Travma 2012-1

Cilt - Volume 18

Sayı - Number 1

Ocak - January 2012

TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY

www.tjtes.org Index Medicus, Medline, EMBASE/Excerpta Medica, Science Citation Index-Expanded (SCI-E), Index Copernicus ve TÜB‹TAK-ULAKB‹M Türk Tıp Dizini’nde yer almaktadır.

Indexed in Index Medicus, Medline, EMBASE/Excerpta Medica and Science Citation Index-Expanded (SCI-E), Index Copernicus and the Turkish Medical Index of TÜB‹TAK-ULAKB‹M.

ISSN 1306 - 696x

ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA AND EMERGENCY SURGERY Editör (Editor) Recep Güloğlu Yardımcı Editörler (Associate Editors) Kaya Sarıbeyoğlu Hakan Yanar Ahmet Nuray Turhan Geçmiş Dönem Editörleri (Former Editors) Ömer Türel Cemalettin Ertekin Korhan Taviloğlu

ULUSAL BİLİMSEL DANIŞMA KURULU (NATIONAL EDITORIAL BOARD) Fatih Ağalar Yılmaz Akgün Levhi Akın Alper Akınoğlu Murat Aksoy Şeref Aktaş Ali Akyüz Ömer Alabaz Nevzat Alkan Edit Altınlı Acar Aren Gamze Aren Cumhur Arıcı Oktar Asoğlu Ali Atan Bülent Atilla Levent Avtan Yunus Aydın Önder Aydıngöz Erşan Aygün Mois Bahar Akın Eraslan Balcı Emre Balık Umut Barbaros Semih Baskan M Murad Başar Mehmet Bayramiçli Ahmet Bekar Orhan Bilge Mustafa Bozbuğa Mehmet Can Başar Cander Nuh Zafer Cantürk Münacettin Ceviz Banu Coşar Figen Coşkun İrfan Coşkun Nahit Çakar Adnan Çalık Fehmi Çelebi Gürhan Çelik Oğuz Çetinkale M. Ercan Çetinus Sebahattin Çobanoğlu Ahmet Çoker Cemil Dalay Fatih Dikici Yalım Dikmen Osman Nuri Dilek Kemal Dolay Levent Döşemeci Murat Servan Döşoğlu Kemal Durak Engin Dursun Atilla Elhan

İstanbul Çanakkale İstanbul Adana İstanbul İstanbul İstanbul Adana İstanbul İstanbul İstanbul İstanbul Antalya İstanbul Ankara Ankara İstanbul İstanbul İstanbul İstanbul İstanbul Elazığ İstanbul İstanbul Ankara Kırıkkale İstanbul Bursa İstanbul Edirne İstanbul Konya Kocaeli Erzurum İstanbul Ankara Edirne İstanbul Trabzon Erzurum İstanbul İstanbul İstanbul Edirne İzmir Adana İstanbul İstanbul Sakarya Antalya Antalya Düzce Bursa Ankara Ankara

Mehmet Eliçevik İmdat Elmas Ufuk Emekli Haluk Emir Yeşim Erbil Şevval Eren Hayri Erkol Metin Ertem Mehmet Eryılmaz Figen Esen Tarık Esen İrfan Esenkaya Ozlem Evren Kemer Nurperi Gazioğlu Fatih Ata Genç Alper Gökçe Niyazi Görmüş Feryal Gün Ömer Günal Nurullah Günay Haldun Gündoğdu Mahir Günşen Emin Gürleyik Hakan Güven Gökhan İçöz İbrahim İkizceli Haluk İnce Fuat İpekçi Ferda Şöhret Kahveci Selin Kapan Murat Kara Hasan Eşref Karabulut Ekrem Kaya Mehmet Yaşar Kaynar Mete Nur Kesim Yusuf Alper Kılıç Haluk Kiper Hikmet Koçak M Hakan Korkmaz Güniz Meyancı Köksal Cüneyt Köksoy İsmail Kuran Necmi Kurt Mehmet Kurtoğlu Nezihi Küçükarslan İsmail Mihmanlı Mehmet Mihmanlı Köksal Öner Durkaya Ören Hüseyin Öz Hüseyin Özbey Faruk Özcan Cemal Özçelik İlgin Özden Mehmet Özdoğan

İstanbul İstanbul İstanbul İstanbul İstanbul Diyarbakır Bolu İstanbul Ankara İstanbul İstanbul Malatya Ankara İstanbul İstanbul Tekirdağ Konya İstanbul Düzce Kayseri Ankara Adana Bolu İstanbul İzmir İstanbul İstanbul İzmir Bursa İstanbul Ankara İstanbul Bursa İstanbul Samsun Ankara Eskişehir Erzurum Ankara İstanbul Ankara İstanbul İstanbul İstanbul Ankara İstanbul Sakarya İstanbul Erzurum İstanbul İstanbul İstanbul Diyarbakır İstanbul Ankara

Şükrü Özer Halil Özgüç Ahmet Özkara Mahir Özmen Vahit Özmen Volkan Öztuna Niyazi Özüçelik Süleyman Özyalçın Emine Özyuvacı Salih Pekmezci İzzet Rozanes Kazım Sarı Esra Can Say Ali Savaş İskender Sayek Tülay Özkan Seyhan Gürsel Remzi Soybir Yunus Söylet Erdoğan Sözüer Mustafa Şahin Cüneyt Şar Mert Şentürk Feridun Şirin İbrahim Taçyıldız Gül Köknel Talu Ertan Tatlıcıoğlu Gonca Tekant Cihangir Tetik Mustafa Tireli Alper Toker Rıfat Tokyay Salih Topçu Turgut Tufan Fatih Tunca Akif Turna Zafer Nahit Utkan Ali Uzunköy Erol Erden Ünlüer Özgür Yağmur Müslime Yalaz Serhat Yalçın Sümer Yamaner Mustafa Yandı Nihat Yavuz Cumhur Yeğen Ebru Yeşildağ Hüseyin Yetik Cuma Yıldırım Bedrettin Yıldızeli Sezai Yılmaz Kaya Yorgancı Coşkun Yorulmaz Tayfun Yücel

Konya Bursa İstanbul Ankara İstanbul Mersin İstanbul İstanbul İstanbul İstanbul İstanbul İstanbul İstanbul Ankara Ankara İstanbul Tekirdağ İstanbul Kayseri Tokat İstanbul İstanbul İstanbul Diyarbakır İstanbul Ankara İstanbul İstanbul Manisa İstanbul İstanbul Kocaeli Ankara İstanbul İstanbul Kocaeli Urfa Balıkesir Adana İstanbul İstanbul İstanbul Trabzon İstanbul İstanbul Tekirdağ İstanbul Gaziantep İstanbul Malatya Ankara İstanbul İstanbul

ULUSLARARASI BİLİMSEL DANIŞMA KURULU INTERNATIONAL EDITORIAL BOARD

Juan Asensio Zsolt Balogh Ken Boffard Fausto Catena Howard Champion Elias Degiannis Demetrios Demetriades Timothy Fabian Rafi Gürünlüoğlu Clem W. Imrie Kenji Inaba Rao Ivatury Yoram Kluger Rifat Latifi Sten Lennquist Ari Leppaniemi Valerie Malka Ingo Marzi Kenneth L. Mattox Carlos Mesquita

Miami, USA New Castle, Australia Johannesburg, S. Africa Bologna, Italy Washington DC, USA Johannesburg, S. Africa Los Angeles, USA Memphis, USA Denver, USA Glasgow, Scotland Los Angeles, USA Richmond, USA Haifa, Israel Tucson, USA Malmö, Sweden Helsinki, Finland Sydney, Australia Frankfurt, Germany Houston, USA Coimbra, Portugal

Ernest E Moore Pradeep Navsaria Andrew Nicol Hans J Oestern Andrew Peitzman Basil A Pruitt Peter Rhee Pol Rommens William Schwabb Michael Stein Spiros Stergiopoulos Michael Sugrue Otmar Trentz Donald Trunkey Fernando Turegano Selman Uranues Vilmos Vecsei George Velmahos Eric J Voiglio Mauro Zago

Denver, USA Cape Town, S. Africa Cape Town, S. Africa Celle, Germany Pittsburgh, USA San Antonio, USA Tucson, USA Mainz, Germany Philadelphia, USA Petach-Tikva, Israel Athens, Greece Liverpool, Australia Zurich, Switzerland Oregon, USA Madrid, Spain Graz, Austria Vienna, Austria Boston, USA Lyon, France Milan, Italy

REDAKSİYON (REDACTION) Erman Aytaç

ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY

Başkan (President) Başkan Yardımcısı (Vice President) Genel Sekreter (Secretary General) Sayman (Treasurer) Yönetim Kurulu Üyeleri (Members)

Recep Güloğlu Kaya Sarıbeyoğlu Ahmet Nuray Turhan Hakan Yanar M. Mahir Özmen Ediz Altınlı Gürhan Çelik

İLETİŞİM (CORRESPONDENCE)

Ulusal Travma ve Acil Cerrahi Derneği İstanbul Üniversitesi İstanbul Tıp Fakültesi Genel Cerrahi Anabilim Dalı, Travma ve Acil Cerrahi Servisi, 34390 Çapa, İstanbul

Tel: +90 212 - 588 62 46 - 531 12 46 Faks (Fax): +90 212 - 533 18 82 e-posta (e-mail): travma@travma.org.tr Web: www.travma.org.tr

ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ YAYIN ORGANI ISSUED BY THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY

Ulusal Travma ve Acil Cerrahi Derneği adına Sahibi (Owner) Yazı İşleri Müdürü (Editorial Director) Yayın Koordinatörü (Managing Editor) Amblem Yazışma adresi (Correspondence address)

Tel Faks (Fax)

Recep Güloğlu Recep Güloğlu M. Mahir Özmen Metin Ertem Ulusal Travma ve Acil Cerrahi Dergisi Sekreterliği Deniz Abdal Mah., Köprülü Mehmet Paşa Sok., Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul +90 212 - 531 12 46 - 531 09 39 +90 212 - 533 18 82

Abonelik: 2011 yılı abone bedeli (Ulusal Travma ve Acil Cerrahi Derneği’ne bağış olarak) 75.- YTL’dir. Hesap No: Türkiye İş Bankası, İstanbul Tıp Fakültesi Şubesi 1200 - 3141069 no’lu hesabına yatırılıp makbuz dernek adresine posta veya faks yolu ile iletilmelidir. Annual subscription rates: 75.- (USD) p-ISSN 1306-696x • e-ISSN 1307-7945 • Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus ve TÜBİTAK ULAKBİM Türk Tıp Dizini’nde yer almaktadır. (Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus and Turkish Medical Index) • Yayıncı (Publisher): KARE Yayıncılık (karepublishing) • Tasarım (Design): Ali Cangül • İngilizce Editörü (Linguistic Editor): Corinne Can • İstatistik (Statistician): Empiar • Online Dergi & Web (Online Manuscript & Web Management): LookUs • Baskı (Press): Yıldırım Matbaacılık • Basım tarihi (Press date): Ocak (January) 2012 • Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur. (This publication is printed on paper that meets the international standard ISO 9706: 1994).

YAZARLARA BİLGİ Ulusal Travma ve Acil Cerrahi Dergisi, Ulusal Travma ve Acil Cerrahi Derneği’nin yayın organıdır. Travma ve acil cerrahi hastalıklar konularında bilimsel birikime katkısı olan klinik ve deneysel çalışmaları, editöryel yazıları, klinik olgu sunumlarını ve bu konulardaki teknik katkılar ile son gelişmeleri yayınlar. Dergi iki ayda bir yayınlanır.

Ulusal Travma ve Acil Cerrahi Dergisi, 2001 yılından itibaren Index Medicus ve Medline’da, 2005 yılından itibaren Excerpta Medica / EMBASE indekslerinde, 2007 yılından itibaren Science Citation Index-Expanded (SCI-E) ile Journal Citation Reports / Science Edition uluslararası indekslerinde ve 2008 yılından itibaren Index Copernicus indeksinde yer almaktadır. 2001-2006 yılları arasındaki 5 yıllık dönemde SCI-E kapsamındaki dergilerdeki İmpakt faktörümüz 0,5 olmuştur. Dergide araştırma yazılarına öncelik verilmekte, bu nedenle derleme veya olgu sunumu türündeki yazılarda seçim ölçütleri daha dar tutulmaktadır. PUBMED’de dergi “Ulus Travma Acil Cerrahi Derg” kısaltması ile yer almaktadır.

Dergiye yazı teslimi, çalışmanın daha önce yayınlanmadığı (özet ya da bir sunu, inceleme, ya da tezin bir parçası şeklinde yayınlanması dışında), başka bir yerde yayınlanmasının düşünülmediği ve Ulusal Travma ve Acil Cerrahi Dergisi’nde yayınlanmasının tüm yazarlar tarafından uygun bulunduğu anlamına gelmektedir. Yazar(lar), çalışmanın yayınlanmasının kabulünden başlayarak, yazıya ait her hakkı Ulusal Travma ve Acil Cerrahi Derneği’ne devretmektedir(ler). Yazar(lar), izin almaksızın çalışmayı başka bir dilde ya da yerde yayınlamayacaklarını kabul eder(ler). Gönderilen yazı daha önce herhangi bir toplantıda sunulmuş ise, toplantı adı, tarihi ve düzenlendiği şehir belirtilmelidir.

Dergide Türkçe ve İngilizce yazılmış makaleler yayınlanabilir. Tüm yazılar önce editör tarafından ön değerlendirmeye alınır; daha sonra incelenmesi için danışma kurulu üyelerine gönderilir.

Tüm yazılarda editöryel değerlendirme ve düzeltmeye başvurulur; gerektiğinde, yazarlardan bazı soruları yanıtlanması ve eksikleri tamamlanması istenebilir. Dergide yayınlanmasına karar verilen yazılar “manuscript editing” sürecine alınır; bu aşamada tüm bilgilerin doğruluğu için ayrıntılı kontrol ve denetimden geçirilir; yayın öncesi şekline getirilerek yazarların kontrolüne ve onayına sunulur. Editörün, kabul edilmeyen yazıların bütününü ya da bir bölümünü (tablo, resim, vs.) iade etme zorunluluğu yoktur.

Yazıların hazırlanması: Tüm yazılı metinler 12 punto büyüklükte “Times New Roman” yazı karakterinde iki satır aralıklı olarak yazılmalıdır. Sayfada her iki tarafta uygun miktarda boşluk bırakılmalı ve ana metindeki sayfalar numaralandırılmalıdır. Journal Agent sisteminde, başvuru mektubu, başlık, yazarlar ve kurumları, iletişim adresi, Türkçe özet ve yazının İngilizce başlığı ve özeti ilgili aşamalarda yüklenecektir. İngilizce yazılan çalışmalara da Türkçe özet eklenmesi gerekmektedir. Yazının ana metnindeyse şu sıra kullanılacaktır: Giriş, Gereç ve Yöntem, Bulgular, Tartışma, Teşekkür, Kaynaklar, Tablolar ve Şekiller.

Başvuru mektubu: Bu mektupta yazının tüm yazarlar tarafından okunduğu, onaylandığı ve orijinal bir çalışma ürünü olduğu ifade edilmeli ve yazar isimlerinin yanında imzaları bulunmalıdır. Başvuru mektubu ayrı bir dosya olarak, Journal Agent sisteminin “Yeni Makale Gönder” bölümünde, 10. aşamada yer alan dosya yükleme aşamasında yollanmalıdır.

Başlık sayfası: Yazının başlığı, yazarların adı, soyadı ve ünvanları, çalışmanın yapıldığı kurumun adı ve şehri, eğer varsa çalışmayı destekleyen fon ve kuruluşların açık adları bu sayfada yer almalıdır. Bu sayfaya ayrıca “yazışmadan sorumlu” yazarın isim, açık adres, telefon, faks, mobil telefon ve e-posta bilgileri eklenmelidir. Özet: Çalışmanın gereç ve yöntemini ve bulgularını tanıtıcı olmalıdır.

Türkçe özet, Amaç, Gereç ve Yöntem, Bulgular, Sonuç ve Anahtar Sözcükler başlıklarını; İngilizce özet Background, Methods, Results, Conclusion ve Key words başlıklarını içermelidir. İngilizce olarak hazırlanan çalışmalarda da Türkçe özet yer almalıdır. Özetler başlıklar hariç 190-210 sözcük olmalıdır.

Tablo, şekil, grafik ve resimler: Şekillere ait numara ve açıklayıcı bilgiler ana metinde ilgili bölüme yazılmalıdır. Mikroskobik şekillerde resmi açıklayıcı bilgilere ek olarak, büyütme oranı ve kullanılan boyama tekniği de belirtilmelidir. Yazarlara ait olmayan, başka kaynaklarca daha önce yayınlanmış tüm resim, şekil ve tablolar için yayın hakkına sahip kişiler-

den izin alınmalı ve izin belgesi dergi editörlüğüne ayrıca açıklamasıyla birlikte gönderilmelidir. Hastaların görüntülendiği fotoğraflara, hastanın ve/veya velisinin imzaladığı bir izin belgesi eşlik etmeli veya fotoğrafta hastanın yüzü tanınmayacak şekilde kapatılmış olmalıdır. Renkli resim ve şekillerin basımı için karar hakemler ve editöre aittir. Yazarlar renkli baskının hazırlık aşamasındaki tutarını ödemeyi kabul etmelidirler.

Kaynaklar: Metin içindeki kullanım sırasına göre düzenlenmelidir. Makale içinde geçen kaynak numaraları köşeli parantezle ve küçültülmeden belirtilmelidir. Kaynak listesinde yalnızca yayınlanmış ya da yayınlanması kabul edilmiş çalışmalar yer almalıdır. Kaynak bildirme “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” (http:// www.icmje.org) adlı kılavuzun en son güncellenmiş şekline (Şubat 2006) uymalıdır. Dergi adları Index Medicus’a uygun şekilde kısaltılmalıdır. Altı ya da daha az sayıda olduğunda tüm yazar adları verilmeli, daha çok yazar durumunda altıncı yazarın arkasından “et al.” ya da “ve ark.” eklenmelidir. Kaynakların dizilme şekli ve noktalamalar aşağıdaki örneklere uygun olmalıdır: Dergi metni için örnek: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of duodenal injuries. Am Surg 1999;65:972-5.

Kitaptan bölüm için örnek: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 735-62.

Sizlerin çalışmalarınızda kaynak olarak yararlanabilmeniz için www.travma.org.tr adresli web sayfamızda eski yayınlara tam metin olarak ulaşabileceğiniz bir arama motoru vardır.

Derleme yazıları: Bu tür makaleler editörler kurulu tarafından gerek olduğunda, konu hakkında birikimi olan ve bu birikimi literatüre de yansımış kişilerden talep edilecek ve dergi yazım kurallarına uygunluğu saptandıktan sonra değerlendirmeye alınacaktır. Derleme makaleleri; başlık, Türkçe özet, İngilizce başlık ve özet, alt başlıklarla bölümlendirilmiş metin ile kaynakları içermelidir. Tablo, şekil, grafik veya resim varsa yukarıda belirtildiği şekilde gönderilmelidir.

Olgu sunumları: Derginin her sayısında sınırlı sayıda olgu sunumuna yer verilmektedir. Olgu bildirilerinin kabulünde, az görülürlük, eğitici olma, ilginç olma önemli ölçüt değerlerdir. Ayrıca bu tür yazıların olabildiğince kısa hazırlanması gerekir. Olgu sunumları başlık, Türkçe özet, İngilizce başlık ve özet, olgu sunumu, tartışma ve kaynaklar bölümlerinden oluşmalıdır. Bu tür çalışmalarda en fazla 5 yazara yer verilmesine özen gösterilmelidir.

Editöre mektuplar: Editöre mektuplar basılı dergide ve PUBMED’de yer almamakta, ancak derginin web sitesinde yayınlanmaktadır. Bu mektuplar için dergi yönetimi tarafından yayın belgesi verilmemektedir.

Daha önce basılmış yazılarla ilgili görüş, katkı, eleştiriler ya da farklı bir konu üzerindeki deneyim ve düşünceler için editöre mektup yazılabilir.

Bu tür yazılar 500 sözcüğü geçmemeli ve tıbbi etik kurallara uygun olarak kaleme alınmış olmalıdır. Mektup basılmış bir yazı hakkında ise, söz konusu yayına ait yıl, sayı, sayfa numaraları, yazı başlığı ve yazarların adları belirtilmelidir. Mektup bir konuda deneyim, düşünce hakkında ise verilen bilgiler doğrultusunda dergi kurallarına uyumlu olarak kaynaklar da belirtilmelidir.

Bilgilendirerek onay alma - Etik: Deneysel çalışmaların sonuçlarını bildiren yazılarda, çalışmanın yapıldığı gönüllü ya da hastalara uygulanacak prosedür(lerin) özelliği tümüyle anlatıldıktan sonra, onaylarının alındığını gösterir bir cümle bulunmalıdır. Yazarlar, bu tür bir çalışma söz konusu olduğunda, uluslararası alanda kabul edilen kılavuzlara ve T.C. Sağlık Bakanlığı tarafından getirilen yönetmelik ve yazılarda belirtilen hükümlere uyulduğunu belirtmeli ve kurumdan aldıkları Etik Komitesi onayını göndermelidir. Hayvanlar üzerinde yapılan çalışmalarda ağrı, acı ve rahatsızlık verilmemesi için neler yapıldığı açık bir şekilde belirtilmelidir.

Yazı gönderme - Yazıların gönderilmesi: Ulusal Travma ve Acil Cerrahi Dergisi yalnızca www.travma.org.tr adresindeki internet sitesinden on-line olarak gönderilen yazıları kabul etmekte, posta yoluyla yollanan yazıları değerlendirmeye almamaktadır. Tüm yazılar ilgili adresteki “Online Makale Gönderme” ikonuna tıklandığında ulaşılan Journal Agent sisteminden yollanmaktadır. Sistem her aşamada kullanıcıyı bilgilendiren özelliktedir.

INFORMATION FOR THE AUTHORS The Turkish Journal of Trauma and Emergency Surgery (TJTES) is an official publication of the Turkish Association of Trauma and Emergency Surgery. It is a peer-reviewed periodical that considers for publication clinical and experimental studies, case reports, technical contributions, and letters to the editor. Six issues are published annually.

As from 2001, the journal is indexed in Index Medicus and Medline, as from 2005 in Excerpta Medica and EMBASE, as from 2007 in Science Citation Index Expanded (SCI-E) and Journal Citation Reports / Science Edition, and as from 2008 in Index Copernicus. For the five-year term of 2001-2006, our impact factor in SCI-E indexed journals is 0.5.

It is cited as ‘Ulus Travma Acil Cerrahi Derg’ in PUBMED. Submission of a manuscript by electronic means implies: that the work has not been published before (except in the form of an abstract or as part of a published lecture, review, or thesis); that it is not under consideration for publication elsewhere; and that its publication in the Turkish Journal of Trauma and Emergency Surgery is approved by all co-authors. The author(s) transfer(s) the copyright to the Turkish Association of Trauma and Emergency Surgery to be effective if and when the manuscript is accepted for publication. The author(s) guarantee(s) that the manuscript will not be published elsewhere in any other language without the consent of the Association. If the manuscript has been presented at a meeting, this should be stated together with the name of the meeting, date, and the place.

Manuscripts may be submitted in Turkish or in English. All submissions are initially reviewed by the editor, and then are sent to reviewers. All manuscripts are subject to editing and, if necessary, will be returned to the authors for answered responses to outstanding questions or for addition of any missing information to be added. For accuracy and clarity, a detailed manuscript editing is undertaken for all manuscripts accepted for publication. Final galley proofs are sent to the authors for approval.

Unless specifically indicated otherwise at the time of submission, rejected manuscripts will not be returned to the authors, including accompanying materials.

TJTES is indexed in Science Citation Index-Expanded (SCI-E), Index Medicus, Medline, EMBASE, Excerpta Medica, and the Turkish Medical Index of TUBITAK-ULAKBIM. Priority of publications is given to original studies; therefore, selection criteria are more refined for reviews and case reports.

Manuscript submission: TJTES accepts only on-line submission via the official web site (please click, www.travma.org.tr/en) and refuses printed manuscript submissions by mail. All submissions are made by the on-line submission system called Journal Agent, by clicking the icon “Online manuscript submission” at the above mentioned web site homepage. The system includes directions at each step but for further information you may visit the web site (http://www.travma.org/en/ journal/).

Manuscript preparation: Manuscripts should have double-line spacing, leaving sufficient margin on both sides. The font size (12 points) and style (Times New Roman) of the main text should be uniformly taken into account. All pages of the main text should be numbered consecutively. Cover letter, manuscript title, author names and institutions and correspondence address, abstract in Turkish (for Turkish authors only), and title and abstract in English are uploaded to the Journal Agent system in the relevant steps. The main text includes Introduction, Materials and Methods, Results, Discussion, Acknowledgments, References, Tables and Figure Legends.

The cover letter must contain a brief statement that the manuscript has been read and approved by all authors, that it has not been submitted to, or is not under consideration for publication in, another journal.

It should contain the names and signatures of all authors. The cover letter is uploaded at the 10th step of the “Submit New Manuscript” section, called “Upload Your Files”.

Abstract: The abstract should be structured and serve as an informative guide for the methods and results sections of the study. It must be prepared with the following subtitles: Background, Methods, Results and Conclusions. Abstracts should not exceed 200 words.

Figures, illustrations and tables: All figures and tables should be numbered in the order of appearance in the text. The desired position of figures and tables should be indicated in the text. Legends should be included in the relevant part of the main text and those for photomicrographs and slide preparations should indicate the magnification and the stain used. Color pictures and figures will be published if they are definitely required and with the understanding that the authors are prepared to bear the costs. Line drawings should be professionally prepared. For recognizable photographs, signed releases of the patient or of his/her legal representatives should be enclosed; otherwise, patient names or eyes must be blocked out to prevent identification.

References: All references should be numbered in the order of mention in the text. All reference figures in the text should be given in brackets without changing the font size. References should only include articles that have been published or accepted for publication. Reference format should conform to the “Uniform requirements for manuscripts submitted to biomedical journals” (http://www.icmje.org) and its updated versions (February 2006). Journal titles should be abbreviated according to Index Medicus. Journal references should provide inclusive page numbers. All authors, if six or fewer, should be listed; otherwise the first six should be listed, followed by “et al.” should be written. The style and punctuation of the references should follow the formats below: Journal article: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of duodenal injuries. Am Surg 1999;65:972-5.

Chapter in book: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 735-62.

Our journal has succeeded in being included in several indexes, in this context, we have included a search engine in our web site (www. travma.org.tr) so that you can access full-text articles of the previous issues and cite the published articles in your studies.

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Case reports: A limited number of case reports are published in each issue of the journal. The presented case(s) should be educative and of interest to the readers, and should reflect an exclusive rarity. Case reports should contain the title, summary, and the case, discussion, and references sections. These reports may consist of maximum five authors.

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Informed consent - Ethics: Manuscripts reporting the results of experimental studies on human subjects must include a statement that informed consent was obtained after the nature of the procedure(s) had been fully explained. Manuscripts describing investigations in animals must clearly indicate the steps taken to eliminate pain and suffering. Authors are advised to comply with internationally accepted guidelines, stating such compliance in their manuscripts and to include the approval by the local institutional human research committee.

ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY C‹LT - VOL. 18

SAYI - NUMBER 1

OCAK - JANUARY 2012

İçindekiler - Contents ix Editörden - Editorial

Deneysel Çalışma - Experimental Studies 1-4 Is neopterin a diagnostic marker of acute appendicitis?

Neopterin akut apandisit tanısında kullanılabilecek bir belirteç midir?

Coşkun K, Menteş Ö, Atak A, Aral A, Eryılmaz M, Onguru Ö, Balkan M, Kozak O, Çetiner S 5-10 Effect of epidural anesthesia on anastomotic leakage in colonic surgery: experimental study Epidural anestezinin kolon cerrahisinde anastomoz kaçağı üzerine etkisi: Deneysel araştırma

Adanır T, Aksun M, Yılmaz Karaören G, Karabuğa T, Nazlı O, Şencan A, Köseoğlu M

Klinik Çalışma - Original Articles 11-17 Effects of repetitive injections of hyaluronic acid on peritendinous adhesions after flexor tendon repair: a preliminary randomized, placebo-controlled clinical trial Fleksör tendon onarım sonrası, tekrarlayan hyaluronik asit enjeksiyonlarının, peritendinöz adezyon üzerine etkisi: Randomize plasebo kontrollü klinik ön çalışma

Özgenel GY, Etöz A 18-22 Cerrahi yoğun bakım hastalarında ziyaretin yaşam bulguları üzerine etkisi: Pilot çalışma The impact of visits on vital signs of the patients in surgical intensive care unit: a pilot study

Karabacak Ü, Şenturan L, Özdilek S, Şimşek A, Karateke Y, Eti Aslan F, Yıldız N, Kaya B, Ertekin C 23-30 Analysis of the necessity of routine tests in trauma patients in the emergency department Acil servise başvuran travma hastalarında rutin testlerin gerekliliğinin analizi

Köksal Ö, Eren Çevik Ş, Akköse Aydın Ş, Özdemir F 31-36 Work-related injuries in textile industry workers in Turkey Türkiyede tekstil sektörü çalışanlarında iş kazalarına bağlı yaralanmalar

Serinken M, Türkçüer İ, Dağlı B, Karcıoğlu Ö, Zencir M, Uyanık E 37-42 Diagnostic peritoneal lavage in hemodynamically stable patients with lower chest or anterior abdominal stab wounds Hemodinamik açıdan stabil, göğüs altı veya ön karın bölgesinde bıçak yaralanması olan hastalarda tanısal peritoneal lavaj

Hashemzadeh S, Mameghani K, Fouladi RF, Ansari E 43-48 Factors affecting the number of debridements in Fournier’s gangrene: our results in 36 cases Fournier gangreninde debridman sayısını etkileyen faktörler: 36 olguda sonuçlarımız

Göktaş C, Yıldırım M, Horuz R, Faydacı G, Akça O, Çetinel CA 49-54 An alternative classification of occupational hand injuries based on etiologic mechanisms: the ECOHI classification Etyolojik mekanizmalarının temelinde iş kazasına bağlı el yaralanmalarında alternatif bir sınıflama: İKEYES sınıflaması

Özçelik B, Ertürer E, Mersa B, Purisa H, Sezer İ, Tunçer S, Kabakaş F, Kuvat SV

Cilt - Vol. 18 Sayı - No. 1

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SAYI - NUMBER 1

OCAK - JANUARY 2012

İçindekiler - Contents 55-60 Upper extremity injuries due to threshing machine Harman dövme makinesine bağlı üst ekstremite yaralanmaları

Işık D, Ceylan MF, Tekin H, Karadaş S, Güner S, Canbaz Y 61-64 Falling television related child injuries in Turkey: 10-year experience Türkiye’de televizyon düşmesi nedeni ile gelişen çocuk yaralanmaları: 10 yıllık deneyim

Güloğlu R, Sarıcı İŞ, Bademler S, Emirikçi S, İşsever H, Yanar H, Ertekin C 65-70 Comparative results of percutaneous cannulated screws, dynamic compression type plate and screw for the treatment of femoral neck fractures Femur boyun kırıklarının tedavisinde perkütan kanüle vida, dinamik kompresyon plak ve vidanın karşılaştırmalı sonuçları

Kaplan T, Akesen B, Demirağ B, Bilgen S, Durak K 71-74 Immediate appendectomy for appendiceal mass Apendiküler kitlelerde erken apendektomi

Kaya B, Sana B, Eriş C, Kutaniş R 75-79 Foreign body traumas of the eye managed in an emergency department of a single-institution Bir merkezin acil servisinde tedavi edilen gözün yabancı cisim travmaları

Yiğit Ö, Yürüktümen A, Arslan S

Olgu Sunumu - Case Reports 80-82 Vertebra kırığı veya çıkığı olmaksızın gelişen çift seviyeli omurilik yaralanması: Olgu sunumu Double-level spinal cord injury without vertebral fracture or dislocation: A case report

Atılgan M 83-86 Repair of an extensive iatrogenic tracheal rupture with a pleural patch and a vascular graft Geniş iyatrojenik trakea rüptürünün vasküler ve plevral yama ile onarımı

Bostancı EB, Özer İ, Ekiz F, Atıcı AE, Reyhan E, Akoğlu M, Erkılınç A, Yakut C 87-88 Traditional Kehr’s sign: Left shoulder pain related to splenic abscess Geleneksel Kehr bulgusu: Splenik apseye bağlı sol omuz ağrısı

Söyüncü S, Bektaş F, Çete Y 89-91 A fish bone causing ileal perforation in the terminal ileum Balık kılçığının neden olduğu terminal ileum perforasyonu

Mutlu A, Uysal E, Ulusoy L, Duran C, Selamoğlu D 92-94 Late-diagnosed bilateral intertrochanteric femur fracture during an epileptic seizure Epilepsi nöbeti sırasında gelişmiş geç tanı konmuş, iki taraflı intertrokanterik femur kırığı

Çopuroğlu C, Özcan M, Dülger H, Yalnız E 95-98 Künt travmaya bağlı diyafram yırtığına sekonder akut mekanik intestinal obstrüksiyon olgusu Evaluation of an acute mechanic intestinal obstruction case secondary to diaphragma rupture due to a blunt trauma

Sözen S, Aysu F, Elkan H, Çakmak A, Yıldız F

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1)

EDİTÖRDEN

Değerli meslektaşlarım, On beş yıldan fazla yayın hayatında olan Ulusal Travma ve Acil Cerrahi Dergisi ile yeni bir yıla başlamaktan duyduğumuz sevinci sizlerle paylaşmaktan editöryel ekip olarak mutluluk duymaktayız. Geçtiğimiz yıl yılda altı sayı olarak çıkan dergimiz bu yıl yine aynı formatta devam edecek.

Geçen yıl yayımlanan yazı sayısı toplam 120’dir. Yayınlanan makalelerin genel dağılımı; 17 Deneysel, 61 Klinik, 38 Olgu Sunumu, 3 Editöre Mektup, 1 Derleme’dir.

Ulusal Travma ve Acil Cerrahi Dergisi’nde İngilizce olarak yayınlanan toplam makale sayısı 93 olmuştur. Ayrıca yurt dışı kaynaklı yayımlanan makaleler 18’dir. Yüz güldürücü olarak, dergimize gönderilen makale sayısı her geçen gün artmaktadır.

Ulusal Travma ve Acil Cerrahi Derneğinin düzenlemiş olduğu 8. Ulusal Travma ve Acil Cerrahi Kongresi (Uluslararası Katılımlı) meslektaşlarımız arasında yaptığımız anketler doğrultusunda 14-18 Eylül 2011 tarihleri arasında Mardan Palace Kongre Merkezi, Antalya’da düzenlenmiştir. Önceki kongrelerimizde olduğu gibi yoğun katılımlı oturumlarda bilimsel ve teknolojik değişikliklerin baş döndürücü hızla yaşandığı Travma ve Acil Cerrahi alanındaki yenilikleri ve değişiklikleri sizlerle paylaşmak, meslektaşlarımızın karşılaştıkları sorunların ve çözüm önerilerini sizlerle tartışma imkanı bulduk. Sunulan bildirilerinize travma web sitemizden http://www.travma.org.tr (PDF formatında) ulaşabilirsiniz. Dergimizin Travma ve Acil Cerrahi sahasındaki güncel literatüre katkı sağlamaya devam edeceğine belirtmek istiyoruz. Bu amaçla bilimsel içerik ve etkinlik açısından en üst düzeyde olması için sizlerin bilimsel çalışmalar ile katılımınız yanında ilgi ve desteğinize ihtiyacımız vardır. Her türlü öneri ve görüşlerinizi memnuniyetle bekliyoruz.

Bu yıl sizlere memnun kalacağınızı umduğumuz bir yenilikle karşınıza çıkıyoruz. Dergi kindle ile (iPad, iPhone, Android) uyumlu hale getirilmiştir. Çağın gerektirdiği elektronik yayıncılık ile ilgili çalışmalarımız hız kazanmıştır. Bu doğrultuda dergi makalelerine her türlü elektronik ortamdan erişilebilmesi için başlatılan çalışmalar tamamlanmak üzeredir.

Günümüzde Travma ve Acil Cerrahi ile uğraşan Genel Cerrah, Ortopedist, Kalp Damar Cerrahı, Çocuk Cerrahı, Radyoloji, Acil Tıp, Beyin Cerrahisi…. ve birçok alandaki meslektaşlarımızın çalışmalarını, nazik katkı ve yoğun desteğini bekliyor, yeni yılda daha güzel çalışmalarda buluşmak ümidi ile esenlikler diliyorum.

Dr. Recep GÜLOĞLU Editör

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www.tjtes.org

www.travma.org.tr

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):1-4

Experimental Study

Deneysel Çalışma doi: 10.5505/tjtes.2012.00087

Is neopterin a diagnostic marker of acute appendicitis?

