and sloughed had it not been treated by immediate operation. The other reason, which has already been mentioned, for internal fixation was to avoid the need for some type of skeletal traction which would have created a difficult nursing problem and made respiratory care difficult. A good argument could be made that the additional time required to place the intramedullary rods in this patient might have been detrimental. If the patient had died during the hypotensive episode, I am sure the orthopedic department could have been criticized. On the other hand, if we had not proceeded with placing intramedullary bilateral rods, I am sure that an equally strong criticism could be made if the patient had died in the postoperative period from complications which could be related to the immobilization required to treat the fractures. Even if the pulmonary complications had not developed, I am sure that one or both limbs would have been lost secondary to infection. It is because of these two opposing options that this patient presented a difficult clinical judgment problem at the time of initial management. Some orthopedic surgeons would be very critical of placing intramedullary rods. Our experience, at this hospital, is supported by that of Gregory at Parkland Hospital. Extensive injuries of this type are optimally managed by internal fixation. This ultimately will result in less mortality and morbidity despite the increased initial risk. DR. TRUNKEY: Dr. Blaisdell, would you have been critical of the decision to proceed with the extensive orthopedic procedures done in this unstabile patient? F. WILLIAM BLAISDELL, MD:t I find myself agreeing completely with Drs. Bovill and Harrington. jtChief of Surgical Service, San Francisco General Hospital; Professor of Surgery, University of California, San Francisco.
TRAUMA ROUNDS
The only alternative treatment available for these injuries was traction. This would have resulted in complete immobilization of this patient in a supine position. Respiratory complications would have been inevitable. Atelectasis, fat embolism, respiratory distress syndrome of trauma and pulmonary embolism are all hazards that this patient was subject to. These are preventable, at least in part by early mobilization. The avulsion injury was another major problem and debridement was necessary to salvage skin coverage and prevent infection. Septic complications introduce an entirely new threat and major wound complication and in themselves are associated with a high incidence of respiratory failure. Operative treatment was the key to management in this case. In my opinion there is no such thing as a patient injured too badly to tolerate surgical operation. If a patient's injuries are so extensive as to be considered critical, operative treatment is mandatory to control blood loss, correct life-endangering problems and reverse the critical trend.
A conservative estimate in this case would be that 2,000 ml of blood was lost from each of the open femur fractures, another 1,000 ml from each of the lower leg fractures and an indeterminate amount-at least another 1,000 ml-from the pelvic fractures. Since the patient's blood volume was not much over 5 liters, the potential volume loss from these injuries, if untreated, was sufficient to cause fatality. The orthopedic surgeon all too often underestimates the volume loss generated by "simple" fractures. Failure to initiate prompt volume resuscitation results in prolonged hypovolemia and all the secondary hazards such as respiratory failure. We monitor these patients carefully and use as the end point of resuscitation, good urine output and good peripheral perfusion as shown by warm, pink extremities. DR. TRUNKEY: Dr. Bovill, the points you have made today should be helpful to all of us. I would like to emphasize your point that there are four categories of true orthopedic emergencies: (1) fractures or dislocations of the spine, (2) compound fractures, (3) fracture dislocations and (4) fractures associated with vascular compromise. All of these require prompt evaluation and treatment-optimally, within six to eight hours of
DR. TRUNKEY: Dr. Bovill, I would like to ask you a question about the amount of blood which can be sequestered in a long bone fracture, such as one involving the femur. Would you comment on that please?
injury.
DR. BOVILL: In a closed femur fracture alone, 1,000 to 2,000 ml of blood can be sequestered.
