Journal of Trauma and Injury

Volume 21(1); June 2008

Review Articles

The Necessity for a Trauma Surgeon and the Trauma Surgeon's Role in the Trauma Care System: Kug Jong Lee; J Korean Soc Traumatol. 2008;21(1):1-7.

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Abstract PDF: When man first walked on this planet, injury must have been a close encounter of the first kind. The outbreak of World War I, during a period of rapid scientific growth in the basic sciences, demonstrated the need to develop better methods of care for the wounded, methods that were later applicable to the civilian population. Trauma is a multisystem disease and, as such, benefits from almost any advance in medical science. As we learn more about the physiology and the biochemistry of various organ systems, we can provide better management for trauma victims. Improved imaging techniques, better appreciation of physiologic tolerance, and increased understanding of the side effects of specific surgical procedures have combined to reduce operative intervention as a component of trauma patient care. On the other hand, because of this rapid development of medical science, only a few doctors still have the ability to treat multisystem injuries because almost doctor has his or her specialty, which means a doctor tends to see only patients with diagnoses in the doctor's specialty. Trauma Surgeons are physicians who have completed the typical general surgery residency and who usually continue with a one to two year fellowship leading to additional board certification in Surgical Critical Care. It is important to note that trauma surgeons do not need to do all kinds of operations, such as neurosurgery and orthopedic surgery. Trauma surgeons are not only a surgeon but also general medical practitioners who are very good at critical care and coordination of patient. In order to achieve the best patient outcomes, trauma surgeons should be involved in prehospital Emergency Medical Services, the Trauma Resuscitation Room, the Operating Room, the Surgical Intensive Care and Trauma Unit, the Trauma Ward, the Rehabilitation Department, and the Trauma Outpatient Clinic. In conclusion, according to worldwide experience and research, the trauma surgeon is the key factor in the trauma care system, so the trauma surgeon should receive strong support to accomplish his or her role successfully.; Summary

Iatrogenic Ureteral Injury: When and How to Treat?: Kang Il Seo, Jong Bouk Lee; J Korean Soc Traumatol. 2008;21(1):8-14.

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Abstract PDF: Iatrogenic ureteral injury is a complication that can occur during a variety of pelvic or abdominal surgeries. The most frequent causes are gynecological ones, followed by colon and vascular surgeries. Management of ureteric injury depends on the time of diagnosis and the severity of organ damage. Injuries diagnosed intraoperatively should be treated immediately. Occasionally, intraoperative ureteral injury is overlooked, and symptoms of the late diagnosis of ureteral injury are usually nonspecific; therefore, the diagnosis is delayed for days or weeks postoperatively. Management of injuries diagnosed postoperatively is more complex. There are differing opinions on whether an initial conservative or immediate operative intervention is the best line of action. Delayed repair is suggested on the grounds that it will reduce inflammation and tissue edema. However, many authors are in favor of early repair, perhaps because tissue planes are easier to find before fibrosis becomes too dense. Ureteral injuries occurring at the level of the pelvic brim should be best managed with an end-to-end anastomosis, preferably around a ureteric stent. More distal injuries also should be ideally managed with an end-to-end anastomosis, after excision of the crushed or compromised segments. However, if the remaining distal segment is short, ureteral reimplantation is the procedure of choice. The Boari flap technique for ureteral reimplantation is invaluable in cases with a short proximal segment. Delayed recognition of iatrogenic ureteral injury may be associated with serious complications, so prompt recognition of ureteral injuries is important. Recognition of the injury before closure is the key to easy, successful, and complications-free repair. Increased awareness of the risk for ureteral damage during certain operative maneuvers is vital to prevent injury, and to decrease the incidence of iatrogenic injury. A sound knowledge of abdominal and pelvic anatomy is the best prevention.; Summary

Original Articles

NEXUS and the Canadian Cervical Spine Rule as a Screening Tool for Computed Tomography Evaluation in Patients with Cervical Spine Injury: Yang Hwan Choi, Junho Cho, Minhong Choa, Yoo Seok Park, Hyun Soo Chung, Sung Pil Chung; J Korean Soc Traumatol. 2008;21(1):15-21.