Neopterin akut apandisit tanısında kullanılabilecek bir belirteç midir?

Kağan COŞKUN,1 Öner MENTEŞ,1 Ayşegül ATAK,2 Arzu ARAL,2 Mehmet ERYILMAZ,3 Önder ONGURU,4 Müjdat BALKAN,1 Orhan KOZAK,1 Sadettin ÇETİNER1

BACKGROUND

AMAÇ

The diagnosis of acute appendicitis, even for experienced surgeons, can sometimes be complex. A delay in diagnosis increases the complication rate. This experimental study aimed to investigate the suitability and significance of neopterin as a marker for acute appendicitis.

Deneyimli bir cerrah için bile akut apandisit tanısı kimi zaman zor olabilir. Tanıdaki gecikme komplikasyon oranını arttırmaktadır. Bu deneysel çalışmadaki amacımız, akut apandisit tanısında belirteç olarak neopterinin uygunluğunun ve öneminin araştırılmasıdır.

METHODS

GEREÇ VE YÖNTEM

The levels of neopterin were measured using an acute appendicitis animal model in 35 New Zealand male rabbits.

They were divided into 5 groups as Group 1= control; Group 2= sham; and Groups 3 (12-hour); 4 (24-hour); and 5 (48-hour) (based on the elapsed time period before their appendectomies).

The neopterin levels of each group were measured by neopterin enzyme immunoassay kit in blood samples (taken before the appendectomies in Groups 3, 4 and 5).

Otuz beş adet Yeni Zellanda tipi erkek tavşanda oluşturulmuş akut apandisit modelinde neopterin düzeyleri ölçüldü.

Hayvanlar apendektomi uygulanana kadar geçen zamana göre 5 gruba ayrıldı. (Grup 1: Kontrol, Grup 2: Sham, Grup 3: 12. saat, Grup 4: 24. saat, Grup 5: 48. saat). Her bir gruptan alınan kan örneklerinde (Grup 3, Grup 4 ve Grup 5’te apendektomi öncesinde) neopterin düzeyleri enzim immunoassey kitinde ölçüldü.

RESULTS

BULGULAR

For the diagnosis of acute appendicitis, the optimal cut-off point was 34.475 nmol/L. The probability of acute appendicitis was found to be 4.667 times higher when the neopterin level was greater than 34.475 nmol/L.

Akut apandisit tanısı için optimal eşik değeri noktası 34,475 nmol/lt olarak saptandı. Neopterin düzeyi 34,475 nmol/lt üzerinde olduğu zaman akut apandisit olma olasılığı 4,667 kat fazla olarak bulundu.

CONCLUSION

SONUÇ

This study was an experimental animal study; however, it provides valuable clues useful in clinical assessment. Neopterin seems to have great potential as a new diagnostic marker for the diagnosis of acute appendicitis.

Bu çalışma deneysel bir hayvan çalışması olsa da klinik uygulamalar açısından değerli ipuçları vermektedir. Neopterinin akut apandisit tanısında kullanılabilecek potansiyele sahip bir belirteç olduğunu düşünüyoruz.

Key Words: Acute appendicitis; marker; neopterin.

Anahtar Sözcükler: Akut apandisit; belirteç; neopterin.

Acute appendicitis was first defined by Fitz in 1886. Several years later, McBurney performed the first operation for acute appendicitis.[1] The diagnosis of acute appendicitis is routinely made using patient

history and physical examination, usually with high precision. However, an ideal diagnostic test has yet to be developed. Although the gold standard treatmentappendectomy-was defined more than 100 years ago,

Departments of 1General Surgery, 3Emergency Medicine, 4Pathology, Gulhane Military Medical Faculty, Ankara; Department of Immunology, Gazi University Faculty of Medicine, Ankara, Turkey.

Gülhane Askeri Tıp Akademisi, 1Genel Cerrahi Anabilim Dalı, 3 Acil Tıp Anabilim Dalı, 4Patoloji Anabilim Dalı, Ankara; 2 Gazi Üniversitesi Tıp Fakültesi, İmmünoloji Bilim Dalı, Ankara.

Correspondence (İletişim): Kağan Coşkun, M.D. GATA, Gen. Tevfik Sağlam Cad., Etlik 06018 Ankara, Turkey.

Tel: +90 - 312 - 304 50 16 e-mail (e-posta): kagancoskun@gmail.com

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Ulus Travma Acil Cerrahi Derg

surgeons are still faced with either complications related to a late diagnosis or unnecessary appendectomies, the rate of which is between 4 and 27% in different series.[2] In both cases, the morbidity and mortality, as well as the financial cost, are increased.

noassay for the quantitative determination of neopterin (nmol/L) in serum, plasma and urine using a high affinity monoclonal antibody specific for neopterin. The assay was performed according to the manufacturer’s instructions.

Neopterin [D-erythro-neopterin] is a low-molecular-weight (253.2 kDa) aromatic pteridine molecule produced mainly by activated monocytes and macrophages, and it serves as a marker for cellular immune system activation.[3,4] It is shown that there is an increase in the levels of neopterin with sepsis, malignancy, acute viral infections, and rheumatological diseases.[5]

Statistical Analysis The Kruskal-Wallis test was used to compare the differences between all groups. The Mann-Whitney U test was used for evaluating the differences between the non-appendicitis and appendicitis groups. A receiver operating characteristic curve (ROC curve) was derived by plotting sensitivity against 1-specificity for different possible decision levels to compare the assets of the test performances. The area under the curve (AUC) was calculated using the Statistical Package for the Social Sciences (SPSS) program. The best cutoff points were selected by comparing specificities and sensitivities at various levels. The results were evaluated in mean ± SD values. All p values <0.05 were considered statistically significant.

In this experimental study, we aimed to investigate the suitability and importance of neopterin as a marker for acute appendicitis.

MATERIALS AND METHODS The study was supported by the Gulhane Military Medical Academy Research Fund and was approved by the Research and Animal Ethics Committees. Thirty-five New Zealand male rabbits (weighing 2850–3200 g) were included in the study. Each animal was housed individually according to the rules of the Animal Ethics Committee.

For the study, 5 groups were constituted, with 7 rabbits in each group. Group 1 was the control group; Group 2 animals received a sham operation; Groups 3, 4, and 5 underwent appendectomies at 12 hours (h), 24 h, and 48 h, respectively. The induction of anesthesia in each group was through injections of 50 mg/ kg intramuscular (i.m.) ketamine (Ketalar, Eczacıbaşı, İstanbul, Turkey) and 4 mg/kg i.m. xylazine (Rampun, Bayer, İstanbul, Turkey). In Groups 2, 3, 4, and 5, after the animals were anesthetized, the abdominal skin was opened with a 3-cm midline incision. In Group 1, blood samples were obtained after initiating anesthesia. In Group 2, blood samples were obtained after the sham operations.

In Groups 3, 4, and 5, the appendix was exteriorized and ligated from its base, preserving the mesentery and blood supply. Appendectomies were performed at 12 h, 24 h, and 48 h for Groups 3, 4, and 5, respectively. Blood samples were obtained before appendectomy in Groups 3, 4 and 5. The appendectomy specimens from all groups were examined histopathologically. The blood samples were centrifuged at 3000 x g for 15 minutes (min), and the sera separated.

Serum samples were stored at -80°C until the neopterin ELISA study.

We used a commercially available neopterin enzyme immunoassay kit (Neopterin ELISA, Tanı Medical Laboratories, Ankara, Turkey) for quantitative analysis of the neopterin levels in the serum samples.

This neopterin assay is a competitive enzyme immu2

RESULTS According to the neopterin concentrations and the obtained optical density (OD) values (at 450 nm) of the standards used, intraassay validation of the assay was meaningful at p=0.0071, r=-0.8903, r2=0.7927. This means that the sample results were also dependable.

In Groups 3, 4, and 5, acute appendicitis was diagnosed histopathologically (Fig. 1a-c).

The mean values of neopterin levels were found to be significantly different in all groups (Table 1).

ROC curves were calculated to find the diagnostic value of neopterin. For the diagnosis of acute appendicitis, the best cutoff point was at 34.475 nmol/L (AUC=0.935) (Fig. 2), and sensitivity, specificity, positive predictive value, and negative predictive value were calculated as 87.5%, 100%, 100%, and 78.57%, respectively. The probability of acute appendicitis was found to be 4.667 times higher when the neopterin level was greater than 34.475 nmol/L.

DISCUSSION The diagnosis of acute appendicitis, even for experienced surgeons, can sometimes be complex. Delay Table 1. The serum neopterin levels of the control and the study groups (p=.0001) Group

1 2 3 4 5

Neopterin (nmol/L) 28.18±1.74 33.56±0.75 38.16±0.81 49.10±2.63 85.87±2.48 Ocak - January 2012

Is neopterin a diagnostic marker of acute appendicitis?

tion increases the risk of new morbidities. In the second case, unnecessary appendectomies are performed.

According to Flum et al.,[7] in a nationwide analysis, 261,134 patients had appendectomies in the United States in 1997. Of these, 15.3% were unnecessary appendectomies, resulting in a total hospital expense of approximately US $741.5 million.

There are laboratory and radiological methods used to assist in the diagnosis of acute appendicitis.[8,9] However, to date, neither an ideal laboratory marker nor a gold-standard radiological technique with 100% sensitivity or specificity has been found. After clinical presentation and a careful and detailed physical examination, if the surgeon still has difficulty with the diagnosis or if the case is paradoxic, a diagnostic marker with high sensitivity and specificity is required. Therefore, we aimed to investigate the potential of neopterin molecules as markers that can be used as a determinant for the diagnosis of acute appendicitis.

(a)

Neopterin is a low-molecular-weight (253.2 kDa) aromatic molecule belonging to the group of pteridines. Neopterin, as well as other pteridines, are derived in vivo from guanosine triphosphate (GTP). The enzyme GTP-cyclohydrolase-I catalyzes this reaction in monocytes and macrophages. Neopterin is excreted by activated monocytes/macrophages, and serves as a marker for cellular immune system activation.[3] The increase of neopterin levels in sepsis, malignancies, acute viral infections, rheumatological diseases, and in the follow-up of graft rejection has been demonstrated previously.[5] Besides being an important marker for follow-up of graft rejection after transplantation,

(b)

1,0

0,8

Fig. 1. An appendix, (a) 12 h (b) 24 h (c) 48 h after ligation from its base, preserving the mesentery and blood supply.

(Color figure can be viewed in the online issue, which is available at www.tjtes.org)

in diagnosis increases the complication rate, causing an increase in mortality and morbidity.[6] On the other hand, negative appendectomies are performed (with no appendicitis) at rates between 4 and 27% in different series.[2] Both cases result in increased morbidity and mortality, as well as increased financial cost. In the first case, a secondary laparotomy may be needed.

Every procedure that is performed during an operaCilt - Vol. 18 Say覺 - No. 1

Sensitivity

(c)

0,6

0,4

0,2

0,0 0,0

0,2

0,4

0,6

0,8

1,0

1 - Specificity

Fig. 2. The ROC plot shows the power of neopterin in the diagnosis of acute appendicitis.

(Color figure can be viewed in the online issue, which is available at www.tjtes.org)

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Ulus Travma Acil Cerrahi Derg

it is also an important marker used in protecting the recipient from infections. Since donor blood samples are not usually tested for all possible infections, the measurement of neopterin in blood donor samples is a useful tool in reducing the risk of infections via blood transfusion or transplantation. Neopterin levels may be significantly increased in some disease states compared to controls and serial measurements of neopterin �������������������������������������� levels�������������������������������� in the same patient may be useful in order to monitor the course. Neopterin may be potentially useful for diagnostic/prognostic purposes in following up trauma and human immunodeficiency virus (HIV) patients, in early detection of graft-vshost disease in bone marrow transplantation, in early detection of graft rejection, in monitoring disease activity in autoimmune diseases, in diagnosis of viral infections, in differential diagnosis of acute viral and bacterial infections, as a prognostic indicator of malignancy, in monitoring immunostimulatory therapy, and in the follow-up of chronic infections.[10,11] From this perspective, we studied neopterin in the diagnosis of acute appendicitis.

Several markers, such as serotonin, bilirubinemia, serum D-lactate, D-dimer, and C-reactive protein, have been studied for the diagnosis of acute appendicitis. Singh et al.[12] and Kalra et al.[13] measured the serotonin level of plasma in early acute appendicitis and found that serotonin could be used as a marker at this stage. Sand et al.[14] found that high levels of bilirubinemia and clinical symptoms related with appendicitis indicated the probability of appendiceal perforation. Duzgun et al.[15] stated that there was a correlation between acute appendicitis and serum D-lactate levels�������������������������������������������������� and that these levels could be used as a diagnostic marker. Mentes et al.[16] studied D-dimer for acute appendicitis, and found no relationship between them.

However, Wu et al.[17] found that C-reactive protein was a prognostic marker for early acute appendicitis.

Our study also showed that neopterin is a valuable marker at 48 hours for acute appendicitis. Between 24 and 48 hours, the level of neopterin was found to be particularly significant.

In our study, the probability of acute appendicitis was found to be 4.667 times higher when the serum neopterin level was greater than 34.475 nmol/L. The mean serum neopterin level of the animals in Groups 3, 4 and 5 (acute appendicitis groups) was higher than in the non-appendicitis groups, indicating that neopterin could be used as a serum marker for the diagnosis of acute appendicitis.

In conclusion, this study is an experimental animal study; however, it provides several valuable clues useful in clinical assessment. Together with a carefully extracted medical history, an accurate interpretation of the clinical presentation, and a complete physical 4

examination, neopterin seems to have great potential as a new diagnostic marker for the diagnosis of acute appendicitis.

Acknowledgements The authors greatly appreciate the contribution of the statistician, Mr. Ahmet Gül.

REFERENCES 1. Saidi HS, Chavda SK. Use of a modified Alvorado score in the diagnosis of acute appendicitis. E Afr Med J 2003;80:4115.

2. Jones PF. Suspected acute appendicitis: trends in management over 30 years. Br J Surg 2001;88:1570-7.

3. Oettl K, Reibnegger G. Pteridines as inhibitors of xanthine oxidase: structural requirements. Biochim Biophys Acta 1999;1430:387-95.

4. Katoh S, Sueoka T, Matsuura S, Sugimoto T. Biopterin and neopterin in human saliva. Life Sci 1989;45:2561-8.

5. Hamerlinck FFV. Neopterin: a review. Exp Dermatol 1999:8:167-76.

6. Pegoli W. Acute appendicitis. In: Cameron JL, editor. Current surgical therapy. 6th ed. St. Louis: Mosby; 1998. p. 263-6.

7. Flum DR, Koepsell T. The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg 2002;137:799-804.

8. Roland EA, Hugander A, Ravn H, Offenbartl K, Ghazi SH, Nystrom PO, et al. Repeated clinical and laboratory examinations in patients with an equivocal diagnosis of appendicitis. World J Surg 2000;24:479-85.

9. Michael AZ, Selzman CH, Cothren C, Sorensen AC, Raeburn CD, Harken AH. Diagnostic implications of C-reactive protein. Arch Surg 2003;138:220-4.

10. Murr C, Widner B, Wirleitner B, Fuchs D. Neopterin as a marker for immune system activation. Curr Drug Metab 2002;3:175-87.

11. Fuchs D, Weiss G, Reibnegger G, Wachter H. The role of neopterin as a monitor of cellular immune activation in transplantation, inflammatory, infectious and malignant diseases.

Crit Rev Clin Lab Sci 1992;29:307-41.

12. Singh MS, Dean HG, Dombel FT, Wilson DH, Flowers MW. Concentrations of serotonin in plasma-a test for appendicitis? Clin Chem 1988;34:2572-4.

13. Kalra U, Chitkara N, Dadoo RC, Singh GP, Gulati P, Narula S. Evaluation of plasma serotonin concentration in acute appendicitis. Indian J Gastroenterol 1997;16:18-9.

14. Sand M, Bechara FG, Holland-Letz T, Sand D, Mehnert G, Mann B. Diagnostic value of hyperbilirubinemia as a predictive factor for appendiceal perforation in acute appendicitis.

Am J Surg 2009;198:193-8.

15. Duzgun AP, Bugdayci G, Sayin B, Ozmen MM, Ozer MV, Coskun F. Serum D-lactate: a useful diagnostic marker for acute appendicitis. Hepatogastroenterology 2007;54:1483-6.

16. Mentes O, Eryilmaz M, Harlak A, Ozer T, Balkan M, Kozak O, et al. Can D-dimer become a new diagnostic parameter for acute appendicitis? Am J Emerg Med 2009;27:765-9.

17. Wu HP, Lin CY, Chang CF, Chang YJ, Huang CY. Predictive value of C-reactive protein at different cutoff levels in acute appendicitis. Am J Emerg Med 2005;23:449-53.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):5-10

Experimental Study

Deneysel Çalışma doi: 10.5505/tjtes.2012.67044

Effect of epidural anesthesia on anastomotic leakage in colonic surgery: experimental study Epidural anestezinin kolon cerrahisinde anastomoz kaçağı üzerine etkisi: Deneysel araştırma Tayfun ADANIR,1 Murat AKSUN,1 Gülşah YILMAZ KARAÖREN,1 Türker KARABUĞA,2 Okay NAZLI,3 Atilla ŞENCAN,1 Mehmet KÖSEOĞLU4 BACKGROUND

AMAÇ

The association between the infusion of continuous epidural anesthesia and the anastomotic strength of colonic anastomosis was examined in an animal model.

Bir hayvan modelinde, sürekli epidural anestezi ile kolon anastomozunun gücü arasındaki ilişki araştırıldı.

METHODS

GEREÇ VE YÖNTEM

Fourteen white male New Zealand rabbits were included in the study and randomly assigned to two groups. Group 1 (n=7) had continuous epidural 0.9% NaCl infusion (0.4 ml kg-1 bolus and 0.2 ml kg-1 h-1 infusion) and Group 2 (n=7) had continuous epidural 1% lidocaine infusion (0.4 ml kg-1 bolus and 0.2 ml kg-1 h-1 infusion). Infusions started at the beginning of the operation and were continued for six hours postoperatively. All experimental animals underwent right colon resection and colo-colonic anastomosis under general anesthesia. On the fourth postoperative day, relaparotomy was applied and the bursting pressures of the anastomosis (BPA) were measured in situ. Segments 1-cm long consisting of the complete suture lines were excised, and the levels of hydroxyproline and collagen were measured.

Beyaz erkek 14 adet Yeni Zelanda tavşanı çalışmaya alındı ve randomize iki grup oluşturuldu. Grup 1’de (n=7) epiduralden sürekli olarak %0,9’luk NaCl infüzyonu (0,4 mlkg-1 bolus ve 0,2 mlkg-1 sa-1 infüzyon) ve Grup 2’de (n=7) epiduralden sürekli olarak %1’lik lidokain infüzyonu (0,4 mlkg-1 bolus ve 0.2 ml kg-1 sa-1 infuzyon) uygulandı. İnfüzyonlara, operasyonların başında başlandı ve cerrahi sonrası 6. saate kadar sürdürüldü. Bütün deney hayvanlarına genel anestezi altında sağ kolon rezeksiyonu ve kolo-kolonik anastomoz uygulandı. Cerrahi sonrası 4. gün, re-laparotomi yapılıp in situ olarak anastomoz patlama basınçları ölçüldü.

Dikiş hattını içine alan 1 cm’lik segment çıkartılıp, hidroksiprolin ve kollajen düzeyleri ölçüldü.

RESULTS

BULGULAR

BPAs were statistically higher in the epidural lidocaine group (median: 248 mmHg; min 117 - max 300) than in the saline group (median: 109 mmHg; min 47 - max 176) (p=0.006). There was no difference between the groups in terms of hydroxyproline and collagen levels in the sample tissues (p>0.05).

Anastomoz patlama basınçları, epidural lidokain grubunda (medyan 248 mmHg - [117-300]) serum fizyolojik grubuna (medyan 109 mmHg - [47-176]) göre anlamlı derecede yüksek bulundu (p=0,006). Doku örneğindeki hidroksiprolin ve kollajen düzeyleri açısından gruplar arasında fark yoktu (p>0,05).

CONCLUSION

SONUÇ

We concluded that the strength of colonic anastomosis may be increased by epidural lidocaine infusion.

Kolon anastomozunun dayanıklılığının epidural lidokain infüzyonu ile artabileceğini düşünüyoruz.

Key Words: Anastomotic strength; colonic anastomosis; epidural anesthesia; lidocaine.

Anahtar Sözcükler: Anastomoz dayanıklılığı; kolon cerrahisi; epidural anestezi; lidokain.

Presented at the Congress of Euroanaesthesia 2009 (June 6-9, 2009, Milan, Italy).

Euroanaesthesia 2009 Kongre’sinde sunulmuştur (6-9 Haziran 2009, Milan, İtalya).

Departments of 1Anesthesiology and Reanimation, 2Surgery, 4Biochemistry, Ataturk Training and Research Hospital, Izmir; 3Department of Surgery, Mugla University Faculty of Medicine, Mugla, Turkey.

Atatürk Eğitim ve Araştırma Hastanesi, 1Anesteziyoloji ve Reanimasyon Kliniği, 2Genel Cerrahi Kliniği, 4Biyokimya Bölümü, İzmir; 3 Muğla Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Muğla.

Correspondence (İletişim): Tayfun Adanır, M.D. Atatürk Eğitim ve Araştırma Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, İzmir, Turkey.

Tel: +90 - 232 - 250 50 50 e-mail (e-posta): tayfunadanir@gmail.com

5

Ulus Travma Acil Cerrahi Derg

Several studies comparing epidural anesthesia versus balanced general anesthesia and systemic opioid analgesia have reported a more rapid recovery of bowel function in epidural anesthesia patients.[1-7] However, some authors have questioned whether epidural analgesia could be detrimental to the healing of gastrointestinal anastomoses because of the increased bowel motility.[8] There is, however, substantial experimental and clinical evidence that epidural anesthesia/analgesia is safe for patients undergoing bowel resections with anastomoses.[9,10] In addition, studies carried out on animals and humans have demonstrated that epidural anesthesia with local anesthetics during surgical stimulation maintains intestinal mucosal blood flow and gastric mucosal pH at physiological levels comparable with controls treated with general anesthetics.[11-13] It has been hypothesized that the increased mucosal flow can promote anastomotic healing.[14] In fact, retrospective cohort controlled studies suggest that regional anesthetic techniques are associated with a beneficial effect on anastomotic healing rates.[10-15] The stimulatory effect of epidural anesthesia on gastrointestinal mobility can lead to theoretical concern about increasing anastomotic leakage, but segmental autonomic blockade may increase the blood supply to the anastomosis and improve healing. In a recently published meta-analysis, the rate of anastomotic leakage remained the same, regardless of the analgesic technique used.[16] Epidural anesthesia is believed to benefit colorectal anastomotic blood flow because it produces sympathetic blockade.[17,18] However, continuous infusion of epidural local anesthetic can lead to an increased incidence of anastomotic leakage owing to the stimulatory effect on bowel motility.[19,20] In this study in a rabbit model, continuous epidural anesthesia with lidocaine was investigated in terms of the bursting pressure of colonic anastomoses (BPA).

Hydroxyproline and collagen are considered as indicators of anastomotic strength, and thus their levels as measured in anastomosis sample tissues were also examined.

MATERIALS AND METHODS Animal Preparation The study design was approved by the Animal Investigations Ethics Committee of Ataturk Training and Research Hospital, which conforms to standard animal treatment guidelines (Home office license number: 489, Date: 11.27.2008). Fourteen white male New Zealand rabbits weighing 2150-2850 g were used in this study. Before the experiment, the rabbits were acclimated for a minimum of 72 hours (h), and carefully checked for pre-existing disease. The daily food ration 6

was not withdrawn until the procedure was carried out. All the procedures were performed between 12:00 and 24:00 h. On the day of the experiment, anesthesia was induced with 20 mg kg-1 intramuscular ketamine (Ketasol 10%, Richter Pharma AG, Wels, Austria) and 8 mg kg-1 intramuscular xylazine (Alfazyne 2%, Alfasan International BV, Woerden, Netherlands).

After cannulation into the right-ear marginal veins of the animals, anesthesia was maintained intravenously with 10 mg kg-1 h-1 ketamine and 0.9% NaCl (5 mg kg-1). The left-ear marginal artery was cannulated to measure mean arterial pressure and heart rate (Petas KMA 800, Professional Electronic Industry and Tic. AS, Turkey). The rabbits were warmed to maintain a constant body temperature. Their tracheas were not intubated, and the animals breathed spontaneously. All animals received antibiotic coverage (cephamezine 20 mg kg-1, i.v.).

Epidural Procedure The hair on the tails and waist regions of the animals were shaved after they were placed in the prone position. The tail regions were scrubbed with 10% povidone iodine. A skin incision was performed 1 cm from the anus, following sterile coverage, and the subcutaneous injection of 1% lidocaine. The connective tissue and paraspinal muscles were dissected and the sacral hiatus opened. An 18-G epidural catheter (Minipack SIMS Portex Ltd, Hyde, Kent, UK) was inserted into the epidural space through the sacral canal up to 4-5 cm cranially. Aspiration was used to check whether the dura mater was punctured. The free edge of the catheter was placed in a subcutaneous tunnel using a Tuohy needle; it was shortened and connected to a screw connector for subsequent use. The catheter was fixed to the skin and the incision sutured. Neurological injury associated with the use of the epidural catheter was evaluated after recovery from the ketamine. Paraplegia and absent flexion reflex of both lower extremities following painful stimuli on the toes of the animals were considered as positive signs of neurological injury. Any animals exhibiting signs of a neurological or motor deficit were eliminated from the study. In order to verify that the catheter was within the epidural space, 1% lidocaine (0.4 ml kg-1) was administered 5 h later via the epidural catheter and flushed with 0.2 ml of 0.9% NaCl. If any motor or sensory blockade was observed within 5 minutes (min), it was concluded that the catheter was in the subdural and not epidural space.

It was verified that motor blockade was observed after 20 min of drug administration. Motor function was assessed according to the criteria of Drummond and Moore[21] (0: free motion without limitation in lower extremities; 1: asymmetry and limitation in providing body support and walking in lower extremities; 2: inability to provide body support by lower extremities; and 3: paralysis of both lower extremities).

Ocak - January 2012

Effect of epidural anesthesia on anastomotic leakage in colonic surgery

Animals were randomly assigned to two groups of seven animals chosen by computer-generated random numbers. After the evaluation of sensory blockade, animals in Group 1 were subjected to continuous epidural saline infusion (0.9% NaCl bolus and 0.2 ml kg-1 h-1 infusions) and those in Group 2 to 1% lidocaine (Aritmal Biosel amp, Beykoz, Turkey). The epidural catheter was used to administer 0.4 ml kg-1 bolus and 0.2 ml kg-1 h-1 infusion to the animals in Group 2. All epidural infusions (saline or lidocaine) were continued for 6 h during the postoperative period, and the degree of motor blockade of animals in Group 2 was maintained at 1 or 2 (by administering additional epidural 1% lidocaine, 0.2 ml kg-1, as needed). In Group 1, ketamine was infused (2-5 mg kg-1 h-1) throughout the postoperative 6-h period to provide adequate analgesia.

Surgery All animals were placed in a supine position. After the evaluation of sensory blockade, anesthesia was maintained intravenously with 10 mg kg-1 h-1 ketamine.

The animals were prepared and draped, and peritoneal access was gained using midline laparotomy. An equal length of incision was used in all animals. The right colon was identified, incised and divided 5 cm distal to the ileocecal valve. Colonic integrity was established with end-to-end anastomoses in all animals. Atraumatic 5/0 Vicryl Rapide® stitch was used for colon anastomoses. The procedures were performed by surgeons blinded to the study groups using a standardized technique. The right colon was selected for the strength of the anastomosis model to ensure that the distance of the anastomoses was standard for all animals.

On the fourth postoperative day, relaparotomy was performed under general anesthesia by another surgeon, also blinded to group assignments. Gross observation of circumferential healing of anastomotic lines was documented. The BPA were measured in situ by another anesthetist blinded to the study groups. The anastomotic segment was dissected from the adhering tissue, opened at the mesenteric side, and a 1-cm long segment containing the complete suture line was excised and washed gently with saline solution. The levels of hydroxyproline and collagen were measured in this sample tissue.

Bursting Pressure Measurements Measurements were carried out in vivo, while the intestinal flow was intact. The colon was ligated 3 cm distal to the anastomotic line. A 14 G silicon doublelumen catheter was inserted from the proximal end of the colon, and this end was ligated 3 cm above the anastomoses over the catheter with silk stitch. Saline solution was infused via one lumen of the catheter at a rate of 10 ml min-1. The hub of the second lumen of the catheter was attached to the transducer (Sasan pressure set, Sasan, Ankara, Turkey) for BPA meaCilt - Vol. 18 Sayı - No. 1

surement. When normal saline solution was infused via the one lumen of the catheter, the maximum pressure recorded on the monitor just before sudden loss of pressure was recorded as the BPA. After the procedures, the animals were euthanized using thiopental (120 mg kg-1, i.v.).

Biochemistry Analyses Tissue samples were homogenized and stored at -40°C. An autoclave was used to hydrolyze the specimens. Chloramine-T was added to provide oxidation at room temperature. Finally, Ehrlich reactive was also used to stain samples measured at 550 nm using a spectrophotometer.[22] Hydroxyproline levels were measured using standard graphics (0.05-1.5 mmol L-1) and collagen concentrations were measured (micg mg-1). These assessments were provided by a biochemist blinded to the study.

Statistical Analysis Statistical analyses were carried out using SPSS for Windows version 15.0 (SPSS Inc., Chicago, IL, USA). Because this was a pilot study, we considered that seven animals constituted an adequate sample size for each condition investigated. Seven animals were adequate for the non-parametric ANOVA tests (Mann-Whitney U tests). In addition, the previously published data[10] revealed that seven animals were required in each group. Results were expressed as median value (min and max value) with 95% confidence interval. The groups were subsequently compared using the Mann-Whitney U test, and values of p<0.05 were considered as significant.

RESULTS The weights of the animals were comparable in each group (Group 1 [n: 7]: median: 2450 g [min 2150 - max 2850] vs. Group 2 [n: 7]: median: 2470 g [min 2190 - max 2840]; p=0.2). No anastomotic complications (dehiscence of the anastomosis or death) occurred in the animals, and gross observation of circumferential healing of anastomotic lines was documented.

The mean hydroxyproline levels were measured as 1.17±0.85 mmol L-1 (min 0.18 - max 2.11) in Group 1 and 1.22±0.44 mmol L-1 (min 0.8 - max 2.12) in Group 2 (Fig. 1). The mean collagen levels were measured as 122±89 µgm L-1 (min 19 - max 221) in Group 1 and 128±46 µgm L-1 (min 84 - max 223) in Group 2 (Fig. 2). No statistically significant difference was detected in tissue hydroxyproline and collagen levels between the groups (p>0.05).

Bursting pressures of the anastomoses (BPAs) were statistically higher in the epidural lidocaine group than the control group (median: 248 mm Hg [min 117, max 300] in Group 2 vs. median: 109 mm Hg [min 47, max 176] in Group 1; p=0.006) (Fig. 3).

7

Ulus Travma Acil Cerrahi Derg

2.5

mmol/L

2 1.5 1 0.5 0

Group 1

Group 2

Fig. 1. Measured anastomotic tissue hydroxyproline levels were comparable between the groups (mmol L-1).

250

mcgm/L

200 150 100 50 0

Group 1

Group 2

Fig. 2. Measured anastomotic tissue collagen levels were comparable between the groups (Âľg L-1).

350 300

mmHg

250 200 150 100 50 0

Group 1

Group 2

Fig. 3. Bursting pressures of the anastomoses in the epidural group were statistically higher than in controls (mmHg). *p<0.05

DISCUSSION In the present study, the tissue levels of collagen and hydroxyproline were comparable between the two groups. However, the elongation of epidural anesthesia with lidocaine for six hours into the postoperative period increased the anastomotic bursting pressure.

8

Anastomotic disruption is a serious complication of colorectal surgery. Adequate blood flow and oxygen perfusion are key elements in the successful healing of an anastomosis.[23] Sympathetic blockade by epidural analgesia can increase colonic blood flow and minimize distension of the colon by stimulating propulsive forces.[17,18] Through these mechanisms, epidural analgesia could facilitate anastomotic healing. However, case reports have suggested that early recovery of colonic motility induced by epidural analgesia could increase the anastomotic disruption rate.[19,20] One study has further suggested that exposure to epidural bupivacaine decreases oxygen perfusion in colorectal anastomosis.[14] Animal, retrospective and randomized clinical studies have added to the debate regarding the effect of epidural analgesia on anastomotic integrity. Blass et al.[24] demonstrated more advanced colonic anastomotic healing at postoperative day 7 in a canine experimental model that received epidural compared with animals receiving no epidural. However, this difference did not persist 14 days postoperatively. Another study demonstrated that rats treated with epidural ropivacaine after colon resection had better propulsive bowel function, more collagen in the anastomosis, and similar bursting pressure to controls.[17] In a porcine model, Schnitzler et al.[10] reported no differences between epidural bupivacaine, morphine or saline with respect to bursting pressure or hydroxyproline content of the anastomosis. No anastomotic complications occurred in these animals. Furthermore, Jansen et al.[25] reported that the bursting pressures of intact colonic anastomoses in dogs were similar in control animals and those receiving epidural bupivacaine. However, of the four animals in the epidural group, one had a bowel intussusception and another had an anastomotic leak.

The authors proposed that the faster return of colonic motility was not functionally propulsive and could be responsible for these complications. In another animal study, epidural anesthesia increased gut mucosal blood flow but reduced intermittent flow in the villus microcirculation in the presence of a decreased perfusion pressure.[18] In a recently published meta-analysis, the anastomotic leak rate remained constant irrespective of the analgesic technique used.[16] Although total splanchnic flow can be increased with epidural analgesia, tonometric bowel pH measurements demonstrate that this is accompanied by a redistribution of blood flow away from anastomoses. The inability of juxtaanastomotic vessels to dilate as much as normal bowel vessels may result in a â&#x20AC;&#x153;stealâ&#x20AC;? of blood flow from the anastomoses to normal bowel.[14] In an animal study, no significant difference in anastomotic bursting pressure seven days after anastomoses with epidural analgesia was evident when compared with conventional general anesthetic.[10] In a recently published review Ocak - January 2012

Effect of epidural anesthesia on anastomotic leakage in colonic surgery

article, no data demonstrated a harmful or beneficial effect of epidural analgesia on the rates of anastomotic leakage.[26] Thinner nerve fibers are affected by lower local anesthetic concentrations than thicker fibers, suggesting that neuronal block is a function of diameter. With increasing local anesthetic concentration, the B fibers (preganglionic sympathetic fibers) are blocked first, followed by C fibers (pain and autonomic fibers) and then the largest A fibers (touch, pressure sensation and motor fibers). The aim of epidural analgesia is to produce a differential nerve block, predominantly affecting nociceptive and sympathetic fibers with no motor effects. However, critical concentrations required to block sympathetic fibers can vary considerably between patients. Therefore, applying epidural analgesia alone may not increase blood flow in the anastomotic line as it does not consistently produce sufficient sympathetic blockade.

In all previous studies concerning this issue, either intra-operative epidural anesthesia (which causes sympathetic blockade) or postoperative analgesia was applied generally. In the case of postoperative epidural analgesia, there may be no direct effect on anastomotic healing as sympathetic blockade may not occur. In the case of epidural anesthesia, sympathetic blockade occurs because of the greater concentration of local anesthetics used. For this reason, we continued epidural anesthesia (i.e., sympathetic blockade) for six hours postoperatively. Epidural anesthesia was applied to avoid the exact evaluation of sympathetic blockade in the experimental animals (by forming moderate motor blockade). The results demonstrated higher anastomotic bursting pressures in the epidural anesthesia group, an indicator of anastomotic strength and anastomotic leakage.

However, there was no difference in terms of tissue collagen and hydroxyproline levels, which are indicators of anastomotic healing. Anastomotic leakage is generally determined 5 to 7 days postoperatively.[27] The strength of the anastomosis decreases markedly during the first 3-4 days owing to changes in the enzymatic structure of collagen bundles, but it increases after the fourth day, with prominent collagen production and accumulation.[28,29] As anastomotic leakage is clinically determined during the 5th to 7th postoperative days, re-laparotomies of the experimental animals were performed on the 4th postoperative day, during which collagen production begins to increase but the strength of anastomosis is still poor. For this reason, enough time may not have elapsed for collagen development to ensue. In previous experimental studies, anastomotic bursting pressures and tissue collagen levels were generally evaluated between the 7th to the 14th postoperative days. However, during this time, Cilt - Vol. 18 Say覺 - No. 1

anastomotic leakage could have formed or healing could be complete. For this reason, re-laparotomies were performed during the 4th postoperative day, and anastomotic bursting pressures were measured as anastomotic leakage had not yet developed.

