Angiographic yield in penetrating extremity trauma.

Indications for angiography in the evaluation of penetrating extremity trauma remain controversial. Our experience was reviewed to determine the yield of angiography in penetrating extremity trauma and to correlate clinical findings with angiographic results. During an 81-month period from 1983 through 1989, 284 extremity arteriograms were carried out in 268 patients. The angiographic yield in patients with abnormal clinical findings was 51%. The angiographic yield in patients when proximity of the injury to major vessels was the only indication was 6% (7% with gunshot wounds and 0% with stab wounds). Neurologic deficit alone as an indication for angiography accounted for 55% of the angiograms interpreted as "negative" and none of those interpreted as "positive". We conclude that the use of angiography in patients with gunshot wounds to the extremity with "proximity injuries" to major vessels should continue, its use is not warranted in extremity stab wounds when proximity is the sole indication, and abnormal neurologic findings in the absence of other findings are a poor predictor of vascular injury.     

The Discovery of a Novel Macrophage Binding Site

1. During the course of studies directed to determine the transport of Angiotensin II AT(2) receptors in the rat brain, we found that stab wounds to the brain revealed a binding site recognized by the AT(2) receptor ligand CGP42112 but not by Angiotensin II. 2. We localized this novel site to macrophages/microglia associated with physical or chemical injuries of the brain. 3. The non-Angiotensin II site was also highly localized to inflammatory lesions of peripheral arteries. 4. In rodent tissues, high binding expression was limited to the spleen and to circulating monocytes. A high-affinity binding site was also characterized in human monocytes. 5. Lack of affinity for many ligands binding to known macrophage receptors indicated the possibility that the non-Angiotensin II CGP42112 binding corresponds to a novel site.6. CGP42112 enhanced cell attachment to fibronectin and collagen and metalloproteinase-9 secretion from human monocytes incubated in serum-free medium but did not promote cytokine secretion. 7. When added in the presence of lipopolysaccharide, CGP42112 reduced the lipopolysaccharide-stimulated secretion of the pro-inflammatory cytokines TNF-alpha, IL-1, IL-1 beta, and IL-6, and increased protein kinase A. 8. Molecular modeling revealed that a CGP42112 derivative was selective for the novel macrophage site and did not recognize the Angiotensin II AT(2) receptor. 9. These results demonstrate that CGP42112, previously considered as a selective Angiotensin II AT(2) ligand, recognizes an additional non-Angiotensin II site different from AT(2) receptors. 10. Our observations indicate that CGP42112 or related molecules could be considered of interest as potential anti-inflammatory compounds.     

Immediate and long-term management of gunshot wounds to the lower face

The steadily increasing level of urban violence and attempted suicides in the recent past has resulted in large numbers of gunshot injuries to the face from small-caliber weapons. Our experience with 35 consecutive cases of civilian gunshot wounds involving primarily the lower face is presented. Initial management included securing of the airway, control of bleeding, and treatment of coexisting injuries. After clinical and radiologic evaluation and conservative debridement of all devitalized tissues, the mandibular fractures were reduced and stabilized appropriately. Large bony defects were treated by stabilization of the mandibular segments followed by secondary bone grafting. Intraoral soft tissues were then repaired with local mucosal flaps or tongue flaps when necessary. Finally, the soft tissues were repaired by primary closure or local flaps. Distant flaps were used only as a secondary procedure. Our results are presented, the differences between civilian and military injuries are discussed, and the principles of gunshot ballistics are described. We conclude that most of these wounds can be treated in a relatively conservative manner immediately after the injury with good functional and cosmetic results.     

CHEST INJURIES AMONG KOREAN CASUALTIES

Major wounds of the chest usually cause immediate or early death. Of 35 patients with major thoracic battle injuries who were treated in one naval hospital, six had non-penetrating wounds of the chest and other areas. Of the 29 with penetrating wounds of the chest, 23 were treated by aspiration of hemothorax, decortication in three cases, and thoracotomy for control of hemorrhage in one case and for removal of a foreign body in another.Four cases are reported, two to illustrate the usual course of treatment and two in which the patient died.     

