• Journal of Trauma and Injury
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• v.36 no.3
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• pp.196-205
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• 2023

Purpose: Surgical stabilization of rib fractures (SSRF) is widely used in patients with flail chests, and several studies have reported the efficacy of SSRF even in multiple rib fractures. However, few reports have discussed the hardware failure (HF) of implanted plates. We aimed to evaluate the clinical characteristics of patients with HF after SSRF and further investigate the related factors. Methods: We retrospectively reviewed the electronic medical records of patients who underwent SSRF for multiple rib fractures at a level I trauma center in Korea between January 2014 and January 2021. We defined HF as the unintentional loosening of screws, dislocation, or breakage of the implanted plates. The baseline characteristics, surgical outcomes, and types of HF were assessed. Results: During the study period, 728 patients underwent SSRF, of whom 80 (10.9%) were diagnosed with HF. The mean age of HF patients was 56.5±13.6 years, and 66 (82.5%) were men. There were 59 cases (73.8%) of screw loosening, 21 (26.3%) of plate breakage, 17 (21.3%) of screw migration, and seven (8.8%) of plate dislocation. Nine patients (11.3%) experienced wound infection, and 35 patients (43.8%) experienced chronic pain. A total of 21 patients (26.3%) underwent reoperation for plate removal. The patients in the reoperation group were significantly younger, had fewer fractures and plates, underwent costal fixation, and had a longer follow-up. There were no significant differences in subjective chest symptoms or lung capacity. Conclusions: HF after SSRF occurred in 10.9% of the cases, and screw loosening was the most common. Further longitudinal studies are needed to identify risk factors for SSRF failure.

• Journal of Trauma and Injury
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• v.36 no.4
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• pp.343-353
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• 2023

Purpose: The COVID-19 pandemic led to significant changes in the lifestyle patterns of children and affected the patterns of pediatric injuries. This study analyzed the changing patterns of pediatric injury overall and by age groups, based on the datasets before and during the COVID-19 pandemic. Methods: This study is based on the data of patients who presented with injuries at 23 hospital emergency departments participating in the Emergency Department-based Injury In-depth Surveillance (EDIIS) conducted by the Korea Disease Control and Prevention Agency. The surveillance data was categorized by injury mechanism, location, activity, and severity. We analyzed the injury patterns of pediatric patients aged 0 to 15 years. Subgroup analysis was conducted by age group in children aged 7 to 15 years, 1 to 6 years, and <1 year. Results: When comparing the COVID-19 pandemic period to the pre-COVID-19 period, the total number of pediatric patients with injuries decreased by 38.7%, while the proportions of in-home injuries (57.9% vs. 67.9%), and minor injuries (38.9% vs. 39.7%) increased. In the 7 to 15 years group, bicycle riding injuries (50.9% vs. 65.6%) and personal mobility device injuries (2.4% vs. 4.6%) increased. The 1 to 6 years group also showed an increase in bicycle accident injuries (15.8% vs. 22.4%). In the <1 year group, injuries from falls increased (44.5% vs. 49.9%). Self-harm injuries in the 7 to 15 years group also increased (1.6% vs. 2.8%). Conclusions: During the COVID-19 pandemic period, the overall number of pediatric injuries decreased, while injuries occurring at home and during indoor activities increased. Traffic accidents involving bicycles and personal mobility devices and self-harm injuries increased in the 7 to 15 years group. In the <1 year group, the incidence of falls increased. Medical and societal preparedness is needed so that we might anticipate these changes in the patterns of pediatric injuries during future infectious disease pandemics.

• Journal of Trauma and Injury
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• v.36 no.4
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• pp.441-446
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• 2023

Inferior vena cava (IVC) injuries, while accounting for fewer than 0.5% of blunt abdominal trauma cases, are among the most difficult to manage. Despite advancements in prehospital care, transportation, operative techniques, and perioperative management, the mortality rate for IVC injuries has remained at 20% to 66% for several decades. Furthermore, 30% to 50% of patients with IVC injuries succumb during the prehospital phase. A 65-year-old male patient, who had been struck in the back by a 500-kg excavator shovel at a construction site, was transported to a regional trauma center. Injuries to the right side of the infrarenal IVC and the right external iliac vein (EIV) were suspected, along with fractures to the right iliac bone and sacrum. The injury to the right side of the infrarenal IVC wall was repaired, and the right internal iliac artery was ligated. However, persistent bleeding around the right EIV was observed, and we were unable to achieve proximal and distal control of the right EIV. Attempts at prolonged manual compression were unsuccessful. To decrease venous return, we ligated the right superficial femoral vein. This reduced the amount of bleeding, enabling us to secure the surgical field. We ultimately controlled the bleeding, and approximately 5 L of blood products were infused intraoperatively. A second-look operation was performed 2 days later, by which time most of the bleeding sites had ceased. Orthopedic surgeons then took over the operation, performing closed reduction and external fixation. Five days later, the patient underwent definitive fixation and was transferred for rehabilitation on postoperative day 22.