Shortfalls in the present study include the absence of measurements of splanchnic blood flow or oxygenation at the anastomotic line and failure to keep the sympathetic blockade for more than six hours. However, the sympathetic blockade was not maintained for more than six hours because the toxic dose level of lidocaine could have been reached. In the lidocaine group, all animals were administered over 20 mg kg-1 lidocaine. However, further studies are required to clarify the association between longer sympathetic blockade by epidural infusion of local anesthetic and strength of colonic anastomoses.

In this experimental rabbit model, epidural 1% lidocaine, which was applied intra-operatively and continued for six hours, increased anastomotic bursting pressure (considered as an indicator of potential anastomotic strength). This could be due to the epidural lidocaine causing sympathetic blockade, resulting in increased splanchnic blood flow.

Declaration of interest The authors have no declaration of interest.

Acknowledgements The authors thank Dr. Ozlem Gunduz for performing the statistical analysis and the staff of the animal research laboratory for skilled technical assistance.

We also thank the Foundation of Izmir Hospitals for their support of the study and BioMeds for the English editing.

REFERENCES 1. Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 1995;82:1474-506.

2. Grass JA. The role of epidural anesthesia and analgesia in postoperative outcome. Anesthesiol Clin North America 2000;18:407-28.

3. Carpenter RL. Gastrointestinal benefits of regional anesthesia/analgesia. Reg Anesth 1996;21:13-7.

4. Ryan P, Schweitzer SA, Woods RJ. Effect of epidural and general anaesthesia compared with general anaesthesia alone in large bowel anastomoses. A prospective study. Eur J Surg 1992;158:45-9.

5. Stevens RA, Mikat-Stevens M, Flanigan R, Waters WB, Furry P, Sheikh T, et al. Does the choice of anesthetic technique affect the recovery of bowel function after radical prostatectomy? Urology 1998;52:213-8.

6. Carli F, Mayo N, Klubien K, Schricker T, Trudel J, Belliveau P. Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Anesthesiology 2002;97:540-9.

7. Liu SS, Carpenter RL, Mackey DC, Thirlby RC, Rupp SM, Shine TS, et al. Effects of perioperative analgesic technique 9

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on rate of recovery after colon surgery. Anesthesiology 1995;83:757-65.

8. Carlstedt A, Nordgren S, Fasth S, Appelgren L, Hultén L. Epidural anaesthesia and postoperative colorectal motility--a possible hazard to a colorectal anastomosis. Int J Colorectal Dis 1989;4:144-9.

9. Carli F, Trudel JL, Belliveau P. The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery: a prospective, randomized trial. Dis Colon Rectum 2001;44:1083-9.

10. Schnitzler M, Kilbride MJ, Senagore A. Effect of epidural analgesia on colorectal anastomotic healing and colonic motility. Reg Anesth 1992;17:143-7.

11. Kapral S, Gollmann G, Bachmann D, Prohaska B, Likar R, Jandrasits O, et al. The effects of thoracic epidural anesthesia on intraoperative visceral perfusion and metabolism. Anesth Analg 1999;88:402-6.

12. Sutcliffe NP, Mostafa SM, Gannon J, Harper SJ. The effect of epidural blockade on gastric intramucosal pH in the perioperative period. Anaesthesia 1996;51:37-40.

13. Johansson K, Ahn H, Lindhagen J, Tryselius U. Effect of epidural anaesthesia on intestinal blood flow. Br J Surg 1988;75:73-6.

14. Sala C, García-Granero E, Molina MJ, García JV, Lledo S. Effect of epidural anesthesia on colorectal anastomosis: a tonometric assessment. Dis Colon Rectum 1997;40:958-61.

15. Aitkenhead AR, Wishart HY, Brown DA. High spinal nerve block for large bowel anastomosis. A retrospective study. Br J Anaesth 1978;50:177-83.

16. Marret E, Remy C, Bonnet F; Postoperative Pain Forum Group. Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery. Br J Surg 2007;94:665-73.

17. Jansen M, Lynen Jansen P, Junge K, Anurov M, Titkova S, Ottinger A, et al. Postoperative peridural analgesia increases the strength of colonic contractions without impairing anastomotic healing in rats. Int J Colorectal Dis 2003;18:50-4.

18. Sielenkämper AW, Eicker K, Van Aken H. Thoracic epidural

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anesthesia increases mucosal perfusion in ileum of rats. Anesthesiology 2000;93:844-51.

19. Bigler D, Hjortsø NC, Kehlet H. Disruption of colonic anastomosis during continuous epidural analgesia. An early postoperative complication. Anaesthesia 1985;40:278-80.

20. Treissman DA. Disruption of colonic anastomosis associated with epidural anesthesia. Reg Anesthesia 1980;5:22-3.

21. Drummond JC, Moore SS. The influence of dextrose administration on neurologic outcome after temporary spinal cord ischemia in the rabbit. Anesthesiology 1989;70:64-70.

22. Reddy GK, Enwemeka CS. A simplified method for the analysis of hydroxyproline in biological tissues. Clin Biochem 1996;29:225-9.

23. Senagore A, Milsom JW, Walshaw RK, Dunstan R, Mazier WP, Chaudry IH. Intramural pH: a quantitative measurement for predicting colorectal anastomotic healing. Dis Colon Rectum 1990;33:175-9.

24. Blass CE, Kirby BM, Waldron DR, Turk MA, Crawford MP. The effect of epidural and general anesthesia on the healing of colonic anastomoses. Vet Surg 1987;16:75-9.

25. Jansen M, Fass J, Tittel A, Mumme T, Anurov M, Titkova S, et al. Influence of postoperative epidural analgesia with bupivacaine on intestinal motility, transit time, and anastomotic healing. World J Surg 2002;26:303-6.

26. Gendall KA, Kennedy RR, Watson AJM, Frizelle FA. The effect of epidural analgesia on postoperative outcome after colorectal surgery. Colorectal Dis 2007;9:584-600.

27. Emet T, Bilsel Y, Tilki M, Sürmelioğlu A, User Y. Early diagnosis of colorectal anastomotic leakages by detection of bacterial genome. Ulus Travma Acil Cerrahi Derg 2005;11:195200.

28. Mast BA. Healing in other tissues. Surg Clin North Am 1997;77:529-47.

29. Oxlund H, Christensen H, Seyer-Hansen M, Andreassen TT. Collagen deposition and mechanical strength of colon anastomoses and skin incisional wounds of rats. J Surg Res 1996;66:25-30.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):11-17

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.95530

Effects of repetitive injections of hyaluronic acid on peritendinous adhesions after flexor tendon repair: a preliminary randomized, placebo-controlled clinical trial Fleksör tendon onarım sonrası, tekrarlayan hyaluronik asit enjeksiyonlarının, peritendinöz adezyon üzerine etkisi: Randomize plasebo kontrollü klinik ön çalışma Güzin Yeşim ÖZGENEL,1 Abdullah ETÖZ2 BACKGROUND

AMAÇ

The aim of this study was to investigate the efficacy of three injections of hyaluronic acid (HA) versus placebo (saline) over a two-week period on functional outcomes after zoneII flexor tendon repairs.

Bu çalışmada, zon-II fleksör tendon onarımlarından sonra, iki haftalık süre içerisinde enjekte edilen 3 doz hyaluronik asit (HA) enjeksiyonunun plaseboya (salin) karşı etkinliği araştırıldı.

METHODS

GEREÇ VE YÖNTEM

Twenty-two patients with isolated zone-II flexor tendon injury of the index fingers were included in this study. Before tenorrhaphy, fingers were randomly divided into two groups; 11 were treated with three injections of HA around the tenorrhaphy site and 11 served as a placebo group and were treated with saline in the same way. The first dose was given at the time of tenorrhaphy and two additional doses were given at one-week intervals. A Kleinert rehabilitation protocol was employed postoperatively. Range of motion was assessed with total active and passive movement evaluation systems at 3 weeks, 3 months and long-term. Functional outcome was evaluated using the Strickland classification.

Çalışmaya İkinci parmak izole zon-II fleksör tendon hasarlanması olan 22 hasta dahil edildi. Tenorafi öncesi, parmaklar randomize olarak iki gruba ayrıldı; 11 parmakta tenorafi çevresine 3 doz HA enjekte edilirken, aynı şekilde salin enjekte edilen 11 parmak da plasebo grubunu oluşturdu. Birinci doz tenorafi sırasında verildi ve ilave 2 doz 1 hafta ara ile enjekte edildi. Operasyon sonrası Kleinert rehabilitasyon protokolü uygulandı. Eklem hareket açıklığı, 3. hafta, 3. ay ve uzun dönemde total aktif ve pasif eklem açıklığı ölçülerek değerlendirildi. Fonksiyonel sonuç, Strickland sınıflandırmasına göre belirlendi.

RESULTS

There were no differences between the two groups in terms of range of motion at 3 weeks. However, at 3 months and long-term, a significant improvement was observed in fingers treated with HA compared to placebo.

Üçüncü haftada eklem hareket açıklığı açısından iki grup arasında bir fark tespit edilmedi. Ancak, 3. ay ve uzun dönemde, eklem hareket açıklığında, HA enjekte edilen parmaklarda plasebo grubuna göre anlamlı derecede iyileşme olduğu gözlendi.

CONCLUSION

SONUÇ

BULGULAR

This preliminary placebo-controlled study suggests that repetitive injections of HA can improve clinical outcomes presumably due to the effect on decreasing adhesions in primary tendon repairs.

Bu plasebo kontrollü ön çalışmada, mükerrer HA enjeksiyonlarının, primer tendon onarımında, muhtemelen adezyon azaltıcı etkisine bağlı olarak, klinik sonuçları iyileştirebildiği ileri sürülmektedir.

Key Words: Adhesion prevention; hyaluronic acid; tendon adhesions; tendon repair.

Anahtar Sözcükler: Adezyon önleme; hyaluronik asit; tendon adezyonları; tendon onarımı.

Department of Plastic, Reconstructive and Aesthetic Surgery, Division of Hand Surgery, Uludag University Faculty of Medicine, Bursa; 2 Department of Plastic Surgery, Inegöl State Hospital, Bursa, Turkey.

1

Uludağ Üniversitesi Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, El Cerrahisi Bilim Dalı, Bursa; 2 İnegöl Devlet Hastanesi, Plastik Cerrahi Bölümü, Bursa.

1

Correspondence (İletişim): Güzin Yeşim Özgenel, M.D. Uludağ Üniversitesi Plastik Cerrahi Anabilim Dalı, Görükle 16059 Bursa, Turkey.

Tel: +090 - 224 - 442 81 93 e-mail (e-posta): gozgenel@yahoo.com

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Ulus Travma Acil Cerrahi Derg

Despite advances in surgical techniques and improved postoperative rehabilitation programs, adhesions between the tendon and the surrounding tissues continue to be an important problem after primary flexor tendon repair, especially in zone II.[1-5] Various pharmacologic agents have been used in an attempt to reduce peritendinous adhesions after flexor tendon surgery.[6-14] One of these agents is hyaluronic acid (HA), a fibroblast-derived glycosaminoglycan. Previous experimental studies show that topical application of high molecular weight HA in high concentrations between an injured tendon and its sheath promotes tendon healing and decreases adhesion formation.[15-20] In these experimental studies, the prevention of peritendinous adhesions was explained by the fact that HA created a scaffold around the tenorrhaphy site because of its high viscoelastic property. This macromolecular network would prevent fibrous ingrowth from the surrounding tissues.[21-23] The other explanation was that HA, being an effective soft tissue lubricant, might decrease the new extracellular matrix formation due to the inhibition of mononuclear phagocytes and lymphocytes.[24] The goal of this clinical study was to compare the effects of repetitive injections of HA with placebo on the functional outcome after primary digital zone- II flexor tendon repair.

MATERIALS AND METHODS Study Design A randomized, double-blind, placebo-controlled trial was performed to determine whether peritendinous adhesions decrease as a result of treatment with HA (Orthovisc; Anika Therapeutics, USA) as opposed to a physiologic saline solution (placebo). The study was approved by our institutional review board and all patients signed an informed-consent form before surgery.

Patients From March 2002 to January 2005, 22 patients with a total of 22 flexor digitorum profundus (FDP) and 22 flexor digitorum superficialis (FDS) tendon transections of the index fingers caused by sharp instruments were operated. Specific characteristics of the patients, including gender, mean age, smoking, hand dominance, etiology, site of injury, and presence of digital nerve injury, are summarized in Table 1. The two groups were similar in terms of age, sex, dominance of the injured hand, injury zone, and the number of the digits with nerve injury.

Fingers that were included in this clinical study were those that had a laceration of the FDP tendon, with a concomitant injury of the FDS tendon, in zone II of the index fingers, which had occurred within 24 hours prior to the surgery. Correspondingly, fingers 12

that were excluded from this study were those that had a cutaneous defect at the repair site, a concomitant fracture, prior hand trauma, or congenital hand defect in order to avoid complications related to the wound site.

Randomization Randomization was performed after it had been determined that the inclusion criteria had been met, but before the patient was taken to the operating room.

The result of the randomization was not available to any of the involved clinicians or patients other than to the surgeon who performed the tendon repair and subsequently injected HA or saline solution. In all cases, the clinician injecting the test substance and the examiner performing the clinical evaluation were separate individuals.

Surgical Procedure All operations were performed by one of the investigators in a standardized way under axillary block anesthesia and tourniquet control within the first 24 hours of injury. Both FDP and FDS tendons were approached through palmar zigzag incisions described

by Brunner, and each FDP tendon was repaired with polypropylene suture (4-0 Prolene®, Johnson & JohnTable 1. Patient details* Treatment group

Placebo group

11 11 Total number of patients Gender 11 10 Male – 1 Female 28 (21-35) 31 (26-36) Mean age (range) (yr) Smoker 9 11 Yes 2 – No Dominant hand 10 9 Right 1 2 Left Injured hand 10 9 Right 1 2 Left Cause of injury 3 4 Knife 6 4 Glass 2 3 Saw Site of injury – – Proximal to A2 pulley 3 3 Under A2 pulley 8 8 Distal to A2 pulley Number of digits with nerve injury 9 8 Injured 9 8 Repaired * Demographic data for 22 patients

Ocak - January 2012

Effects of repetitive injections of hyaluronic acid on peritendinous adhesions after flexor tendon repair

son, Switzerland) using the modified Kessler technique, followed by an epi-tendinous running suture (6-0 Prolene®, Johnson & Johnson, Switzerland). The injured FDS tendon was treated in the same way as the FDP tendon. In all cases, the membranous portion of the flexor tendon sheath was sutured. The management of the pulley system of flexor tendon sheath was performed according to the site of the tendon injury.

When the cut was a little distal to the A2 pulley, the distal one-third of the A2 pulley was released. When the tendon was repaired under the middle and proximal part of the A2 pulley, half of the A2 pulley was divided. When the tendon cut was at the level of the A3 pulley, all annular pulleys were preserved. When the cut was between the proximal interphalangeal (PIP) joint and A4 pulley, only the A3 pulley was divided.

In addition, all associated digital nerve divisions were repaired with polypropylene suture (10-0 Prolene®, Johnson & Johnson, Switzerland).

Before closing the wound, the catheter (23G x 3/4 inch, Vacuette®) tip was placed closest to the FDP tenorrhaphy site adjacent to the closed flexor tendon sheath and threaded subcutaneously, exiting the skin at the level of the A1 pulley just like a suction drain, and it was fixed to the skin at the exit point by a suture in order to maintain the catheter tip adjacent to the tenorrhaphy site. After closing the wound, in the treatment group, 0.4 ml of high molecular weight HA (1.0-2.9 million Daltons) in high concentrations (15 mg/ml) was injected through the catheter, and then the end of the catheter was covered with a tap. In the placebo group, an equivalent volume of physiologic saline solution was administered in the same way. Next, a sterile dressing was applied, followed by a dorsal plaster splint, extending from beyond the fingertip to the proximal forearm. The wrist was held in approximately 30° palmar flexion, the metacarpophalangeal (MCP) joints were flexed approximately 60° and the PIP and distal interphalangeal (DIP) joints were flexed 0°. The splint allowed full extension of the PIP and DIP joints.

After surgery, two injections were given through the inserted catheter at one-week intervals and at the completion of the injections, the catheter was withdrawn. The skin sutures were removed on the 10th day.

Post-Operative Follow-Up All operated fingers had similar postoperative care.

Rehabilitation was started on the 3rd postoperative day with a passive flexion and active extension protocol according to the method of Kleinert and continued for the first 4 weeks.[25,26] At the 5th week, the plaster splint was removed and active flexion was started.

All patients were followed by the same blinded clinician (twice a week for the first 12 weeks and then Cilt - Vol. 18 Sayı - No. 1

once at 6 months). Each visit included visual inspection and physical examination of the operated finger and assessment for signs of wound dehiscence or infection. Range of motion of MCP, PIP and DIP joints of each finger was measured using a goniometer at 3 weeks, 3 months and long-term (range: 58-91 months) after the surgery. Range of motion values for passive and active movements of three joints in each finger were summed up and recorded as the total range of passive motion (TPM) and the total range of active motion (TAM). The revised Strickland grading system (Strickland, 1985) was used to assess the final active motion of each operated finger at the long-term followup. The active motion value was found by subtracting the extension deficit of the involved joints from the maximal possible flexion. Results were classified as excellent (>131°), good (88-131°), fair (44-87°) and poor (<44°).

Statistical Analysis The Mann-Whitney U test was performed for unpaired groups and categorical variables were analyzed

by Fisher’s exact test. A p value less than 0.05 was considered statistically significant.

RESULTS All patients complied with the rehabilitation protocol. During the first two weeks, there was a limited range of active and passive movements in each group because of pain and swelling. After two weeks, pain and swelling decreased and the range of motions increased gradually. No adverse events such as discomfort at the injection site and/or localized swelling were seen in any of the patients. HA did not produce any clinical signs of inflammation. On gross examination, all operated fingers appeared to be free of infection.

No flexion contracture developed. Tendon rupture was not seen in any of the cases.

Placebo Group The TPM value for the saline-treated group was 155.9° (19.6) (range: 110-175°) at postoperative 3 weeks and increased to 177.7° (23.3) (range: 120200°) at 3 months and 181.8° (20.2) (range: 130-200°) at long-term. The TAM value was measured as 107.3° (18.4) (110-175°) at 3 weeks and found to increase to 141.4° (21.7) (120-200°) at the end of the 3rd month and 147.7° (19.5) (110-170°) at long-term. In 11 fingers, 7 were rated as good and 4 as fair according to the revised Strickland classification system (Table 2).[27] Treatment Group The TPM value for the HA-treated group was 167.7° (21.8) (120-195°) at postoperative 3 weeks and increased to 212.3° (33.5) (140-240) at 3 months and 217.7° (26.9) (160-240°) at long-term. The TAM value was measured as 118.6° (15.3) (90-135°) at 3 weeks 13

Ulus Travma Acil Cerrahi Derg

Table 2. Length of follow-up information and functional outcomes calculated using the revised Strickland classification system for each patient Placebo group Patient 1 2 3 4 5 6 7 8 9 10 11

Treatment group

Duration of follow-up

(months)

Mean±SD Range

58 59 60 60 61 59 91 62 61 65 60

Strickland

Patient

Good Fair Good Good Good Fair Good Fair Fair Good Good

1 2 3 4 5 6 7 8 9 10 11

63±2 58-91

Comparison There was no statistically significant difference in TPM and TAM values between the two groups at 3 weeks after surgery (p>0.05). However, at 3 months and long-term, a significant increase was observed in the total values of the passive and active range of motions of the fingers treated with HA compared with the fingers treated with saline (p<0.05) (Figs. 1, 2). The assessment of range of motion using the revised Strickland classification system gave 3/11 excellent and 8/11 good results in the HA-treated group compared with 7/11 good results in the placebo group (Table 2).

p=0.08

p=0.02

Strickland

Excellent Good Good Good Excellent Good Good Excellent Good Good Good

Mean±SD Range

and was found to increase to 166.4° (14.8) (135-185°) at the end of the 3rd month and 176.4° (12.7) (150190°) at long-term. In 11 fingers, 3 were rated as excellent and 8 as good according to the revised Strickland classification system (Table 2).[27]

250

Duration of follow-up

(months)

DISCUSSION The main problem after flexor tendon surgery is the formation of adhesions between the tendon and the tendon sheath or other tissues that restricts tendon gliding. Several different types of interpositional materials, both biologic and synthetic, have been used as a barrier around the site of tendon repair.[28,29] These isolation techniques have generally been unsuccessful.

Some of them were found to cause impairment of the tendon healing process and some materials stimulated a severe inflammatory response. Various pharmacologic agents such as 5-fluorouracil, indomethacin and ibuprofen have been proposed.[10-12,14] Prostaglandin inhibitors, such as indomethacin and ibuprofen, may decrease the endogenous local damage by reducing the pro-inflammatory agents. The consequence could be a decrease in peritendinous fibroplasia. Steroids, antihistamines and beta-aminopropionitrile have shown

180

200

p=0.002

160 140 Placebo Treatment

100

63±2 59-85

200

p=0.07

150

59 60 60 60 61 62 85 62 61 65 61

120

p=0.001

p=0.12 Placebo

100

Treatment

80 60 40

50

20 0

TPM at 3-week

TPM at 3-month

TPM at long term

Fig. 1. Comparison of the results of total passive range of joint motions (degrees).

14

0

TPM at 3-week

TPM at 3-month

TPM at long term

Fig. 2. Comparison of the results of total active range of joint motions (degrees).

Ocak - January 2012

Effects of repetitive injections of hyaluronic acid on peritendinous adhesions after flexor tendon repair

experimental promise, but cannot be used clinically because of toxicity or impairment of wound healing.

[7,8,13] Additionally, aprotinin and 5-fluorouracil have been used with variable results.[9,11] Human amniotic fluid has some type of inhibitory effect on fibroblast proliferation. It was shown that the least adhesion and the best healing were observed in tendons treated with human amniotic fluid application.[30] However, no human trial has been reported.

Recently, there has been a great interest in HA, which is richly found in the extracellular matrix of soft connective tissues and synovial fluids in the human body.[31] HA provides a healing process through regeneration and growth rather than scarring and fibrosis.

[21,22] However, this effect has been variable.[32] The molecular weight and the concentration of the preparation are critical to its potential beneficial effects.

Low concentration and low molecular weight seem to have a stimulating effect on granulocyte function.

[33] In contrast, high concentration and high molecular weight HA inhibits the movements and phagocytosis of granulocytes.[34,35] It was found that the critical molecular weight seems to be around 105 to 106 Daltons for inhibition of granulocyte function.[15] In this present study, Orthovisc (Anika Therapeutics, USA) was used. The molecular weight and the concentration of hyaluronan in Orthovisc was about 106 Daltons and 15 mg/ml.

Several experimental studies have claimed that exogenously administered sodium hyaluronate helps to prevent the formation of postoperative adhesions after flexor tendon repair in zone II without interfering with healing.[15,17-20,36] The first prospective, double-blind, randomized clinical study about the HA effect on prevention of adhesions in hand surgery was performed

by Hagberg.[36] In that study, Hagberg did not demonstrate any significant benefit of single-dose injection of HA into the tendon sheath after flexor tendon repair in limiting adhesions. We believe this to be due to the rapid elimination of single-dose application of the HA preparation around the sites of tendon repair. Additionally, the wound would dilute the effectiveness of the HA solution. In order to overcome these limitations, in this clinical study, we preferred three injections of HA. The first injection was given at the time of the repair and two additional doses were given at one-week intervals. Therefore, we provided the maintenance of sufficient amounts of HA around the tenorrhaphy site during the first two weeks, which is defined as a critical period for peritendinous adhesions. A one-week interval was chosen because it was shown that HA was eliminated within 7 days.[15,30,31] This clinical study compared HA to saline. The concentration of electrolytes in normal saline solution (0.9%NaCl) is similar to that of blood and it is metaCilt - Vol. 18 Say覺 - No. 1

bolically inert (Hoppe et al., 2010). Therefore, saline does not create an inferior environment for the tendons and in the majority of the experimental and clinical studies, saline is used as placebo.[36-38] However, a study that had both placebo and untreated groups (simply leaving the catheter in) can be planned in order to distinguish the placebo effect.

Postoperative rehabilitation methods improve the clinical outcomes in flexor tendon surgery by reducing the peritendinous adhesions and providing more tensile strength by favoring tendon nutrition and intrinsic tendon healing.[4] However, early active mobilization protocols may increase the repair site elongation and rupture rates.[39,40] In order to solve these problems, many multi-strand tendon suture techniques have been described.[41,42] Experimental studies have shown that suture strength and resistance to repair site gap formation increase with the number of suture strands crossing the tendon repair site.[43-45] However, this makes the suture techniques more complex and increases the difficulty of using these configurations in clinical cases. On the other hand, multi-strand repairs may increase the peritendinous adhesions and damage the nutrition in the tendon ends. In addition, if appropriate pulleys are not released during the flexor tendon surgery, multi-strand repairs alone cannot eliminate the danger of tendon rupture.[46] For these reasons, we preferred to use the modified Kessler suture technique.

This conventional two-strand repair augmented with a peripheral suture provides sufficient gap resistance and tensile strength that may be able to withstand early active mobilization after flexor tendon repair. In addition, the material used for core and peripheral suture, length of the core suture purchase and depth and length of the peripheral suture purchase are the other factors that affect the results of the tendon surgery.[42] In this clinical study, a peripheral suture was placed deep into the tendon instead of superficially only through the epitenon and 2 mm from the cut tendon ends in order to increase the repair site strength.

Strickland classification[27] is most commonly used evaluation system especially for zone-II flexor tendon repairs.[27,44,46-49] In this article, functional status was evaluated using the revised Strickland classification system. The fingers treated with HA showed 27% excellent and 73% good results, whereas fingers treated with saline showed 64% good and 36% fair results. As a result, HA-treated fingers showed superior results compared with the saline-treated fingers.

In conclusion, this preliminary clinical study shows that repetitive injections of HA around the tenorrhaphy site after flexor tendon surgery reduces the formation of restrictive adhesions. However, large series are needed in order to support the results of this clinical study.

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Acknowledgements We thank İlker ERCAN for support with the statistical analysis. No benefits in any form have been received related to the subject of this article.

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2. Gelberman RH, Manske PR. Factors influencing flexor tendon adhesions. Hand Clin 1985;1:35-42.

3. Jansen CW, Watson MG. Measurement of range of motion of the finger after flexor tendon repair in zone II of the hand. J Hand Surg Am 1993;18:411-7.

4. Manske PR. Flexor tendon healing. J Hand Surg Br 1988;13:237-45.

5. Matthews P, Richards H. Factors in the adherence of flexor tendon after repair: an experimental study in the rabbit. J Bone Joint Surg Br 1976;58:230-6.

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7. Kapetanos G. The effect of the local corticosteroids on the healing and biomechanical properties of the partially injured tendon. Clin Orthop Relat Res 1982;163:170-9.

8. Ketchum LD. Effects of triamcinolone on tendon healing and function. A laboratory study. Plast Reconstr Surg 1971;47:471-82.

9. Komurcu M, Akkus O, Basbozkurt M, Gur E, Akkas N. Reduction of restrictive adhesions by local aprotinin application and primary sheath repair in surgically traumatized flexor tendons of the rabbit. J Hand Surg Am 1997;22:826-32.

10. Kulick MI, Smith S, Hadler K. Oral ibuprofen: evaluation of its effect on peritendinous adhesions and the breaking strength of a tenorrhaphy. J Hand Surg Am 1986;11:110-20.

11. Moran SL, Ryan CK, Orlando GS, Pratt CE, Michalko KB. Effects of 5-fluorouracil on flexor tendon repair. J Hand Surg Am 2000;25:242-51.

12. Nishimura K, Nakamura RM, diZerega GS. Ibuprofen inhibition of postsurgical adhesion formation: a time and dose response biochemical evaluation in rabbits. J Surg Res 1984;36:115-24.

13. Speer DP, Feldman S, Chvapil M. The control of peritendinous adhesions using topical beta-aminopropionitrile base. J Surg Res 1985;38:252-7.

14. Szabo RM, Younger E. Effects of indomethacin on adhesion formation after repair of zone II tendon lacerations in the rabbit. J Hand Surg Am 1990;15:480-3.

15. Amiel D, Ishizue K, Billings E Jr, Wiig M, Vande Berg J, Akeson WH, et al. Hyaluronan in flexor tendon repair. J Hand Surg Am 1989;14:837-43.

16. Hagberg L, Tengblad A, Gerdin B. Hyaluronic acid in flexor tendon sheath fluid after sheath reconstructions in rabbits. A comparison between tendon sheath transplantation and conventional two stage procedures. Scand J Plast Reconstr Surg Hand Surg 1991;25:103-7.

17. Nishida J, Araki S, Akasaka T, Toba T, Shimamura T, Amadio PC, Effect of hyaluronic acid on the excursion resistance of tendon grafts. A biomechanical study in a canine model in vitro. J Bone Joint Surg Br 2004;86:918-24.

18. Ozgenel GY. The effects of a combination of hyaluronic and amniotic membrane on the formation of peritendinous adhe16

sions after flexor tendon surgery in chickens. J Bone Joint Surg Br 2004;86:301-7.

19. St Onge R, Weiss C, Denlinger JL, Balazs EA. A preliminary assessment of Na-hyaluronate injection into “no man’s land” for primary flexor tendon repair. Clin Orthop Relat Res 1980;146:269-75.

20. Tuncay I, Ozbek H, Atik B, Ozen S, Akpinar F. Effects of hyaluronic acid on postoperative adhesion of tendo calcaneus surgery: an experimental study in rats. J Foot Ankle Surg 2002;41:104-8.

21. Burd DA, Greco RM, Regauer S, Longaker MT, Siebert JW, Garg HG. Hyaluronan and wound healing: a new perspective. Br J Plast Surg 1991;44:579-84.

22. Longaker MT, Adzick NS. The biology of fetal wound healing: a review. Plast Reconstr Surg 1991;87:788-98.

23. Longaker MT, Chiu ES, Harrison MR, Crombleholme TM, Langer JC, Duncan BW, et al. Studies in fetal wound healing.

IV. Hyaluronic acid-stimulating activity distinguishes fetal wound fluid from adult wound fluid. Ann Surg 1989;210:66772.

24. Swann DA, Bloch KJ, Swindell D, Shore E. The lubricating activity of human synovial fluids. Arthritis Rheum 1984;27:552-6.

25. Lister GD, Kleinert HE, Kutz JE, Atasoy E. Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg Am 1977;2:441-51.

26. Kitsis CK, Wade PJ, Krikler SJ, Parsons NK, Nicholls LK. Controlled active motion following primary flexor tendon repair: a prospective study over 9 years. J Hand Surg Br 1998;23:344-9.

27. Strickland JW. Results of flexor tendon surgery in zone II. Hand Clin 1985;1:167-79.

28. Menderes A, Mola F, Tayfur V, Vayvada H, Barutçu A. Prevention of peritendinous adhesions following flexor tendon injury with seprafilm. Ann Plast Surg 2004;53:560-4.

29. Stark HH, Boyes JH, Johnson L, Ashworth CR. The use of paratenon, polyethylene film, or silastic sheeting to prevent restricting adhesions to tendons in the hand. J Bone Joint Surg Am 1977;59:908-13.

30. Ozgenel GY, Samli B, Ozcan M. Effects of human amniotic fluid on peritendinous adhesion formation and tendon healing after flexor tendon surgery in rabbits. J Hand Surg Am 2001;26:332-9.

31. Swann DA, Radin EL, Nazimiec M, Weisser PA, Curran N, Lewinnek G. Role of hyaluronic acid in joint lubrication.

Ann Rheum Dis 1974;33:318-26.

32. Rydell N. Decreased granulation tissue reaction after installment of hyaluronic acid. Acta Orthop Scand 1970;41:307-11.

33. Håkansson L, Hällgren R, Venge P. Regulation of granulocyte function by hyaluronic acid. In vitro and in vivo effects on phagocytosis, locomotion, and metabolism. J Clin Invest 1980;66:298-305.

34. Brown AF. Neutrophil granulocytes: adhesion and locomotion on collagen substrata and in collagen matrices. J Cell Sci 1982;58:455-67.

35. Pisko EJ, Turner RA, Soderstrom LP, Panetti M, Foster SL, Treadway WJ. Inhibition of neutrophil phagocytosis and enzyme release by hyaluronic acid. Clin Exp Rheumatol 1983;1:41-4.

36. Hagberg L. Exogenous hyaluronate as an adjunct in the prevention of adhesions after flexor tendon surgery: a controlled clinical trial. J Hand Surg Am 1992;17:132-6.

37. Dogramaci Y, Kalac A, Atik E, Esen E, Altuğ ME, Onel E, Ocak - January 2012

Effects of repetitive injections of hyaluronic acid on peritendinous adhesions after flexor tendon repair

et al. Effects of a single application of extractum cepae on the peritendinous adhesion: an experimental study in rabbits.

Ann Plast Surg 2010;64:338-41.

38. Jubb RW, Piva S, Beinat L, Dacre J, Gishen P. A one-year, randomised, placebo (saline) controlled clinical trial of 500-730 kDa sodium hyaluronate (Hyalgan) on the radiological change in osteoarthritis of the knee. Int J Clin Pract 2003;57:467-74.

39. Corradi M, Bellan M, Frattini M, Concari G, Tocco S, Pogliacomi F. The four-strand staggered suture for flexor tendon repair: in vitro biomechanical study. J Hand Surg Am 2010;35:948-55.

40. Harris SB, Harris D, Foster AJ, Elliot D. The aetiology of acute rupture of flexor tendon repairs in zones 1 and 2 of the fingers during early mobilization. J Hand Surg Br 1999;24(3):275-80.

41. Hoffmann GL, Büchler U, Vögelin E. Clinical results of flexor tendon repair in zone II using a six-strand double-loop technique compared with a two-strand technique. J Hand Surg Eur Vol 2008;33:418-23.

42. Kim HM, Nelson G, Thomopoulos S, Silva MJ, Das R, Gelberman RH. Technical and biological modifications for enhanced flexor tendon repair. J Hand Surg Am 2010;35:10318.

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43. Kubota H, Aoki M, Pruitt DL, Manske PR. Mechanical properties of various circumferential tendon suture techniques. J Hand Surg Br 1996;21:474-80.

44. Osada D, Fujita S, Tamai K, Yamaguchi T, Iwamoto A, Saotome K. Flexor tendon repair in zone II with 6-strand techniques and early active mobilization. J Hand Surg Am 2006;31:987-92.

45. Winters SC, Gelberman RH, Woo SL, Chan SS, Grewal R, Seiler JG 3rd. The effects of multiple-strand suture methods on the strength and excursion of repaired intrasynovial flexor tendons: a biomechanical study in dogs. J Hand Surg Am 1998;23:97-104.

46. Elliot D. Primary flexor tendon repair--operative repair, pulley management and rehabilitation. J Hand Surg Br 2002;27:507-13.

47. Kleinert HE, Verdan C. Report of the Committee on Tendon Injuries (International Federation of Societies for Surgery of the Hand). J Hand Surg Am 1983;8:794-8.

48. Jansen CW, Watson MG. Measurement of range of motion of the finger after flexor tendon repair in zone II of the hand. J Hand Surg Am 1993;18:411-7.

49. Tang JB. Indications, methods, postoperative motion and outcome evaluation of primary flexor tendon repairs in Zone 2. J Hand Surg Eur Vol 2007;32:118-29.

17

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):18-22

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.58908

Cerrahi yoğun bakım hastalarında ziyaretin yaşam bulguları üzerine etkisi: Pilot çalışma The impact of visits on vital signs of the patients in surgical intensive care unit: a pilot study Ükke KARABACAK,1 Leman ŞENTURAN,2 Sebahat ÖZDİLEK,3 Aygün ŞİMŞEK,3 Yeliz KARATEKE,3 Fatma ETİ ASLAN,1 Nebahat YILDIZ,3 Bülent KAYA,4 Cemalettin ERTEKİN4

AMAÇ

BACKGROUND

Bu araştırma, yoğun bakım ünitesinde yatan hastalara yapılan ziyaretin hastanın yaşam bulguları üzerindeki etkisini incelemek amacıyla yapıldı.

This research was conducted to analyze the impact of visiting patients in the intensive care unit on the vital signs of the patients.

GEREÇ VE YÖNTEM

METHODS

Tanımlayıcı olarak gerçekleştirilen çalışma İstanbul ilinde bir üniversite hastanesinin acil cerrahi yoğun bakım ünitesinde gerçekleştirildi. Araştırmanın örneklemini 24 saatten fazla süre ünitede bulunan, 18 yaş ve üzeri 43 hasta oluşturdu.

Verilerinin toplanmasında hastaların demografik özellikleri ile ziyaret öncesi, sırası ve sonrasındaki yaşam bulgularının yer aldığı bilgi ve değerlendirme formu kullanıldı. Veriler ziyaret öncesi, ziyaret sırasında ve ziyaretten sonra ölçüldü.