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Abstract PDF: PURPOSE
National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian Cervical Spine rule (CCR) are commonly used in cervical trauma patients to determine whether a plain cervical X-ray should be performed. However, plain cervical X-rays are so inaccurate that cervical spine computed tomography (CT) is often considered as a screening test. We studied the usefulness of the NEXUS criteria and the CCR for determining the need for a CT evaluation in the emergency department (ED).
METHODS
This prospective observational study was conducted from January 2007 to March 2008. Plain Xray and CT scans of the cervical spine were performed on blunt trauma patients with neck pain. The relevancy of CT was examined using the NEXUS criteria and the CCR. Sensitivity, specificity, positive predicted value, and negative predicted value analyses were performed to diagnose the cervical spine injury.
RESULTS
During the study period, 284 patients were enrolled in this study. The sensitivity, specificity, positive predicted value, and negative predicted value of the NEXUS criteria were 87.5%, 1.1%, 5.0%, and 60.0% respectively, while those of the CCR were 87.5%, 8.2%, 5.3%, and 91.6%. There were two missed fracture cases when the NEXUS criteria and the CCR were applied independently, however, no cases were missed when both were applied.
CONCLUSION
This study suggests the NEXUS and the CCR in combination can be used as a guide to CT evaluation for cervical spine injury in the ED.; Summary

Factors Affecting Hemodynamic Instability in Patients with Pelvic Bone Fracture: Seung Min Park, Kang Hyun Lee, Han Ju Choi, Kyung Hye Park, Sang Chul Kim, Hyun Kim, Sung Oh Hwang; J Korean Soc Traumatol. 2008;21(1):22-27.

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Abstract PDF: PURPOSE
Treatment and prognosis in patients with pelvic bone fracture depend on the characteristics of the fracture and the stability of the pelvic ring. The purpose of this study is to analyze the characteristics of and the relationships between fracture patterns, injury mechanisms, clinical courses, and prognoses according to the hemodynamic pattern.
METHODS
Between January 2004 and September 2006, 89 patients under diagnosis of pelvic bone fracture were retrospectively analyzed on the basis of medical records and radiologic examinations. Patients with confirmed hemorragic shock with a systolic pressure of less than 90 mmHg were defined as the shock group. Young's classification was used to characterize fracture patterns. Factors relating to the clinical manifestation and to treatments such as transfusion and surgery were analytically compared.
RESULTS
The mean age of the patients was 48.8+/-18.7, among which 49 (55.1%) were male. The numbers of shock and non-shock patients were 35 (39.3%) and 54 (60.7%) respectively. Eighteen (51.4%) of the shock patient had injuries resulting from pedestrian accidents (p=0.008). According to Young's classification, lateral impact fractures amounted to 20 and 33, front-rear impact fractures to 9 and 20, and multiple fractures to 6 and 1 among the shock and non-shock patients, respectively (p=0.027). Thirty-nine (39) cases in non-shock injuries were conservatively managed while 18 cases in shock injuries were surgically treated. In the shock group, the liver and the kidney were often damaged, as well. Among the shock patients, the average admission period was 7.5+/-8.7 days in intensive care and 55.1+/-47.9 days in total, which were longer than the corresponding numbers of days for the non-shock patients (p<0.05). No deaths occurred in the non-shock group while 5 deaths (14.2%) occurred in the shock group (p=0.007).
CONCLUSION
The factors affecting hemodynamic instability in patients with pelvic bone fracture are injury mechanism, classification of fracture, and associated injuries.; Summary

Impact of Initial Helical Abdominal Computed Tomography on the Diagnosis of Hollow Viscus Injury and Blunt Abdominal Traumare: Young Duck Cho, Yun Sik Hong, Sung Woo Lee, Sung Hyuk Choi, Young Hoon Yoon, Sung Ik Lim, Ik Jin Jang, Seung Won Baek; J Korean Soc Traumatol. 2008;21(1):28-35.

