Journal of Trauma and Injury

Case Reports

Reperfusion injury or cytokine storm? Utilizing plasmapheresis in severe trauma-induced multiorgan failure: a case report: Gun Woo Kim, Suyeong Hwang, Kyoung Hoon Lim, Sung Hoon Cho; Received July 29, 2024 Accepted September 24, 2024 Published online December 4, 2024; DOI: https://doi.org/10.20408/jti.2024.0051 [Epub ahead of print]

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Abstract PDF: Reperfusion injury can cause tissue damage due to ischemia, with severe cases potentially resulting in multiorgan failure. Cytokine storm, a life-threatening systemic inflammatory state characterized by elevated levels of circulating cytokines and hyperactive immune cells, can also lead to tissue damage and multiorgan failure. Reperfusion injury and cytokine storm sometimes exhibit similar clinical features, necessitating specific treatment in severe cases. A 31-year-old man sustained a stab wound to his left knee. Computed tomography angiography and surgical exploration revealed a transection of the left popliteal artery and vein. Both vessels were revascularized via end-to-end anastomosis approximately 3 hours after the injury. On postoperative day 2, marked increases were observed in levels of aspartate aminotransferase (8,600 U/L), alanine transaminase (6,690 U/L), creatine phosphokinase (26,817 U/L), and lactate dehydrogenase (7,398 U/L) levels. Elevated levels of interleukin 6 (178 pg/mL) and ferritin (41,079 ng/mL) were also noted. Given the possibility of either reperfusion injury or cytokine storm, plasmapheresis was initiated. Following two rounds of plasmapheresis, the patient’s condition rapidly improved, and he was discharged without complications. Reperfusion injury can arise when a target blood vessel is revascularized, particularly during severe stages of ischemia. Cytokine storm represents a life-threatening systemic inflammatory state characterized by high levels of circulating cytokines and overactive immune cells. Both reperfusion injury and cytokine storm can cause systemic inflammation and multiorgan failure. These two conditions may exhibit similar clinical features, necessitating supportive care primarily to prevent organ dysfunction. However, plasmapheresis may represent an effective treatment option in cases of severe progression.; Summary

Treatment of placental abruption following blunt abdominal trauma: a case report: Jinjoo Kim, Seokyung Kim, Dongwook Kwak, Donghwan Choi; Received July 23, 2024 Accepted October 7, 2024 Published online December 4, 2024; DOI: https://doi.org/10.20408/jti.2024.0050 [Epub ahead of print]

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Abstract PDF: Trauma during pregnancy poses a potentially tragic risk to both the fetus and mother, making its management particularly challenging. Here, we present the case of a 35-year-old woman at 34 weeks and 2 days gestation who was in a motor vehicle accident and subsequently suffered placental abruption and underwent an emergency cesarean section. We also present a review of traumatic placental abruption and its epidemiology. On arrival at the trauma bay, the patient showed no significant abdominal findings other than a seat belt sign. However, 2 hours after admission, the patient developed abdominal pain and vaginal bleeding. Ultrasonography revealed no clear evidence of placental abruption. This case demonstrates the necessity of close maternal and fetal monitoring with cooperation between the trauma and obstetric teams. Even in the absence of typical symptoms such as abdominal pain on initial presentation, a high-energy mechanism of injury should be suspected.; Summary

Original Article

Injuries from blank cartridge shots in suicide attempts within the South Korean military: a case series of five patients: Jeong Il Joo, Changsin Lee, Kyungwon Lee; Received June 17, 2024 Accepted September 23, 2024 Published online December 4, 2024; DOI: https://doi.org/10.20408/jti.2024.0037 [Epub ahead of print]