Brief communication: neurotraumatological aspects of head injuries resulting from sharp and blunt force in the early medieval period of southwestern Germany

Approximately 10% (33 of 304) of the predominantly male skulls from the 6th through 8th centuries in southwestern Germany exhibit cranial fractures derived from blunt or sharp force trauma. No evidence of fracture healing characterizes 24% (n = 8) of these individuals. All nonhealed fractures were caused by sharp force, and four of these wounds cross the sagittal sinus. The lengths of these straight-edged wounds, produced exclusively by sword blows, measure around 8.0 cm for fatal, and about 5.0 cm for nonfatal wounds. Seventy-six percent (n = 25) of these skulls exhibit some healing, which indicates that these injuries did not lead to immediate death. In this group are all depressed fractures resulting from blunt force blows. Two thirds of the 45 cranial injuries noted on these 33 skulls are located on the left side of these individuals, with a concentration in the frontoparietal region. Bony indications of wound infection occur in four cases (12%). Three crania exhibit circular trepanations in association with fractures. These phenomena are discussed in the context of modern neurotraumatological knowledge.     

Repairing Facial Injury with Refining Plastic Surgery Techniques

The purpose of this study was to evaluate the refining plastic surgery techniques for repairing facial surface injury. For this purpose, 82 patients with facial surface injury were recruited in the study. All wounds were repaired by refining plastic surgery techniques. The wounds were processed by fine wound excision and plastic surgery repair technique. The deep tissue fracture and dislocation were sutured and reduced using 8-0 absorbable suture and the skin wounds were sutured using 8-0 cosmetic suture. The facial injuries showed good rates of healing with fine debridement and fine recovering. The minimum scarring was observed and good cosmetic effect was achieved. We conclude that refining plastic surgery techniques including fine debridement and fine recovering are ideal for the reconstruction of facial injuries.     

Monitoring acute skin-flap failure

Reliable and repeatable means for the objective postoperative monitoring of skin flaps is a necessity. If a failing free flap can be recognized early, it can be salvaged by revision of the appropriate anastomoses. For the threatened distal portion of a conventional flap, external factors, such as kinking or hematoma, may be corrected or drug therapy instituted. We have analyzed blood from stab wounds in experimental pig flaps for pO2, pCO2, pH, and hematocrit. The results were compared with fluorescein penetration and flap surface temperature. The most significant finding was hematocrit readings of threatened flaps (54 percent) elevated above those of control flaps (35 percent). pH readings in the jeopardized flaps were 0.4 units below control. These two measures proved to be more reliable than intermittent temperature readings. In contrast to the fluorescein test, which can be used only once, stab wound analysis is repeatable at any time in the postoperative period. It can be effectively used to follow dynamic changes within a skin flap.     

Limb salvage of lower-extremity wounds using free gracilis muscle reconstruction

An extensive series reviewing the benefits and drawbacks of use of the gracilis muscle in lower-extremity trauma has not previously been collected. In this series of 50 patients, the use of microvascular free transfer of the gracilis muscle for lower-extremity salvage in acute traumatic wounds and posttraumatic chronic wounds is reviewed. In addition, the wound size, injury patterns, problems, and results unique to the use of the gracilis as a donor muscle for lower-extremity reconstruction are identified. In a 7-year period from 1991 to 1998, 50 patients underwent lower-extremity reconstruction using microvascular free gracilis transfer at the University of Maryland Shock Trauma Center, Johns Hopkins Hospital, and Johns Hopkins Bayview Medical Center. There were 22 patients who underwent reconstruction for coverage of acute lower-extremity traumatic soft-tissue defects associated with open fractures. The majority of patients were victims of high-energy injuries with 91 percent involving motor vehicle or motorcycle accidents, gunshot wounds, or pedestrians struck by vehicles. Ninety-one percent of the injuries were Gustilo type IIIb tibial fractures and 9 percent were Gustilo type IIIc. The mean soft-tissue defect size was 92.2 cm2. Successful limb salvage was achieved in 95 percent of patients. Twenty-eight patients with previous Gustilo type IIIb tibia-fibula fractures presented with posttraumatic chronic wounds characterized by osteomyelitis or deep soft-tissue infection. Successful free-tissue transfer was accomplished in 26 of 28 patients (93 percent). All but one of the patients in this group who underwent successful limb salvage (26 of 27, or 96 percent) are now free of infection. Use of the gracilis muscle as a free-tissue transfer has been shown to be a reliable and predictable tool in lower-extremity reconstruction, with a flap success and limb salvage rate comparable to those in other large studies.     