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Abstract PDF: PURPOSE
This study was conducted to examine the clinical significance IV-contrasted helical abdomen computed tomography (CT) as a diagnostic screening tool to evaluate hollow viscus injury in blunt abdominal trauma patients.
METHODS
This is a retrospective study encompassing 108 patients, presenting to Korea University Medical Center (KUMC) Emergency Department (ED) from January 2007 to December 2007, with an initial CT finding suggestive of intra-abdominal injury. An initial non-enhanced abdomen CT was taken, followed by an enhanced CT with intravenous contrast. Patients' demographic data, as well as the mechanisms of injury, were inquired upon and obtained, initial diagnosis, as dictated by specialized radiologists, were added to post-operational (post-OP) findings and to additional CT findings acquired during their hospital stays, and all were combined to arrive at final diagnosis. Initial CT findings were further compared with the final diagnosis, yielding values for sensitivity, specificity, and accuracy, as well as positive and negative predictive values. Patients were further divided into two groups, namely, those that underwent operational intervention and those that did not. The initial CT findings of each group were subsequently compared and analyzed.
RESULTS
Initial CT scans revealed abnormal findings in a total of 212 cases - solid organ injuries being the most common finding, as was observed in 97 cases. Free fluid accumulation was evident in another 69 cases. Based on the CT findings, 77 cases (71.3%) were initially diagnosed as having a solid organ injury, 20 cases (18.5%) as having a combined (solid organ + hollow viscus) injury, and 11 cases (10.2%), as having an isolated hollow viscus injury. The final diagnosis however, were somewhat different, with only 67 cases (62.0%) attributed to solid organ injury, 31 cases (28.7%) to combined injury (solid + hollow), and 10 cases (9.3%) to hollow viscus injury. The sensitivity (CI 95%) of the initial helical CT in diagnosing hollow viscus injury was 75.6%, and its specificity was 100%. The accuracy in diagnosing hollow viscus injury was also meaningfully lower compared to that in diagnosis of solid organ injury. Among patients initially diagnosed with solid organ injuries, 10 patients (2 from follow-up CT and 8 from post-OP finding) turned out to have combined injuries. A total of 38 patients underwent an operation, and the proportion of initial CT findings suggesting free air, mesenteric hematoma or bowel wall thickening turned out to be significantly higher in the operation group.
CONCLUSION
Abdominal CT was a meaningful screening test for hollow viscus injury, but the sensitivity of abdominal CT was significantly lower in detecting hollow viscus injury as compared to solid organ injury. This calls for special consideration and careful observation by the ED physicians when dealing with cases of blunt abdominal trauma.; Summary

Incidences of Lower Extremity Injuries in Korea: Chang Sun Kim, Hyuk Joong Choi, Jai Yong Kim, Sang Do Shin, Sang Baek Koh, Kug Jong Lee, Tai Ho Im; J Korean Soc Traumatol. 2008;21(1):36-45.

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Abstract PDF: PURPOSE
We conducted this retrospective epidemiological study to assess the incidence and severity of lower extremity injuries in Korea METHODS: For this study, we retrospectively reviewed nationwide lower-extremity injury data compiled from 2001 to 2003 based on the National Injury Database, what included National Health Insurance Corporation (NHIC), Car Insurance, and Industry Insurance data. Data were standardized in terms of demographic characteristics, region, and socioeconomic status by using NHIC data. To assess the degree of the injuries, we used the Modified Abbreviated Injury Scale (MoAIS), what has been changed from the International Classification of Disease-10 (ICD-10) code. By using the Excess Mortality Ratio-adjusted Injury Severity Score (EMR-ISS), we classified the degree of severity into four categories: mild, moderate, severe and critical.
RESULTS
From 2001 to 2003, lower extremity injuries increased slightly, with a yearly average of 2,437,335. Insurance data should that lower-extremity injuries were the most common, followed by upper-extremity injuries. Significant difference were seen in the numbers of lower extremity injuries based on gender and age. As for provinces, Seoul and Gyeongi provinces had the highest numbers of cases. Junlabukdo had the highest rate of 55,282 cases per 1 million people for standardized gender and population. The annual incidence of the insured patients with lower extrimity injuries was higher than the employer's medical insurance contributions to the medical insurance program. Daily cases occur most often in May and June, with the lowest occurrences being in January and February.
CONCLUSION
The result of this study shows that lower extremity injuries comprised common cause of all injuries. In addition, differences associated with gender, location and socioeconomic status were observed. Further studies are needed to find reasons and then this knowledge will allow strategies to prevent the lower extremity injuries.; Summary