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Abstract PDF: Purpose
Blank cartridges are designed to produce the sound and gas flare of a gunshot without firing a bullet. However, blank cartridge shots (BCS) can still cause injuries ranging from minor to life-threatening. Within the South Korean military, most BCS-related injuries have occurred during suicide attempts. This study documents a case series of patients who sustained injuries from BCS during such attempts.
Methods
We examined the medical records of Korean soldiers at a military trauma center between April 2022 and April 2024 who had sustained injuries from BCS during suicide attempts. The analyzed data included general characteristics, injury site, surgical and psychiatric interventions, and length of hospitalization.
Results
The case series included five patients between 19 and 20 years old (mean age, 19.6±0.55 years). Four of these patients sustained self-inflicted gunshot wounds to the submandibular area, while one targeted the right temporal area. Although initial vital signs and laboratory findings were unremarkable, computed tomography scans revealed injuries from projectile gas and gunpowder, including burns, subcutaneous emphysema, and major structural damage. Cases 1 and 2 required emergency surgery for foreign body removal and debridement. The average length of hospitalization was 35.2±12.11 days. Patients were first admitted to the trauma surgery department for BCS injury management, and then transferred to the psychiatry department for emotional support. The average stay was 15.6±15.87 days in trauma surgery and 19.6±14.99 days in psychiatry.
Conclusions
This study highlights the consequences of BCS from suicide attempts in the South Korean military and provides valuable insights for medical personnel who may encounter patients with BCS injuries.; Summary

Case Reports

Heterodigital flap as a solution for a thumb defect: a case report: Bontor Daniel Sinaga, Dwi Purnomo Setyo Budi, Mochamad Sadabaskara; Received July 19, 2024 Accepted October 1, 2024 Published online November 18, 2024; DOI: https://doi.org/10.20408/jti.2024.0049 [Epub ahead of print]

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Abstract PDF: Thumb traumatic injuries are incredibly common in hand injuries. The thumb is essential to hand function in order to do daily tasks like gripping, holding, opposing, circumducting, and movements. As a result, compared to injuries to other fingers, a thumb injury significantly impairs hand function. Traumas can cause soft tissue loss linked to vascular injuries that require revascularization. Replantation is the surgical treatment most frequently suggested to patients who have had their thumbs amputated in an attempt to restore function and attractiveness. There are alternative reconstructive techniques, such as skin grafting or local, distal, and free flaps, when replantation of the severed segment is not feasible. Reconstruction techniques vary depending on where the amputation occurred and include transfer site reconstruction and homodigital and heterodigital flaps. We reported a case of a woman who has a right traumatic thumb injury due to blender accident. Primary suturing and debridement were done to save the thumb. But after several days, the thumb was necrotic and not viable. Heterodigital island flap from the right middle finger was chosen. Radial forearm skin was grafted to cover the middle finger defect. This gave satisfactory results. Wound healing was quite good, but there were signs of scar tissue growth after several months of follow-up. The function and mobility of the thumb and hand were also achieved well through the QuickDASH (quick Disability of the Arm, Shoulder and Hand) score. Heterodigital flap provides satisfactory results both aesthetically and functionally in traumatic thumb injury cases.; Summary

Differentiation of antimicrobial toxicity and sepsis-induced disseminated intravascular coagulation in an orthopedic burn patient in India: a case report: Parampreet Singh Saini, Ankita Aggarwal, Tarunpreet Saini; Received June 27, 2024 Accepted September 19, 2024 Published online November 18, 2024; DOI: https://doi.org/10.20408/jti.2024.0040 [Epub ahead of print]

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Abstract PDF: Drug-induced thrombocytopenia, hemolytic anemia, and leukopenia are serious, and sometimes fatal, complications of common medications. These conditions are challenging to diagnose in patients with polytrauma injuries due to the presence of multiple potential etiologies. In such clinical scenarios, sepsis-induced disseminated intravascular coagulation is a more frequent diagnosis. The clinical manifestations of these conditions can be indistinguishable. We present the case of a 32-year-old man who sustained a left open grade 2 leg fracture and 18% to 20% second-degree superficial electrical flash burns on his right leg. Following primary management, skin testing for antibiotic sensitivity was performed, and prophylactic therapy with ceftriaxone, gentamycin, and metronidazole was initiated for the grossly contaminated wounds. On the second day of emergency admission, the patient developed hepatorenal dysfunction accompanied by severe thrombocytopenia (<30×103/mm3). The suspected antimicrobial agents were discontinued by the third day. Within 48 hours, the patient’s hepatorenal function markedly improved; however, the blood dyscrasia progressed to severe pancytopenia over the next few days. Despite worsening parameters, the patient’s vitals were maintained, and he exhibited no overt bleeding. On the fourth day, the patient developed opportunistic fungal bronchopneumonia, indicated by bilateral lower lobe infiltrates on chest x-ray and an elevated serum galactomannan level. He received supportive care, broad-spectrum antibiotics, and antifungal treatment, with a full recovery within 2 weeks. Antibiotic toxicity must be distinguished from other medical conditions to ensure appropriate management and a favorable prognosis.; Summary