• Journal of Trauma and Injury
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• v.36 no.4
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• pp.362-368
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• 2023

Purpose: Clinical reports on treatment outcomes of sternal fractures are lacking. This study details the clinical features, treatment approaches, and outcomes related to traumatic sternal fractures over a 10-year period at a single institution. Methods: A retrospective cohort study was conducted of patients admitted to a regional trauma center between January 2012 and December 2021. Among 7,918 patients with chest injuries, 266 were diagnosed with traumatic sternal fractures. Patient data were collected, including demographics, injury mechanisms, severity, associated injuries, sternal fracture characteristics, hospital stay duration, mortality, respiratory complications, and surgical details. Surgical indications encompassed emergency cases involving intrathoracic injuries, unstable fractures, severe dislocations, flail chest, malunion, and persistent high-grade pain. Results: Of 266 patients with traumatic sternal fractures, 260 were included; 98 underwent surgical treatment for sternal fractures, while 162 were managed conservatively. Surgical indications ranged from intrathoracic organ or blood vessel injuries necessitating thoracotomy to unstable fractures with severe dislocations. Factors influencing surgical treatment included flail motion and rib fracture. The median length of intensive care unit stay was 5.4 days (interquartile range [IQR], 1.5-18.0 days) for the nonsurgery group and 8.6 days (IQR, 3.3-23.6 days) for the surgery group. The median length of hospital stay was 20.9 days (IQR, 9.3-48.3 days) for the nonsurgery group and 27.5 days (IQR, 17.0 to 58.0 days) for the surgery group. The between-group differences were not statistically significant. Surgical interventions were successful, with stable bone union and minimal complications. Flail motion in the presence of rib fracture was a crucial consideration for surgical intervention. Conclusions: Surgical treatment recommendations for sternal fractures vary based on flail chest presence, displacement degree, and rib fracture. Surgery is recommended for patients with offset-type sternal fractures with rib and segmental sternal fractures. Surgical intervention led to stable bone union and minimal complications.

• Journal of the Korean Society of Radiology
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• v.84 no.4
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• pp.809-823
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• 2023

Trauma is an injury to the body that involves multiple anatomical and pathophysiological changes caused by forces acting from outside the body. The number of patients with trauma is increasing as our society becomes more sophisticated. The importance and demand of traumatology are growing due to the development and spread of treatment and diagnostic technologies. In particular, damage to the large blood vessels of the chest can be life-threatening, and the sequelae are often severe; therefore, diagnostic and therapeutic methods are becoming increasingly important. Trauma to nonaortic vessels of the thorax and aorta results in varying degrees of physical damage depending on the mechanism of the accident and anatomical damage involved. The main damage is hemorrhage from non-aortic vessels of the thorax and aorta, accompanied by hemodynamic instability and coagulation disorders, which can be life-threatening. Immediate diagnosis and rapid therapeutic access can often improve the prognosis. The treatment of trauma can be surgical or interventional, depending on the patient's condition. Among them, interventional procedures are increasingly gaining popularity owing to their convenience, rapidity, and high therapeutic effectiveness, with increasing use in more trauma centers worldwide. Typical interventional procedures for patients with thoracic trauma include embolization for non-aortic injuries and thoracic endovascular aortic repair for aortic injuries. These procedures have many advantages over surgical treatments, such as fewer internal or surgical side effects, and can be performed more quickly than surgical procedures, contributing to improved outcomes for patients with trauma.