Management of pelvic fractures (Trauma Rounds). West J Med 120:421424, May 1974
REFERENCE 1. Chapman M:
THE WESTERN JOURNAL OF MEDICINE
79
Trauma ounds Chief Discussant... EDWIN. G .BOVILL, M.D Editors DONALD D. TRUNKEY, MD F. WILLIAM BLAISDELL, MD
Orthopedic Emergen c/es
This Is one of a series at Conferences on Trauma at San Francisco General Hfosptal:
CLARK BOREN, MD: * The patient, a 27-year-old woman, was struck by a car and crushed as she walked around the rear of another vehicle. She was brought immediately to Mission Emergency Hospital. On physical examination the patient was seen to be in compensated shock characterized by tachycardia, hypotension and mild agitation. There were no obvious head injuries. However, a cerebral arteriogram made several hours later showed frontal lobe contusion. The chest was clear to auscultation and the abdomen was soft with no guarding. On examination of the lower extremities, compound fractures of both femurs and of both lower extremities including the tibia and fibia were noted. There was a severe degloving injury involving both upper legs to the knees. The skin from the legs was rolled up onto the lower abdomen, which was also partially involved in the degloving injury. There were palpable pedal pulses on the left but no pulses on the right. Capillary filling of the right foot was good. Resuscitation was carried out with the appropriate placement of large bore catheters and the administration of two liters of Ringer's lactate. On exploratory laparotomy, done four hours after admission, no significant intraperitoneal injuries were noted. The fractures were managed by bilateral intramedullary rods to the femur and short *Trauma Service Intern. Sponsored by the American College of Surgeons Northern California Trauma Committee. Supported in part by NIH Grant GM18470. Reprint requests to: D. D. Trunkey, MD, Department of Surgery, San Francisco General Hospital, San Francisco, CA 94110.
76
JANUARY 1975 * 122 * 1
leg casts. The extensive degloving injury was debrided, defatted and replaced as a full-thickness skin graft over the injury. The patient's intraoperative course was very stormy, with extensive bleeding from all wounds and fracture sites. At one point there was no palpable blood pressure, necessitating reopening of the abdomen and clamping the abdominal aorta. Fluid replacement during operation consisted of 20 units of whole blood, 6 liters of colloid and 3 of crystalloid solution. Since the initial operation, five subsequent operations for management of the lower extremity fractures have been required, consisting for the most part of realignment and placement of tibial pins. In addition, multiple skin grafting over the degloving injuries was necessary, particularly on the thigh. At present, however, the patient's wounds are 95 percent covered. Depressed sensorium due to the frontal lobe contusion was treated with dexamethasone (Decadron®) and there has been a complete recovery neurologically. DONALD D. TRUNKEY, MD;t I have two questions in regard to the course of this patient. First, was there a pelvic fracture in addition to the other injuries and second, were there any pulmonary complications? DR. BOREN: Yes, there was a type III pelvic fracturet involving the left pubic ramis. In regard to pulmonary function, the patient did remarkably tChief of Surgery, Mission Emergency Hospital; Assistant Professor of Surgery, University of California, San Francisco.
TRAUMA ROUNDS
well and there were no overt signs of the respiratory distress syndrome. DR. TRUNKEY: Treatment of this patient represents a triumph in regard to resuscitation but more importantly, it was a triumph from an orthopedic standpoint. The management was optimal, in that the lesion was potentially fatal. We have asked Dr. Edwin Bovill to give his concepts of care in the type of case that has been presented today.
EDWIN G. BOVILL, MD:* I would preface my remarks by stating that usually orthopedic injuries are not life threatening. However, there are four situations where the management of a traumatized patient's orthopedic problems assumes a higher priority when accompanying many of the usually more urgent general surgical problems. These include in particular, fractures or dislocations of the spine, compound fractures, fractures associated with vascular compromise and fracture dislocations. It behooves the emergency physician to be aware of the possibility of a spine fracture and to protect the patient to prevent any, or further, neurological damage. In particular the emergencyroom physician must recognize that in multiply injured patients there may be many other more dramatic symptoms and signs than those accompanying a complete or partial spinal cord injury, and that every traumatized patient should have a sufficient preliminary gross neurologic survey to detect such a possibility. Unconscious patients, in particular, represent a clinical situation where paraplegia or quadriplegia or perhaps evidence of partial spinal cord injury can easily be overlooked since the lack of movement of the extremities is attributed to a more central lesion rather than to spinal cord involvement. Flaccid paralysis and the absence of withdrawal from pain stimuli are hallmarks suggesting acute spinal cord injury in comatose patients. Open fractures or dislocations require meticulous debridement and irrigation of the wound,
frequently followed by subsequent secondary closure or grafting to cover the wound. Although compound fractures are not of themselves lifethreatening, in the emergency situation the incidence of residual infection with ultimate chronic osteomyelitis and possible loss of limb increases as the time increases between injury and debride*Chief of Orthopedics, San Francisco General Hospital; Professor of Orthopedic Surgery, University of Califomia, San Francisco.