Acute irreducible anterior shoulder dislocation due to interposition of the subscapularis muscle and the lesser tuberosity: a case report: Nazim Sifi, Ahmad Madani, Mahdi Zeghdoud; Received July 7, 2024 Accepted August 29, 2024 Published online October 21, 2024; DOI: https://doi.org/10.20408/jti.2024.0044 [Epub ahead of print]

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Abstract PDF: Efforts to reduce an anterior shoulder dislocation can fail due to numerous mechanical obstructions caused by soft tissue interposition (long head of the biceps, rotator cuff muscles, labrum, musculocutaneous nerve) and/or bony elements (displaced fragment of a greater tuberosity or glenoid fracture, bone impaction such as a Hill-Sachs lesion fixed on the glenoid rim, a bony Bankart lesion). Herein, we report the case of a 35-year-old man who sustained an anterior shoulder fracture-dislocation of his left shoulder after a fall. Despite a postreduction radiological examination that appeared misleadingly reassuring, subtle signs of persistent subluxation raised concerns. A computed tomography (CT) scan revealed subscapularis muscle entrapment along with avulsion of its bony insertion from the lesser tuberosity of the humerus, and a comminuted avulsion fracture of the greater tuberosity of the humerus. The patient underwent surgery using a deltopectoral approach. This involved releasing the entrapped subscapularis muscle and fixing the two fractured fragments. The lesser tuberosity was reduced and secured with two cannulated screws, and the comminuted fragment of the greater tuberosity was reattached using transosseous sutures. At 12-month follow-up, the patient achieved a Constant-Murley score of 85 of 100, with limitation in internal rotation at L3 but no signs of instability or new dislocation episode. This case underscores the importance of confirming shoulder reduction on at least two orthogonal views and paying close attention to the patient’s feedback about sensation in their shoulder. Additionally, it highlights the utility of CT or magnetic resonance imaging scans if doubt exists about the integrity of the reduction.; Summary

A starry night: a case report of severe liver injury due to a close-range shotgun blast in Argentina: Rodrigo Antonio Gasque, José Gabriel Cervantes, Magalí Chahdi Beltrame, Marcelo Enrique Lenz-Virreira, Emilio Gastón Quiñonez; Received June 16, 2024 Accepted August 29, 2024 Published online October 21, 2024; DOI: https://doi.org/10.20408/jti.2024.0036 [Epub ahead of print]

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Abstract PDF: This report presents the case of a 20-year-old man who sustained a severe liver injury from a closerange shotgun blast. A prompt medical intervention, including damage control exploratory laparotomy and surgical debridement, was undertaken due to the extent of liver damage. Despite challenges such as a nondirected biliary fistula and extensive liver parenchymal injury, comprehensive surgical management led to successful treatment. Postoperative complications, including biloma and fungal infection, were managed appropriately, highlighting the importance of vigilant follow-up care. The case underscores the complexity of managing severe liver trauma and emphasizes the evolving role of trauma damage control strategies and minimally invasive procedures in achieving favorable outcomes.; Summary

Purtscher retinopathy following isolated chest compression: a case report: Min Uk Jang, Ho Gil Jung, Youngwoong Kim; Received May 24, 2024 Accepted September 10, 2024 Published online October 21, 2024; DOI: https://doi.org/10.20408/jti.2024.0032 [Epub ahead of print]

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Abstract PDF: This case report describes the case of a 56-year-old man who developed Purtscher retinopathy following compressive chest trauma. During the tertiary survey, the patient was found to have a unilateral partial vision decline despite sustaining only mild rib fractures. The patient was diagnosed with a rare complication of Purtscher retinopathy. At a 2-week follow-up outpatient examination, improved visual acuity was observed. This case highlights the importance of conducting a tertiary survey not only on the directly impacted site, but also comprehensively across all sites, while attentively listening to and addressing the patient’s complaints.; Summary