This descriptive study was conducted at the emergency surgical intensive care unit of a university hospital in Istanbul.

The sample consisted of 43 patients aged 18 and above, who stayed at the unit for more than 24 hours. Data collection included the demographic features of the patients as well as the information and evaluation form including the vital signs of patients before, during and after visits. Data were measured before, during and after visits.

BULGULAR

RESULTS

Hastaların %39,5’i (n=17) kadın, %60,5’i (n=26) erkekti.

Ziyaret öncesi ateş değerleri ortalaması 36,7±0,81 sonrası 36,8±,94; nabız değeri ortalaması öncesinde 97,3±26,4, sonrasında 98,4±26,1; solunum değeri ortalaması 23,76±4,55 sonrasında 24,30±4,53; sistolik basınç değeri 113,4±25,86, sonrasında 120,4±21,15; diyastolik basınç değeri 64,81±8, sonrasında 67,30±3 bulundu.

39.5% (n=17) of the patients were female and 60.5% (n=26) were male. Values before and after visits, respectively, were as follows: Mean fever 36.7±0.81 and 36.8±.94; pulse 97.3±26.4 and 98.4±26.1; mean respiration 23.76±4.55 and 24.30±4.53; systolic pressure 113.4±25.86 and 120.4±21.15; and diastolic pressure 64.81±8 and 67.30±3.

SONUÇ

CONCLUSION

Pilot bir çalışma niteliğinde yürütülen bu araştırmada, yoğun bakım ortamında bulunan hastaya yapılacak ziyaretlerin hastayı etkilediği, ancak bu etkinin yaşam bulgularında ciddi bir fizyolojik değişime neden olmadığı sonucuna varıldı.

This study, carried out as a pilot study, found that visiting patients in intensive care units affects the patients; however, this effect does not cause a serious physiological change in the vital signs of the patient.

Anahtar Sözcükler: Yaşam bulguları; yoğun bakım; ziyaret.

Key Words: Vital signs; intensive care; visiting.

Acıbadem Üniversitesi Sağlık Bilimleri Fakültesi, Hemşirelik Bölümü, İstanbul; 2Haliç Üniversitesi Sağlık Bilimleri Yüksekokulu, İstanbul; İstanbul Üniversitesi, İstanbul Tıp Fakültesi 3Acil Cerrahi, Yoğun Bakım Servisi, 4Genel Cerrahi Anabilim Dalı, Çapa, İstanbul.

1

Acıbadem University, Faculty of Health Sciences, Nursing Department, Istanbul; 2Halic University, School of Health Sciences, Istanbul; Istanbul University Istanbul Faculty of Medicine, 3Surgical Intensive Care Unit, 4Department of Surgery, Çapa, Istanbul, Turkey.

1

İletişim (Correspondence): Dr. Ükke Karabacak. Gülsuyu Mah., Fevzi Çakmak Cad., Divan Sok., No: 1, Maltepe, İstanbul, Turkey.

Tel: +90 - 216 - 458 08 59 e-posta (e-mail): ukke.karabacak@acibadem.edu.tr

18

Cerrahi yoğun bakım hastalarında ziyaretin yaşam bulguları üzerine etkisi

Yoğun bakım (YB) üniteleri fiziksel ortamı, kullanılan teknik donanımı ve işleyiş biçimi nedeniyle, hastanelerin diğer bölümlerinden farklı olduğundan, bu ünitede bulunuyor olmak, hem hastalar hem de yakınları için oldukça sıkıntılı ve stresli bir deneyimdir.[1] Böyle bir ortamda yaşamın kurtarılması ve yaşamsal faaliyetlerin sürdürülmesi kadar, hastaya ve ailesine destek olmak da yoğun bakım ekibinin temel görevleri arasındadır.[2] Hastanın ailesi ve yakınları, bakımın bir parçası olarak, bütüncül hasta bakımının vazgeçilmez öğesidir.[3] Hasta ve ailesinin desteklenmesi, büyük oranda yoğun bakım ünitesinde çalışan hemşireler tarafından üstlenilmektedir.[2] Bu nedenle bir destek şekli olarak kabul edilen hasta ziyaretinin yönetilmesinde anahtar rol, hasta ile en fazla etkileşimde bulunan hemşirelere düşmektedir.

Yoğun bakım ünitesinde ziyaretin hasta ve aile yönünden destek olarak düşünülmesine karşın yapılıp yapılmamasına ya da nasıl yapılacağına ilişkin iki farklı görüş vardır.[1] Bir grup klinisyen ve araştırmacı, ziyaretin pozitif etkisi olduğunu diğerleri ise, negatif etkisi olduğunu savunmaktadır. Pozitif görüş bildiren sağlık profesyonelleri ziyaretin hastanın iyileşme ve yaşama isteği üzerinde olumlu etkisi olduğunu vurgulamakta; serbest ya da esnek ziyaretin hasta üzerinde olumsuz bir fizyolojik durum yaratmadığını ileri sürmektedirler.[4,5] Bu görüşe sahip olanlar ziyaretin hastayı hayata bağladığını, sevdiği kişiyle birlikte olmanın umut ve güç vererek hastalığı ile mücadele etmesine yardım ettiğini savunmaktadırlar.[1,6] Ayrıca ziyaret sırasında hasta yakınlarının çalışanlar ile iletişim kurmaları güven ilişkisini oluşturduğu ve sağlık ekibinin de ailesinden dinleyerek hastayı daha iyi tanıdığı ifade edilmektedir.[1] Buna karşın negatif görüş bildirenler, ziyareti kurum ve hasta için bir engel olarak görmektedirler. Ziyaretin hastayı yorabileceğini, heyecan yaratarak nabız ve kan basıncı değerlerini yükseltebileceğini, ziyaretçinin varlığının çalışanın zaman ve enerjisini tüketeceğini, karmaşaya yol açarak bakımı ve tıbbi tedaviyi engelleyebileceğini, diğer hastaların mahremiyetinin engelleneceği, şiddet ve güvenlik ile ilgili sorunlar yaşanabileceğini ileri sürmektedirler.[1,7,8] Ziyaretin şekli, süresi, hangi sıklıkta yapılacağına ilişkin tutumların oldukça değişken olduğu bilinmektedir. Ziyaret tamamen kısıtlı olabildiği gibi açık, hasta kontrollü, kısıtlı, esnek ya da yapılandırılmış olarak oldukça geniş bir yelpazede uygulanmaktadır. Açık ziyarette hasta ve ailelerin istediği saat ve sürede ziyaret yapmakta; hasta kontrollü ziyarette, ziyaret edecek kişiyi ve ziyaretin ne zaman hangi sürede gerçekleşeceğinin kararını hasta vermekte; esnek, yapılandırılmış ve kısıtlı ziyarette sağlık ekibi tarafından belirlenen zaman dilimi içinde ve belirlenen sürede ziyaret gerçekleştirilmektedir.[8] Cilt - Vol. 18 Sayı - No. 1

Bu farklı yaklaşımlardan hangisi doğru? Bu sorudan yola çıkarak planlanan araştırma, yoğun bakım ünitesinde yatan hastalara yapılan ziyaretin yaşam bulguları üzerindeki etkisini incelemek ve benzer çalışmalara ışık tutmak amacıyla pilot bir çalışma olarak yapıldı.

GEREÇ VE YÖNTEM Tanımlayıcı olarak gerçekleştirilen çalışma İstanbul ilinde bir üniversite hastanesinin acil cerrahi yoğun bakım ünitesinde yapıldı. Pilot çalışma niteliğindeki araştırmanın evrenini iki ay içinde yoğun bakım ünitesine kabul edilen tüm hastalar, örneklemini ise ünitede 24 saatten daha uzun süre kalan, 18 yaş ve üzeri 43 hasta oluşturdu. Enfeksiyonu olan, kardiyovasküler problemi olan ve özgeçmişinde hipertansiyon problemi olan ve çocuk hastalar çalışma dışı bırakıldı. Hastaların bilinç durumları basit bir şekilde sınıflandırıldı. Hastalar verdikleri tepkilere göre uyanık, söz ya da işaret ile anlamlı tepki tepki verenler bilinci açık; uyanık olup anlamlı tepki veremeyenler bulanık, uykuda olup herhangi bir tepki vermeyenler bilinci kapalı olarak kabul edildi. Verilerin toplanmasında hasta bilgi formu ile yaşam bulguları değerlendirme formu olmak üzere iki araç kullanıldı. Bilgi formunda, hastaların cinsiyeti, yaşı, üniteye kabul sebebi, bilinç düzeyi, gelen ziyaretçinin yakınlığı ile ilgili sorular yer aldı. Diğer araç, vücut sıcaklığı, nabız, solunum, kan basıncı ve oksijen satürasyonu gibi yaşam parametrelerinin kaydedildiği formdu. Ziyaret süreci, kurumun rutin prosedürleri içinde sürdürüldü. Kısıtlı ziyaret uygulanan ünitenin rutin uygulamaları doğrultusunda herhangi bir girişim yapılmaksızın ziyaretçiler içeri alındı ve hastaları ile görüşmeleri sağlandı.

Ziyaret için ünitenin ve hastanın uygun olduğu bir zamanda hasta yakınları hemşireler tarafından hastalarının yanına kısıtlı sürelerde alındı. Çalışma grubundaki hastaların yaşam bulguları ziyaret saatinden hemen önce, ziyaret sırasında ve ziyaretten sonra olmak üzere üç kez ölçülerek ilgili forma kaydedildi.

Araştırmanın Etik Yönü Çalışmanın yapıldığı hastanenin ilgili makamlarından çalışma izni, hasta bedenine invaziv uygulama yapılmaması ve maliyet arttırmamasına rağmen bilinci açık olan hastaların kendilerinden, kapalı olanların birinci derece yakınlarından, çalışmanın amacı açıklanarak izinleri alındı. Örnekleme alınma kriterlerine uyan hasta ve yakınlarından araştırmada yer almak istemeyen olmadı.

Verilerin değerlendirilmesinde yüzdelik dağılımlar, verilerin dağılımının normalliğini test etmek için tek örneklem Kolmogorov-Smirnov Testi, normal dağılıma uymayan verilerin karşılaştırılmasında Wilcoxon işaret testi kullanıldı. Veriler %95 güven aralığında, p<0,05 istatistiksel anlamlılık olarak kabul edildi.

19

Ulus Travma Acil Cerrahi Derg

BULGULAR Araştırma kapsamındaki hastaların %39,5’i kadındı ve yaş ortalamaları 48,7±2,64 idi (min=18, maks=89).

Hastaların %65,1’inin bilinci açıktı, %30,2’sinin kapalıydı diğerlerinin (%2) ise bulanıktı. Gelen ziyaretçilerin %20,9’unun anne/babalar, %37,2’sini çocuklar oluşturdu (Tablo 1).

Hastaların ziyaret başlamadan önceki vücut ısı değerleri ortalamaları 36,7±0,81, sırasında 36,8±0,91, sonrasında ise 36,8±0,94 bulundu. Ziyaret öncesine göre ziyaret sonrasında görülen bu artış istatistiksel olarak anlamlıydı (z=-2,103, p=0,035). Hastaların ziyaret başlamadan önceki nabız değeri ise 97,3±26,4 bulundu. Bu değerde ziyaret sırasında ve sonrasında da istatistiksel olarak anlamlı bir değişim olmadığı görüldü (p>0,05) (Tablo 2). Hastaların ziyaret başlamadan önceki, solunum ve oksijen satürasyonu değerleri ile, sırası ve sonrasındaki değerler arasında istatistiksel olarak anlamlı bir değişim yoktu (p>0,05). Sistolik ve diyastolik kan basıncı ortalamasında ziyaret sırasında ve sonrasında, ziyaret başlangıcına göre oluşan yükselme de istatistiksel olarak anlamlı bulunmadı (p>0,05).

TARTIŞMA Ziyaretin ne zaman, nasıl, hangi şartlarda gerçekleştirileceğine karar vermek oldukça zordur. Ziyaretçilerin enfeksiyon riski oluşturdukları, uygulamaları engelledikleri ve hastada taşikardi, hipertansiyon, aritmi gibi değişikliklere neden olabilecekleri düşünülerek yoğun bakım ünitelerine ziyaretler sınırlandırılmakta ya da tamamen engellenmektedir.[1,9] Ancak farklı ve karmaşık bir ortamda izole bir şekilde bulu-

Tablo 1. Hastaların demografik özellikleri (n=43) Özellikler

Sayı (n)

Cinsiyet

Kadın 17 Erkek 26 Bilinç durumu

Açık 28 Kapalı 13 Bulanık 2 Gelen ziyaretçilerin yakınlığı

Eş 6 Anne/baba 9 Çocuklar 16 Kardeş 6 Diğer 6 Yaş ortalaması 48,7±2,64 (min=18, maks=89).

Yüzde (%) 39,5 60,5 65,1 30,2 4,7 14,0 20,9 37,2 14,0 14,0

nan hastaların ve ailelerin psikolojik desteğe ihtiyaçları olduğu unutulmamalıdır.[1,8,10] Yoğun bakım hastalarının gereksinimleri, tercihleri ve stresörlerin incelendiği bir araştırmada 40 stresör belirlenmiş ve dört numaralı stres kaynağının “eşin eksik olması” ve sekiz numaralı stresörün “aile ve arkadaşları her gün sadece bir kaç dakika görebilme” olarak ifade ettikleri belirlenmiştir.[8] Akın ve Arıboğan[11] çalışmalarında, YBÜ’de tedavi edilen hastalarda strese neden olan faktörleri cinsiyetler açısından değerlendirmişler ve her iki cinsiyet için ortak stres nedeni olarak “aile ile sınırlı birliktelik” ifadesinin üçüncü sırada yer aldığını belirlemişlerdir.

Tablo 2. Hastaların ziyaret öncesi, sırası ve sonrası yaşam bulgularının dağılımı Yaşam bulguları

Ziyaret

Ort±SD

Vücut sıcaklığı (ºC)

Nabız

Solunum

Sistolik basınç

Diyastolik basınç

Oksijen satürasyonu

Öncesi Sırası Sonrası Öncesi Sırası Sonrası Öncesi Sırası Sonrası Öncesi Sırası Sonrası Öncesi Sırası Sonrası Öncesi Sırası Sonrası

36,7±0,81 36,8±0,91 36,8±0,94 97,3±26,4 99,7±26,9 98,4±26,1 23,76±4,55 24,51±4,80 24,30±4,53 113,4±25,8 118,5±2,07 120,4±21,1 64,8 ±15,05 65,9±14,71 67,3±15,15 97,4±2,70 97,3±2,67 97,3±3,5

Min

Maks

Ziyaret öncesi - Sonrası

Ziyaret sırası - Sonrası

35 35 35 45 43 47 12 12 12 13 75 70 40 41 40 91 92 80

38,7 39,3 39,3 174 174 174 38 40 38 160 157 166 111 107 102 100 100 100

z=-2,103, p=0,035

z=-1,850, p=0,064

z=-1,299, p=0,194

z=-1,260, p=0,208

z=-1,549, p=0,121

z=-,485, p=0,628

z=-,017, p=0,986 z=-,677, p=0,498 z=-,605, p=0,545 z= -,343, p=0,732 z=-1,511, p=0,131 z=-1,136, p=0,256

SD: Standart deviation.

20

Ocak - January 2012

Cerrahi yoğun bakım hastalarında ziyaretin yaşam bulguları üzerine etkisi

Yapılan çalışmalarda, esnek ziyaretin hasta ve yakınları üzerinde memnuniyeti arttırma anksiyeteyi azaltma açısından olumlu etkisinin olduğu belirtilmektedir.[10,12] Ancak bireyin fizyolojik ya da psikolojik durumunun en önemli göstergeleri olan yaşam bulguları ile ilgili somut veriler oldukça sınırlıdır. Bu çalışma sonuçlarında da yapılan ziyaretlerin hasta üzerindeki fizyolojik etkileri farklı olmakla beraber, genellikle olumlu etkilerden bahsedilmektedir.[4,8,13-15] Walker ve arkadaşları[5] travmatik beyin yaralanması olan hastaları izledikleri araştırmada hastaların ziyaretçilerinin konuşmalarını dinlerken bir huzursuzluk yaşamadıklarını ya da intrakraniyal basınçta, sistolik ve diyastolik basınçta ya da kalp ve solunum hızında bir değişiklik oluşmadığını göstermişlerdir. Benzer olarak koroner tedavi uygulanan hastalarla yapılan randomize bir çalışmada, hastanın istediği süre ve sıklıkta ziyaret uygulanan grupta günde sadece iki kez ziyaret uygulanan gruba göre kardiyovasküler komplikasyonların daha düşük olduğu belirlenmiştir. Bu sonucun aile ve ziyaretçilerle geçirilen zamanın anksiyeteyi azaltması ve kortizol seviyesini düşmesine bağlı olabileceği bildirilmiştir.[4]

yaret ile sessiz saat olarak adlandırılan ziyaretin olmadığı sürelerin kombine olarak uygulandığı ziyaret politikasının hasta ve yakının yanı sıra sağlık çalışanları için yaralı olabileceği bildirilmiştir.

Çalışmada ziyaret öncesi, sırası ve sonrasında hastaların yaşam bulguları değerlendirildiğinde üç ölçüm arasında hafif bir değişim olduğu ancak vücut sıcaklığı dışında bunun istatistiksel olarak anlamlı bir fark oluşturmadığı belirlendi. Yaşam bulgularındaki bu değişim olumlu olarak kabul edildi hastanın ziyaret sürecine tepki verdiği ancak bunun fizyolojik olarak çok ciddi bir tepki oluşturmadığını düşündürdü.

KAYNAKLAR

Çalışmada ziyaret öncesi, sırası ve sonrasında hastaların yaşam bulguları değerlendirildiğinde üç ölçüm arasında hafif bir değişim olduğu ancak vücut sıcaklığı dışında bunun istatistiksel olarak anlamlı bir fark oluşturmadığı belirlendi (Tablo 2). Yaşam bulgularındaki bu değişim olumlu olarak kabul edildi. Hastanın ziyaret sürecine tepki verdiği, ancak bunun fizyolojik olarak çok ciddi bir sonuç oluşturmadığını göstermektedir. Vücut sıcaklığındaki değişimin normal değerler arasında olması (36-37,2ºC) bu bulgunun da ziyaret için olumsuz bir duruma neden olmadığını düşündürmektedir. Kısıtlı ziyaret uygulama nedenlerinden biri de mikrobiyal kontaminasyona neden olacağı düşünülmesidir. Literatürde yoğun bakım ünitesinde kısıtlanmayan ziyaretin çevresel mikrobiyal kontaminasyonu arttırdığı, fakat bunun septik komplikasyonlara neden olmadığını gösteren çalışmalar mevcuttur.[2,4] Smith ve arkadaşlarının[12] yaptığı, ziyaretin etkisi üzerine farklı ülkelerde ve YB ortamında yapılmış 15 çalışmayı içeren sistematik derlemede sonuçlar, hasta ve yakınları ile sağlık çalışanları açısından değerlendirilmiş. Elde edilen kanıtlara göre YB ortamında açık ziyaretin hasta ve yakını için anksiyeteyi azaltma ve memnuniyeti arttırmada yararlı olabileceği, açık ziCilt - Vol. 18 Sayı - No. 1

Çalışmada, ziyaret sırasında hasta yakınlarının, hastalarına yaklaşmaktan çekingen davrandıkları gözlendi. Hasta ve aileyi içeren bütüncül bir yaklaşımla bakım veren hemşirelere ziyaretin kısıtlanmaması, esnek ziyaret uygulanmasında, hasta ve ailenin gereksinimlerini belirleyerek, ünitenin ziyaret uygulaması konusunda eğitmeleri, aile üyelerini ziyaret sırasında bakıma katılmalarını desteklemeleri gerektiği düşünülmektedir.

Pilot çalışma niteliğinde yürütülen bu araştırmada, yoğun bakım ortamında yapılacak ziyaretlerin hastayı olumlu etkileyebildiği, fizyolojik olarak olumsuz bir etkisinin olmadığı görülmektedir. Bu sonuç doğrultusunda esnek ziyaret uygulama konusunda hasta, aile ve sağlık ekibini kapsayan metodolojik çalışmaların yapılarak yoğun bakım ünitelerinde ziyaret konusunda konsensus içeren protokollerin geliştirilmesi önerilmektedir.

1. Farrell ME, Joseph DH, Schwartz-Barcott D. Visiting hours in the ICU: finding the balance among patient, visitor and staff needs. Nurs Forum 2005;40:18-28.

2. Taşdemir N, Özşaker E. Yoğun bakım ünitesinde ziyaret uygulaması: ziyaretin hasta, hasta ailesi ve hemşire üzerine etkileri C.Ü. Hemşirelik Yüksekokulu Dergisi 2007;11:2731.

3. Sucu G, Cebeci F, Karazeybek E. The needs of the critical patients’ relatives in the emergency department and how they are met. Ulus Travma Acil Cerrahi Derg 2009;15:473-81.

4. Fumagalli S, Boncinelli L, Lo Nostro A, Valoti P, Baldereschi G, Di Bari M, et al. Reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit: results from a pilot, randomized trial. Circulation 2006;113:946-52.

5. Walker JS, Eakes GG, Siebelink E. The effects of familial voice interventions on comatose head-injured patients. J Trauma Nurs 1998;5:41-5.

6. Eriksson T, Bergbom I. Visits to intensive care unit patients-frequency, duration and impact on outcome. Nurs Crit Care 2007;12:20-6.

7. Sims JM, Miracle VA. A look at critical care visitation: the case for flexible visitation. Dimens Crit Care Nurs 2006;25:175-80.

8. Makic MB, VonRueden KT, Rauen CA, Chadwick J. Evidence-based practice habits: putting more sacred cows out to pasture. Crit Care Nurse 2011;31:38-62.

9. Marco L, Bermejillo I, Garayalde N, Sarrate I, Margall MA, Asiain MC. Intensive care nurses’ beliefs and attitudes towards the effect of open visiting on patients, family and nurses. Nurs Crit Care 2006;11:33-41.

10. Terzi B, Kaya N. Yoğun bakım hastasında hemşirelik bakımı.

Yoğun Bakım Dergisi 2011;1:21-5.

11. Akın Ş, Arıboğan A.Yoğun bakım ünitesinde tedavi edilen hastalarda strese neden olan faktörlerin cinsiyetler açısından değerlendirilmesi. Anestezi Dergisi 2006;14:232-6.

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Ulus Travma Acil Cerrahi Derg

12. Smith LS, Medves J, Harrison MB, Tranmer J, Waytuck B. The impact of hospital visiting hours policies on paediatric and adult patients and their visitors. JAN 2009;65;2293-8.

13. Fuller BF, Foster GM. The effects of family/friend visits vs. staff interaction on stress/arousal of surgical intensive care patients. Heart Lung 1982;11:457-63.

14. Schulte DA, Burrell LO, Gueldner SH, Bramlett MH,

22

Fuszard B, Stone SK, et al. Pilot study of the relationship between heart rate and ectopy and unrestricted vs restricted visiting hours in the coronary care unit. Am J Crit Care 1993;2:134-6.

15. Kleman M, Bickert A, Karpinski A, Wantz D, Jacobsen B, Lowery B, et al. Physiologic responses of coronary care patients to visiting. J Cardiovasc Nurs 1993;7:52-62.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):23-30

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.84748

Analysis of the necessity of routine tests in trauma patients in the emergency department Acil servise başvuran travma hastalarında rutin testlerin gerekliliğinin analizi Özlem KÖKSAL, Şebnem EREN ÇEVİK, Şule AKKÖSE AYDIN, Fatma ÖZDEMİR

BACKGROUND

AMAÇ

The necessity of routine tests as regarded in the Advanced Trauma Life Support protocols has become controversial in recent years. The aim of this study was to analyze the necessity of routine tests in trauma patients.

Son yıllarda ileri travma yaşam desteği protokollerine göre rutin testlerin gerekliliği tartışılmaktadır. Bu çalışmanın amacı, majör travma hastalarında rutin testlerin gerekliliği ve tanısal değerini analiz etmektir.

METHODS

GEREÇ VE YÖNTEM

This was a prospective study. A total of 103 blunt trauma patients aged between 15 and 65 years who presented to the emergency department with major trauma, Glasgow Coma Scale of 15 and Revised Trauma Score of 12 were admitted to the study.

Bu prospektif çalışmada, Glasgow Koma Skoru 15, Revize Travma Skoru 12 olan ve 15-65 yaş arası majör travma ile acil servise başvuran toplam 103 künt travma hastası değerlendirildi.

RESULTS

Hastaların (%30,1 kadın,%69,9 erkek) yaş ortalaması 35±12.97 idi. Tüm hastaların %72,8’i araç içi trafik kazası, %12,6’sı araç dışı trafik kazası ve %14,6’sı yüksekten düşme ile başvurdu. Rutin testlerin hepsi ayrı ayrı değerlendirildi. Servikal inceleme ile lateral servikal röntgen istemi, pelvik muayene ile tam kan sayımı ve idrar testi istemi hariç, tam kan sayımı, yan servikal röntgen ve karın ultrasonografisi istem nedenleri ile diğer test sonuçları ve istem nedenleri karşılaştırıldığında önemli farklılıklar saptandı.

The average age of the patients (30.1% female, 69.9% male) was 35±12.97 years. A total of 72.8% of the patients presented for motor vehicle crashes, 12.6% for pedestrian injury and 14.6% for fall from a height. All of the routine tests were evaluated separately. With the exception of cervical examination-lateral cervical X-ray results and pelvic examinationcomplete blood count and urinalysis test results, significant relations were determined between the reason for requiring a test and the results of the other tests (complete blood count, lateral cervical X-ray and abdominal ultrasonography).

CONCLUSION

According to our study, biochemical tests, anterior-posterior chest X-ray and anterior-posterior pelvic X-ray can be ordered as targeted tests. Conducting targeted tests will reduce costs and workload.

BULGULAR

SONUÇ

Çalışmamıza göre biyokimyasal testler, ön-arka göğüs grafisi ve ön-arka pelvis grafisi hedefe yönelik testler olarak istenebilir. Hedefe yönelik testlerin istemi ile maliyet ve iş yükü azalacaktır.

Key Words: Major trauma; routine tests; reason for requirement; targeted test.

Anahtar Sözcükler: Majör travma, rutin testler, istem nedeni, hedefe yönelik test.

Department of Emergency Medicine, Uludag University Faculty of Medicine, Bursa, Turkey.

Uludağ Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Bursa.

Correspondence (İletişim): Özlem Köksal, M.D. Uludağ Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Görükle Yerleşkesi, Bursa, Turkey.

Tel: +090 - 224 - 295 32 22 e-mail (e-posta): koksalozlem@gmail.com

23

Ulus Travma Acil Cerrahi Derg

Trauma is the leading cause of death in the population of patients aged less than 45 years.[1] Overall, 50% of deaths in the age group under 14 years, 80% of deaths in the age group 15-24 years and 65% of deaths in the age group 25-40 years are caused by trauma.[2] Therefore, most young and healthy patients should be carefully examined for masked injury. In accordance with the primary problem of the patient, the most appropriate laboratory and screening tests should be ordered. Medical knowledge, habits, local customs, institutional policies, and legal concerns may affect the physician’s decisions about the diagnostic tests. Tests are done for many reasons; however, the most important reason is to facilitate the patient’s treatment.[3] On the other hand, the diagnostic accuracy of tests may not be clear when they are ordered. Another issue is the time spent for the tests. Time spent on unnecessary tests has significant importance in the emergency department (ED). Finally, each test has a cost.[3] Rising costs and increasing demand for the limited resources of trauma care threaten the viability of trauma programs.[4] In current practice, because treatment periods are long and costs are high, the situation worsens when unnecessary X-rays and laboratory tests are ordered. Nowadays, there is a trend to reduce whenever possible the number of X-rays and laboratory studies ordered.[5] Advanced Trauma Life Support (ATLS) protocols, which are prepared by the American College of Surgeons, are standardized protocols for the management of trauma patients, which present a concise approach for the assessment and management of multipleinjured patients. ATLS protocols are revised by the ATLS subcommittee approximately every four years.

[6] According to ATLS, there are some routine tests in the management of blunt trauma patients. These are hemoglobin or hematocrit values, biochemical tests that consist of liver and renal function tests, urinalysis, anterior-posterior chest X-ray, anterior-posterior pelvic X-ray, lateral cervical X-ray, and focused assessment sonography in trauma (FAST). Today, the diagnostic value, necessity and cost of routine trauma tests, which are ordered for trauma patients who meet the criteria of major/multiple trauma and have no pathologic signs in the physical examination, are being scrutinized. There are very few studies in this context, and these studies are mostly about the necessity of isolated cervical or pelvic X-rays or the costeffectiveness of the trauma tests.

In this study, routine laboratory and radiologic tests in patients who presented to our ED with major trauma were analyzed. Every unnecessary test causes additional burden with respect to either time or medical expenditures in trauma patients. The aim of this study was to analyze the necessity and diagnostic value of 24

routine tests in major trauma patients with a Glasgow Coma Scale (GCS) of 15 as well as a Triage-Revised Trauma Score (T-RTS) of 12, and to gain a new point of view for the assessment of trauma patients.

MATERIALS AND METHODS This was a prospective observational study performed from February 1, 2009 through June 30, 2009 at the Uludag University Faculty of Medicine Hospital ED, following the ethics committee approval (approval number: 2009-2/26). A total of 103 blunt trauma patients aged between 15 and 65 years who presented to the ED with motor vehicle crash, pedestrian injury or fall from a height, with a GCS of 15 and a T-RTS of 12, corresponding to major trauma criteria of ATLS according to the mechanism of occurrence, and who voluntarily enrolled were admitted to the study. Major trauma criteria according to the mechanism of occurrence were accepted as ejection from auto, death in the same passenger compartment, pedestrian thrown or run over, high speed auto crash (initial speed >64 kph, major auto deformity >50 cm, intrusion into passenger compartment >30 cm), extrication time >20 min, falls >3 m, rollover, auto-pedestrian injury with >8 kph impact, and motorcycle crash >32 kph or with separation of rider and bike. Patients with GCS <15, T-RTS <12, age <15 or >65 years, or who were intoxicated were excluded from the study.

The trauma patients’ data were recorded on the “Trauma Patient Assessment Form” by a resident physician of emergency medicine. Whether or not the patient was in shock was determined by examining blood pressure, pulse rate, respiratory rate, T-RTS, and the general condition of the patient; these values were noted on the form. After the initial assessment of the patient and the organization of diagnostic tests, it was ensured that the form was filled out, and the results and consultations recorded by the resident physician.

In the thorax-cardiovascular system, abdominal, and genitourinary system examinations, the existence of lesions, ecchymosis, abrasions, and lacerations was inspected, lung and heart sounds were auscultated, and the presence of crepitation and tenderness was investigated with palpation on thorax examination. The presence of hematoma and hematochezia was investigated on rectal and genitourinary examination. A neurologic examination was also conducted; crepitations, deformities, subcutaneous hematomas, and lacerations on the scalp and face were examined. On muscle and skeleton system examination, deformities, tenderness and crepitations were examined. The existence of any of these was accepted as a positive finding. In the examination of patient, the positive findings were recorded on the form by the resident physician. The positive findings are shown in Table 1. On the form, three options were presented for recording the underOcak - January 2012

Analysis of the necessity of routine tests in trauma patients in the emergency department

Table 1. Positive findings on physical examination of trauma patients Positive findings

Number of Patients

Abnormal lung sounds, tachypnea Tenderness on thorax with palpation Tenderness on abdominal examination Laceration, ecchymosis or abrasion on abdomen Laceration, ecchymosis or abrasion on thorax Tenderness on pelvis with palpation Tenderness on cervical vertebrae with palpation Tenderness on thoracal/lumbar vertebrae with palpation Tenderness on extremities with palpation Deformity or open fracture on extremities A cut or abrasion on the scalp or face Tenderness, hematoma or ecchymosis on scalp or face Amnesia, nausea, emesis A cut, ecchymosis or abrasion on extremities Epistaxis Tenderness, hematoma or ecchymosis on genitourinary region No positive findings

3 17 20 1 1 4 10 11 32 10 33 14 1 24 2 1 7

Is the patient corresponding to the study criterions?

Vital signs (blood pressure, pulse rate, respiratory rate) 15 < Age < 65 GKS = 15 , T-RTS = 12 Major criterions according to the mech

Physical examination

Ordering tests

Recording data Patient’s vital signs, Positive findings, Reason for requested test

Conducting tests (CBC, biochemistry, urinalysis, radiography, FAST, etc.)

Recording the results of tests

Fig. 1. Flow of the study.

Cilt - Vol. 18 Sayı - No. 1

For statistical analyses, SPSS 13.0 (Statistical Package for the Social Sciences for Windows) software was used. According to the characteristics of the variables that were used in the study, descriptive statistics and frequency distributions were calculated. To compare categorical variables, Fisher’s exact test was used in 2x2 tables and Pearson’s chi-square test was used in larger tables. Statistical significance was accepted at p<0.05.

One month after the last study patient presented to the ED, all of the records in the University Hospital were examined. It was determined that the study patients presented to the polyclinics due to the previously identified pathologies in the ED; on the other hand, it was determined from the records that no additional pathologies regarding the trauma were found.

Trauma patient

Yes

lying reason for the requested test for the trauma patient, and the resident physician was asked to select one of them. These options and the leading conditions were as follows: In the physical examination, if no pathology was determined, but the test was ordered as a routine trauma test, then the resident physician was requested to select the option “I do not suspect a pathology, but I request this test because it is routine.”

In case no specific or significant pathological finding was determined in the physical examination, but the resident physician could not clarify that there was no pathology, then the doctor was requested to select the option “I’m not sure”. Finally, if a significant abnormal finding was determined in the patient’s physical examination, then the doctor was requested to select the option “I suspect a pathology”. The flow of the study is shown in Figure 1.

No Exclude patient from the study

RESULTS A total of 103 blunt trauma patients aged between 15 and 65 years who presented to the ED from February 1, 2009 through June 30, 2009, with a GCS of 15 and a T-RTS of 12 and fulfilling major trauma criteria of ATLS according to the mechanism of trauma were admitted to the study. The average age of the patients who were accepted to the study was 35±12.9 years.

Most of the patients who were accepted to the study were in their 3rd decade (Fig. 2). Overall, 30.1% of the patients (n=31) were female and 69.9% (n=72) were male. The reasons for presenting to the ED were motor vehicle crashes (72.8%), pedestrian injury (12.6%) and fall from height (14.6%). No significant difference was found between the female and male ratios in traffic accidents (motor vehicle crashes, pedestrian injury) and fall from height (p=0.544). The mean Injury Severity Score (ISS) was 5.0 for the patient group admitted to the study.

Not all of the routine trauma tests were ordered for all patients in the study. The decision of which routine 25

Ulus Travma Acil Cerrahi Derg

30

Number of pathologic tests 100

25 80

20

Number of tests

15 10 5

20

60-65

The Relation between the Physical Examination and Test Results: When the physical examination findings and the test results were compared, the following results were obtained. If there was an injury because of trauma to one or more systems, e.g. the thorax-cardiovascular, abdominal or genitourinary systems, then a decrease in the hemoglobin and hematocrit values may have occurred. Therefore, the three systems were grouped together when the statistical calculation was performed. No significant difference was found between the hemoglobin and hematocrit values and the determination of a pathologic finding in at least one of the systems mentioned above in the physical examination (p=0.525).

When the aspartate aminotransferase and alanine aminotransferase (SGOT and SGPT) values in a normal abdominal examination and abnormal abdomi-

U S

lv ic X R

lX R

A P

rv ce

La

te r

al

pe

ic a

tX R es

C CB

trauma tests should be ordered for each patient was left to the discretion of the resident physician. Each test was evaluated separately; thus, the number of ordered tests was calculated separately. The number of routine tests ordered and the number of pathologic results are shown in Figure 3.

cr

0

Fig. 2. Distribution of patientsâ&#x20AC;&#x2122; ages by decades.

a-

50-59

ch

40-49 Age

U re

30-39

A P

20-29

SG PT

15-19

40

SG O T

0

60

U A

Number of patients

Number of ordered tests

Distribution of patients according to age

35

Test name

Fig. 3. Ordered tests in trauma patients.

CBC: Complete Blood Count; UA: Urine analysis; SGOT: Serum glutamic-oxaloacetic transaminase; SGPT: Serum glutamate pyruvate transaminase; Cr: Creatinine; AP: Anteroposterior; XR: X-ray; US: Ultrasonography.

nal examination were compared, significant p values were found (p=0.024 and p=0.020, respectively). If the physical examination of the thorax and cardiovascular system was normal, the probability of a normal anterior-posterior chest X-ray was significantly high (p<0.001). When cervical examination and lateral cervical X-ray results were compared, no significant difference was found (p=0.347). As to the comparison of pelvic examination and pelvic X-ray results, if the pelvic examination was normal, the probability of no pathologic finding on pelvic X-ray was found significantly high (p=0.012). If the abdominal and genitourinary system examinations were normal, the probability of no pathologic finding on abdominal ultrasonography (US) was significantly high (p=0.046) (Table 2).