ment. Optimally, a compound fracture should be treated within six to eight hours of injury, since contamination usually remains superficial up to this point. From this time on, progressive bacterial invasion of the soft tissues takes place and local treatment may not be as effective in removing contamination. The third area that requires urgent definitive treatment is the fracture associated with vascular impairment due either to a large artery laceration or compartmental vascular compression. The initial evaluation of the fractures should include a careful evaluation of the circulatory status of the limb. A warm extremity with good pulses is reassurance that vascular compromise is negligible. On the other extreme, a cool pulseless extremity, without sensation or with impaired muscle function is a nonviable limb. A cool limb with impaired pulses but intact sensation is a marginal limb. If reduction of the fracture does not result in immediate improvement of circulation, arteriographic studies are indicated and can usually be done on the operating table without the need to resort to special equipment. Arterial repair should be made for any injury detected-preferably within four to six hours of injury to avoid the development of ischemic damage, muscle swelling and secondary vascular compression due to the development of one of the compartmental compression syndromes. Immediate decompression of the compartmental syndrome, unaccompanied by major artery injury, by fasciotomy can salvage muscle compartments or limbs. However, this must be begun early if it is to be of significant benefit. It is particularly important that following repair of a major arterial injury, skeletal fixation be achieved when possible to protect the arterial repair from reinjury from adjacent fracture fragments. Another injury that requires immediate treatment is joint dislocation. The most important areas are the hip and knee. It is well documented that leaving a hip dislocated for periods longer than six to eight hours is associated with a high incidence of avascular necrosis of the femoral head with residual permanent disability. Most dislocations in the extremities are readily apparent to the emergency-room physician and are relatively easy to reduce. The knee presents somewhat of a special problem since it has a higher incidence of major vascular damage and associated potential loss of limb due to the close relationships of the popliteal vessels to the dislocated parts. We THE WESTERN JOURNAL OF MEDICINE
77
TRAUMA ROUNDS
consider it good judgment to do arteriographic studies in all knee dislocations as part of the initial assessment. Repair of any vascular injury detected assumes priority in the patient's management. The last area that I wish to call your attention to is particularly poignant in regards to this patient. This is the treatment of fractures associated with severe soft tissue injury. In this patient, there not only was massive soft tissue injury but also multiple associated injuries. This puts the patient at risk for fat embolism or the disseminated intravascular clotting syndrome. This syndrome results from a combination of extensive soft tissue injury and shock. Internal fixation helped to reduce the likelihood of further soft tissue injury. In addition, it permitted early mobilization, which is so essential in these patients to prevent the pulmonary complications so frequently seen following multiple injuries of this severity. In this patient, bilateral intramedullary rods were placed, making it much easier for the nurse to move the patient and obtain optimal ventilation of all lung segments. The full-thickness skin loss involving all of both thighs in this particular patient created bilateral circumferential massive soft tissue wounds, interlaced with varying degrees of crush injury to the musculature. This could only have been managed in traction with any semblance of efficiency by placing the hips at 90 degrees and confining the patient to bed with little attention to fracture position. The internal fixation of this patient afforded stable fixation, not only for the femoral fracture, but also "splinted" the soft parts with the associated benefit in the later attempts to secure skin cover. I would now like to turn the discussion over to Dr. Kevin Harrington, who was the orthopedic surgeon in charge of this patient. KEVIN HARRINGTON, MD:* My comments will be confined to the management of this patient. The case represents the classic dilemma that the orthopedic surgeon is faced with in regard to immediate management. Although abdominal problems and cerebral problems in this patient were managed quickly, there still was a problem of volume loss due to continued loss of blood into the soft tissues around the fracture sites. In addition, I thought that the continuous soft tissue blood loss was ag*Staff Surgeon, San Francisco General Hospital; Assistant Professor of Orthopedic Surgery, University of California, San Francisco.