Leg injuries and wound repair among cosmetid harvestmen (Arachnida,Opiliones, Laniatores)

Previous studies of leg injuries in harvestmen have focused on the fitness consequences for individuals that use autospasy (voluntary detachment of the leg) as a secondary defense mechanism. Leg damage among non‐autotomizing species of laniatorean harvestmen has not been investigated. Under laboratory conditions, we damaged femur IV of Cynorta marginalis and observed with scanning electron microscopy (SEM) the changes in these wounds over ten days. We also used SEM to examine leg damage from individuals of three species of cosmetid harvestmen that were collected in the field. On the basis of changes in the external surface of the hemolymph coagulum, we classified these wounds as fresh (coagulum forming), recent (coagulum with smooth surface), older (coagulum is scale‐like with visible cell fragments), and fully healed (scale replaced by new cuticle growth on the terminal stump). Our observations indicate that wound healing in harvestmen occurs in a manner comparable to that of other chelicerates. Leg injuries exhibited interspecific variation with respect to the overall frequency of leg wounds and the specific legs that were most commonly damaged. In addition, we measured walking and climbing speeds of adult C . marginalis and found that individuals with fresh injuries (lab‐induced) to femur IV walked at speeds significantly slower than uninjured adults or individuals collected from the field that had fully healed wounds to a single leg. J. Morphol. 278:73–88, 2017. ©© 2016 Wiley Periodicals,Inc.     

Behavior and biological action of large amounts of 239Pu following intramuscular administration in rats undergoing long-term therapy with Zn- and Ca-DTPA

The authors submit the results of the studies of the influence of large amounts of 239Pu, administered to rats via stab wounds, and subsequent treatment there of with clinical doses of Zn- and Ca-DTPA for two months. It is shown that the absorbed doses considerably decrease and the average life of treated rats increases; the incidence of malignant tumors does not change after the treatment with Ca-DTPA.     

Effects of mutant rat dynamin on endocytosis

The process of wound repair in monolayers of the intestinal epithelial cell line, Caco-2BBe, was analyzed by a combination of time-lapse differential interference contrast (DIC) video and immunofluorescence microscopy, and laser scanning confocal immunofluorescence microscopy (LSCIM). DIC video analysis revealed that stab wounds made in Caco-2BBe monolayers healed by two distinct processes: (a) Extension of lamellipodia into the wounds; and (b) Purse string closure of the wound by distinct arcs or rings formed by cells bordering the wound. The arcs and rings which effected purse string closure appeared sharp and sheer in DIC, spanned between two and eight individual cells along the wound border, and contracted in a concerted fashion. Immunofluorescence analysis of the wounds demonstrated that the arcs and rings contained striking accumulations of actin filaments, myosin-II, villin, and tropomyosin. In contrast, arcs and rings contained no apparent enrichment of microtubules, brush border myosin-I immunogens, or myosin- V. LSCIM analysis confirmed the localization of actin filaments, myosin- II, villin, and tropomyosin in arcs and rings at wound borders. ZO-1 (a tight junction protein), also accumulated in arcs and rings around wounds, despite the fact that cell-cell contacts are absent at wound borders. Sucrase-isomaltase, an apically-localized integral membrane protein, maintained an apical localization in cells where arcs or rings were formed, but was found in lamellipodia extending into wounds in cells where arcs failed to form. Time-course, LSCIM quantification of actin, myosin II, and ZO-1 revealed that accumulation of these proteins within arcs and rings at the wound edge began within 5 minutes and peaked within 30-60 minutes of wounding. Actin filaments, myosin-II, and ZO-1 achieved 10-, 3-, and 4-fold enrichments, respectively, relative to cell edges which did not border wounds. The results demonstrate that wounded Caco-2BBe monolayers assemble a novel cytoskeletal structure at the borders of wounds. The results further suggest that this structure plays at least two roles in wound repair; first, mediation of concerted, purse string movement of cells into the area of the wound and second, maintenance of apical/basolateral polarity in cells which border the wound.     