Table 2. The relationship between physical examination and test results

Pathologic SGOT and SGPT value

Positive

Pathologic finding on Pathologic finding on anterior-posterior pelvic X-ray chest X-ray

Negative

Positive Negative

Pathology on abdominal US

Positive Negative

Positive Negative

SGOT

SGPT

SGOT

SGPT

Pathologic Positive finding on

physical examination Negative

5.2% (n=5)

6.3% (n=6)

14.6% (n=14)

13.5% (n=13)

5.9% (n=6)

9.8% (n=10)

2% (n=2)

2% (n=2)

3.8% (n=3)

21.3% (n=17)

5.2% (n=5)

7.3% (n=7)

75% (n=72)

72.9% (n=70)

2.9% (n=3)

81.4% (n=83)

3% (n=3)

92.9% (n=92)

1.3% (n=1)

73.8% (n=59)

*When a pathologic finding was present on abdominal examination, SGOT and SGPT values were significantly high (p values were 0.024 and 0.020, respectively).

In the event of a normal physical examination of the thorax and cardiovascular system, the probability of not having a pathologic anterior-posterior chest X-ray was significantly high (p<0.001). When the pelvic examination was normal, the possibility of no pathologic finding on pelvic X-ray was significantly high (p=0.012).

When the abdominal and genitourinary system examinations were normal, the possibility of no pathologic finding on abdominal US was significantly increased (p<0.05).

26

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Analysis of the necessity of routine tests in trauma patients in the emergency department

Table 3. The relationship between the reason for requiring tests and their results Pathologic finding Pathologic SGOT value on urinalysis

Pathologic SGPT Pathologic finding Pathologic finding on anterior-posterior on pelvic X-ray value chest X-ray

Positive Negative Positive Negative Positive Negative Positive Negative Positive Negative The reason Because it for requiring is routine a test I am not sure

8.4% (n=7)

50.6% (n=42)

2.1% (n=2)

60.4% (n=58)

3.1% (n=3)

59.4% (n=57)

0% (n=0)

58.8% (n=60)

0% (n=0)

62.6% (n=62)

7.2% (n=6)

24.1% (n=20)

3.1% (n=3)

22.9% (n=22)

5.2% (n=5)

20.8% (n=20)

2% (n=2)

24.5% (n=25)

2% (n=2)

25.3% (n=25)

I suspect a 7.2% pathology (n=6)

2.4% (n=2)

5.2% (n=5)

6.3% (n=6)

5.2% (n=5)

6.3% (n=6)

6.9% (n=7)

7.8% (n=8)

3% (n=3)

7.1% (n=7)

*When the urinalysis test was ordered because of routine, the possibility of normal urinalysis was increased (p=0.02). There was a significant difference between the reason for requiring biochemical tests and SGOT and SGPT values (p values were 0.005 and 0.003, respectively). When the anterior-posterior chest X-ray was ordered because of routine, the possibility of non-pathologic finding in the anterior-posterior chest X-ray was significantly high (p=0.0001). When the pelvic X-ray was ordered because of routine, the possibility of non-pathologic finding on the pelvic X-ray was significantly high (p=0.0006).

No significant difference between pelvic examination and hemoglobin-hematocrit values (p=0.999) or between pelvic examination and urinalysis (p=0.223) was found.

The Relation between Reasons for Requirement and Results of the Tests: No significant difference was found between the reason for ordering a complete blood count (CBC) and the hemoglobin and hematocrit results (p=0.143). When the reason for requiring a urinalysis and the results of the test were compared, it was found that if the resident physician did not suspect a urinary system injury and the reason for requiring the test was because it was routine, then the probability of a normal urinalysis was increased (p=0.020).

A significant difference was found between the reason for requiring biochemical tests and SGOT and SGPT values (p=0.005 and p=0.003, respectively).

The reason for requirement and the results of anteriorposterior chest X-ray were compared. If there was no suspicion of any pathologic finding and the reason for requirement of the test was routine, then the probability of a non-pathologic finding in the anterior-posterior chest X-ray was significantly high (p=0.0001). There was no significant difference between the reason for requirement and the result of lateral cervical X-ray (p=0.299). We compared the reason for requirement and the results of pelvic X-ray. If there was no suspicion of any pathologic finding in the pelvic X-ray and the reason for requirement of the test was routine, then the probability of no pathologic finding on the pelvic X-ray was significantly high (p=0.006) (Table 3).

There was no significant difference between the reason for requirement and the result of abdominal US (p=0.313).

As a result, according to our study, hemoglobinhematocrit, urinalysis, lateral cervical X-ray, and FAST should be the routine tests; however, biochemiCilt - Vol. 18 SayÄą - No. 1

cal tests, anterior-posterior chest X-ray and anteriorposterior pelvic X-ray should be the targeted tests in evaluating major trauma patients.

DISCUSSION Clinical guidelines are ideal solutions for using laboratory tests. The development of a guideline takes time; however, it eliminates the necessity of the physicianâ&#x20AC;&#x2122;s individual assessment of every laboratory testordering decision.[3] On the other hand, it may mean the ordering of an unnecessary test. Screening panels are defined as automatic tests obtained for all trauma patients irrespective of their history or severity of injuries.[4] Recently, the necessity of clinical guidelines in trauma has been discussed. Tasse et al.[4] studied the clinical significance and cost of routine trauma tests over a period of three months. In that study, the greatest cost was for chest X-ray (90% unnecessary), C-spine X-ray (98% unnecessary) and pelvic X-ray (94% unnecessary). In another study, Chu et al.[7] determined that by using selective tests instead of routine tests, the annual savings was $1.5 million. In our study, the necessity of routine tests in major trauma patients who presented to the ED for motor vehicle crash, pedestrian injury or fall from height was reviewed and analyzed. The initial routine test in trauma patients is the CBC. Determining occult blood loss is one of the most important components of the evaluation of a trauma patient. Despite large-scaled studies, determining occult blood loss in trauma patients is still an important problem for emergency physicians. The serial hematocrit measurements are part of routine trauma studies in many institutions in the United States. In studies by Snyder et al.,[8,9] the sensitivity of the initial hematocrit value for determining intraabdominal and intrathoracic injuries that require operative intervention was 50%, and tachycardia was seen not to be a reliable sign of hypovolemic shock. Furthermore, infusion of intra27

Ulus Travma Acil Cerrahi Derg

venous fluids in trauma patients may decrease hematocrit values and make it difficult to assess the hematocrit.[8] Tasse et al.[4] studied CBC tests in 367 patients.

CBC results were abnormal in 42% of the patients and clinically significant in only 0.3% of the patients. In our study, the physical examination of the cardiovascular, abdominal and genitourinary systems and CBC values were compared; however, no significant difference was found (p=0.525).

The abdomen often represents a â&#x20AC;&#x153;black boxâ&#x20AC;? with respect to early diagnosis, and failure to appropriately evaluate the abdomen has been identified as the most common error in trauma management.[10] In their study, Michetti et al.[11] determined that in such situations, even when the abdominal examination was completely normal, about 10% of the patients still had abdominal or pelvic injuries. Furthermore, they pointed out that pain from concomitant injuries and intoxicants were common in trauma patients at the time of presentation.

Thus, because of the potential masking effect of distracting pain, alcohol or drugs, the physical examination of the patients in the trauma bay should not be used as the sole screening test to detect abdominal or pelvic injury. Keller et al.[12] determined that children with SGOT and SGPT abnormalities were more likely to have liver injury than children presenting with normal levels. They found that 67% of the children with SGOT levels greater than 400 U/L and 78% of the children with SGPT levels greater than 400 U/L would have a gradable liver injury (p<0.050). Karaduman et al.[13] reported that a statistically significant positive correlation was found between radiologically detected intra-abdominal pathology and increased SGOT (above 110.5 U/L) and SGPT (above 63.5 U/L) levels (p<0.010, r values for SGOT and SGPT 0.63 and 0.58, respectively). In our study, SGOT and SGPT values were measured in 96 patients. Respectively, in 10 and 13 patients, SGOT and SGPT values were pathologic (>60 IU/L). In 60 patients, the reasons for requirement of biochemical tests were because they were routine and there was no expectation of pathologic results.

The abdominal physical examination and SGOT and SGPT values were also compared, and a significant relationship was found between them. When the abdominal examination was compared with SGOT values, the negative predictive value (NPV) was measured as 93.5%; when compared with SGPT values, the NPV was measured as 90.0%. The positive predictive value (PPV) was low (when compared with SGOT values, PPV was 26.3%; when compared with SGOT values, PPV was 31.6%).

The rate of the occurrence of urinary system injuries after abdominal trauma is approximately 10%.

The most widely injured urinary system organ is the kidney, followed by the bladder and urethra. Urinary 28

system trauma rarely occurs in isolation, and when other critically important injuries are given priority, urinary system trauma may escape notice. Hematuria is a nonspecific finding; however, it is the only finding that warns the emergency physician about a urinary system trauma. Hematuria is a characteristic sign of renal trauma, despite a poor correlation with the severity of injury.[14] According to ATLS, urinalysis is one of the routine trauma tests. In our study, urinalysis was studied in 83 patients. Urinalysis was ordered as a routine test in 59.0% of these patients, and microscopic hematuria (erythrocyte >10/hpf) was determined in 14.3% of the routine urinalysis tests; however, in 85.7% of these cases, there was no pathologic finding.

There was a significant difference between the reason for requirement of urinalysis and the result of urinalysis (p=0.020).

C-spine injuries constituted 2-6% of trauma patients who presented to the ED, and most of the Cspine injuries occurred after traffic accidents or falls from a height. A fast and accurate diagnosis of cervical spine injuries is important because a delayed or undiagnosed, unstable injury can lead to severe morbidity and mortality.[15] In their study, Ersoy et al.[16] diagnosed C-spine injury in 5% (n=13) of 267 patients, and in all of these injuries, it was observed that there was cervical pain in the history and/or cervical tenderness on examination. In 3 of these 13 patients, there was also a neurological deficit. Fifty-two out of the 267 study patients (20%) experienced pain and/or tenderness. In 39 patients who complained about cervical pain and/or cervical tenderness with palpation, there was no cervical injury. Bandiera et al.[17] mentioned that 110,000 C-spine radiography assessments are done each year in Canada on alert, stable, adult trauma patients, of which 98% are normal. They also mentioned that the cost of inexpensive, high-volume tests might contribute more to rising health care costs than more expensive high-technology procedures. Duane et al.[18] executed a study of 1004 patients, regardless of GCS; in 84 of these patients, cervical fracture was determined with cervical computed tomography (CT). In 68 of these 84 patients with cervical fracture, C-spine X-ray was not appropriately imaged. They determined that when C-spine X-ray was compared to cervical CT, lateral cervical X-ray had a sensitivity of 19.0% and a PPV of 69.6%. Because most of the lateral cervical X-rays were performed inappropriately and did not image all the cervical vertebrae, they argued that lateral cervical X-ray in blunt trauma patients has no value as a screening test and should be excluded from the ATLS algorithm. In the 2008 revision of the ATLS algorithm, it was determined that CT may supersede C-spine X-ray in the evaluation of cervical vertebrae.

[19] According to Dickinson et al.,[20] inefficient use of C-spine radiography wastes health care dollars, proOcak - January 2012

Analysis of the necessity of routine tests in trauma patients in the emergency department

longs uncomfortable immobilization with hard collars and back boards, results in unnecessary exposure to ionizing radiation, and delays ED discharge. In our study, C-spine X-ray was ordered in 103 patients; in 60.2% of these patients, there was no pathologic finding on the physical examination and the test was ordered because it was routine. A pathology was identified on C-spine X-ray in only 3.9% (n=4) of these 103 patients.

Thoracic trauma is the second most common lifethreatening trauma after head trauma.[7] Rezendo-Neto et al.[21] determined that the detection of small amounts of air in the pleural space or in the mediastinum in admission trauma chest X-ray can be significantly impaired by the supine position of the patients. They argued that up to 30% of pneumothoraces were missed by supine radiographs. In our study, anterior-posterior chest X-ray was ordered in 102 patients, and 58.8% of these were ordered as routine tests. There was no pathologic finding in any of them. In 9 patients, there was a pathologic finding in the anterior-posterior chest X-ray. Among these 9 patients, the resident physician suspected a pathologic finding in 7 patients and he/ she was not sure about the examination in the other 2 patients. Finally, the NPV of the physical examination of the thorax-cardiovascular system was 96.5% when it was compared with the result of anterior-posterior chest X-ray.

Since mortality can be as high as 40%, routine pelvic X-ray is suggested in the evaluation of blunt trauma patients according to ATLS protocols.[6,22] Ersoy et al.[5] studied the necessity of pelvic X-ray in a series of 65 blunt trauma patients. All of the patients with pelvic fracture complained about pain, and in all of them, tenderness was also revealed during the examination.

In their study, Salvino et al.[23] determined that 92% of the patients with pelvic fracture were symptomatic.

At the same time, in 1% of the asymptomatic patients, there was a pelvic fracture. Because of these issues, Salvino et al. argued that pelvic X-ray is unnecessary for patients who are alert and have no pain in their history or on pelvic examination. Gonzalez et al.[24] evaluated 2176 patients with a GCS of 14-15 for the presence of pelvic fracture. From the entire study population, a total of 97 patients (4.5%) were diagnosed with pelvic fractures. There were 7 (sensitivity 93%) missed pelvic fractures on clinical examination, with 13 (sensitivity 87%) missed pelvic fractures by anterior-posterior radiography, and these were determined to be significant. Kessel et al.[25] compared pelvic CT and pelvic X-ray. They determined that CT of the abdomen and pelvis identified 35.6% more pelvic fractures than the pelvic X-ray. Compared to CT, the sensitivity and specificity of the pelvic X-ray were 64% and 90%, respectively. This supports the idea that CT Cilt - Vol. 18 Say覺 - No. 1

is more helpful in the presence of suspicion of a pelvic fracture, and routine pelvic X-ray does not affect the treatment. In our study, if there was no pathologic finding on the pelvic examination, the possibility of a normal pelvic X-ray was determined as significantly higher. The NPV of the pelvic examination was high (96.8%); however, the PPV was 50.0%.

In the evaluation of the abdomen, ATLS suggests FAST. FAST is a portable, instantly appraisable, reliable, repeatable method, and does not disrupt resuscitation. At the same time, it gives extensive and dynamic diagnostic information. The major limitation of FAST is that it is operator-dependent. Furthermore, it is also patient-dependent; imaging is difficult in some patients. In determining abdominal free fluid, the sensitivity of FAST varies between 42-98%, and the specificity is 95-100%.[26] In our study, abdominal US was ordered for 80 patients. In 45 patients, abdominal US was ordered as a routine test. For 9 out of the remaining 35 patients, the resident physician suspected a pathology, and in 26 patients, the resident physician was not sure about the abdominal examination. Of the 80 patients who received abdominal US, pathologic findings were determined in only 4 patients. Of these 4 patients, 1 had splenic contusion, 2 had liver lacerations and 1 had parenchymal contusion with evident perihepatic and perisplenic fluid.

One of the greatest contributions of ATLS protocols in trauma is to relieve the physician. However, it has been seen that most of the routine tests are reported as normal. When targeted tests were done, the number of the patients who escaped notice was very few and the pathologies in these patients were not clinically important.

A deficiency of our study is that the number of patients was limited and the study was a unicentral study.

Similar studies, which are more extensive and conducted in larger populations, should be done to study the use of targeted tests.

In conclusion, in recent years, many studies were conducted on the use of diagnostic tests and cost-effectiveness, not only in trauma patients, but also related to other medical issues. The importance of the subject is becoming better understood. With this study, we wanted to question if we can diagnose the pathology in a trauma patient in the quickest manner and with a limited number of tests; however, each additional test means additional time spent. In the ED, time is synonymous with life. Loss of time with unnecessary tests that make no difference in the treatment of the patient can be harmful. Furthermore, they decrease the quality of patient care that the medical personnel conducts. According to our study, biochemical tests, anterior-posterior chest X-ray and anterior-posterior 29

Ulus Travma Acil Cerrahi Derg

pelvic X-ray can be ordered as targeted tests. Conducting targeted tests will reduce costs and workload.

This will also contribute positively to a prospective effect in the area of health care. We believe that studies will be more informative if they are repeated in larger populations for longer periods, if they are supported by follow-up of the patients after the period in the ED, and if they are compared with gold standard methods.

REFERENCES 1. Committee on Injury Prevention and Control Division of health Promotion and Disease Prevention. In: Bonnie RJ, Fulco CE, Liverman CT, editors. Reducing the Burden of Injury; 1-17. Advencing Prevention and Treatment. Washington, DC: National Academy Pres; 1999.

2. Ertekin C. Multipl travmalı hastaya yaklaşım. Yoğun Bakım Dergisi 2002;2:77-87.

3. Ergene U, Fowler J. Costeffectivity of diagnostic tests in emergency medicine. 1st ed. [Çeviri Editörü: Oktay C].

Isparta: Süleyman Demirel Üniversitesi Yayınları; No: 3, 1999. s. 11-15.

4. Tasse JL, Janzen ML, Ahmed NA, Chung RS. Screening laboratory and radiology panels for trauma patients have low utility and are not cost effective. J Trauma 2008;65:1114-6.

5. Ersoy G, Karcioğlu O, Enginbaş Y, User N. Should all patients with blunt trauma undergo ‘routine’ pelvic X-ray? Eur J Emerg Med 1995;2:65-8.

6. American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors student course manual. 7th ed. Chicago: American College of Surgeons; 2004.

7. Chu UB, Clevenger FW, Imami ER, Lampard SD, Frykberg ER, Tepas JJ 3rd. The impact of selective laboratory evaluation on utilization of laboratory resources and patient care in a level-I trauma center. Am J Surg 1996;172:558-63.

8. Snyder HS. Significance of the initial spun hematocrit in trauma patients. Am J Emerg Med 1998;16:150-3.

9. Snyder HS, Dresnick SJ. Lack of tachycardic response to hypotension in penetrating abdominal injuries. J Emerg Med 1989;7:335-9.

10. Mackersie RC, Dicker RA. Pitfalls in the evaluation and management of the trauma patient. Curr Probl Surg 2007;44:778833.

11. Michetti CP, Sakran JV, Grabowski JG, Thompson EV, Bennett K, Fakhry SM. Physical examination is a poor screening test for abdominal-pelvic injury in adult blunt trauma patients. J Surg Res 2010;159:456-61.

12. Keller MS, Coln CE, Trimble JA, Green MC, Weber TR. The

30

utility of routine trauma laboratories in pediatric trauma resuscitations. Am J Surg 2004;188:671-8.

13. Karaduman D, Sarioglu-Buke A, Kilic I, Gurses E. The role of elevated liver transaminase levels in children with blunt abdominal trauma. Injury 2003;34:249-52.

14. Bent C, Iyngkaran T, Power N, Matson M, Hajdinjak T, Buchholz N, et al. Urological injuries following trauma. Clin Radiol 2008;63:1361-71.

15. Saltzherr TP, Fung Kon Jin PH, Beenen LF, Vandertop WP, Goslings JC. Diagnostic imaging of cervical spine injuries following blunt trauma: a review of the literature and practical guideline. Injury 2009;40:795-800.

16. Ersoy G, Karcioğlu O, Enginbaş Y, Eray O, Ayrik C. Are cervical spine X-rays mandatory in all blunt trauma patients?

Eur J Emerg Med 1995;2:191-5.

17. Bandiera G, Stiell IG, Wells GA, Clement C, De Maio V, Vandemheen KL, et al. The Canadian C-spine rule performs better than unstructured physician judgment. Ann Emerg Med 2003;42:395-402.

18. Duane TM, Dechert T, Brown H, Wolfe LG, Malhotra AK, Aboutanos MB, et al. Is the lateral cervical spine plain film obsolete? J Surg Res 2008;147:267-9.

19. Kortbeek JB, Al Turki SA, Ali J, Antoine JA, Bouillon B, Brasel K, et al. Advanced trauma life support, 8th edition, the evidence for change. J Trauma 2008;64:1638-50.

20. Dickinson G, Stiell IG, Schull M, Brison R, Clement CM, Vandemheen KL, et al. Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments. Ann Emerg Med 2004;43:507-14.

21. Rezende-Neto JB, Hoffmann J, Al Mahroos M, Tien H, Hsee LC, Spencer Netto F, et al. Occult pneumomediastinum in blunt chest trauma: clinical significance. Injury 2010;41:403.

22. American College of Surgeons Committee on Trauma. Advanced trauma life support. Chicago; 1990.

23. Salvino CK, Esposito TJ, Smith D, Dries D, Marshall W, Flisak M, et al. Routine pelvic x-ray studies in awake blunt trauma patients: a sensible policy? J Trauma 1992;33:4136.

24. Gonzalez RP, Fried PQ, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma.

J Am Coll Surg 2002;194:121-5.

25. Kessel B, Sevi R, Jeroukhimov I, Kalganov A, Khashan T, Ashkenazi I, et al. Is routine portable pelvic X-ray in stable multiple trauma patients always justified in a high technology era? Injury 2007;38:559-63.

26. Rippey JC, Royse AG. Ultrasound in trauma. Best Pract Res Clin Anaesthesiol 2009;23:343-62.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):31-36

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.54376

Work-related injuries in textile industry workers in Turkey Türkiyede tekstil sektörü çalışanlarında iş kazalarına bağlı yaralanmalar Mustafa SERİNKEN,1 İbrahim TÜRKÇÜER,1 Bekir DAĞLI,1 Özgür KARCIOĞLU,2 Mehmet ZENCİR,3 Emrah UYANIK1 BACKGROUND

AMAÇ

This study was conducted as a survey including work-related injuries (WRI) of workers in the textile and clothing industry admitted to the emergency department (ED).

Bu çalışma, acil servise başvuran tekstil ve giyim sektörü çalışanlarında işle ilgili yaralanmaları araştırmak için yapıldı.

METHODS

GEREÇ VE YÖNTEM

This prospective study included patients with WRI reportedly occurring in the textile and clothing industry over a two-year period. The study sample comprised only the casualties occurring at the workplace and while working de facto.

Prospektif tasarlanan çalışmaya iki yıllık araştırma süresince tekstil ve dokuma endüstrisinde çalışanların iş kazaları ile ilişkili başvurular alındı. Çalışma örnekleminde sadece iş yerinde ve fiilen çalışma sırasında olan yaralanmalar analiz edildi.

RESULTS

BULGULAR

A total of 374 patients were eligible for the study. More than three-fourths of the study sample were females (76.2%, n=285). A significant proportion of the patients were between 14 and 24 years of age (44.7%, n=167). Approximately twothirds reported that this was their first admission to a hospital related to WRI (65.8%, n=246). WRIs occurred most frequently between 07:00-09:00 (27.3%) and 23:00-01:00 (17.9%). “Carelessness” and “rushing” were the most commonly reported causes of WRIs from the patients’ perspective (40.6% and 21.4%, respectively). Three-fourths of the patients reported that they were using protective equipment (74.3%, n=278). With respect to injury types, laceration/ puncture/ amputation/avulsion injuries accounted for 55.6% (n=208) of the sample. Trauma to the upper extremities was the main type of injury in 75.1% (n=281) of the cases.

Toplam 374 hasta çalışma kriterlerine uygun bulundu. Olguların büyük bölümünü kadınlar (%76,2, n=285), yaş dilimleri içinde ise 14-24 yaş arasındakiler oluşturdu (%44,7, n=167). Olguların yaklaşık üçte ikisi iş kazasına bağlı olarak ilk kez hastaneye başvurduğunu bildirdi (%65,8, n=246). İş kazaları en sık 07:00 ile 09.00 (%27,3) ve 23:00 ile 01:00 (%17,9) saatleri arasında oluştu. Hastalar kazaların nedenini en sık olarak dikkatsizlik ve acelecilik olarak bildirdi (sırasıyla, %40,6 ve %21,4). Hastaların yaklaşık dörtte üçü olay sırasında koruyucu malzeme kullandığını bildirdi (%74,3, n=278). Yaralanma tiplerine bakıldığında, kesi/batma/amputasyon/ avulsiyon yaralanmaları %55,6 (n=208) oranındaydı. En sık olarak üst ekstremite yaralanması (%75,1 n=281) görüldü.

SONUÇ

CONCLUSION

Broad population-based studies are needed to define the situation as a whole in WRIs in the textile and clothing industry in the country. Strict measures should be undertaken and revised accordingly to prevent WRIs in these growing sectors.

Ülkemizde tekstil ve dokuma endüstrisinde çalışanların iş kazalarını bir bütün olarak tanımlamak için geniş, toplum tabanlı araştırmalara gereksinim vardır. Hızla gelişen bu sektörde iş kazalarının azaltılması için düzenlemeler yapılmalıdır.

Key Words: Emergency department; occupational injuries; textile industry; work-related injuries.

Anahtar Sözcükler: Acil servis; mesleki yaralanmalar; tekstil sanayi; iş kazaları.

Departments of 1Emergency Medicine, 3Public Health, Pamukkale University, Faculty of Medicine, Denizli; 2Department of Emergency Medicine, Acibadem University, Faculty of Medicine, Istanbul, Turkey.

Pamukkale Üniversitesi Tıp Fakültesi, 1Acil Tıp Anabilim Dalı, Halk Sağlığı Anabilim Dalı, Denizli; Acıbadem Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Denizli.

3

Correspondence (İletişim): Mustafa Serinken, M.D. Pamukkale Üniversitesi Tıp Fakültesi Hastanesi, Acil Servisi, 20070 Kınıklı, Denizli, Turkey.

Tel: +090 - 258 - 212 71 94 e-mail (e-posta): mserinken@hotmail.com

31

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The textile and clothing industry grows rapidly, while witnessing a harsh rivalry throughout the world.

Turkey ranked as the 7th largest exporter in textile and 4th in haute couture in 2007. Those two items comprise up to one-third of the exported sum of the country.[1] In this context, Denizli, in western Turkey, is one of the leading industrialized cities carrying a majority of the industry load.[2] The city has a population of approximately 900,000. There are about 30,000 textile ateliers, which weave a total of 1000 tons of rope per day. Around 14,600 employees work in textile factories, which are mostly situated in organized industry zones. The total number of employees in the textile industry is 35,000, including those in 550 factories. The workers are generally assigned into three shifts (07:00-15:00, 15:00-23:00, 23:00-07:00) in these factories, while some small enterprises employ two 12-hour shifts, mostly 7 days a week. More than 3% (2,500/73,923) of countrywide occupational accidents in 2005 consisted of injuries registered in databases in this single city. Another interesting fact is that the male-to-female ratio in occupational accidents is much lower in Denizli when compared to the countrybased figures (7.7 vs. 21.1) due to predominance of the textile sector, in which the majority of the workforce is comprised of women in the city. Metal-machinery and mining are the other common areas of employment in the region.[2,3] More than 2500 admissions due to occupational injuries are recorded in the health facilities annually in Denizli.[4] Severe injuries and multiple casualties generally tend to be transported with state-run ambulance services (112), while other casualties are handled via the facility’s own resources. Around one-third of the patients exposed to work-related injuries (WRI) are referred to the University hospital, which has the most advanced technology in the city. The facility has 24hour coverage regarding replantation, microsurgery and other advanced interventions for occupational injuries, in contrast to the other hospitals. Therefore, the patients are commonly transferred from other hospitals to the University hospital.

The Social Security Institution (SSK) is the largest or main state-run institution established to manage the social security issues of the Turkish workers. Unregistered workers constitute up to 46.2% of the entire working population according to Turkish statistics compiled in 2007, despite sanctions pursued by the state.[5] This phenomenon, namely, precarious workforce, is widespread in the textile sector in Turkey, as seen in many developing countries. This is reflected in agreements with the employers, income, and insurance status, etc. Coupled with the high circulation rate of the labor force, the sector can be seen as highly staffed by inexperienced young workers.

32

In brief, WRI is a commonly encountered public health problem in the textile sector in the region.

Although rarely fatal, these injuries are estimated to cause serious illnesses in association with substantial workforce losses and financial burden.

This study was conducted as a survey recruiting workers in the textile and clothing industry exposed to WRI and consequently admitted into the University-based emergency department (ED). The objective of the study was to analyze epidemiological data and mechanisms and characteristics of injury in the sector.

MATERIALS AND METHODS This prospective study included patients with WRI reportedly occurring in the textile and clothing industry over a two-year period (2006-2008). Institutional Review Board approval was obtained before commencement of the study. The study sample comprised only the casualties occurring in the workplace and while working de facto. Excluded were the events occurring while commuting to and from work. The data sheets comprised sociodemographic and injury-related information accumulated in a 15-item questionnaire. A special data recording system was developed for the prospective study. The data were abstracted via face-to-face contact in the ED. Causes of occupational injuries as reported by the victims were assigned to one of two groups as ‘worker-related causes’ and ‘workplace-related causes’.

An isolated room in the ED was used for this purpose in order to prevent bias, and the patients were not accompanied by any person other than the medical personnel in charge of due medical care. The patients were also assured that the information obtained by the survey was to be used for research purposes only and that no feedback was to be given to employers or related persons.

Patients who did not give consent for the study, fatal accidents and patients younger than 14 years of age were excluded from the analysis.

Statistical Analysis All data obtained in the study were recorded in and analyzed using the Statistical Package for the Social Sciences for Windows, version 11. Numerical variables were given as mean and standard deviation (SD), while categorical variables were given as frequencies (n) and percentages.

RESULTS Demographic Data A total of 1335 patients were admitted to the ED due to occupational injuries within the two-year study period. Following the metal industry and machinery Ocak - January 2012

Work-related injuries in textile industry workers in Turkey

Sociodemographic variables Sex Male Female Age 14-24 25-34 > 34 Social security status Social Security Institution (SSK) None Other (Other state-run institution or private insurance) Level of education Illiterate Elementary school Secondary school-college University-high school Years worked in the sector 1-3 yrs 3-6 yrs >6 yrs N of previous WRIs reported 0 1 ≥2 Day of injury Monday Tuesday Wednesday Thursday Friday Saturday Sunday Mode of disposition Discharge Admission

n

89 285

167 147 60

308 40 26

14 87 234 39

240 49 85

246 99 29

84 60 39 40 34 66 51

282 92

% 23.8 76.2 44.7 39.3 16.0 82.3 10.7 6.8 3.8 23.2 62.6 10.4 64.2 13.1 22.7 65,8 26,5 7,7 22.5 16.0 10.4 10.7 9.1 17.6 13.6 75.4 24.6

(30.1%), textile was the second largest field with a high percentage of WRIs (384 cases, 28.7%). Eight cases (2.1%) out of 384 refused to participate in the study, while 2 (0.5%) fatal occupational injuries were excluded from the analysis. The remaining 374 eligible patients composed the study group.

Three-fourths of the study sample were females (76.2%, n=285). The mean age of the patients was 26.6±7.6 years (range: 14-59) (31.3±7.9 for males; 25.2±6.2 for females), with the largest percentage aged 14-24 years (44.7%, n=167).

Although a majority of the patients had been registered in social security institutions, 40 cases (10.7%) had no insurance, which is legally banned in Turkey.

Cilt - Vol. 18 Sayı - No. 1

The average number of years worked in the sector was 4.5±3.6 years (range: 1-32). The majority had worked between 1 and 3 years (64.2%, n=240). When the patients were asked if they had suffered from such injury before, approximately two-thirds reported that this was their first admission to a hospital related to WRI (65.8%, n=246) (Table 1).

WRIs occurred most frequently between 07:0009:00 (27.3%) and 23:00-01:00 (17.9%) (Fig. 1).

Monday was the most common day of injuries (22.5%, n=84). Nearly one- third of all WRIs were noted to have occurred on the weekend (31.3%) (Table 1).

Emergency care and management was sufficient for 75.4% (n=282) of the cases, who were discharged from the ED, while 24.6% (n=92) were admitted to the hospital. The mean length of stay in the hospital was 5.7 ± 2.9 days.

Causes of Injuries (Self-Reported) Patients were asked to clarify the source of their injury. The responses were assigned into three groups, as worker-related causes, workplace-related causes, or both. More than half of the patients (57.8%, n=216) reported that their injury resulted from solely workerrelated causes, while 13.9% (n=52) cited workplacerelated causes as the culprit. The rest of the sample considered that both factors were responsible (28.3%, n=106).

“Carelessness” and “rushing” were the most commonly reported causes of WRIs from the patients’ perspective (40.6% and 21.4%, respectively). Improper physical conditions in the workplace (floor, noise, heat, chaos/untidiness) was the third most commonly reported cause (Table 2). Three-fourths of the patients reported that they were using protective equipment (such as gloves, goggles and gown, etc.) (74.3%, n=278) at the moment of the event. On the other hand, 12.3% (n=46) of the patients reported that this equipment was not available in sufficient quantities or was unavailable in their workplace.

70 60 Number of subjects

Table 1. Sociodemographic characteristics of WRI among the 374 study subjects

50 40 30 20 10 0

1 2

3 4 5 6 7

8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Time of injury (h)

Fig. 1. The time of the injury for work-related injuries among the 374 study subjects.

33

Ulus Travma Acil Cerrahi Derg

Table 2. Causes of occupational injuries as reported by the victims

Table 3. Physical characteristics of occupational

injuries

Causes of Injuries

Location of the injury

Worker-related causes (n=390) Carelessness Rushing Sleepiness Inexperience Not duly trained Not using/lack of protective measures Other Workplace-related causes (n=105) Improper physical conditions in the workplace (floor, noise, heat, chaos/untidiness) Lack of protective measures (unavailability of gloves, goggles, gown, etc.)

Other Total

n*

%

201 106 37 21 11 10 4

40.6 21.4 7.5 4.3 2.2 2.0 0.8

53

10.7

45 7 495

9.1 1.4 100

Type of injury

* Some patients reported more than one cause for their injuries.

Physical Characteristics of Injuries Trapped hands in the machines (46.5%, n=174), misuse or improper use of the machines and tools (13.1%, n=49) and falls from height (8.3%, n=31) were the most common mechanisms of injury. Table 3 depicts the distribution of occupational injuries according to localization. With respect to injury types, laceration/puncture/amputation/avulsion injuries accounted for 55.6% (n=208) of the sample (Table 3).

Trauma to the upper extremities was present in 75.1% (n=281) of the cases. Isolated finger injuries accounted for 65.8% (n=185) of upper extremity injuries (Table 4). The majority of the hand injuries involved the right hand (74.0%, n=137), and the index finger was the most commonly injured (58.9%, n=109), followed by the thumb (25.4%, n=47) and third finger (11.4%, n=21).

DISCUSSION This study was conducted as a survey to investigate characteristics of WRI among workers in the textile and clothing industry admitted into the ED. These untoward events are shown to afflict more commonly the poorly educated, young female workers in the sector.

The workers most commonly reported causes of WRIs as “carelessness” and “rushing” (40.6% and 21.4%, respectively).

Trapped hands in the machines was the mechanism of injury in nearly half of the victims in the present study. As for the localization of the injuries, threefourths of the patients suffered from trauma to the upper extremities, while laceration/puncture/amputation/ avulsion injuries were reported as the most common 34

Head Neck Trunk Upper limb Lower limb Multiple locations General injuries Total

n

%

29 3 11 281 36 9 5 374

7.8 0.8 2.9 75.1 9.6 2.4 1.3 100.0

Laceration/puncture/amputation/avulsion Contusion/abrasion/hematoma/crush Fracture/dislocation Sprain/strain Inhalation Burn Total

208 71 59 28 5 3 374

55.6 19.0 15.8 7.5 1.3 0.8 100.0

Table 4. Anatomical classification of the upper

extremity injuries Location of the injury Shoulder Arm and elbow Forearm and wrist Hand Finger(s) More than one body part listed above Total

n

%

8 15 20 41 185 12 281

2.9 5.3 7.1 14.6 65.8 4.3 100

injury types, comprising more than half of the sample.

Two-thirds of the upper extremity injuries were isolated finger injuries, and the index finger was the most commonly injured, while the right hand dominated over the left. The first day of the week and the first hours of the working shifts witnessed the peak rates of injuries.

Although the textile sector is one of the main industries for the country, scarce data are available on WRIs in the workplace. The Social Security Institution (SSK) reported that around 380,000 WRIs occurred in Turkey between 2001 and 2005, with only 4.6% being women. Of note, these data mostly reflect the injuries serious enough to be referred to a health facility and also those recorded by a social security institution. Thus, one can postulate that the real numbers are far more than these formal data. In 2005, around one-tenth of all WRIs in Turkey consisted of those reported in the textile sector.[5,6] Data elicited from countries with a developed texOcak - January 2012

Work-related injuries in textile industry workers in Turkey

tile industry demonstrate that female workers dominate the workforce.[7-9] Formal reports cite that twofifths of women (1337 out of 3334) suffering from WRI in 2005 had been employed in the textile industry.[6] The mean age of female workers involved in WRIs in Turkey was 29, whereas the corresponding figure in the present study was 25.2. Nearly half of the patients were between 14 and 24 years of age (44.7%).