78
JANUARY 1975 * 122 * 1
gravated by the flail nature of the fractures. This in itself was an indication for internal fixation. Certainly nonoperative management would have led to necrosis of the flaps and infection. Another comment I would make about the management of this patient was the need for especially meticulous debridement and hemostasis for treatment of the soft tissue injuries. I think that this is another very important adjunct in preventing infection and further blood loss, and minimizing the amount of postoperative pulmonary complications. The degloving injury most certainly would have become necrotic and infected, and sloughed had it not been treated by immediate operation. The other reason, which has already been mentioned, for internal fixation was to avoid the need for some type of skeletal traction which would have created a difficult nursing problem and made respiratory care difficult. A good argument could be made that the additional time required to place the intramedullary rods in this patient might have been detrimental. If the patient had died during the hypotensive episode, I am sure the orthopedic department could have been criticized. On the other hand, if we had not proceeded with placing intramedullary bilateral rods, I am sure that an equally strong criticism could be made if the patient had died in the postoperative period from complications which could be related to the immobilization required to treat the fractures. Even if the pulmonary complications had not developed, I am sure that one or both limbs would have been lost secondary to infection. It is because of these two opposing options that this patient presented a difficult clinical judgment problem at the time of initial management. Some orthopedic surgeons would be very critical of placing intramedullary rods. Our experience, at this hospital, is supported by that of Gregory at Parkland Hospital. Extensive injuries of this type are optimally managed by internal fixation. This ultimately will result in less mortality and morbidity despite the increased initial risk. DR. TRUNKEY: Dr. Blaisdell, would you have been critical of the decision to proceed with the extensive orthopedic procedures done in this unstabile patient? F. WILLIAM BLAISDELL, MD:t I find myself agreeing completely with Drs. Bovill and Harrington. jtChief of Surgical Service, San Francisco General Hospital; Professor of Surgery, University of California, San Francisco.
TRAUMA ROUNDS
The only alternative treatment available for these injuries was traction. This would have resulted in complete immobilization of this patient in a supine position. Respiratory complications would have been inevitable. Atelectasis, fat embolism, respiratory distress syndrome of trauma and pulmonary embolism are all hazards that this patient was subject to. These are preventable, at least in part by early mobilization. The avulsion injury was another major problem and debridement was necessary to salvage skin coverage and prevent infection. Septic complications introduce an entirely new threat and major wound complication and in themselves are associated with a high incidence of respiratory failure. Operative treatment was the key to management in this case. In my opinion there is no such thing as a patient injured too badly to tolerate surgical operation. If a patient's injuries are so extensive as to be considered critical, operative treatment is mandatory to control blood loss, correct life-endangering problems and reverse the critical trend.
A conservative estimate in this case would be that 2,000 ml of blood was lost from each of the open femur fractures, another 1,000 ml from each of the lower leg fractures and an indeterminate amount-at least another 1,000 ml-from the pelvic fractures. Since the patient's blood volume was not much over 5 liters, the potential volume loss from these injuries, if untreated, was sufficient to cause fatality. The orthopedic surgeon all too often underestimates the volume loss generated by "simple" fractures. Failure to initiate prompt volume resuscitation results in prolonged hypovolemia and all the secondary hazards such as respiratory failure. We monitor these patients carefully and use as the end point of resuscitation, good urine output and good peripheral perfusion as shown by warm, pink extremities. DR. TRUNKEY: Dr. Bovill, the points you have made today should be helpful to all of us. I would like to emphasize your point that there are four categories of true orthopedic emergencies: (1) fractures or dislocations of the spine, (2) compound fractures, (3) fracture dislocations and (4) fractures associated with vascular compromise. All of these require prompt evaluation and treatment-optimally, within six to eight hours of
DR. TRUNKEY: Dr. Bovill, I would like to ask you a question about the amount of blood which can be sequestered in a long bone fracture, such as one involving the femur. Would you comment on that please?
injury.
DR. BOVILL: In a closed femur fracture alone, 1,000 to 2,000 ml of blood can be sequestered.
Management of pelvic fractures (Trauma Rounds). West J Med 120:421424, May 1974
REFERENCE 1. Chapman M:
THE WESTERN JOURNAL OF MEDICINE
79