• Journal of Trauma and Injury
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• v.37 no.1
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• pp.20-27
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• 2024

Purpose: Severe abdominal injuries often require immediate clinical assessment and surgical intervention to prevent life-threatening complications. In Jeju Regional Trauma Center, we have instituted a protocol for emergency department (ED) laparotomy at the trauma bay. We investigated the mortality and time taken from admission to ED laparotomy. Methods: We reviewed the data recorded in our center's trauma database between January 2020 and December 2022 and identified patients who underwent laparotomy because of abdominal trauma. Laparotomies that were performed at the trauma bay or the ED were classified as ED laparotomy, whereas those performed in the operating room (OR) were referred to as OR laparotomy. In cases that required expeditious hemostasis, ED laparotomy was performed appropriately. Results: From January 2020 to December 2022, 105 trauma patients admitted to our hospital underwent emergency laparotomy. Of these patients, six (5.7%) underwent ED laparotomy. ED laparotomy was associated with a mortality rate of 66.7% (four of six patients), which was significantly higher than that of OR laparotomy (17.1%, 18 of 99 patients, P=0.006). All the patients who received ED laparotomy also underwent damage control laparotomy. The time between admission to the first laparotomy was significantly shorter in the ED laparotomy group (28.5 minutes; interquartile range [IQR], 14-59 minutes) when compared with the OR laparotomy group (104 minutes; IQR, 88-151 minutes; P<0.001). The two patients who survived after ED laparotomy had massive mesenteric bleeding, which was successfully ligated. The other four patients, who had liver laceration, kidney rupture, spleen injury, and pancreas avulsion, succumbed to the injuries. Conclusions: Although ED laparotomy was associated with a higher mortality rate, the time between admission and ED laparotomy was markedly shorter than for OR laparotomy. Notably, major mesenteric hemorrhages were effectively controlled through ED laparotomy.

• Journal of Trauma and Injury
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• v.37 no.1
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• pp.37-47
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• 2024

Purpose: This study aimed at developing a novel tube thoracostomy technique using the sternum, a fixed anatomical structure, as an indicator to reduce the possibility of incorrect chest tube positioning and complications in patients with chest trauma. Methods: This retrospective study analyzed the data of 184 patients with chest trauma who were aged ≥18 years, visited a single regional trauma center in Korea between April and June 2022, and underwent chest computed tomography (CT) with their arms down. The conventional gold standard, 5th intercostal space (ICS) method, was compared to the lower 1/2, 1/3, and 1/4 of the sternum method by analyzing CT images. Results: When virtual tube thoracostomy routes were drawn at the mid-axillary line at the 5th ICS level, 150 patients (81.5%) on the right side and 179 patients (97.3%) on the left did not pass the diaphragm. However, at the lower 1/2 of the sternum level, 171 patients (92.9%, P<0.001) on the right and 182 patients (98.9%, P= 0.250) on the left did not pass the diaphragm. At the 5th ICS level, 129 patients (70.1%) on the right and 156 patients (84.8%) on the left were located in the safety zone and did not pass the diaphragm. Alternatively, at the lower 1/2, 1/3, and 1/4 of the sternum level, 139 (75.5%, P=0.185), 49 (26.6%, P<0.001), and 10 (5.4%, P<0.001), respectively, on the right, and 146 (79.3%, P=0.041), 69 (37.5%, P<0.001), and 16 (8.7%, P<0.001) on the left were located in the safety zone and did not pass the diaphragm. Compared to the conventional 5th ICS method, the sternum 1/2 method had a safety zone prediction sensitivity of 90.0% to 90.7%, and 97.3% to 100% sensitivity for not passing the diaphragm. Conclusions: Using the sternum length as a tube thoracostomy indicator might be feasible.

• Journal of Trauma and Injury
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• v.37 no.1
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• pp.48-59
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• 2024

Purpose: Research on rib fracture management has exponentially increased. Predicting fracture patterns based on the mechanism of injury (MOI) and other possible correlations may improve resource allocation and injury prevention strategies. The Chest Injury International Database (CIID) is the largest prospective repository of the operative and nonoperative management of patients with severe chest wall trauma. The purpose of this study was to determine whether the MOI is associated with the resulting rib fracture patterns. We hypothesized that specific MOIs would be associated with distinct rib fracture patterns. Methods: The CIID was queried to analyze fracture patterns based on the MOI. Patients were stratified by MOI: falls, motor vehicle collisions (MVCs), motorcycle collisions (MCCs), automobile-pedestrian collisions, and bicycle collisions. Fracture locations, associated injuries, and patient-specific variables were recorded. Heat maps were created to display the fracture incidence by rib location. Results: The study cohort consisted of 1,121 patients with a median RibScore of 2 (range, 0-3) and 9,353 fractures. The average age was 57±20 years, and 64% of patients were male. By MOI, the number of patients and fractures were as follows: falls (474 patients, 3,360 fractures), MVCs (353 patients, 3,268 fractures), MCCs (165 patients, 1,505 fractures), automobile-pedestrian collisions (70 patients, 713 fractures), and bicycle collisions (59 patients, 507 fractures). The most commonly injured rib was the sixth rib, and the most common fracture location was lateral. Statistically significant differences in the location and patterns of fractures were identified comparing each MOI, except for MCCs versus bicycle collisions. Conclusions: Different mechanisms of injury result in distinct rib fracture patterns. These different patterns should be considered in the workup and management of patients with thoracic injuries. Given these significant differences, future studies should account for both fracture location and the MOI to better define what populations benefit from surgical versus nonoperative management.