In China -the champion of haute-couture exportersnearly half of all workers were women between 20 and 24 years of age.[10] Although legally banned in Turkey, around onetenth of the patients with WRI in this study sample had no insurance. Another interesting point in the present study is that WRI most commonly occurred among inexperienced workers who were new on the job. Workers who had been working in the sector between 1 and 3 years constituted up to two-thirds of the sample. National statistics reported that workers with less than one year’s experience account for 18.7% of those with WRI, while 44.3% had been working less than two years.[5] These findings are similar to the reports published by Perry et al.[8] The precarious workforce is extensively exploited in the textile sector in Turkey. It can be seen as unregistered employment, temporary employment and other forms. All these deceptive acts result in decreased costs of labor and extremely rapid turnover of the workforce. The end products of all these are precarious, inexperienced workers who work for longer than recommended, i.e., factors paving the way to WRIs. Precarious employment is a major issue in the context of the World Health Organization (WHO) Commission for Social Determinants of Health. The EMCONET Study Group concluded that precarious labor appears to be an independent risk factor for inequalities in health services. Researches pointed out that this enhances rates of WRI and due mortality.[11] Many studies showed that precarious employment is also a major risk factor in non-lethal WRIs.[12-14] Benavides et al.[15] investigated the mechanisms of WRIs in uninsured and temporary workers. They emphasized that short work experience, deficient knowledge of dangers in the workplace and short maintenance periods on any given job are associated with WRIs. It is known that most WRIs are recorded in the starting hours in ateliers, both in the morning and evening [07:00-09:00 (27.3%), 23:00-01:00 (15.8%)].

Statistical reports cite that 18.5% of all occupational injuries in Turkey in 2005 occurred within the first working hour, while 33.7% were noted in the first two hours. Most WRIs in Turkey occurred between 08:0010:00 and 10:00-12:00 (19.6% and 18.7%, respectively).[5,6] Justis et al.[16] investigated occupational hand Cilt - Vol. 18 Sayı - No. 1

injuries and pointed out that 24% of work-related hand injuries occurred within the first working hour. On the same issue, Lombardi et al.[17] reported that the highest frequency of injury was observed from 08:00-12:00 (54.6%), with a peak from 10:00-11:00 a.m. (14.9%).

The median time into the work shift for injury was 3.5 hours.

Sanati et al.[18] conducted a study with the workers in synthetic fiber factories and reported that almost half of the WRIs (46%) involved the hand and the most common mechanism was falls from height. This study demonstrates that falls are a serious safety concern in the workplace. On the other hand, falls were the third most common mechanism of injury in the present study, following trapped hands and misuse of tools and machines. Another Turkish study on workrelated hand injuries also put forth that trapped hands in machines was the most common mechanism of injury (59.7%).[19] Ind et al.[20] emphasized the importance of needlestick-type injuries among workers in the clothing industry. Laceration and puncture-type injuries comprised a substantial part of WRIs referred to the ED in this study. Perry et al.[8] indicated that cutting/piercing instruments were the major culprits in WRI, and a major part of WRI diagnoses consisted of open wounds involving the upper limb (29.0%).

The index finger was the most commonly injured (58.9%, n=109), followed by the thumb (25.4%, n=47) and third finger (11.4%, n=21) in the present study. Previous studies indicated the most commonly involved digit as the middle finger, followed by the fourth and index fingers, respectively, regardless of the sector.[4,19] This difference between findings may result from the tendency to use the index finger in textile machines, i.e., while feeding the machine with fabric.

The workers tended to blame themselves or selfrelated conditions instead of workplace-related circumstances as the cause of the WRIs. The causes most commonly reported were “carelessness” and “rushing” (40.6% and 21.4%, respectively). A number of other studies including all sectors have also mentioned “carelessness” as the most commonly blamed.[4,19] These findings may have resulted from the worker’s tendency to protect their own employer, indirectly defending themselves against unemployment and poverty. Recurrent questioning on the cause(s) of the accident may render findings to be extrapolated.

Three prominent risk factors for work-related hand injuries have been reported as lack of proper utilization of protective measures (gloves, etc.), insufficient work experience and worker-related factors (sleepiness, carelessness, etc.).[21] Hertz et al.[22] put forth that age under 25 is another risk factor. They also stressed that 35

Ulus Travma Acil Cerrahi Derg

use of defective equipment at the moment of the injury and assignment of a non-typical task to the workers contribute to the occurrence of WRIs. Chow et al.[23] described seven significant transient risk factors for acute hand injuries: using malfunctioning equipment/ materials, using a different work method, performing an unusual work task, working overtime, feeling ill, being distracted, and rushing.

The Turkish Statistical Institute declared that a 2.3% annual growth rate was recorded in the textile sector and 1.8% in the clothing sector in 2007.[5] This also indicates the need to augment the protective measures in these ever-growing fields in the country against WRIs. National policies are to be developed to curb further increases in precarious labor in terms of both employment and working conditions. Widespread application and improvization of workers’ health and workplace safety will also have an appreciable role in diminishing WRIs. In this context, efforts are to be aimed at determination of the causes of WRI and identification of measures to eliminate these causes, while promoting safe behavioral patterns through robust training on the issue. These should be combined with improvement in workplace conditions and repeated inspections and sanctions pursued by the state. Finally, broad, population-based studies are to be conducted to highlight the risk factors for WRI in Turkey.

REFERENCES 1. World Trade Organization web site. International Trade Statistics 2004. available from http://www.wto.org/english/ res_e/statis_e/its2004_e/its04_bysector_e.htm. (Accessed 20 September 2010).

2. Serinken M, Karcioglu O, Zencir M, Turkcuer I. Direct medical costs and working days lost due to non-fatal occupational injuries in Denizli, Turkey. J Occup Health 2008;50:70-4.

3. Denizli Textile Exporters’ Association web site. About Denizli – Economy. Available from http://www.detkib.org.tr/english/abautden.htm. (Accessed 20 September 2010).

4. Serinken M, Karcioglu O, Sener S. Occupational hand injuries treated at a tertiary care facility in western Turkey. Ind Health 2008;46:239-46.

5. Social Security Statistics, Turkish Statistical Institute (TURKSTAT) (online). Available from http://www.turkstat. gov.tr/VeriBilgi.do. (Accessed 20 September 2010).

6. Social Insurance Institution Yearly Statistical Report, 2005.

Türkiye Sosyal Sigortalar Kurumu (SSK) Web Site. Available from: http://www.ssk.gov.tr. (Accessed 20 September 2010).

7. Checkoway H, Ray RM, Lundin JI, Astrakianakis G, Seixas NS, Camp JE, et al. Lung cancer and occupational exposures other than cotton dust and endotoxin among women

36

textile workers in Shanghai, China. Occup Environ Med 2011;68:425-9.

8. Perry MJ, Sun BX, Zhang HX, Wang X, Christiani D. Emergency department surveillance of occupational injuries in Shanghai’s Putuo District, People’s Republic of China. Ann Epidemiol 2005;15:351-7.

9. Cakir E, Uyan ZS, Varol N, Ay P, Ozen A, Karadag B, Effect of occupation and smoking on respiratory symptoms in working children. Am J Ind Med 2009;52:471-8.

10. Li W, Ray RM, Gao DL, Fitzgibbons ED, Seixas NS, Camp JE, et al. Occupational risk factors for pancreatic cancer among female textile workers in Shanghai, China. Occup Environ Med 2006;63:788-93.

11. Benach J, Muntaner C, Solar O, Santana V, Quinlan M. Introduction to the WHO Commission on Social Determinants of Health Employment Conditions Network (EMCONET) study, with a glossary on employment relations. Int J Health Serv 2010;40:195-207.

12. Santana VS, Loomis D. Informal jobs and non-fatal occupational injuries. Ann Occup Hyg 2004;48:147-57.

13. Benavides FG, Delclos J, Benach J, Serra C. Occupational injury, a public health priority. [Article in Spanish] Rev Esp Salud Publica 2006;80:553-65.

14. Saha A, Kulkarni PK, Chaudhuri R, Saiyed H. Occupational injuries: is job security a factor? Indian J Med Sci 2005;59:375-81.

15. Benavides FG, Benach J, Muntaner C, Delclos GL, Catot N, Amable M. Associations between temporary employment and occupational injury: what are the mechanisms? Occup Environ Med 2006;63:416-21.

16. Justis EJ, Moore SV, LaVelle DG. Woodworking injuries: an epidemiologic survey of injuries sustained using woodworking machinery and hand tools. J Hand Surg Am 1987;12:8905.

17. Lombardi DA, Sorock GS, Hauser R, Nasca PC, Eisen EA, Herrick RF, Temporal factors and the prevalence of transient exposures at the time of an occupational traumatic hand injury. J Occup Environ Med 2003;45:832-40.

18. Sanati KA, Yadegarfar G, Naghavi SH, Sadr AH, Gholami M, Hadipour M, et al. Occupational injuries in a synthetic fibre factory in Iran. Occup Med (Lond) 2009;59:62-5.

19. Unlü RE, Abacı Ünlü E, Orbay H, Sensöz O, Ortak T. Crush injuries of the hand. [Article in Turkish] Ulus Travma Derg 2005;11:324-8.

20. Ind JE, Jeffries DJ. Needlestick injury in clothing industry workers and the risks of blood-borne infection. Occup Med (Lond) 1999;49:47-9.

21. Lombardi DA, Sorock GS, Holander L, Mittleman MA. A case-crossover study of transient risk factors for occupational hand trauma by gender. J Occup Environ Hyg 2007;4:790-7.

22. Hertz RP, Emmett EA. Risk factors for occupational hand injury. J Occup Med 1986;28:36-41.

23. Chow CY, Lee H, Lau J, Yu IT. Transient risk factors for acute traumatic hand injuries: a case-crossover study in Hong Kong. Occup Environ Med 2007;64:47-52.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):37-42

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.89137

Diagnostic peritoneal lavage in hemodynamically stable patients with lower chest or anterior abdominal stab wounds Hemodinamik açıdan stabil, göğüs altı veya ön karın bölgesinde bıçak yaralanması olan hastalarda tanısal peritoneal lavaj Shahriar HASHEMZADEH, Kamran MAMEGHANI, Rohollah F FOULADI, Elnaz ANSARI

BACKGROUND

AMAÇ

Managing hemodynamically stable patients with thoracoabdominal stab wounds is still under dispute. This study aimed at discussing cut-off points of red blood cell (RBC) count in diagnostic peritoneal lavage (DPL) effluent in these patients.

Torakoabdominal bıçak yaralanmaları bulunan ve hemodinamik açıdan stabil olan hastaların tedavisi halen tartışmalıdır. Bu çalışmada, bu tip hastalardaki tanısal peritoneal lavaj (TPL) sıvısındaki eritrosit sayısındaki optimal değer tartışıldı.

METHODS

GEREÇ VE YÖNTEM

Three hundred and eighty-eight patients with thoracoabdominal stab wounds and hemodynamically stable status were enrolled. In cases without a clear indication of laparotomy, the peritoneal cavity was washed out with 1000 ml of normal saline and the effluent fluid was analyzed for RBC count. RBC counts of >100,000/mm3 in abdominal wounds and of >10,000/mm3 in lower chest wounds were considered as indications for exploratory laparotomy (conventional approach). New cut-off points for RBC count were calculated in backward analysis.

Hemodinamik yönden stabil ve torakoabdominal bıçak yaralanması olan 388 hasta çalışmaya alındı. Laparotomi yönünden açık bir endikasyona sahip olmayan olgularda, peritoneal kavite 1000 cc serum fizyolojikle yıkandı ve akıntı sıvısındaki eritrosit sayısı analiz edildi. Karın yaralarında >100,000/mm3 ve alt göğüs yaralarında >10,000/mm3 seviyesinde eritrosit sayısı eksploratuvar laparotomi (konvansiyonel yaklaşım) için endikasyonlar olarak kabul edildi. Geriye dönük yapılan analizde, eritrosit sayısı için yeni eşik değerler hesaplandı.

RESULTS

BULGULAR

Sensitivity and specificity of the conventional approach were 90% and 84%, respectively. RBC counts >15,000/ mm3 in abdominal wounds and >25,000/mm3 in lower chest wounds were the best cut-off points in distinguishing patients with and without need of operation, with a sensitivity and specificity of 94% and 96%, respectively.

Konvansiyonel yaklaşımın duyarlılığı ve özgüllüğü, sırasıyla %90 ve %84 olmuştur. Karın yaralarında >15,000/ mm3 ve alt göğüs yaralarında >25,000/mm3 seviyesindeki eritrosit sayısı, operasyon gereksinimi olan veya olmayan hastaların ayırt edilmesinde, sırasıyla %94 ve %96’lık bir duyarlılık ve özgüllük ile en uygun eşik değeri bulundu.

CONCLUSION

SONUÇ

New cut-off points of RBC count in DPL effluent may promote management of patients with thoracoabdominal stab wounds and no obvious indication for operation.

Tanısal peritoneal lavaj sıvısında eritrosit sayısı ile ilgili yeni eşik değer, torakoabdominal bıçak yaralanmaları bulunan ve hiçbir açık operasyon endikasyonu bulunmayan TPL hastalarının tedavisine kullanılabilir.

Key Words: Thoracoabdominal stab wounds; laparotomy; thoracotomy; diagnostic peritoneal lavage; red blood cell.

Anahtar Sözcükler: Torakoabdominal bıçak yaralanmaları; laparotomi; torakotomi; tanısal peritoneal lavaj; eritrosit.

Department of Thoracic Surgery, Tabriz University of Medical Sciences, Tabriz, Iran.

Tebriz Tıp Bilimleri Üniversitesi, Göğüs Cerrahisi Anabilim Dalı, Tebriz, İran.

Correspondence (İletişim): Rohollah F Fouladi, M.D. Tabriz University of Medical Sciences, Golgasht Ave., Tabriz, Iran.

Tel: +98 - 914 - 4122542 e-mail (e-posta): medicorelax@yahoo.com

37

Ulus Travma Acil Cerrahi Derg

Prior to the 20th century, high mortality rates were the rule when stab or gunshot wounds were managed non-operatively.[1] Dealing with penetrating abdominal stab wounds has remained under debate. Traditionally, concern of delayed diagnosis of intra-abdominal injuries has led many trauma centers to propose mandatory abdominal exploration when a penetrating stab wound into the abdominal cavity was suspected.

[2,3] Selective operative management of asymptomatic patients was therefore advocated in 1960, when it was revealed that 25% to 33% of patients with stab wounds had no peritoneal penetration, and in penetrated cases, significant injuries were present in only some 45%.

[4,5] This liberal approach resulted in a reluctant acceptance of a 50% incidence of non-therapeutic laparotomies in an attempt to prevent delayed diagnosis of intra-abdominal injuries.[6] In order to overcome the diagnostic delay and concomitantly reduce the number of non-therapeutic laparotomies, diagnostic peritoneal lavage (DPL) was employed, which resulted in a reduced incidence of non-therapeutic laparotomies to 7%-15%.[7] Since the initial description of DPL in 1965, and emergence of the promoted type in 1977, this test has been considered as a tool to triage patients in the emergency ward to the operating room.[8,9] This is despite the availability of more sophisticated and less invasive options in managing patients with thoracoabdominal trauma, such as computed tomography (CT), focused assessment with sonography for trauma (FAST), thoracoscopy, or laparoscopy. However, DPL has remained a cornerstone in trauma work-up

Excluded

MATERIALS AND METHODS In a prospective setting, hemodynamically stable patients with stab wound injuries to the anterior abdomen or lower chest were evaluated during a four-year period (2007-2011) at an urban level I trauma center in Tabriz, Iran. The anterior abdomen was defined as a region confined to the inferior costal margin superiorly, the inguinal ligament inferiorly, and the anterior axillary lines laterally.[15] The lower chest (or thorax) was defined as a region placed between the anterior abdomen inferiorly and the forth intercostal space superiorly.[16] The managing protocol is summarized in Figure 1.

Hemodynamically unstable patients (systolic blood pressure <90) and/or patients in need of urgent opera-

Hemodynamically stable (n=388) Patients with stab wound to the anterior abdomen (n=195)

Patients with stab wound to the lower chest (n=193)

Peritoneal penetration in local exploration

Diaphragmatic injury in local exploration

No

Yes

Yes

DPL (n=193)

Grossly negative (n=148)

Grossly negative (n=164)

RBC count >100,000 mm3

Yes

No

DPL (n=195)

Grossly positive (n=47)

Laparotomy (n=91)

This study aimed at re-evaluating current cut-off points of the RBC count in DPL effluent fluid in patients with lower chest or anterior abdominal stab wounds.

Patients with stab wound to the anterior abdomen/lower chest (n=592)

Hemodynamically unstable (n=204)

Excluded (n=0)

because the mentioned techniques are expensive and time-consuming, with variable diagnostic sensitivity/ specificity, especially in penetrating thoracoabdominal trauma.[10-14] Using the DPL, one ideally wants to avoid missed injuries and minimize unnecessary operations. The red blood cell (RBC) count in DPL effluent fluid has been proposed as a sensitive and specific indicator; however, the optimal cut-off point is still controversial. In our center, at least, as a main referral place for such victims, the current guidelines are apparently unsatisfying.

RBC<1000 mm (n=76)

3

Grossly positive (n=29) 10,000 mm3 <RBC (n=63)

1000<RBC<10,000 mm (n=25)

3

No Discharged (n=104)

Observation for 3 days (n=116)

Observation for 3 days

Thoracotomy ÂąLaparotomy (n=105)

Discharged (n=88)

+ Thoracoscopy â&#x20AC;&#x201C;

Fig. 1. The flow chart of management in patients with thoracoabdominal stab wounds.

38

Ocak - January 2012

Diagnostic peritoneal lavage in hemodynamically stable patients with lower chest or anterior abdominal stab wounds

tion for any reason (evisceration, peritonitis, etc.) were excluded. The peritoneum or diaphragmatic violation was confirmed by exploration under local anesthesia.

Open DPL was performed through a lunar incision on the left side of the umbilicus. The DPL was considered grossly positive when more than 10 ml of free blood was aspirated through the catheter. In lesser volumes, 1 L of saline was instilled and the patient was gently rocked in different directions. In the aspirated effluent, RBC counts >100,000/mm3 and >10,000/mm3 were considered positive in anterior abdominal and lower thoracic lesions, respectively. In the latter, thoracoscopy was performed when the RBC count was between 1,000 and 10,000/mm3. Presence of bile, vegetable or fecal material, or observation of effluent draining through a chest tube, nasogastric tube, or Foley catheter was also considered as a grossly positive result.

[17] Exploratory laparotomy or thoracoscopy was performed in cases with a grossly positive finding or a positive DPL result. Otherwise, the patients were meticulously monitored for at least three days.[18,19] Development of hemodynamic instability, peritonitis, or evidence of ongoing blood loss prompted laparotomy.

Otherwise, the patient was discharged after feeding was tolerated. All the stable patients with easily and immediate access to our center were advised to present for another visit 10 days after discharge. These patients and their family members were informed about possible alerting signs or symptoms during their stay at home. Working backward, the RBC count in DPL effluent was employed for calculating an optimal cutoff point based on the final diagnosis made according to results of laparotomy, thoracoscopy or 10-day follow-up. The sensitivity was defined as the ability of the DPL to detect an injury (or penetration) to the visceral and/or intra-abdominal organs or the diaphragm, if present, and the specificity was defined as the ability of the DPL to rule out an injury (or penetration) to the visceral and/or intra-abdominal organs or the diaphragm if none existed.[8] This study was approved by the Ethics Committee of our University of Medical Sciences. Data were analyzed with the SPSS statistical software package (version 15.0; SPSS Inc, Chicago). Receiver operating characteristic (ROC) curve coordinates were used for determining optimal cut-off points of the RBC count in DPL effluent fluid. Continuous variables were expressed as mean±standard deviation, and categorical data were shown as frequency and percent. The contingency table (chi-square and Fisher’s exact tests where appropriate) was employed for comparisons. A p value less than 0.05 was considered statistically significant.

RESULTS Five hundred ninety-two patients with lower chest or anterior abdominal stab wound injuries were reCilt - Vol. 18 Sayı - No. 1

ferred to our center during the study period. Three hundred and eighty-eight patients met the criteria and were enrolled in the study. There were 195 patients (50.3%) with isolated anterior abdominal stab wounds (Group A) and 193 patients (49.7%) with isolated injuries in the lower chest (Group B). In Group A, there were 181 males (92.8%) and 14 females (7.2%), with a mean age of 23.3±7.3 (15-52) years. In Group B, there were 184 males (95.3%) and 9 females (4.7%), with a mean age of 27.2±9.0 (19-48) years. Initial aspiration and subsequent DPL analysis yielded a grossly positive result in 76 patients (19.6%), including 47 cases in Group A and 29 cases in Group B. A therapeutic laparotomy was performed in all these patients.

The RBC in DPL was counted in the remaining 312 patients (80.4% including 148 cases in Group A and 164 cases in Group B). After RBC count, 76 patients (24.4%) underwent exploratory laparotomies including 32 cases in Group A and 44 cases in Group B. Thirty-two patients with lower chest wounds were evaluated by thoracoscopy, all with negative findings, and the remaining 204 patients (75.6%) were closely observed, including 116 cases in Group A and 88 cases in Group B. In the three-day observational period, 12 other patients in Group A underwent operation due to emergence of an indication. Finally, 192 patients were discharged without any intervention including no laparotomy or thoracoscopy. There were no deaths and/or major complications 10 days after discharge.

Intra-operative findings were present in 83 cases in Group A, including injury to the small bowel (41 patients), colon (16 patients), liver (8 patients), vessels (8 patients), stomach (7 patients), spleen (2 patients) and gallbladder (1 patient). In Group B, similar findings were present in 37 cases, including injury to the diaphragm (23 patients), lung (9 patients), stomach (4 patients), and spleen (1 patient). The final outcomes after management of the patients are summarized in Table 1.

By backward analysis of the patients, RBC counts >15,000/mm3 in Group A and >25,000/mm3 in Group B were the optimal cut-off points in distinguishing patients with or without need of further evaluation (Table 2).

By applying the new cut-off points, specificities were significantly improved in patients with lower chest stab wounds and overall (odds ratio=0.8, 95% confidence interval 0.7-0.9, p<0.001, and odds ratio=4.6, 95% confidence interval 1.5-14.2, p=0.005, respectively).

DISCUSSION Diagnostic peritoneal lavage (DPL) has been introduced as one of the sensitive procedures in the management of patients with penetrating injuries to their 39

Ulus Travma Acil Cerrahi Derg

Table 1. Outcome of the conventional management* in patients with stab wound injuries to the anterior abdomen or the lower chest Location Lower chest Anterior abdomen Overall

A

B

C

D

E

F

G

H

37 (19.2%) 71 (36.4%) 108 (27.8%)

120 (62.2%) 104 (53.3%) 224 (57.7%)

36 (18.6%) 8 (4.1%) 44 (11.3%)

– 12 (6.2%) 12 (3.2%)

100% 86% 90%

– 0.7-0.9 0.8-1.0

77% 93% 84%

0.7-0.8 0.9-1.0 0.8-0.9

A: True positive; B: True negative; C: False positive; D: False negative; E: Sensitivity; F: 95% confidence interval; G: Specificity; H: 95% confidence interval. * Red blood cell count >100,000/mm3 and >10,000/mm3 in anterior abdominal and lower thoracic lesions, respectively.

Table 2. Outcome of the new management* in patients with stab wound injuries to the anterior abdomen or the lower chest Location Lower chest Anterior abdomen Overall

A

B

C

D

E

F

G

H

37 (19.2%) 76 (39%) 113 (29.1%)

156 (80.8%) 100 (51.2%) 256 (66%)

– 12 (6.2%) 12 (3.1%)

– 7 (3.6%) 7 (1.8%)

100% 92% 94%

– 0.8-0.0 0.9-1.0

100% 89% 96%

– 0.8-0.9 0.9-1.0

A: True positive; B: True negative; C: False positive; D: False negative; E: Sensitivity; F: 95% confidence interval; G: Specificity; H: 95% confidence interval. * Red blood cell count >15,000/mm3 and >25,000/mm3 in anterior abdominal and lower thoracic lesions, respectively.

lower chest or anterior abdomen. However, appropriate approaches and indices are still under debate. In this study, we showed that aspiration of a grossly positive fluid, i.e. gross blood volume >10 ml and/or traces of feces, food remnants and bile, would lead to unexceptionally therapeutic laparotomies. Nagy et al.,[20] in contrast, concluded that because aspiration-positive patients are not more critically injured or unstable than DPL-positive patients, and because DPL is more accurate in detecting need of operative intervention, aspiration should be withheld as a part of the DPL procedure in patients with abdominal trauma. In another series, Drost et al.[21] showed that a grossly positive peritoneal lavage might lead to “false- positive” results in patients with penetrating abdominal wounds. They indicated that such “false- positive” lavages most commonly result from blood entering the abdominal cavity from the wound, although nonoperative injuries to solid viscera and iatrogenic trauma are sometimes implicated. Considering “quantity” and “quality” in evaluating the initial aspiration of the peritoneal cavity in patients thusly injured seems to be the main difference between the current study and others. Aspiration not as a separate procedure but as an initial part of a DPL can be quickly evaluated without wasting time.

The rather large number of patients (76 cases) in our study with 100% therapeutic consequent laparotomies was a great advantage in present study. Sriussadaporn et al.[22] also found that during use of DPL in patients with stab wounds in the anterior abdomen, initial aspiration of gross blood from the lavage catheter of more than 10 ml is a highly sensitive indicator of injury. Apparently, inward bleeding of a stab wound will hardly reach a volume of 10 ml, and this amount of gross blood probably originates from an organ laceration.

The RBC count in a negative DPL effluent fluid, indi40

cating an injury of visceral and/or intra-abdominal organ in patients with lower chest or anterior abdominal stab wounds, is one of the most controversial indices.

By now, various studies have recommended different cut-off points for RBC count in patients with thoracoabdominal stab wounds. In Thacker’s study[23] in patients with stab wounds to the anterior lower chest and/or abdomen, a RBC count >100,000 mm3 in DPL effluent fluid was reported to be an accurate cut-off point, particularly when it was employed along with other positive criteria such as increased white cells, bile and amylase. In another study by Henneman[24] in 336 patients with penetrating trauma, the initial DPL according to the conventional guideline yielded a sensitivity of 87% and a specificity of 89% in predicting the need of operation. Sriussadaporn et al.[22] reported that a RBC count in lavage fluid >10,000/mm3 as a positive criterion for exploratory laparotomy yielded a sensitivity and a specificity of 100% and 87%, respectively. Zappa et al.[25] concluded that a RBC count of 50,000/mm3 discriminated satisfactorily those patients who required surgery from those who did not. Flaws in the management of patients and a variety of other disadvantages limit the accuracy of these studies.[26-29] In our series, the intra-operative findings were present in 83 cases in Group A, including 8 liver and 2 spleen injuries. In Group B, similar findings were present in 37 cases, including 23 cases with diaphragm, 9 patients with lung and 1 patient with spleen injuries. All these cases underwent therapeutic laparotomy/thoracotomy based on the criteria employed, such as a grossly positive DPL or increased RBC count, thoracoscopic findings or emergence of alerting signs/symptoms within the observational period (Fig. 1). None of them could be treated by nonoperative management.

Ocak - January 2012

Diagnostic peritoneal lavage in hemodynamically stable patients with lower chest or anterior abdominal stab wounds

Excluding the patients with grossly positive results, we reported new optimal cut-off points for RBC count in DPL effluent fluid with more accurate outcomes. A RBC count in DPL effluent fluid of >25,000/mm3 in lower chest wounds and of >15,000/mm3 in the anterior abdomen led to a sensitivity of 94% and a specificity of 96%, which were greatly better than the results of the conventional approach, including a RBC count >10,000/mm3 in lower chest injuries and of >100,000/ mm3 in the anterior abdomen, with a sensitivity of 90% and a specificity of 84%. To our �������������������� knowledge,���������� these results are the best ever reported in this group of patients in the literature. It should be noted that all the new cut-offs of RBC counts in the present study were made in a backward fashion; i.e., the outcome was clear and the new cut-offs were not tested in a fresh group of patients. Indeed, the main objective of this study was to evaluate and propose, if possible, new cut-offs of RBC counts in this group. It could be claimed that the new figures could omit or decrease the rate of delayed diagnosis of real injured cases after the phase of employment of previously proposed cut-offs; i.e. after more invasive evaluations such as thoracoscopy or exploratory laparotomy, or during the close observational periods. Of course, the new proposed cut-offs will cut the rate of false-negative or false-positive cases encountered in this study, and the high diagnostic accuracy confirms this; however, their efficiency in decreasing unnecessary and nontherapeutic operations while at the same time preventing missed cases needs to be examined in future patients in further studies using the same protocol along with the newly proposed RBC count cut-offs in DPL. There are a few of limitations to this study. Although this study was performed in a prospective manner, further randomized investigations might be ideal to prove the concept. A five-year period with a certain number of changing surgeons might be another issue. Conducting similar studies in other centers may further elucidate the findings. The close follow-up period was 10 days in the current study, which may seem short. During this follow-up period, repeated contact is made by the medical staff with the patients or the relatives responsible for their care. The contact persons are fully educated about the condition and alerting signs/symptoms before discharge. In addition, only the patients with easy and rapid access to the medical centers were allowed to stay at home after three days of in-hospital observation. Working in a major referral center and with a considerable amount of experience, the authors believe that this period is sufficient to closely follow patients with thoracoabdominal penetrating injuries. The upcoming results also confirmed this concept. Nonetheless, as mentioned earlier, we only recruited patients who were in close contact for immediate action, and regular visits were performed Cilt - Vol. 18 Sayı - No. 1

after this period of time, but not as closely as in the mentioned 10-day period.

In conclusion, the results of DPL assessment in stable patients with stab wounds in the lower chest or anterior abdomen could be considered as an accurate and safe method of management. Apparently, this is more complex in anterior abdominal stab wounds compared with injuries in the lower chest. However, combining DPL findings based on the newly proposed cut-off points with a rather short period of observation in patients with negative results might increase the sensitivity and specificity of management. Further studies with larger sample sizes, particularly in patients with anterior abdominal injuries, are recommended. Penetrating lesions in the back and flank are important issues as well.

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22. Sriussadaporn S, Pak-art R, Pattaratiwanon M, Phadungwidthayakorn A, Wongwiwatseree Y, Labchitkusol T. Clinical uses of diagnostic peritoneal lavage in stab wounds of the anterior abdomen: a prospective study. Eur J Surg 2002;168:490-3.

42

23. Thacker LK, Parks J, Thal ER. Diagnostic peritoneal lavage: is 100,000 RBCs a valid figure for penetrating abdominal trauma? J Trauma 2007;62:853-7.

24. Henneman PL, Marx JA, Moore EE, Cantrill SV, Ammons LA. Diagnostic peritoneal lavage: accuracy in predicting necessary laparotomy following blunt and penetrating trauma. J Trauma 1990;30:1345-55.

25. Zappa MJ, Harwood-Nuss AL, Wears RL, Fallon WF. Objective determination of the optimal red blood cell count in diagnostic peritoneal lavage done for abdominal stab wounds.

J Emerg Med 1992;10:553-8.

26. Alyono D, Morrow CE, Perry JF Jr. Reappraisal of diagnostic peritoneal lavage criteria for operation in penetrating and blunt trauma. Surgery 1982;92:751-7.

27. Muckart DJ, McDonald MA. Unreliability of standard quantitative criteria in diagnostic peritoneal lavage performed for suspected penetrating abdominal stab wounds. Am J Surg 1991;162:223-7.

28. DeMaria EJ, Dalton JM, Gore DC, Kellum JM, Sugerman HJ. Complementary roles of laparoscopic abdominal exploration and diagnostic peritoneal lavage for evaluating abdominal stab wounds: a prospective study. J Laparoendosc Adv Surg Tech A 2000;10:131-6.

29. Sweeney JF, Albrink MH, Bischof E, McAllister EW, Rosemurgy AS. Diagnostic peritoneal lavage: volume of lavage effluent needed for accurate determination of a negative lavage. Injury 1994;25:659-61.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):43-48

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.36599

Factors affecting the number of debridements in Fournier’s gangrene: our results in 36 cases Fournier gangreninde debridman sayısını etkileyen faktörler: 36 olguda sonuçlarımız Cemal GÖKTAŞ,1 Mehmet YILDIRIM,2 Rahim HORUZ,1 Gökhan FAYDACI,1 Oktay AKÇA,1 Cihangir Ali ÇETİNEL1

BACKGROUND

AMAÇ

We aimed to evaluate the factors potentially affecting the number of surgical debridements in patients with Fournier’s gangrene (FG) who underwent single or multiple operative sessions.

Bu çalışmada, tek veya çok sayıda cerrahi debridman gereken Fournier gangreni (FG) hastaları karşılaştırıldı, debridman sayısını etkileyebilecek faktörler araştırıldı.

METHODS

Fournier gangreni nedeniyle tedavi edilen 36 hastanın verileri geriye dönük olarak incelendi. Hastalar uygulanan debridman sayısına göre iki gruba ayrıldı (Grup I: tek seans; Grup II: ≥2 seans). Hastalara ait veriler (klinik ve cerrahi veriler, lezyon özellikleri, FG şiddet indeksi, prognoz verileri) gruplar arasında karşılaştırıldı.

We retrospectively reviewed the data of 36 patients with FG. The patients were assigned to one of two groups according to the number of debridements (Group I: single session; Group II: ≥2 sessions). Data of the patients (clinical and surgical data, lesion characteristics, FG severity index, and prognosis) were compared between the groups.

RESULTS

The mean age of the patients was 55.5 years, and all were male. Group I consisted of 21 patients and Group II of 15 patients. The mean number of debridements was 2.2 in Group II. Our overall mortality rate was 11% (Group I: 4.8% vs Group II: 20%; p=0.287). Diabetes was the most common coexistent pathology (44%). Time to admission to the clinic, size of the lesions at admission, and FG Severity Index (FGSI) scores of the groups were similar. In Group II, FGSI scores were found increased before each of the repeated debridement sessions (p<0.05).

CONCLUSION

GEREÇ VE YÖNTEM

BULGULAR

Hastaların ortalama yaşı 55,5 idi ve hepsi erkekti. Grup I’de 21, Grup II’de 15 hasta incelendi. Grup II’de ortalama debridman sayısı 2,2 idi. Genel mortalite oranı %11 olarak saptandı (Grup I’de %4,8, Grup II’de %20; p=0,287). Diyabet en sık karşılaşılan komorbidite idi (%44). Hastaneye başvuruya kadar geçen süre, başvuru sırasında lezyonun boyutu ve FG şiddet indeksi açısından gruplar arasında fark tespit edilmedi. Grup II’de FG şiddet indeksi skorunun tekrarlanan her operasyon öncesinde anlamlı derecede artış gösterdiği saptandı (p<0,05).

SONUÇ

There was no difference in the clinical data of the patients who required single or multiple debridement sessions; however, FGSI may be useful in deciding repeated debridements, as it was found increased at each repeated session.

Her ne kadar tek veya çok sayıda debridman uygulanan hastalar arasında debridman sayısını etkileyebilecek anlamlı fark saptanmamışsa da; FG şiddet indeksi, tekrarlanan her debridmanda arttığı tespit edildiği için, ilave debridmanlara karar vermede yardımcı olabilir.

Key Words: Debridement; Fourniers gangrene; mortality; prognosis; surgical procedures.

Anahtar Sözcükler: Debridman; Fournier gangreni; mortalite; prognoz; cerrahi prosedürler.

Departments of 1Urology, 2General Surgery, Dr. Lutfi Kirdar Kartal Training and Research Hospital, Istanbul, Turkey.

Dr. Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi, 1Üroloji Kliniği, 2 Genel Cerrahi Kliniği, İstanbul.

Correspondence (İletişim): Rahim Horuz, M.D. Dr. Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi, 2. Üroloji Kliniği, Cevizli, Kartal, İstanbul, Turkey.

Tel: +090 - 216 - 441 39 00 / 1921 e-mail (e-posta): rahimhoruz@yahoo.com

43

Ulus Travma Acil Cerrahi Derg

Fournierâ&#x20AC;&#x2122;s gangrene (FG) is a rare necrotizing infection that affects the perineal and genital area, and is an emergent disease that still carries a high risk of mortality.[1] The principle of the treatment is achieving an urgent debridement combined with an appropriate wide-spectrum antibiotherapy. Since FG has a progressive nature, repeated debridements may be required in some cases.

In this study, we compared the clinical findings and treatment outcomes of cases that underwent single or multiple surgical debridement sessions because of FG, with an aim to evaluate the potential association between the number of debridements and prognosis, in order to test a hypothesis that the prognosis might be worse in patients requiring additional debridements.