Comparison of Survival in Pelvic Bone Fractures with Arterial Embolization: Woo Youn Kim, Eun Seok Hong, Jung Seok Hong, Ryeok Ahn, Jae Cheol Hwang, Sun Hyu Kim; J Korean Soc Traumatol. 2008;21(1):46-52.

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Abstract PDF: PURPOSE
This study was to evaluate the effect of arterial embolization on survival in patients with pelvic bone fractures and arterial bleeding.
METHODS
From January 2001 to December 2007, in all, 18 patients with pelvic bone fractures that had been treated with interventional arterial embolization were included in this retrospective study. The Injury Severity Score (ISS), the Revised Trauma Score (RTS), the initial hemodynamic status, the blood gas analysis, blood transfusion data, and mortality were the main outcome measurements.
RESULTS
Pelvic bone fractures were classified into lateral compression (LC), antero-posterior compression (APC), vertical shear (VS), and combined (CM) type according to the Young-Burgess classification. The Survivor group included 11 patients (61.1%), and the non-survivor group included 7 patients (38.9%). The mean ages for the survivor and the non-survivor groups were 40.0 and 45.6 years (p=0.517). The types of pelvic bone fractures were LC 11 (61.1%), APC 6 (33.3%), and VS 1 (5.6%): LC 7 (63.6%), and APC 4 (36.4%) in the survivor group and LC 4 (57.1%), APC 2 (28.6%), and VS 1 (14.3%) in the non-survivor group. The internal iliac artery was the predominant injured vessel among both the survivors (n = 5, 45.5%) and the non-survivors (n = 4, 57.1%). No differences in initial blood pressures, ISS, and RTS existed between the two groups, but the arterial pH was lower in the non-survivor group (pH 7.09 (+/-0.20) vs 7.30 (+/-0.08), p=0.018). The number of transfused 24-hour units of packed RBC was greater in the non-survivor group (24.1+/-12.5 vs 14.4+/-6.8, p=0.046).
CONCLUSION
No differences in initial blood pressure and trauma scores existed between survivors and nonsurvivors with pelvic bone fractures, who had been treated with arterial embolization, but arterial pH was lower the in non-survivors.; Summary

Characteristics of Head Injuries After Skiing and Snowboarding Accident: Sung Chan Kang, Kang Hyun Lee, Han Joo Choi, Kyung Hye Park, Sang Chul Kim, Hyun Kim, Sung Oh Hwang; J Korean Soc Traumatol. 2008;21(1):53-58.

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Abstract PDF: PURPOSE
Skiing and snowboarding are becoming increasingly popular. Accordingly, the incidences of injuries among skiers and snowboarders are also increasing. The purpose of this study was to investigate the injury patterns of and the contributing factors to head injuries of skiers and snowboarders and to evaluate the differences in characteristics between skiing and snowboarding head injuries.
METHODS
One-hundred patients who visited the emergency department of Wonju Christian Hospital between January 2005 and March 2007 due to head injuries from skiing and snowboarding were enrolled. The mechanisms and the histories of the injuries were investigated by surveying the patients, and the degrees of head injuries were estimated by using brain CT and the Glasgow Coma Scale. The degrees and the characteristics of brain injuries were also analyzed and compared between skiers and snowboarders.
RESULTS
Out of 100 patients, 39 were injured by skiing, and 61 were injured by snowboarding. The mean age of the skiers was 26.7+/-10.0, and that of the snowboarders was 26.7+/-6.2. The percentage of male skiers was 43.6%, and that of snowboarders was 63.9%. The most frequent initial chief complaints of head-injured skiers and snowboarders were headache and mental change. The most common mechanism of injuries was a slip down. The mean Abbreviated Injury Scale Score (AIS score) of the skier group was 4.5+/-2.1 and that of the snowboarder group was 5.9+/-5.0 (p=0.222). The percentage of helmet users was 7.1% among skiers and 20.8% among snowboarders (p=0.346). Head injuries were composed of cerebral concussion (92.0%) and intracranial hemorrhage (8.0%). Intracranial hemorrhage was most frequently caused by falling down (62.5%).
CONCLUSION
The most common type of head injury to skiers and snowboarders was cerebral concussion, and severe damage was usually caused by jumping and falling down. No differences in the characteristics of the head injuries existed between skiing and snowboarding injuries.; Summary