Minimally invasive techniques as adjuncts in low- versus high-lying retained rectal foreign bodies of autoerotic nature in young men: a tailored management algorithm with two contrasting case reports from India: Shubham Kumar Gupta, Vivek Kumar Katiyar, Sumit Sharma, Shashi Prakash Mishra, Satyanam Kumar Bhartiya; J Trauma Inj. 2024;37(3):238-242. Published online September 30, 2024; DOI: https://doi.org/10.20408/jti.2024.0003

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Abstract PDF: Retained rectal foreign bodies (RFBs) of an autoerotic nature represent an emerging and rare surgical emergency, posing a sensitive challenge for surgeons. RFBs exhibit a wide range of presentations and require varied management approaches, with the choice of treatment modality differing from case to case. Recently, minimally invasive techniques have been employed for the retrieval of RFBs. In 2021, the World Society of Emergency Surgery and the American Association for the Surgery of Trauma released guidelines on anorectal emergencies, highlighting the usefulness of these techniques as adjunctive tools for both diagnosis and ruling out associated complications. In this report, we describe two noteworthy cases of men who presented to the trauma emergency department with foreign bodies lodged in their rectums. We also highlight the potential role of minimally invasive techniques within a “step-up” approach for the management of retained RFBs.; Summary

Original Article

The causes and numbers of hospital admissions and deaths during the Korean War: Kun Hwang, Hun Kim, Chan Yong Park; J Trauma Inj. 2024;37(3):214-219. Published online September 30, 2024; DOI: https://doi.org/10.20408/jti.2023.0067

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PDF: Summary

Case Report

Endoscopic transorbital approach for the removal of a frontal lobe foreign body: a case report: Charles Gervais, Conrad Pelletier, Mathieu Laroche, Pascal Lavergne; Received January 17, 2024 Accepted August 29, 2024 Published online September 25, 2024; DOI: https://doi.org/10.20408/jti.2024.0002 [Epub ahead of print]

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Abstract PDF: Low-velocity orbital penetrating injuries may result in an intracranial retained foreign body that requires surgical removal. We describe the endoscopic transorbital removal of a retained umbrella tip in the frontal lobe, which was secondary to trauma to the orbital roof. This technique facilitated the complete removal of the foreign body without causing additional damage to the surrounding tissue. The patient had a successful postoperative recovery. We also discuss the utility of the transorbital neuroendoscopic procedure in managing these traumatic injuries.; Summary

Review Article

Renal embolization for trauma: a narrative review: Peter Lee, Simon Roh; J Trauma Inj. 2024;37(3):171-181. Published online September 24, 2024; DOI: https://doi.org/10.20408/jti.2024.0021

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Abstract PDF: Renal injuries commonly occur in association with blunt trauma, especially in the setting of motor vehicle accidents. Contrast-enhanced computed tomography is considered the gold-standard imaging modality to assess patients for renal injuries in the setting of blunt and penetrating trauma, and to help classify injuries based on the American Association for the Surgery of Trauma injury scoring scale. The management of renal trauma has evolved in the past several decades, with a notable shift towards a more conservative, nonoperative approach. Advancements in imaging and interventional radiological techniques have enabled diagnostic angiography with angiographic catheter-directed embolization to become a viable option, making it possible to avoid surgical interventions that pose an increased risk of nephrectomy. This review describes the current management of renal trauma, with an emphasis on renal artery embolization techniques.; Summary

Original Article

Evaluating chemical venous thromboembolism prophylaxis in trauma patients at a single Australian center: Natalie Quarmby, Minh Tu Vo, Sean Weng Chan; J Trauma Inj. 2024;37(3):209-213. Published online September 24, 2024; DOI: https://doi.org/10.20408/jti.2024.0020