Care of the degloved penis and scrotum: a 25-year experience

Injuries to the penis and scrotum are both physically and mentally traumatic. If poorly managed in the acute setting, these injuries may become long-term problems or permanent disabilities. The purpose of this study was to review our approach to degloving injuries of the penis and scrotum and to present our experience. Over the past 25 years, we have cared for eight patients with complete degloving injuries of the genitalia. Farm equipment accidents were responsible for the majority of injuries. We attempted to close all wounds of the denuded penis and near-total avulsed scrotum at the initial operative intervention using the method of repair described. Postoperatively, all patients had an acceptable appearance and normal mictural and erectile function. We conclude that degloving injuries of the penis and scrotum can be best treated with this approach definitively in the acute setting with successful functional and aesthetic results.     

Experience-driven brain plasticity: beyond the synapse

The brain is remarkably responsive to its interactions with the environment, and its morphology is altered by experience in measurable ways. Histological examination of the brains of animals exposed to either a complex ('enriched') environment or learning paradigm, compared with appropriate controls, has illuminated the nature of experience-induced morphological plasticity in the brain. For example, this research reveals that changes in synapse number and morphology are associated with learning and are stable, in that they persist well beyond the period of exposure to the learning experience. In addition, other components of the nervous system also respond to experience: oligodendrocytes and axonal myelination might also be permanently altered, whereas changes in astrocytes and cerebrovasculature are more transient and appear to be activity- rather than learning-driven. Thus, experience induces multiple forms of plasticity in the brain that are apparently regulated, at least in part, by independent mechanisms.     

Management of human bite injuries of the hand.

On the basis of experience at the Ottawa Civic Hospital over the past 10 years, a classification of and protocol for the management of human bite injuries of the hand are presented. Early exploration of such wounds under local anesthesia improves the outcome by facilitating adequate cleansing of the wound and enabling deep structures to be visualized. In this way the risk of major sepsis and of the disability so frequently associated with these innocent-looking injuries can be reduced.     

The Organization of Hospital Services for Casualties due to the Bombing of Cities,Based on Experience Gained in Barcelona-with Special Reference to the Classification of Casualties: (Section of Orthopædics)