Effect of Heat Shock Protein 70 on Inducible Nitric Oxide Synthase during Sepsis in Rats: Yong Keun Lee, Hyo Keun Shin, Woon Yong Kwon, Gil Joon Suh, Yeo Kyu Youn; J Korean Soc Traumatol. 2008;21(1):59-65.

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Abstract PDF: PURPOSE
The aim of this study was to evaluate the effect of overexpression of heat shock protein 70 (HSP70) on the expression of inducible nitric oxide synthase and on the concentration of nitric oxide and to determine the mechanism for the relationship between HSP70 and inducible nitric oxide synthase (iNOS) in sepsis.
METHODS
Experiments were performed on male Sprague-Dawley rats, and sepsis was induced by using cecal ligation and puncture (CLP). Glutamine (GLN) or saline was administered 1 h after initiation of sepsis. We acquired serum and lung tissues from the rats 12 h or 24 h after initiation of sepsis. We analyzed the concentration of nitric oxide, the expression of HSP70 in the lung, and the gene expression of iNOS in the lung.
RESULTS
In CLP+GLN, glutamine given after initiation of sepsis enhanced the expression of HSP70 in the lung at 12 h (CLP+GLN vs. CLP:: 47.19 +/- 10.04 vs. 33.22 +/- 8.28, p = 0.025) and 24 h (CLP+GLN vs. CLP: 47.06 +/- 10.60 vs. 31.90 +/- 4.83, p = 0.004). In CLP+GLN, glutamine attenuated the expression of iNOS mRNA in the lung at 12 h (CLP+GLN vs. CLP: 4167.17 +/- 951.59 vs. 5513.73 +/- 1051.60, p = 0.025) and 24 h (CLP+GLN vs. CLP: 9,437.65 +/- 2,521.07 vs. 18,740.27 +/- 8,241.20, p = 0.016) and reduced the concentration of nitric oxide in serum at 12 h (CLP+GLN vs. CLP: 0.86 +/- 0.48 vs. 3.82 +/- 2.53 micromol/L, p = 0.016) and 24 h (CLP+GLN vs. CLP: 0.39 +/- 0.25 vs. 1.85 +/- 1.70 micromol/L, p = 0.025).
CONCLUSION
The overexpression of HSP70 induced by the administration of glutamine in sepsis attenuated the gene expression of iNOS and reduced the concentration of nitric oxide.; Summary

Case Report

A Case of Traumatic Bilateral Abducens Nerve Palsy Associated with Skull Base Fracture: Jeong In Hwang, Jin Seong Cho, Seung Chul Lee, Jeong Hun Lee; J Korean Soc Traumatol. 2008;21(1):66-69.

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Abstract PDF: Traumatic bilateral abducens nerve palsy is rare and is associated with intracranial, skull and cervical spine injuries. We report a case of bilateral abducens nerve palsy in a 40-month-old patient with a skull base fracture. The injury mechanism was associated with direct nerve injury caused by a right petrous bone fracture and indirect injury by frontal impact on the abducens nerve at the point of fixation to the petrous portion and Dorello`s canal. The emergency physician should be aware of injuries and the mechanism of abducens nerve palsy in head trauma.; Summary

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