• Journal of Trauma and Injury
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• v.37 no.1
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• pp.60-66
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• 2024

Purpose: This study investigated changes in interpersonal violence and utilization of trauma recovery services during the COVID-19 pandemic. At an urban level I trauma center, trauma recovery services (TRS) provide education, counseling, peer support, and coordination of rehabilitation and recovery to address social and mental health needs. The COVID-19 pandemic prompted considerable changes in hospital services and increases in interpersonal victimization. Methods: A retrospective analysis was conducted between September 6, 2018 and December 20, 2020 for 1,908 victim-of-crime patients, including 574 victims of interpersonal violence. Outcomes included length of stay associated with initial TRS presentation, number of subsequent emergency department visits, number of outpatient appointments, and utilization of specific specialties within the year following the initial traumatic event. Results: Patients were primarily female (59.4%), single (80.1%), non-Hispanic (86.7%), and Black (59.2%). The mean age was 33.0 years, and 247 patients (49.2%) presented due to physical assault, 132 (26.3%) due to gunshot wounds, and 76 (15.1%) due to sexual assault. The perpetrators were primarily partners (27.9%) or strangers (23.3%). During the study period, 266 patients (mean, 14.9 patients per month) presented before the declaration of COVID-19 as a national emergency on March 13, 2020, while 236 patients (mean, 25.9 patients per month) presented afterward, representing a 74.6% increase in victim-of-crime patients treated. Interactions with TRS decreased during the COVID-19 period, with an average of 3.0 interactions per patient before COVID-19 versus 1.9 after emergency declaration (P<0.01). Similarly, reductions in length of stay were noted; the pre-COVID-19 average was 3.6 days, compared to 2.1 days post-COVID-19 (P=0.01). Conclusions: While interpersonal violence increased, TRS interactions decreased during the COVID-19 pandemic, reflecting interruption of services, COVID-19 precautions, and postponement/cancellation of elective visits. Future direction of hospital policy to enable resource and service delivery to this population, despite internal and external challenges, appears warranted.

• Journal of Trauma and Injury
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• v.37 no.1
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• pp.13-19
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• 2024

Purpose: Trauma is an important public health concern, and it is important to increase the survival rate of patients with trauma and enable them to return to society in a better condition. Initial treatment in the emergency department (ED) is closely associated with the prognosis of patients with trauma. However, studies regarding laboratory biomarker tests that can help predict the prognosis of trauma patients are limited. Presepsin is a novel biomarker of inflammation that can predict a poor prognosis in patients with sepsis. This study aimed to determine whether presepsin could be used as a prognostic indicator in patients with polytrauma. Methods: The study included patients with trauma who had visited a single regional ED from November 2021 to January 2023. Patients who had laboratory tests in the ED were included and analyzed retrospectively through chart review. Age, sex, injury mechanism, vital signs, surgery, the outcome of ED treatment (admission, discharge, transfer, or death), and trauma scores were analyzed. Results: Overall, 550 trauma patients were enrolled; 59.1% were men, and the median age was 64 years (interquartile range, 48.8-79.0 years). Patients in a hypotensive state (systolic blood pressure, <90 mmHg; n=39) had higher presepsin levels (1,061.5±2,522.7 pg/mL) than those in a nonhypotensive state (n=511, 545.7±688.4 pg/mL, P<0.001). Patients hospitalized after ED treatment had the highest presepsin levels (660.9 pg/mL), followed by those who died (652.0 pg/ mL), were transferred to other hospitals (514.9 pg/mL), and returned home (448.0 pg/mL, P=0.041). Conclusions: Serum presepsin levels were significantly higher in trauma patients in a hypotensive state than in those in a nonhypotensive state. Additionally, serum presepsin levels were the highest in hospitalized patients with trauma, followed by those who died, were transferred to other hospitals, and returned home.