(1) Difference between modern "total population" war and old-fashioned war. Difference between bombing of (a) military objectives and (b) civilian population.(a) The heavy bomb, e.g. 750 lb., with large fragments, upward throw, great destruction of buildings.(b) The light bomb with finger nail fragments, horizontal throw, great velocity.There is in addition the incendiary bomb, little used in Barcelona because the buildings are built of stone and concrete.(2) Aerial bombing of a town produces injuries needing more immediate hospitalization than most front-line wounds. At the same time it is possible in a town to organize rapid collection of patients and their immediate transfer to hospital.(3) Experience shows that it is most desirable to make this transfer of patients to hospital a primary consideration. On arrival they are "sorted" and minor injuries are given First Aid treatment and sent home, others are fully examined, classified, and dispatched to the theatres on a priority list, to nearby wards for resuscitation, to wards for rest, or sent on to plaster rooms for splintage, or to a neurosurgical centre.(4) First-aid posts in a town should be in hospitals and treat superficial injuries, &c., after primary sorting in the hospital reception room.(5) First-aid posts in outlying areas should carry out the same function for the same type of cases; all the more seriously wounded, including those with tiny penetrating wounds, should be dispatched without first aid treatment direct to hospital.(6) Hospital arrangements, for circulation of ambulances, for sorting, undressing of patients, docketing of valuables, &c.(7) Classification must be carried out by surgeons of experience and judgment. They must regard not only a standard priority list but the particular clinical picture and prognosis in each case.(8) The surgeon will furthermore draft the cases with regard to the special abilities of the surgical units available, e.g. chest, abdomen, or limbs.(9) Review of wounds in limbs, chest, abdomen, and head, caused by fragments from heavy bombs or by splinters from small light bombs.(10) Injuries from falling masonry.(11) Standard classification by urgency of operation.(12) Classification re possible early evacuation.     

Management of hepatic injury.

Liver injuries may be due to either blunt or penetrating trauma to the thorax or abdomen. Specific treatment depends on the site and extent of hepatic injury. Following resuscitation with intravenous fluids and blood as needed, surgical therapy is directed to provide hemostasis, remove necrotic liver tissue and promote adequate external drainage in the postoperative period. While local measures are usually sufficient, complex hepatic wounds may require extensive resection and vascular ligature or repair.     

Surgical repair of corneal injury

Operations on the cornea relating to trauma are discussed, and included are tangential flaps, corneal injuries, old adherent leukoma, and optical iridectomy. Variations from the usual technique and the immediate surgical closure of corneal wounds are emphasized.     

SURGICAL REPAIR OF CORNEAL INJURY

Operations on the cornea relating to trauma are discussed, and included are tangential flaps, corneal injuries, old adherent leukoma, and optical iridectomy. Variations from the usual technique and the immediate surgical closure of corneal wounds are emphasized.     

Regeneration of articular cartilage in healer and non-healer mice

Mammals rarely regenerate their lost or injured tissues into adulthood. MRL/MpJ mouse strain initially identified to heal full-thickness ear wounds now represents a classical example of mammalian wound regeneration since it can heal a spectrum of injuries such as skin and cardiac wounds, nerve injuries and knee articular cartilage lesions. In addition to MRL/MpJ, a few other mouse strains such as LG/J (a parent of MRL/MpJ) and LGXSM-6 (arising from an intercross between LG/J and SM/J mouse strains) have now been recognized to possess regenerative/healing abilities for articular cartilage and ear wound injuries that are similar, if not superior, to MRL/MpJ mice. While some mechanisms underlying regenerative potential have been begun to emerge, a complete set of biological processes and pathways still needs to be elucidated. Using a panel of healer and non-healer mouse strains, our recent work has provided some insights into the genes that could potentially be associated with healing potential. Future mechanistic studies can help seek the Holy Grail of regenerative medicine. This review highlights the regenerative capacity of selected mouse strains for articular cartilage, in particular, and lessons from other body tissues, in general.     

Immediate closure of traumatic upper arm and forearm injuries with the latissimus dorsi island myocutaneous pedicle flap

This paper reports the authors' experience with latissimus dorsi island pedicle flaps in the acute treatment of massive arm injuries. Seven patients with upper arm injuries and four patients with forearm injuries were treated with latissimus dorsi pedicle flaps. All cases involved massive soft-tissue loss and open fractures. Primary healing of wounds occurred without complications in 10 of 11 patients; the eleventh developed a wound infection. There were no instances of flap loss or vascular complications. This report compares and discusses surgical management options and details the importance of robust, immediate soft-tissue coverage for optimal functional recovery. Contrary to traditional thought, delay in definitive wound closure may be unnecessary when aggressive debridement is followed by acute flap closure.