MATERIALS AND METHODS We retrospectively reviewed the data of 36 patients with the diagnosis of FG treated in our clinic from 2004 to 2010. The diagnosis was primarily based on physical examination; data of complete blood count and serum levels of creatinine, sodium, potassium, and bicarbonate were noted. Infected tissues of the lesions were sampled during debridement and were examined microbiologically. In all cases, applied antibiotherapy and clinical outcomes were evaluated.

The patients were allocated into one of two groups according to the number of debridements: Group I consisted of cases with single debridement, while Group II consisted of the cases that underwent two or more debridement sessions. Patient data including demographics, characteristics of the lesion, factors in the etiology, coexistent pathologies, scores of Fournierâ&#x20AC;&#x2122;s Gangrene Severity Index (FGSI) before each debridement, localization of the primary lesion, lesion size on presentation, duration between the appearance of primary lesion and admission, results of microbiological cultures and antibiogram, and antibiotherapy schedules applied were compared between the groups.

Cases resulting in death were particularly evaluated.

Statistical evaluation was performed by use of chisquare, Kruskal-Wallis and Mann-Whitney U tests.

RESULTS Group I consisted of 21 patients and Group II of 15 patients. Since 11 of 15 patients in Group II had 2 debridement sessions and 4 patients had 3 debridement sessions, the total number of debridement procedures was 55. The mean number of debridements per patient was 1.5.

The mean ages of patients overall, in Group I and in Group II were comparable, as 55.5 (22-80), 54.8 (2280) and 56.5 (31-73) years, respectively (p=0.936). All of the cases were male. While the primary lesion was classified as of urogenital or perineal origin in 53% 44

and 9% of the cases, respectively, it was not possible to specify an etiologic origin in 38% of the cases.

In 23 cases (64%), there was at least one coexisting pathology, and diabetes mellitus (DM) was the most common, at a ratio of 44% (n=16). While DM was the only documented comorbidity in 11 patients, it coexisted with at least one other systemic pathology, such as chronic renal disease, hypertension, coronary artery disease, or chronic obstructive pulmonary disease, in the remaining 5. Of these 5 cases, 1 patient also had prostate cancer, and another had paraplegia as an underlying pathology. The rates of coexistent disease in Groups I and II were 52.2% and 80%, respectively, and the difference was not statistically significant (p=0.484) (Table 1).

The mean duration between the appearance of the initial lesion and admission to the clinic was detected as relatively long, at 5.2 days, and was similar when compared between the groups (p=0.441) (Table 1).

The mean size of lesions at the first physical examination was similar in Group I and Group II (26.6 cm2 vs.

37.8 cm2, respectively; p=0.172) (Table 1).

Overall FGSI score of the cases was 2.4 on admission. There was no significant difference in FGSI scores between groups (2.1 and 2.8 in Group I and Group II, respectively; p=0.149). On the other hand, the mean FGSI scores were found as 2.4, 2.9 and 3.7 before the first, and if performed, the second and third debridement sessions, respectively. The difference was statistically significant (p=0.0001, for all groups). The FGSI of the 4 patients with mortality was a mean of 4.7.

Regarding the initial localization of the lesion during the first physical examination, it was seen that the scrotal area had been involved in all cases either as the only affected site or with neighboring skin. While a single session of surgical debridement was adequate in 69% of the cases with isolated scrotal lesion, the rate of one successful debridement was 52% in patients in whom neighboring tissues had been involved in addition to the scrotum. Although the number of required sessions appeared to be higher in larger lesions involving adjacent tissues along with the scrotum, this difference was not found as significant (p=0.484) (Table 1).

Once FG had been diagnosed by physical examination, wide-spectrum antibiotherapy with cefazolin 2 x 1 g/day, gentamicin 1 x 160 mg/day and metronidazole 2 x 500 mg/day was started in all of the patients.

When microbiological reports were evaluated, it was seen that culture was negative in 8 (22%) of the patients, while a single bacterial agent was reported in 24 (67%) and mixed infection in 4 (11%) of the patients.

The most commonly reported bacterial agent was Escherichia coli (in 15 of 19 single agent infections, and in all of 4 mixed infections). Microbiological Ocak - January 2012

Factors affecting the number of debridements in Fournier’s gangrene

Table 1. Summary of the demographic, clinical and microbiological data of the patients

Patients (n) Debridement (n) Age (years) Etiology (n) Urogenital origin Scrotal skin infection Orchitis and/or scrotal abscess Perineal origin Unknown Underlying coexistent disease (n) Size of the lesion in initial examination (cm2) Time to the admission (day±SD, range) Microbiological results (n) Single agent E. coli MRSA Pseudomonas Enterococcus Streptococcus Mixed Culture-negative Change in antibiotherapy regimen (n) FGSI Before first debridement (n=36) Before second debridement (n=15) Before third debridement (n=4) Mortality (n) Localization during admission (n) Penoscrotal Scrotal Perineoscrotal Perineopenoscrotal

Group I

Group II

Overall

p

21 21 54.8

15 34 56.5

36 55 55.5±15.1

0.936

9 2 0 10 11 (52%) 26.6±20.6 (6-96) 5.5±2.5 (2-9)

4 4 3 4 12 (80%) 37.8 ±27.4 (12-100) 4.9±2.5 (3-14)

13 6 3 14 23 (64%) 31.2 (6-100) 5.2±2.6 (2-14)

0.484 0.172 0.441

12 7 3 1 1 0 3 6 6

12 8 1 0 2 1 1 2 7

24 15 4 1 3 1 4 8 13

0.310

2.1±1.3

1 (4.8%)

2.8±1.8 2.9±1.9 3.7±2.1 3 (20.0%)

2.4±1.7

4 (11.1%)

3 9 6 3

5 4 3 3

8 13 9 6

0.149 0.287

n: Number; FGSI: Fournier’s Gangrene Severity Index; MRSA: Methicillin-resistant Staphylococcus aureus.

results are shown in Table 1. The antibiotic regimen had to be changed according to the results of bacterial culture in 13 patients (6 in Group I, 7 in Group II; p=0.310).

Data regarding duration of hospitalization was significantly different between the groups, at 18.6 and 33.5 days in patients in Group I and Group II, respectively (p=0001). Our overall mortality rate was 11% (n=4) (1 patient in Group I vs 3 patients in Group II; p=0.287). It is notable that there was at least one coexistent underlying pathology in all of our mortal cases, and the mean FGSI score of these patients (4.7) was apparently higher than that of the others. Data of the cases resulting in mortality are summarized in Table 2.

DISCUSSION Necrotizing fasciitis is a rare and potentially fatal infectious condition characterized by acute onset and high risk of morbidity and mortality, and FG is a speCilt - Vol. 18 Sayı - No. 1

cific form of this disease that affects primarily the skin and subcutaneous tissues of the external genitalia and perineum.[1] It is generally characterized by a polymicrobial infection that results in obliterative endarteritis, ischemia, and consequently, necrosis of the skin and adjacent tissues.[2,3] Genitourinary infections, trauma, anorectal abscess, immunosuppression, DM, renal or hepatic dysfunction, and alcoholism are reported among the predisposing factors in the literature.[4] Since it was first defined, FG remains among the most important emergent diseases in the practice of urologists with its high mortality.[5] With its rapidly progressive nature, necrotizing fasciitis carries the risk of invading unexpectedly large areas of the skin if not treated appropriately and, most importantly, on time.

In addition to the systemic effects of the infection itself, exotoxins released from the affected necrotic tissue may result in disturbed hemostasis, septic/toxic 45

Ulus Travma Acil Cerrahi Derg

Table 2. Data of the cases resulting in mortality

Patient (n) Sessions (n) Age (years) Etiology Perineal abscess Scrotal abscess Coexistent disease (n, %) Prostate carcinoma (n) DM+CRF (n) DM (n) Size of the lesion at admission (mm) Time to the admission (days) Initial FGSI Microbiologic culture E. coli Streptococcus E. coli+Enterococcus Negative Localization of the lesion Scrotal Penoscrotal Perineoscrotal Perineopenoscrotal

Group I

Group II

Overall

1 1 72

3 7 52

4 8 57

0 1 1 (100%) 1

30 3 4.0

2 1 3 (100%)

1 2 36.6 4.8 5.0

2 2 4 (100%)

1 – – –

– 1 1 1

1 1 1 1

1 – – –

– 1 1 1

1 1 1 1

35 4.2 4.7

n: Number; DM: Diabetes mellitus; CRF: Chronic renal failure; FGSI: Fournier’s Gangrene Severity Index.

shock, and eventually death in some of the cases.[6] The rate of progression of the lesion in necrotizing fasciitis was reported in the literature as being as fast as 2 mm per hour.[7] It may result from various etiological origins; however, its course may be more mortal when developed from an anorectal origin than with urogenital origin.[8-11] Our series did not include any patient with anorectal origin.

While early recognition of the lesion is one of the major determinants of the outcome of the disease, surgical treatment along with medical measures are the cornerstones of therapy. In order to be able to prevent its rapid progression, aggressive surgical debridement, local wound care and broad-spectrum systemic antibiotherapy should be performed without delay. Since the visible borders of the gangrene may often be misleading, an efficient debridement should involve removal of 1-2 cm of healthy-appearing tissues that surround the lesion after clearance of all necrotic tissues of the skin and subcutaneous layers.

Reappearance of the necrosis indicates that the initial debridement was insufficient and a repeat is necessary. In most of the studies, the mean number of debridements per patient was reported as higher than one.[10,12,13] Similarly, repeated debridements were required in 42% of our patients.

In a study of Laor et al.,[14] it was reported that the 46

number of debridements is not associated with the patient’s outcome. In comparison, Chawla et al.[13] reported a higher number of debridements in the nonsurvival group of their study, although they concluded that this has no predictive value regarding the prognosis. In that study, they reported the mean number of debridements as 2.2 for 14 patients who survived and as 5.2 for 5 cases resulting in mortality. They attributed this finding as due to the fact that sicker patients require more debridements.[13] In our study, 3 of 4 deaths were in the group of cases with repeated debridement sessions. In other words, while the mortality rate in patients treated with a single session of debridement was 4.8%, it was found as high as 20% in the group of patients who required multiple debridements. Although not statistically significant, this difference may support the suggestion that the mortality increases as the number of debridements increases in FG. Some authors have associated the prognosis of FG with the age and sex of the patients, and reported an increased risk in female and elderly patients.[15,16] However, we did not detect any direct relation between age and the number of debridements, and we had no female patients in our series.

Although the initial localization of the lesion may be helpful in determining the etiological origin, FG generally presents with lesions larger than the original one as they progressively involve the surrounding arOcak - January 2012

Factors affecting the number of debridements in Fournier’s gangrene

eas of the initial lesion. When we evaluated the origins of the lesions in our patients, the chance of surgical cure by single debridement appeared to be higher in the patients in whom the initial lesion had been in the scrotum; however, this finding was not statistically significant. In one study, Tuncel et al.[17] reported that the extent of disease has a predictive value on prognosis. In our patients, the mean size of the lesion at admission was higher in Group II than in Group I. However, we could not detect any significant association between the size of the lesion and the number of debridements in our series.

Diabetes mellitus (DM) is generally observed as a comorbid disease in patients with FG, and it was the most common comorbidity in our study. DM has been reported as a risk factor and prognostic factor of FG in the literature.[18-20] In one study, Nisbet et al.[18] showed that the number of debridements was not different between the diabetic and non-diabetic FG patients. Similarly, we found that presence of comorbidities did not affect the number of debridements required (p<0.05).

Fournier’s Gangrene Severity Index (FGSI) has been a widely used instrument by urologists since it was first described by Laor.[14] In spite of the presence of some studies objecting to the use of the FGSI score as a predictive factor,[17] a significant relationship between the FGSI score and prognosis in FG was reported in several studies.[10,21,22] Ersay et al.[10] reported a significant correlation between FGSI score and duration of hospitalization and number of debridements.

In our study, although no association was detected between the FGSI score of the initial examination and number of debridements, we found that the FGSI showed a tendency to increase in Group II patients in the preoperative evaluations of each repeated debridement. This result may mean that the patients with increasing FGSI are at risk of a progression that will potentially require repeated debridements. Although the mean interval between the debridement sessions was calculated as 4.3 days in our study, we do not have enough data to comment on the exact frequency of assessment of the laboratory components of FGSI. Early diagnosis is an important prognostic factor in FG.[9,12] Akgün et al.[9] reported that the duration between the first signs of the disease and admission to the hospital was longer in the cases resulting in mortality. However, regarding the admission or diagnosis time, we could not detect any difference in the cases in whom multiple debridements were required or in fatal cases when compared with the others.

Since FG is an infectious disease, antibiotics are also of key importance in the treatment in addition to the surgery. Among the first measures, a broad-spectrum antibiotic regimen with Gram-negative, GramCilt - Vol. 18 Sayı - No. 1

positive and anaerobic coverage should be started immediately. In accordance with the literature,[6] the most frequent microbial agent in our study was also E. coli.

Changes in the initial broad-spectrum antibiotherapy regimens according to the results of bacterial culture tests showed no association with the number of debridements.

Although we were not able to show a significant relationship between the number of debridements and the prognosis of FG, and there was no statistical difference between the groups of patients with single or multiple debridements in our study, we believe that a potential relation between debridement number and prognosis should be tested in larger studies. On the other hand, the direct correlation we detected between the number of debridements and the increasing FGSI in per-patient analysis may be interpreted as indicating that FGSI, in the case of its increase, may be helpful as an adjunct to other clinical parameters when deciding a repeated debridement session, by alerting physicians about the prognosis.

In conclusion, since there was no difference in the clinical data of the patients with FG who required single or multiple debridement sessions, we could not identify a predictive tool for repeated surgical interventions in the treatment of FG. FGSI may be useful in deciding repeated debridements, as it was found increased at every repeated session; however, its prognostic and predictive value should be tested in larger studies.

REFERENCES 1. Sorensen MD, Krieger JN, Rivara FP, Klein MB, Wessells H. Fournier’s gangrene: management and mortality predictors in a population based study. J Urol 2009;182:2742-7.

2. Mehl AA, Nogueira Filho DC, Mantovani LM, Grippa MM, Berger R, Krauss D, et al. Management of Fournier’s gangrene: experience of a university hospital of Curitiba. Rev Col Bras Cir 2010;37:435-41.

3. Vick R, Carson CC 3rd. Fournier’s disease. Urol Clin North Am 1999;26:841-9.

4. Smith GL, Bunker CB, Dinneen MD. Fournier’s gangrene.

Br J Urol 1998;81:347-55.

5. Basoglu M, Ozbey I, Atamanalp SS, Yildirgan MI, Aydinli B, Polat O, et al. Management of Fournier’s gangrene: review of 45 cases. Surg Today 2007;37:558-63.

6. Martínez-Rodríguez R, Ponce de León J, Caparrós J, Villavicencio H. Fournier’s gangrene: a monographic urology center experience with twenty patients. Urol Int 2009;83:323-8.

7. Atakan IH, Kaplan M, Kaya E, Aktoz T, Inci O. A lifethreatening infection: Fournier’s gangrene. Int Urol Nephrol 2002;34:387-92.

8. Enriquez JM, Moreno S, Devesa M, Morales V, Platas A, Vicente E. Fournier’s syndrome of urogenital and anorectal origin. A retrospective, comparative study. Dis Colon Rectum 1987;30:33-7.

9. Akgün Y, Yilmaz G. Factors affecting mortality in Fournier’s gangrene. Ulus Travma Acil Cerrahi Derg 2005;11:49-57.

47

Ulus Travma Acil Cerrahi Derg

10. Ersay A, Yilmaz G, Akgun Y, Celik Y. Factors affecting mortality of Fournier’s gangrene: review of 70 patients. ANZ J Surg 2007;77:43-8.

11. Eke N. Fournier’s gangrene: a review of 1726 cases. Br J Surg 2000;87:718-28.

12. Norton KS, Johnson LW, Perry T, Perry KH, Sehon JK, Zibari GB. Management of Fournier’s gangrene: an eleven year retrospective analysis of early recognition, diagnosis, and treatment. Am Surg 2002;68:709-13.

13. Chawla SN, Gallop C, Mydlo JH. Fournier’s gangrene: an analysis of repeated surgical debridement. Eur Urol 2003;43:572-5.

14. Laor E, Palmer LS, Tolia BM, Reid RE, Winter HI. Outcome prediction in patients with Fournier’s gangrene. J Urol 1995;154:89-92.

15. Czymek R, Frank P, Limmer S, Schmidt A, Jungbluth T, Roblick U, et al. Fournier’s gangrene: is the female gender a risk factor? Langenbecks Arch Surg 2010;395:173-80.

16. Simsek Celik A, Erdem H, Guzey D, Celebi F, Birol S, Erozgen F, et al. Fournier’s gangrene: series of twenty patients.

Eur Surg Res 2011;46:82-6.

48

17. Tuncel A, Aydin O, Tekdogan U, Nalcacioglu V, Capar Y, Atan A. Fournier’s gangrene: Three years of experience with 20 patients and validity of the Fournier’s Gangrene Severity Index Score. Eur Urol 2006;50:838-43.

18. Nisbet AA, Thompson IM. Impact of diabetes mellitus on the presentation and outcomes of Fournier’s gangrene. Urology 2002;60:775-9.

19. Malik AM, Sheikh S, Pathan R, Khan A, Sheikh U. The spectrum of presentation and management of Fournier’s gangrene--an experience of 73 cases. J Pak Med Assoc 2010;60:617-9.

20. Korkut M, Içöz G, Dayangaç M, Akgün E, Yeniay L, Erdoğan O, et al. Outcome analysis in patients with Fournier’s gangrene: report of 45 cases. Dis Colon Rectum 2003;46:64952.

21. Lin E, Yang S, Chiu AW, Chow YC, Chen M, Lin WC, et al.

Is Fournier’s gangrene severity index useful for predicting outcome of Fournier’s gangrene? Urol Int 2005;75:119-22.

22. Yeniyol CO, Suelozgen T, Arslan M, Ayder AR. Fournier’s gangrene: experience with 25 patients and use of Fournier’s gangrene severity index score. Urology 2004;64:218-22.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):49-54

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.45656

An alternative classification of occupational hand injuries based on etiologic mechanisms: the ECOHI classification Etyolojik mekanizmalarının temelinde iş kazasına bağlı el yaralanmalarında alternatif bir sınıflama: İKEYES sınıflaması Bülent ÖZÇELİK,1 Erden ERTÜRER,2 Berkan MERSA,1 Hüsrev PURİSA,1 İlker SEZER,1 Serdar TUNÇER,3 Fatih KABAKAŞ,1 Samet Vasfi KUVAT4 BACKGROUND

AMAÇ

The aim of this study was to construct an alternative classification system for occupational hand injuries based on etiologic mechanisms and to analyze the injury patterns resulting from various mechanisms.

Bu çalışmanın amacı, etyolojik mekanizmalarına bağlı olarak iş kazalarına bağlı el yaralanmaları için alternatif bir sınıflama sistemi ortaya koymaktır.

METHODS

İki el cerrahisi ünitesi cerrahlarınca, Ocak 2005 ile Aralık 2007 yılları arasında ameliyat edilen hastaların geriye dönük olarak analizleri yapıldı. Hasta dosyaları retrospektif incelendi ve yaralanmaya neden olan mekanizmalar incelendi. Benzer yaralanma mekanizmaları aynı gruplarda sınıflandırıldı ve görülme sıklıkları araştırıldı. Yaralanmaların sınıflandırılmasında hasarlanan dokular temel alındı. Hastaneye yatırılan 4120 el cerrahisi hastasından 2188’i (%53,1) iş kazası sonucu yaralanan olgular idi. Bunların 2063’ü erkek (%94,3), 125’i kadındı (%6,7). Ortalama yaş 28,2 (dağılım 15-71 yaş) idi.

A retrospective analysis of patients operated between January 2005 and December 2007 in two hand surgery units staffed by a team of hand surgeons was made. The patient files were retrospectively examined, and mechanisms causing the injuries were analyzed. Similar mechanisms were classified in the same groups, and the mechanism of injury was matched with type of injury often caused by this mechanism. In the classification of injuries, the tissues that were injured were taken as a basis for classification. 4120 upper extremity injuries were seen in the study hospitals, and 2188 (53.1%) of them were occupational injuries. There were 2063 males (94.3%) and 125 females (6.7%). The mean age was 28.2 (range: 15-71) years.

RESULTS

Examination of the agents causing injury yielded 62 agents.

Further examination of these agents showed that the mechanism by which they caused injury was similar in some agents, and these agents were placed in the same groups, which constituted the Etiologic Classification of Hand Injuries (ECOHI) classification. These groups of mechanisms were: cutting-penetrating, cutting-crushing, crushing-penetrating, crushing-compressing, crushing-burning, stinging, avulsing, electrical current, and chemical injuries and miscellaneous burns. The two most common mechanisms were crushing-compressing and cutting-crushing types, constituting 744 (34.0%) and 514 (23.5%) of injuries, respectively.

CONCLUSION

We believe that ECOHI is important to form a common language for the classification of etiologic factors.

Key Words: Occupational hand injuries; etiologic classification.

1 Ist-el Hand Surgery, Microsurgery and Rehabilitation Group, Istanbul; Şişli Etfal Training and Research Hospital, Orthopedic Clinic and Trauma Clinic, Istanbul; 3Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul Bilim University, Istanbul; 4Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey.

2

GEREÇ VE YÖNTEM

BULGULAR

Yaralanmaya neden olan ajanların incelenmesinde 62 ajan belirlendi. Bu ajanların ileri incelemesi ile benzer yaralanmaya neden olan ajanlar “iş kazalarına bağlı el yaralanmalarının etyolojik sınıflandırması”na (İKEYES) göre gruplandırıldı. Bu grupları kesici-delici, kesici-ezici, ezici-delici, ezici-sıkıştırıcı, ezici-yakıcı, batıcı, avulziyon, elektrik çarpması ve kimyasal yaralanmalar ve diğer yanıklar oluşturdu. Etyolojideki en sık iki mekanizmayı 744 (%34,0) olgu sayısı ile ezici-sıkıştırıcı yaralanmalar ile 514 (%23,5) olgu sayısı ile kesici-ezici yaralanmalar oluşturmaktaydı.

SONUÇ

İKEYES sınıflamasının literatürde etyolojik faktörlerin sınıflaması için ortak bir dil oluşturulabilmekte önemli olduğuna inanmaktayız.

Anahtar Sözcükler: İş kazalarına bağlı el yaralanmaları; etyolojik sınıflama. İst-el El Cerrahisi, Mikrocerrahi ve Rehabilitasyon Grubu, İstanbul; Şişli Etfal Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul; 3İstanbul Bilim Üniversitesi Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, İstanbul; 4 İstanbul Üniversitesi İstanbul Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, İstanbul.

1

2

Correspondence (İletişim): Bülent Özçelik, M.D. Bahçeşehir Mesa Nurol Evleri, Kirazlıbahçe Sitesi C3 D6, Başakşehir, İstanbul, Turkey.

Tel: +090 - 212 - 632 81 44 e-mail (e-posta): bulent-ozcelik@hotmail.com

49

Ulus Travma Acil Cerrahi Derg

The International Labour Organization (ILO) defines occupational accident as â&#x20AC;&#x153;an unexpected and unplanned occurrence, including acts of violence, arising out of or in connection with work, which results in a personal injury, disease or death.[1,2] According to the ILO data, 270 million occupational accidents annually result in the death of 5000 and 2,000,000 million people every day and every year, respectively. Occupational accidents also cause significant financial and work losses. In the United States per se, financial losses due to fatal and non-fatal occupational accidents were 145.37 billion USD in 1992.[3] Therefore, prevention of these accidents carries great significance. Unfortunately, despite developments in health and safety systems, the frequency of occupational accidents remains high.[4,5] In a retrospective analysis of health-related social security benefits, occupational injuries constituted 7.3% of all benefits due to health problems and illnesses.[6] Work-related hand injuries constitute a major portion of occupational accidents and range from simple skin lacerations to amputations.[7] Classifications and scoring systems are helpful in predicting the outcomes of injury in addition to the assessment of their severity.[8] Although numerous classification systems and scales have been developed for injuries of the lower extremity, their equivalents for the upper extremity are limited.[8,9] The most commonly used scoring system in hand injuries is the Hand Injury Severity Score (HISS), developed by Campbell and Kay in 1996.[10] Other scoring systems in hand injuries are also based on severity of the injury, and the mechanism of the injury is often not considered in these systems. However, the mechanism of injury is significant in determining the type and severity of injury. The definition and classification of these mechanisms is an important step in the formation of a common language, which will assist in studies that will determine the etiologies of occupational accidents and in strategies to decrease their occurrence. Using our database on occupational injury, the aim of this study was to construct an alternative classification system for occupational hand injuries based on etiologic mechanisms and to analyze the injury patterns resulting from the various mechanisms. Therefore, it is different from previous classification systems because of its particular emphasis on the mechanism of injury.

MATERIALS AND METHODS A retrospective analysis of patients operated between January 2005 and December 2007 in two hand surgery units staffed by a team of hand surgeons was made. These hand surgery units serve as tertiary referral centers for upper extremity injuries, and owing to their proximity to industrial regions of the city, they provide care for a wide spectrum of occupational hand injuries. The patient files were retrospectively 50

examined, and mechanisms causing the injuries were analyzed. Similar mechanisms were classified in the same groups, and the mechanism of injury was matched with type of injury often caused by this mechanism. In the classification of injuries, the tissues that were injured were taken as a basis for classification.

RESULTS During the study period, 4120 upper extremity injuries were seen in the study hospitals, and 2188 (53.1%) of them were occupational injuries. There were 2063 males (94.3%) and 125 females (6.7%). The mean age was 28.2 (range: 15-71) years. The dominant zone for the injury is zone II in the classification based on flexor zones of the hand.

Examination of the agents causing injury yielded 62 agents, including glass, cleaver, rivet, hot press, needle, stair, electricity, and hot water, etc. Further examination of these agents showed that the mechanism by which they caused injury was similar in some agents, and these agents were placed in the same groups, which constituted the Etiologic Classification of Hand Injuries (ECOHI) classification.

These groups of mechanisms were: 1. Cutting-penetrating, 2. Cutting-crushing, 3. Crushing-penetrating, 4. Crushing-compressing, 5. Crushing-burning, 6.

Stinging, 7. Avulsing, 8. Electrical current, and 9.

Chemical injuries and miscellaneous burns (Table 1).

The two most common mechanisms were crushingcompressing and cutting-crushing types, constituting 744 (34.0%) and 514 (23.5%) of injuries, respectively, whereas burn injury was the least common mechanism, causing injury in 11 patients (0.52%). The most common injury type in crushing-compressing mechanism was tendon laceration+vessel and/or nerve injury+fracture (35.1%). The most common type of injury in cutting-crushing type mechanism was tendon lacerations+fracture (33.9%). Burns caused tissue defects (Table 2). Among all patients, the most common type of injury was simultaneous injury of the tendons, nerves, vessels, and bones. This was followed by amputations in 372 patients, and isolated nail bed injuries in 275 patients (Table 3).

DISCUSSION Occupational accidents constitute 6.6%-28.6% of all diseases, and are the leading causes of death or severe disability.[11-13] Cooperation between clinicians, employers, labor organizations, and Ministries of Health is necessary to decrease the incidence of occupational injuries. The execution of most daily and work activities depends on the hand; therefore, it is the most common body part injured in occupational accidents. The hands are involved in 35.3% to 53.1% of occupational injuries.[14,15] Ocak - January 2012

Etiologic classification of occupational hand injuries

Table 1. Etiologic classification of injuries Etiologic classification 1

2

3

4

5

Cutting - Penetrating

Cutting- Crushing

Crushing- Penetrating

Crushing- Compressing

471 21.52%

514 23.49%

353 16.13% Rivet

Snap fastener Drill

Nail Shaping saw

6

7

8

9

Crushing- Penetrating Burning

Avulsion type

Electric Injury

Burns

744 34%

41 1.87%

21 0.89%

19 0.87%

14 0.64%

11 0.52%

Press

Cylinder Wringer

Machine Door-Window

Hot press

Injection Oven lid

Flat iron

Needle

Iron fragment Splinter

Ladder

Ring Elevator

Electricity

Scalding burn (water) Fire burn Chemical burn

Etiologic agents Glass

Metal sheet Tin

Knife Tile Guillotine (Publishing) Mould Scissors Hook

Cleaver

Axe Milling machine

Buzz saw Stone motor Strap-belt pulley

Chain

Sandpaper

Cogwheel

Saw

Propeller

Cable

Spiral saw

Carpenter’s plane Plate sheet cutter Lawnmower

Chopping machine Grinding machine

Hammer Stone Marble Package Timber Seat - chair Packing machine Mill Scanning machine Vise Mold

The nature of hand injuries caused by occupational accidents differs with respect to the developmental level of the country and regional differences in the type of industry within the same country. In a large retrospective analysis involving 37,405 nonfatal occupational accidents, Layne et al.[15] investigated occupational injuries in the United States within a six-month period during 1992, and found that finger and hand injuries were the most common, with a rate of 44.3%. The authors reported that the most common injury types were lacerations and burns, with rates of 39.0% and 17.7%, respectively. According to Birgen et al.,[14] in areas where heavy industry is predominant, the fingers and the hand were injured most commonly (48.6%), yet the most common type of injury was amputation due to industrial machines (38.3%). In our study, the most common mechanisms were crushing-compressing and cutting-crushing types, and the most common injuries were tendon laceration+vessel and/or nerve injury+fracture and tendon laceration+fracture.

In addition to the nature of the work, there are numerous factors that affect the frequency and nature Cilt - Vol. 18 Sayı - No. 1

of accidents, which include low age of the workers, inadequate knowledge of the machine, inadequate experience, and lack of attention.[5,16] Accidents among adolescent workers are common, and their fatality is greater.[17] Absoud and Harrop[18] analyzed 73 patients and found that the underlying cause of the accident was inadequate knowledge of the machine they were operating in 14%. Considering that age and experience are closely related, they should be evaluated together. In our patient group, most injuries occurred in patients aged 25-30 years. The injuries were relatively less common in patients under age 15; however, they were mostly mutilating hand injuries. Patients over 50 years of age often had minor injuries.

Numerous classification and scoring systems have been developed for hand injuries. The most widely known of these are the mutilating hand classification of Campbell Reid,[19] and the Hand Injury Severity Score (HISS) scoring of Campbell and Kay.[10,20] Campbell Reid[19] in his book on ‘mutilated hands’, classified these injuries in five groups as: dorsal injuries, palmar injuries, radial hemi-amputation, ulnar hemi-amputation, and distal amputation. This clas51

Ulus Travma Acil Cerrahi Derg

Table 2. The lesion types and numbers of patients for each injury Group

Lesion

Cutting-penetrating injuries (n=471)

Cutting-crushing injuries (n=514)

Crushing-penetrating injuries (n=353)

Crushing-compressing injuries (n=744)

Crushing-burning injuries (n=41)

Penetrating injuries (n=21)

Avulsion injuries (n=21)

Electric injuries (n=14)

Chemical burns (n=11)

Skin laceration alone Tendon+vessel+nerve injury Amputation Other Tendon laceration+fracture Fracture alone Amputation Other Fracture alone Nail bed injury alone Tendon laceration+fracture Other Tendon+vessel+nerve injury+fracture Amputation Nail bed injury alone Other Fracture+tissue defect Tissue defect alone Compartment syndrome Other Skin laceration alone Nerve injury alone Tissue defect alone Amputation Tissue defect alone Tissue defect alone Amputation Tissue defect alone

Number of patients

%

Zone of injury

184 152 71 64 174 122 93 125 102 81 70 100 261 178 116 189 14 10 8 9 10 9 2 12 7 10 4 11

39.06 32.27 15.07 13.6 33.85 23.73 18.09 24.33 28.89 23.07 19.83 28.21 35.08 23.94 15.59 25.41 34.14 24.89 19.51 21.96 47.64 42.85 9.51 63.15 36.85 71.43 28.57 100

I II II I II II II I III I II II III II I II II III V II II II III II I I II I

* Dominant flexor zone for the injury.

sification is helpful in the determination of treatment strategies. However, it is not quantitative and involves only mutilating hand injuries and anatomic areas.

Based on 100 patients, Campbell and Kay[10] developed a scoring system (HISS) that can be used in injuries distal to the carpal bones, and this is the most widely known severity scoring system. Other scoring

systems used commonly for determining the severity of hand injuries are Tamaiâ&#x20AC;&#x2122;s score[21] and the Quick DASH score.[22] These systems are based on healing and prognosis, and although they are used frequently, there is no widely accepted etiologic classification.

The tic-tac-toe classification is used for the classification of mutilating hand injuries using orientation,

Table 3. Detailed injury types Injury type

Tendon+vessel+nerve injury+fracture Amputation Nail bed injury alone Tendon laceration+fracture Fracture alone Skin laceration alone Tendon+vessel+nerve injury Tendon laceration alone Fracture+tissue defect Tissue defect alone 52

Number of patients

%

381 372 275 266 240 203 146 117 58 45

17.41 17.00 12.56 12.15 10.96 9.27 6.67 5.34 2.65 2.05

Injury type

Compartment syndrome Nerve injury alone Vascular injury alone Tendon+vessel injury Vessel+nerve injury Tendon+nerve injury Vessel+nerve injury+tissue defect Fracture+nerve injury Fracture+nerve injury

Number of patients

%

14 12 11 11 10 9 8 6 4

0.64 0.55 0.5 0.5 0.45 0.41 0.40 0.39 0.37

Ocak - January 2012

Etiologic classification of occupational hand injuries

wound type and zone of injury.[23] This classification separates the etiologic mechanisms according to soft tissue loss, bone loss, combined tissue loss, and vascularized or devascularized tissues; however, because it focuses on mutilating hand injuries, it does not represent a wide spectrum of etiologic factors. The ECOHI classification presented here was developed on the basis of a large series of patients and includes a wide selection of mechanisms.

The International Classification of External Causes of Injuries (ICECI) is a very detailed classification system of external causes.[24] It is useful in epidemiological studies.[25] However, it is too long and detailed to form a common language for the classification of etiologic factors in hand injuries. Also, it is not aimed to classify occupational hand injuries; therefore, it covers all types of injuries, including poisoning, falling, drowning, and even exposure to low gravity. The ECOHI classification proposed in this study is brief and easy to learn and forms a common language between hand surgeons.

There are numerous mechanisms for injury in the workplace. The 2188 patients involved in this study were injured by 62 separate agents. The seven groups of the etiologic classification were developed considering the injury mechanisms of these agents. Agents that have the potential to cause injury, yet were not included in our database, can be added to appropriate groups.

The two most common mechanisms for injury in our ECOHI classification were crushing-compressing and cutting-crushing type injuries, and the two most common injury types were tendon+vessel+nerve+bone injuries and amputations. The ECOHI classification does not give information on the severity or the prognosis of injury, which constitutes one of the weaknesses of the study. This is due to inadequate data regarding the functional outcomes of the patients. Nevertheless, we believe that such a classification is important to form a common language for the classification of etiologic factors.

REFERENCES 1. International Labour Organization, Statistics of occupational injuries. Report III, Sixteenth International Conference of Labour Statisticians. Geneva, 6-15 October 1998. http:// www.ilo.org/public/english/bureau/stat/download/16thicls/ report3.pdf. (Accessed online on 08.11.2010) 2. Hijioka A, Narusawa K, Nakamura T. Risk factors for longterm treatment of whiplash injury in Japan: analysis of 400 cases. Arch Orthop Trauma Surg 2001;121:490-3.

3. Leigh JP, Markowitz SB, Fahs M, Shin C, Landrigan PJ. Occupational injury and illness in the United States. Estimates of costs, morbidity, and mortality. Arch Intern Med 1997;157:1557-68.

4. Altan L, Akin S, Bingöl U, Ozbek S, Yurtkuran M. The progCilt - Vol. 18 Sayı - No. 1

nostic value of the Hand Injury Severity Score in industrial hand injuries. Ulus Travma Acil Cerrahi Derg 2004;10:97101.

5. Tan KK, Fishwick NG, Dickson WA, Sykes PJ. Does training reduce the incidence of industrial hand injuries? J Hand Surg Br 1991;16:323-6.

6. Santana VS, Araújo-Filho JB, Albuquerque-Oliveira PR, Barbosa-Branco A. Occupational accidents: social insurance costs and work days lost. [Article in Portuguese] Rev Saude Publica 2006;40:1004-12.

7. Nelson NA, Park RM, Silverstein MA, Mirer FE. Cumulative trauma disorders of the hand and wrist in the auto industry. Am J Public Health 1992;82:1550-2.

8. Matsuzaki H, Narisawa H, Miwa H, Toishi S. Predicting functional recovery and return to work after mutilating hand injuries: usefulness of Campbell’s Hand Injury Severity Score. J Hand Surg Am 2009;34:880-5.

9. Yokoyama K, Itoman M, Nakamura K, Uchino M, Nitta H, Kojima Y. New scoring system predicting the occurrence of deep infection in open upper and lower extremity fractures: efficacy in retrospective re-scoring. Arch Orthop Trauma Surg 2009;129:469-74.