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Abstract PDF: Purpose
Trauma patients are at an elevated risk of developing venous thromboembolism (VTE), with the subsequent mortality in patients requiring intensive care unit admission ranging from 25% to 38%. There remains significant variability in clinical practice related to VTE prophylaxis in trauma patients due to the frequent presence of contraindications impacting the timing and consistency of application. This study aimed to assess the effectiveness of the current practice of chemical VTE prophylaxis in trauma patients at a single Australian center. Methods: A prospective review was conducted on patients admitted to the ACT Trauma Service (Canberra, Australia) from July to November 2022. The included patients were 18 years or older, without a direct contraindication to anticoagulation, who received chemical VTE prophylaxis with low-molecular-weight heparin (enoxaparin) for at least three doses and underwent subsequent testing of anti-factor Xa (aFXa) levels. Results: During the study period, 187 patients were admitted, of whom 63 were included in the study. Of these, 47 patients achieved therapeutic levels of anticoagulation as determined by their aFXa levels, while 16 were subtherapeutic. The only statistically significant difference between the two groups was in weight, with patients in the subtherapeutic group weighing an average of 91.9 kg compared to 79.1 kg in the therapeutic group (P<0.05). Conclusions: A fixed-dose enoxaparin regimen was utilized, with limited individualization based on patient factors, such as injuries, comorbidities, and other biological factors. Sixteen patients (25%) had subtherapeutic VTE prophylaxis, as measured by aFXa levels. Higher weight was significantly correlated with inadequate VTE prophylaxis dosing. While age, sex, and smoking status might play important roles in clinical decision-making, weight-based dosing of low-molecular-weight heparin may be more effective in achieving adequate VTE prophylaxis.; Summary

Case Reports

Penetrating cardiac injury resulting in a bullet embolus: a case report: Sammy Shihadeh, Anwar Khan, Kristen Walker, Ali Al-Rawi, Alfredo Cordova; J Trauma Inj. 2024;37(3):233-237. Published online September 3, 2024; DOI: https://doi.org/10.20408/jti.2024.0018

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Abstract PDF: Bullet embolism is a potential complication of a gunshot wound, especially with a low-velocity missile. This is because the trajectory of the low-velocity bullet can be significantly slowed as it passes through tissue. An unusual form of travel can occur in which the bullet enters the vasculature but does not have enough kinetic energy to create a through-and-through wound, leading it to remain inside the vasculature. Once inside the vasculature, the bullet could migrate to different parts of the body, potentially causing complications such as ischemia, becoming a source of thromboembolism, or functioning as a nidus for infection. The management of a bullet embolism varies from case to case, as each patient with this issue has a unique body habitus that can result in infinite possibilities of the trajectory and destination of the bullet embolus. Additional damage to surrounding vasculature or tissue can occur, as well as embolization of the bullet to critical areas of the body. Here we present the case of a 72-year-old man who had a self-inflicted gunshot wound to the chest with a low-velocity bullet, which penetrated the right atrium of the heart. It traveled into the venous vasculature through the right atrium, into the inferior vena cava, and eventually settled in the right internal iliac vein. He refused further intervention and management after initial workup and resuscitation.; Summary

Delayed diagnosis of proximal ureter injury after a blunt abdominal trauma in Korea: a case report: Soon Ki Min, Byungchul Yu, Gil Jae Lee, Min A Lee, Yang Bin Jeon, Youngeun Park, Kang Kook Choi, Hyuk Jun Yang; J Trauma Inj. 2024;37(3):243-246. Published online September 3, 2024; DOI: https://doi.org/10.20408/jti.2024.0016

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Abstract PDF: Traumatic ureteral injuries account for fewer than 1% of traumatic urologic injuries, and those caused by blunt trauma are even rarer than those caused by penetrating trauma. The symptoms associated with ureteral injury may be subtle, with or without hematuria, making it difficult to diagnose. We report the case of a 31-year-old man with a delayed diagnosis of proximal ureter injury after abdominal blunt trauma sustained in a motorcycle traffic accident. The patient underwent emergency laparotomy on admission for liver injury, mesenteric injury, and resultant hemoperitoneum. On postoperative day 6, he underwent angioembolization for suspected remnant intra-abdominal bleeding. Persistent symptoms of flank pain and leukocytosis led to follow-up imaging studies that revealed proximal ureter injury, and the patient underwent unilateral nephrectomy. This case stresses the importance of clinical suspicion for genitourinary injuries in the presence of abdominal trauma.; Summary

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