10. Campbell DA, Kay SP. The Hand Injury Severity Scoring System. J Hand Surg Br 1996;21:295-8.

11. Dias JJ, Garcia-Elias M. Hand injury costs. Injury 2006;37:1071-7.

12. Mathur N, Sharma KK. Medico-economic implications of industrial hand injuries in India. J Hand Surg Br 1988;13:3257.

13. Chan JC, Ong JC, Avalos G, Regan PJ, McCann J, Groarke A, et al. Illness representations in patients with hand injury. J Plast Reconstr Aesthet Surg 2009;62:927-32.

14. Birgen N, Yavuz MS, Okyay M. The medico-legal evaluation of occupational injuries. [Article in Turkish] J Forensic Medicine 2001;15:14-8.

15. Layne LA, Castillo DN, Stout N, Cutlip P. Adolescent occupational injuries requiring hospital emergency department treatment: a nationally representative sample. Am J Public Health 1994;84:657-60.

16. Ünlü RE, Abacı Ünlü E, Orbay H, Şensöz Ö, Ortak T. Crush injuries of the hand. Ulus Travma Acil Cerrahi Derg 2005;11:324-8.

17. Castillo DN, Landen DD, Layne LA. Occupational injury deaths of 16- and 17-year-olds in the United States. Am J Public Health 1994;84:646-9.

18. Absoud EM, Harrop SN. Hand injuries at work. J Hand Surg Br 1984;9:211-5.

19. Campbell Reid DA. Severely mutilated hand. In: Campbell Reid DA, Tubiana R, editors. Mutilating injuries of the hand.

London: Churchil Livingstone, Longman Group Ltd; 1979. p. 3-14.

20. van der Molen AB, Matloub HS, Dzwierzynski W, Sanger JR. The hand injury severity scoring system and workers’ compensation cases in Wisconsin, USA. J Hand Surg Br 1999;24:184-6.

21. Tamai S. Twenty years’ experience of limb replantation-review of 293 upper extremity replants. J Hand Surg Am 1982;7:549-56.

22. Imaeda T, Toh S, Wada T, Uchiyama S, Okinaga S, Kusunose K, et al. Validation of the Japanese Society for Surgery of the 53

Ulus Travma Acil Cerrahi Derg

Hand Version of the Quick Disability of the Arm, Shoulder, and Hand (QuickDASH-JSSH) questionnaire. J Orthop Sci 2006;11:248-53.

23. Weinzweig J, Weinzweig N. The “Tic-Tac-Toe” classification system for mutilating injuries of the hand. Plast Reconstr Surg 1997;100:1200-11.

54

24. http://www.rivm.nl/who-fic/ICECI/ICECI 1-2 2004 July.pdf.

(Accessed at 28.09.09).

25. Davas Aksan A, Durusoy R, Ada S, Kayalar M, Aksu F, Bal E. Epidemiology of injuries treated at a hand and microsurgery hospital. Acta Orthop Traumatol Turc 2010;44:35260.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):55-60

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.01212

Upper extremity injuries due to threshing machine Harman dövme makinesine bağlı üst ekstremite yaralanmaları Dağhan IŞIK,1 M. Fethi CEYLAN,2 Hakan TEKİN,1 Sevdegül KARADAŞ,3 Savaş GÜNER,2 Yasin CANBAZ1

BACKGROUND

AMAÇ

The aim of this study was to report the patients who were admitted to our hospital with upper extremity injuries due to threshing machine, to determine the most appropriate classification, to estimate the treatment modalities, and to discuss the prevention methods.

Bu çalışmanın amacı, hastanemize başvuran harman dövme makinesine bağlı üst ekstremite yaralanması bulunan hastaları sunmak, en uygun sınıflandırmayı belirlemek, tedavi seçeneklerini değerlendirmek ve korunma yollarını tartışmaktır.

METHODS

GEREÇ VE YÖNTEM

Twenty-five patients who had suffered injuries sustained by a threshing machine were retrospectively investigated.

The patients were analyzed with respect to age, gender, admission month, hospitalization period, the type of injured tissue, and the treatment modality.

Harman dövme makinesine bağlı yaralanması olan 25 hasta geriye dönük olarak incelendi. Hastaların yaşları, cinsiyetleri, başvuru ayları, hastanede kalma süreleri, yaralanan dokuların çeşidi ve uygulanan tedaviler açısından analiz edildi.

RESULTS

BULGULAR

Twenty-four of the patients were male and one was female, and the mean age of the patients was 19.4 (2-51) years; 60% of the patients were under the age of 15. The patients were admitted most commonly in the month of August.

Hastaların 24’ü erkek 1’i kadın ve yaş ortalamaları 19,4 (dağılım, 2-51 yaş) idi. Hastaların %60’ı 15 yaşın altındaydı. Hastalar en çok Ağustos ayında başvuru yaptılar.

CONCLUSION

Tarım makinelerinin yaralanmaya sebep olan dönen parçalarının korunaklarla saklanmasının, tarım ile uğraşan ailelerin sağlık çalışanları tarafından bilgilendirilmelerinin, çocukların tarım makinelerinin olduğu bölgelere girmelerinin yasaklanmasının, tarım sektörünün geliştiği bölgelerdeki okullarda çocuklara tarım kazaları ve önleme yolları hakkında bilgi verilmesinin, yılın en sıcak olduğu aylarda tarım çalışanlarının mesai saatlerinde ayarlamalar yapılmasının tarım makinelerine bağlı kazaların önlenmesinde faydalı olacağı kanaatindeyiz.

We believe that shielding the rotating components of farming machinery that cause injuries, informing and educating farming families (by physicians), forbidding the entrance of children to areas with agricultural machines, providing information to children in schools (in those regions with developing agriculture) about agricultural accidents and their prevention methods, and adjusting the working hours of farming personnel, especially in the hottest months of the year, may be beneficial in preventing accidents due to farming machinery.

SONUÇ

Key Words: Agricultural workers; agricultural worker's disease; amputation; hand injuries; classification.

Anahtar Sözcükler: Tarım işçileri; tarım işçileri hastalıkları; amputasyon; el yaralanmaları; sınıflandırma.

Departments of 1Plastic and Reconstructive Surgery, 2Orthopedics and Traumatology, 3Emergency Medicine, Yuzuncu Yil University, Faculty of Medicine, Van, Turkey.

Yüzüncü Yıl Üniversitesi, Tıp Fakültesi, 1Plastik ve Rekonstrüktif Cerrahi Anabilim Dalı, 2Ortopedi ve Travmatoloji Anabilim Dalı, 3 Acil Tıp Anabilim Dalı, Van.

Correspondence (İletişim): Dağhan Işık, M.D. Yüzüncü Yıl Üniversitesi Tıp Fakültesi, Araştırma Hastanesi, Plastik Cerrahi, Maraş Cad., 65100 Van, Turkey.

Tel: +90 - 432 - 215 04 71 (6535) e-mail (e-posta): daghanmd@yahoo.co.uk

55

Ulus Travma Acil Cerrahi Derg

It is seen that there has been an increase in the type and number of farming machines to increase the productivity in the farming sector. In England, the rate of accidents in the farming sector is more than that in the many other industrial fields.[1] In the United States, in 1992, $4.57 billion was spent for farming accidents.[2] One of the farming machines used to increase productivity, especially in cereal agriculture, is the threshing machine. The thresher is a device pulled and powered by a tractor that separates the hay and chaff from wheat or grain (Fig. 1). When the time for collecting the product emerges, thresher and other agricultural machine accidents that commonly result in injuries to the upper extremities begin to be seen.

In this report, we discuss the classification of 25 patients with threshing machine injury who were retrospectively analyzed and their treatments, together with the related literature.

MATERIALS AND METHODS Twenty-five patients ranging in age from 2 to 51 (mean: 19.4) years, whose upper extremities were injured by a threshing machine between January 2007 - December 2009, were retrospectively analyzed with regard to their injured regions and treatment modalities. The patients were divided into six groups for classification according to their injury type as follows: 1st degree: Patients with only soft tissue injury (5 patients); 2nd degree: Patients with tendon damage with/ without first-degree injury (2 patients); 3rd degree: Patients with bone fracture with/without second-degree injury (3 patients); 4th degree: Patients with vascular/ neural damage with/without third-degree injury (3 patients); 5th degree: Patients with amputation in the finger region (10 patients); and 6th degree: Patients with amputation of the hand or more proximal regions (2 patients) (Table 1).

RESULTS The number of patients in each injury group is given in Table 1. One of the patients was female, while the remaining 24 were male. Fifteen of the patients were children (under 15 years of age) and 10 were adults (Table 2). The mean hospitalization time of the patients was 4.0 (1-26 days) days. The most commonly

Fig. 1. The threshing machine. The arrows indicate the parts of the machinery responsible for injuries.

Fig. 2. The scheme showing amputation levels (total and subtotal) in the hands of the patients with 5th degree injury.

(Color figures can be viewed in the online issue, which is available at www.tjtes.org)

observed injury was the 5th degree injury and the most commonly affected fingers in this group were the third and fourth fingers (Fig. 2). While 14 of the patients had left upper extremity injury (Fig. 3), 10 had right upper extremity injury (Fig. 4), and 1 had bilateral upper extremity injuries. The injuries were most commonly observed in August (Table 3). Fifteen of the accidents due to threshing machine occurred in 2009, while 7 occurred in 2008, and 3 in 2007 (Table 4).

Table 1. Classification and treatment algorithm for threshing machine injuries Injury/Number of pts Injured tissue

Treatment modalities

1st degree / 5 patients 2nd degree / 2 patients 3rd degree / 3 patients 4th degree / 3 patients 5th degree /10 patients 6th degree / 2 patients

PS, covering with skin grafting or flap TR ± repair of 1st degree injury Bone fixation (ORIF, KW) ± repair of 2nd degree injury VR / NR ± repair of 3rd degree injury SR (PR, with LF or grafting), revascularization, re-implantation Vessel ligation and SR (PR, with LF or grafting), re-implantation

Patients with only soft tissue injury Patients with tendon injury ± 1st degree injury Patients with bone fracture ± 2nd degree injury Patients with vascular / neural injury ± 3rd degree injury Patients with amputations on fingers Patients with amputations of the hand or more proximal part

ORIF: Open reduction internal fixation; KW: K-wire; VR: Vein repair; NR: Nerve repair; AR: Arterial repair; TR: Tendon repair; PR: Primary repair; SR: Stump repair; PS: Primary saturation; LF: Local flap.

56

Ocak - January 2012

Upper extremity injuries due to threshing machine

(a)

(b)

(c)

Fig. 3. Appearance of Case 22 preoperatively (a), after the first operation (paraumbilical flap application) (b), and at the 3rd postoperative week (c).

(Color figures can be viewed in the online issue, which is available at www.tjtes.org)

DISCUSSION Technologies used to increase productivity in agriculture require the intense use of farming machines.

Increase in the numbers and diversities of agricultural enterprises bring about work accidents. In the

literature, injuries due to farming machines including corn-picker,[3-6] wheat thresher,[7] grain auger,[8-10] or hay baler[11] have been reported. These accidents in agricultural enterprises result in income loss, production loss, material defects in devices, and high ex-

Table 2. Demographic features, injury type and applied treatment modalities in patients with hand injury due to threshing machine No Age/Sex Injury type 1

2

3

4

5 6 7

8 9 10

11 12 13 14 15 16 17

18 19 20

21 22

23

24

25

28/M

13/M

18/M

44/M

5/M 7/M 31/M

4/M 12/M 6/M

26/F 15/M 51/M 14/M 18/M 2/M 4/M

36/M 36/M 4/M

3/M 4/M

46/M

45/M

14/M

Applied treatment

Degree

Subtotal amputation from the DIP joint of 3rd finger and IP joint of 1st finger of the left hand, KW and TR (1st finger), severed digital nerve and artery in 3rd finger (no circulation in the 3rd finger) AR, NR, PS (3rd finger) Abrasion of the left handâ&#x20AC;&#x2122;s 2nd-3rd-4th-5th fingers with deep cut in MCP joint of the 2nd and Revascularization, NR, PS 5th fingers, severed nerve and artery, no circulation in the 5th finger

Subtotal amputation at the DIP joint of the right hand 3rd and 4th fingers, severed tendon V-Y advancement flap and

repair with pullout Total amputation from the distal phalanx of the 2nd finger of the left hand Stump repair with V-Y

advancement flap Near total amputation from the distal part of the 4th finger of the right hand Use of amputate as graft Subtotal amputation from the proximal part of the nail bed of the 3rd and 4th fingers on the left hand Repair with primary saturation Abrasion on the posterior of the right arm Left for secondary repair with

dressing Separation and cut in the epiphysis of the IP joint of the left handâ&#x20AC;&#x2122;s first finger, severed digital nerve Suturation and placing in splint, NR Total amputation in a crushing manner, from the DIP joint on the 3rd finger of the left hand SR with V-Y advancement flap Partially severed extensor tendon on the 3rd and totally severed tendon on the 4th and 5th fingers of TR, KW the right hand, fracture of the carpal bones

Total amputation from IP joint of right hand thumb; Degloving in proximal phalanx Reparation with para-umbilical flap Total amputation from the nail bed of the 3rd and 4th fingers of the right hand SR with V-Y advancement flap Subtotal amputation at zone 1 of the 3rd and 4th fingers PS, KW (4th finger), LF (3rd finger) Distal end defect on the DIP joint of the 3rd finger and volar part of the 4th finger of the right hand FTSG (3rd finger), PS (4th finger) Total amputation from the proximal of the distal phalanx of the 4th finger on the left hand SR Cut on the volar part of the distal phalanx of the 5th finger of the left hand PS Amputation from the metacarpal bone of the 2nd finger of the left hand, comminuted fracture of AR, NR, TR, KW the metacarpal of the 3rd finger, fracture of the distal phalanx of the 4th finger

Amputation from the mid part of the middle phalanx of the 2nd finger of the right hand SR Tissue defect on the pulp of the 5th finger of the left hand Left for secondary repair Cut on the distal phalanx of the 2nd finger of the right hand, subtotal amputation from PS (2nd finger), TR and PS (3rd finger) the distal phalanx of the 3rd finger, FDP cut on the 2nd finger Total amputation of the left hand 3rd and 4th fingers from the beginning of the nail bed SR De-gloving amputation of the left hand first finger from the MCP joint, fracture of Phalanx stabilization, the proximal phalanx Para-umbilical flap Metacarpal fracture of the left hand 1st and 2nd fingers, radius open fracture, Dorsal interosseous flap for tissue defect on dorsal forearm tissue defect Bilaterally amputation over the elbow. Left arm was amputated from the level of SR deltoid insertion on proximal 1/3 and right arm was amputated from distal 1/3 level Amputation from right elbow SR

4 4 2 5 5 1 1 4 5 3 5 5 3 1 5 1 5 5 1 2 5 5 3 6 6

KW: K-wire; NR: Nerve repair; AR: Arterial repair; TR: Tendon repair; PR: Primary repair; SR: Stump repair; PS: Primary saturation; LF: Local flap; FDP: Flexor digitorum profundus; FTSG: Full-thickness skin graft.

Cilt - Vol. 18 SayÄą - No. 1

57

Ulus Travma Acil Cerrahi Derg

(a)

(b)

Fig. 4. Preoperative (a) and postoperative (b) appearance of Case 11.

(Color figures can be viewed in the online issue, which is available at www.tjtes.org)

penditures due to physical disabilities.[2,12] In 1954, Maxim et al. used the term “corn-picker hand” for the hand injures due to corn-picker. In the 1950’s, when debridement and stump closing were generally performed for corn-picker injuries, the term “corn-picker hand” seemed to be appropriate for patients who lost a few fingers in a similar way.

Nowadays,����������������������������������������� we have at our disposal many reconstructive weapons that provide the opportunity to not accept defeat easily. Nevertheless, since the infection rates in injuries with farming devices are high[3] and given the presence of amputations that are not appropriate for micro-surgery,[4] the number of cases that result in limb and severe functional loss is not low. In the literature, despite the fact that some manuscripts have reported that all re-implanted cases of amputations due to farming machines have failed,[4] some reports have suggested that a number of cases could be saved with micro-surgery.[9] Revascularization was attempted in only two of the reported 25 cases in this manuscript and these were successful. Other patients [6]

with amputation were injured in such a way that was not appropriate for re-implantation. In two cases amputated from the proximal wrist, since the amputated part of the extremity was smashed, re-implantation was not possible. The causes of upper extremity injuries due to farming machines include handling the engine belt of farming machines accidentally,[13] or trying to unclog the wheat thresher or corn-pickers manually, which can become plugged with wheat or wet corn stalks.[4] As a result of these injuries, lacerations, crushing, avulsion and friction burns, de-gloving, direct amputation or digital devascularization, and severe mutilations and later severe functional losses can be observed.[3,4,6,14] Although there are a few articles in the literature about the classification of upper extremity injuries due to farming machines, since the present classifications do not cover all cases and an appropriate treatment algorithm cannot be created as a result of these classifications, new classifications are still necessary.[4,6,11,13] Maxim et al.[6] reported three types of severe hand in-

Table 3. Admission month and degree of trauma among patients Months April May June July August September Total

1st degree

2nd degree

3rd degree

4th degree

5th degree

6th degree

Total

2

3

5

1

1

2

3

3

1 1

1 3

3

1 4 2 10

2 2

1 3 3 2 11 5 25

Table 4. Admission year and degree of trauma among patients

58

Years

1st degree

2nd degree

3rd degree

4th degree

5th degree

6th degree

Total

2007 2008 2009 Total

1 2 2 5

1 1

2

3 3

1

2 3

4 6 10

2 2

3 7 15 25 Ocak - January 2012

Upper extremity injuries due to threshing machine

juries due to corn-picker accidents in their study reported in 1954. Type 1 included the injuries in which the thumb was preserved but the other fingers were lost; type 2 included the injuries in which all fingers including the thumb were lost; and type 3 included the injuries in which one or more fingers were lost in the radial aspect of the hand together with the thumb. On the other hand, Gorsche and Wood[4] used the classification of Maxim et al. in their study in 1988; however, since they had patients in types 1 and 2 groups but did not have any patients in the type 3 group, they revised type 3 to indicate hand injury in which the thumb and at least one finger were preserved but the other fingers were amputated. Both of these classifications only included multiple hand injuries and did not cover other injury types. Alternatively, Ozyurekoglu et al.[11] classified 21 cases with injuries due to hay baler as group 1: single digit injury; group 2: viable hand with limited tissue injury or loss; group 3: viable hand with extensive��������������������������������������������� tissue loss; group 4: amputation or devascularization with limited tissue injury or loss; and group 5: amputation or devascularization with extensive tissue loss. In this type of classification, there were no data about the involved tissue in the injury (bones, tendons, nerves, vessels, etc). In 2004, Terzioglu et al.[13] suggested classifying the hand injuries due to farming machines as 1st degree: soft tissue injury; 2nd degree: degree 1 + tendinous injury; 3rd degree: degree 2 + bony injury; 4th degree: degree 3 + vascular and nerve injury; and 5th degree: amputation. In our opinion, the most appropriate classification among the reported classifications on this topic seems to be the classification of Terzioglu et al. However, this classification does not cover all cases. For example, a case with only bone fracture and soft tissue injury without tendon damage cannot be classified according to this classification (Case 23 in the current study). Furthermore, a patient with a distal phalanx amputation would be evaluated in the same category as a patient with hand or arm amputations. The classification suggested in this manuscript is a modified version of the classification of Terzioglu.

The time for product collection in our region is between the second half of April and September. Momcilovic et al.[5] reported that farm machine injuries were more commonly seen in the month of October.

On the other hand, while Terzioglu et al. described that these injuries peaked in the months of July and August,[13] Ozyurekoglu et al.[11] reported this peak in the month of June. In our study, threshing machine injuries were most commonly observed in the month of August. This may be attributed to the fact that the highest air temperature felt in this region was in the month of August. There are a number of articles in the literature about the negative effects of the hot environment on the workers.[15-17] Working under conditions of Cilt - Vol. 18 Sayı - No. 1

thermal stress has associated risks and consequences.

Impairment of mental function and increased fatigue have implications for workplace safety. In a retrospective evaluation of the cases, it was observed that 60% (15/25) of cases were admitted in the last year.

This may be attributed to the more widespread use of farming machinery in agriculture. A special age group at risk for injuries due to farming machines is children.[12] Ninety percent of agricultural injuries were reported to be seen in the childhood period.[18] In the reported case series here, 60% (15/25) of the patients were aged 15 years or younger. In particular, children living on farms or children staying with their parents while they are working can be easily injured by farming machines.

It is clear that preventing hand injuries due to agricultural machines is more beneficial than developing new treatment modalities for these injuries. Grogono et al.[10] reported that for grain auger injuries, the part of the machine that caused the accidents most commonly could be kept under a protective shield. On the other hand, Ozgenel et al.[19] stated that informing the farming families (by physicians), providing communication via the media and government agencies, and shielding the rotating components of agricultural machines can be effective.

In conclusion, forbidding the entrance of children to areas with agricultural machines, informing children in schools (in those regions with developing agriculture) about agricultural accidents and their prevention methods, and adjusting the working hours of farming personnel, especially in the hottest months of the year, may be beneficial in preventing accidents due to farming machines.

REFERENCES 1. Solomon C. Accidental injuries in agriculture in the UK. Occup Med (Lond) 2002;52:461-6.

2. Leigh JP, McCurdy SA, Schenker MB. Costs of occupational injuries in agriculture. Public Health Rep 2001;116:235-48.

3. Melvin PM. Corn picker injuries of the hand. Arch Surg 1972;104:26-9.

4. Gorsche TS, Wood MB. Mutilating corn-picker injuries of the hand. J Hand Surg Am 1988;13:423-7.

5. Momcilović D, Prokes B, Janjić Z. Mechanical cornpicker hand injuries. Med Pregl 2005;58:479-82.

6. Maxim ES, Webster FS, Willander DA. The cornpicker hand.

J Bone Joint Surg Am 1954;36:21-9.

7. Chari PS, Kharshiing W, Balakrishnan C. Wheat thresher hand injuries. Indian J Med Res 1975;63:829-32.

8. Hansen RH. Major injuries due to agricultural machinery.

Ann Plast Surg 1986;17:59-64.

9. Beatty ME, Zook EG, Russell RC, Kinkead LR. Grain auger injuries: the replacement of the corn picker injury? Plast Reconstr Surg 1982;69:96-102.

10. Grogono BJ. Auger injuries. Injury 1973;4:247-57.

11. Ozyürekoğlu T, Napolitano M, Kleinert JM. Hay baler inju59

Ulus Travma Acil Cerrahi Derg

ries to the upper extremity. J Trauma 2007;63:62-9.

12. Angoules AG, Lindner T, Vrentzos G, Papakostidis C, Giannoudis PV. Prevalence and current concepts of management of farmyard injuries. Injury 2007;38:S27-34.

13. Terzioglu A, Aslan G, Ates L. Injuries to childrenâ&#x20AC;&#x2122;s hands caused by the engine belts of agricultural machines: classification and treatment. Scand J Plast Reconstr Surg Hand Surg 2004;38:297-300.

14. Bruner JM. Corn picker injuries of the hand. Plast Reconstr Surg Transplant Bull 1958;21:306-14.

15. Tanaka M. Heat stress standard for hot work environments in Japan. Ind Health 2007;45:85-90.

60

16. Nag PK, Nag A, Ashtekar SP. Thermal limits of men in moderate to heavy work in tropical farming. Ind Health 2007;45:107-17.

17. Miller VS, Bates GP. The thermal work limit is a simple reliable heat index for the protection of workers in thermally stressful environments. Ann Occup Hyg 2007;51:553-61.

18. Hartling L, Brison RJ, Crumley ET, Klassen TP, Pickett W. A systematic review of interventions to prevent childhood farm injuries. Pediatrics 2004;114:483-96.

19. Ozgenel GY, Akin S, Ozbek S, Kahveci R, Ozcan M. Severe hand injuries in children related to farm tractors: a report of 70 cases. Ulus Travma Acil Cerrahi Derg 2008;14:299-302.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):61-64

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.54775

Falling television related child injuries in Turkey: 10-year experience Türkiye’de televizyon düşmesi nedeni ile gelişen çocuk yaralanmaları: 10 yıllık deneyim Recep GÜLOĞLU,1 İnanç Şamil SARICI,1 Süleyman BADEMLER,1 Selman EMİRİKÇİ,1 Halim İŞSEVER,2 Hakan YANAR,1 Cemalettin ERTEKİN1 BACKGROUND

AMAÇ

METHODS

GEREÇ VE YÖNTEM

RESULTS

BULGULAR

CONCLUSION

Injuries related to TV falls can lead to significant morbidity and mortality in children. As they are preventable injuries, restricted activity and improved supervision of children around the TV can potentially lead to fewer incidences.

Televizyon düşmeleri ile ilgili yaralanmalar çocuklarda ciddi morbidite ve mortaliteye yol açabilir. Bunlar önlenebilir yaralanmalardır. Çocukların televizyon etrafındaki hareketleri kısıtlanmalı ve çocuklar mutlaka iyi denetlenmelidir.

Key Words: Children; furniture type; pediatric Glasgow coma scale; pediatric trauma score; television; injury.

Anahtar Sözcükler: Çocuk; mobilya tipi; pediatrik Glaskow koma skalası; pediatrik travma skoru; televizyon; yaralanma.

Presented at the 8th Congress of National Trauma and Emergency Surgery (September 14-18, 2011, Antalya, Turkey).

8. Ulusal Travma ve Acil Cerrahi Kongresi’nde sunulmuştur (14-18 Eylül 2011, Antalya).

Departments of 1General Surgery, Trauma and Emergency Surgery Service, 2 Public Health, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey.

İstanbul Üniversitesi İstanbul Tıp Fakültesi, 1Genel Cerrahi Anabilim Dalı, Travma ve Acil Cerrahi Servisi, 2Halk Sağlığı Anabilim Dalı, İstanbul.

We reviewed retrospectively TV-related injuries to determine the risk factors, type of injuries, and operative intervention(s) required in children injured by falling TVs. This was a retrospective descriptive study conducted on 42 pediatric patients who were admitted to Istanbul University, Istanbul Medical Faculty, Emergency Surgery Department.

Case notes included all demographic and injury details, TV and TV-related furniture type, mechanism of injury, Pediatric Trauma Score (PTS), Pediatric Glasgow Coma Scale (PGCS), length of hospital stay, need for intensive care unit assessments, and management plans.

More than 65% of the children were aged 1 to 3 years. The injury rate was higher for boys (66.7%) than girls (33.3%).

Of the 42 patients identified, 17 (40.5%) sustained only head injuries, with almost half of these having a definite traumatic brain injury; 6 (14.3%) had only thoracic injury, and 4 (9.5%) had only limb injury. The PGCS ranged from 3 to 15, with a mean of 7. The PTS ranged from -6 to 12, with a mean of 9.

Five children (11.9%), all aged 2 years or younger, died in the hospital as a result of the TV-related injury, all sustaining head and thorax injuries, which are reflected in a significantly lower PTS and lower PGCS on admission compared with older children. TV falls on to children often occur because of unstable supports, with dressers and shelves being the most common. The most common mechanism of injury (71.4%) among all age groups was fall/tipping of furniture. Pulling the furniture onto oneself (19%) was the second most frequent mechanism of injury.

Bu çalışmada, üzerine televizyon (TV) düşmesi sebebiyle yaralanan çocukların risk faktörleri, yaralanma çeşitleri ve cerrahi girişimler geriye dönük olarak incelendi.

Bu çalışmaya İstanbul Üniversitesi, İstanbul Tıp Fakültesi, Travma ve Acil Cerrahi Birimine başvuran 42 çocuk hasta dahil edildi. Olguların tümünde demografik ve yaralanma detayları, televizyon tipleri, mobilya türü, yaralanmanın mekanizması, pediatrik travma skoru (PTS), pediatrik Glaskow koma skalası (PGKS), hastanede kalış süresi, yoğun bakım ünitesi değerlendirmesinin gerekliliği ve tedavi planları incelendi. Çocukların %65’inden fazlası 1 ile 3 yaş arasında idi. Yaralanma erkeklerde (%66,7), kızlara (%33,3) oranla daha fazla idi. Kırk iki hastanın 17’sinde (%40,5) sadece kafa travması mevcuttu, bunların yaklaşık olarak yarısında travmatik beyin hasarı görüldü. Altı hastada sadece toraks travması (%14,3) ve dört hastada ise (%9,5) sadece ekstremite travması saptandı. Ortalama PGKS 7 (3-15) ve ortalama PTS 9 (-6 ve 12) idi. TV düşmesi sonucu beş çocuk hayatını kaybetti, bunların hepsi iki yaş ve altında idi ve hepsinde kafa ve toraks travması bulunmaktaydı. Bu çocukların başvuru anındaki PTS ve PGKS skorları daha büyük çocuklara oranla daha düşüktü. TV düşmesi sonucu yaralanmaların en sık nedeni uygun olmayan sabitleyicilerdir. Büfeler ve raflarda bu sorun daha sıktır (%71,4), en sık yaralanma mekanizmaları ise mobilyanın üzerine düşmesi veya çocuğun mobilyayı kendi üzerine doğru çekmesidir (%19).

SONUÇ

Correspondence (İletişim): İnanç Şamil Sarıcı, M.D. Tercüman Sitesi Konutları, A-6 Blok Da: 54, Zeytinburnu, İstanbul, Turkey.

Tel: +090 - 212 - 416 34 98 e-mail (e-posta): isamilsarici@hotmail.com

61

Ulus Travma Acil Cerrahi Derg

Trauma is responsible for a significant number of childhood deaths, with a high percentage of injuries occurring within the home environment.[1,2] Television (TV) falls are a significant cause of morbidity and mortality in pediatric patients, most frequently among those between 0 and 5 years of age, and tend to result in head, thoracic and extremity injuries.[3,4] There are few studies documenting this relatively unknown problem in the pediatric literature.[5] The rising number and nature of pediatric injuries secondary to falling TV sets correlate with the increasing number of home TVs sold per year.[3] We reviewed retrospectively TV-related injuries to determine the risk factors, spectrum of injuries, and operative intervention(s) required in children injured by falling TVs. This article represents the first study to be conducted in Turkey about injuries among children due to falling TVs.

MATERIALS AND METHODS This was a retrospective descriptive study conducted among 42 pediatric patients who were admitted to Istanbul University, Istanbul Medical Faculty, Emergency Surgery Department with a TV fall injury between January 2001 and December 2010. All children were under the age of 9 years. Information gathered from the registry and case notes included all demographic and injury details, TV types, furniture type, mechanism of injury, Pediatric Trauma Score (PTS), Pediatric Glasgow Coma Scale (PGCS), length of hospital stay, need for intensive care unit (ICU) assessments, and management plans. Analyses of injury and hospitalization data were performed on selected age groups, based on consideration of developmental skills that might be involved in this type of injury. The children were grouped as follows: <1 year, 1-3 years, and ≥3 years. Patients underwent a physical examination, and complete blood count, biochemical analysis, abdominal X-ray, abdominal ultrasonography, and cranial, thoracic and abdominal computerized tomography (CT) were performed. All patients were consulted with orthopedics, neurosurgery and pediatrics.

Statistical Analysis The Statistical Package for the Social Sciences (SPSS) 16.0 (SPSS Inc, Chicago, IL) program was Table 1. TV injuries according to gender and age groups

Age groups <1 year 1-3 years ≥3 years Total 62

Gender

Significance

Male Female Total 5 19 4 28

9 5 14

5 28 9 42

X2=4.51 p=0.10

used for the statistical analysis. The results regarding continuous variables were given as the mean and standard deviation, while results regarding discrete data were given as frequency and percentage. According to gender and age, varying types and the results were compared with chi-square. Statistical significance was considered to be two-way and with a p value <0.05.

RESULTS The patients who were injured by TV falls and admitted to our hospital ranged in age from 0 to 9 years, with a mean age of 2.1 years. More than 65% of the children were in the 1-3 years range, and the rate of injury was higher among boys (66.7%) than girls (33.3%) (Table 1). The majority of injuries sustained by children involved trauma to the head, thorax and abdomen and extremity fractures. Of the 42 patients identified, 17 (40.5%) had sustained only head injuries, with almost half of these having a definite traumatic brain injury; 6 (14.3%) had only thoracic injury, and 4 (9.5%) had only limb injury. Three (7.1%) patients had head and thoracic injury, and 2 (4.8%) had head and limb injury (Table 2). The PGCS ranged from 3 to 15, with a mean of 7. The PTS ranged from -6 to 12, with a mean of 9. Five (11.9%) children, all aged 2 years or younger, died in the hospital as a result of TV-related injury (Table 3), all sustaining head and thorax injuries, which are reflected in a significantly lower PTS and lower PGCS on admission compared with older children. The mean length of hospital stay was 2.3 days. Sixteen (38.1%) patients were admitted to the ICU. The mean length of stay in the ICU was 16.2 days. Children aged 1-3 years were observed to have the longest overall hospital stay. Twelve (28.6%) patients required surgery, and all of them were younger than 6 years. Five patients underwent neurosurgical procedures - 2 had thoracic surgery and 3 had abdominal operations. Orthopedic stabilization was required in 5 patients aged 4-6 years. Plastic surgery was needed for 3 patients, all over 7 years of age. All TV-related injuries were sustained in the child’s own home, with the exception of one that occurred at a relative’s house.

However, 95.2% of the events were not witnessed by a caregiver at the time of the incident. The caregiver was either the mother (32 patients), father (9 patients) or a relative (1 patient). The most common TV size was 22 inches (24 patients), but sizes ranged from 15.4 inches (10 patients) to 27 inches (8 patients).

The average height of the fall was 1.2 meters (range: 0.8 to 3 meters). A trend toward an increased number of liquid crystal display (LCD) TV-related injuries during the study period was observed, especially after 2004. TV falls occurred often because of unstable supports. The type of furniture was grouped into 6 categories (Fig. 1), with dressers and shelves being the most common. The mechanism of injury was Ocak - January 2012

Falling television related child injuries in Turkey

Table 2. TV injuries according to age groups and injury area Age groups

Thorax

Extremity

Head+Thorax+Abdomen+Pelvis

Head

Abdomen

Total

Significance

1 5 1 7

1 3 – 4

– 6 2 8

1 11 5 17

2 3 1 6

5 28 9 42

X2=6.44 p=0.59

< 1 year 1-3 years ≥ 3 years Total

Table 3. Age groups and mortality

Mortality

Age groups <1 year 1-3 years ≥3 years Total

Significance

Yes

No

Total

0 5 0 5

5 23 9 37

5 28 9 42

X2=2.83 p=0.10

grouped into 4 categories as: (1) falling/tipping over, (2) pulling onto self, (3) climbing furniture, and (4) unknown. The most common (71.4%) mechanism of injury among all age groups was falling/tipping over of furniture, followed by pulling the furniture onto oneself (19%).

DISCUSSION Today, the TV has become an integral part of every household around which most family activity is centered. This popular electronic item is a relatively unknown in-home hazard, and a small number of previous studies have documented TV falls as a significant cause of morbidity and death in younger pediatric patients.[3-5] Previous studies suggest that the incidence of these types of injuries may be on the rise.

[4,6] DiScala et al.[4] reported 183 injured children from the National Pediatric Trauma Registry over a 10-year period, and Scheidler et al.[3] reported 43 cases over 10 years from the Pennsylvania Trauma Outcome Study.

The overall consensus is that, although most injuries are mild, the potential for serious harm exists, as re25 No. of accidents

20 15 10 5

er w ra D

ck Ra

lf /S he le

in

et

Ta b

Ca b

St a TV

D

re

ss

er

nd

0

Fig. 1. Type of furniture as grouped into 6 categories.

Cilt - Vol. 18 Sayı - No. 1

flected by the number of ICU admissions and deaths.

[3-6] In this study, a total of 42 pediatric injuries by TV fall occurred during the 10-year period, and the mortality rate was 11.9% (5/42).

In the previous literature, head injuries were the most common form of injury and cause of death in pediatric trauma patients.[3,4] The results of this study are similar to previous reports of TV-related injuries being highest among children aged 1-3 years, with a higher proportion of head injuries. It is unlikely that children under 1 year of age can pull the TV onto themselves; it is more likely that the child bumps into the TV stand, causing the TV to fall onto the child. The first body part hit by the falling TV is likely to be the head due to the child’s height in relation to the height of the stand.

Moreover, toddlers sustained a high number of concomitant abdominal injuries.[7] Thus, a thorough abdominal evaluation is required in a child injured by a fallen TV to identify occult injuries. In this study, the most commonly injured site was the head (40.5%), but 3 patients (7.1%) over the age of 3 years required an abdominal operation. Thus, an abdominal evaluation is needed for these kinds of injuries.

There are several possible explanations for the increase in TV fall-related injuries. Many studies have documented the rise in the number of TVs in recent years.[8,9] Thus, the more TVs in a household, the greater the child’s exposure to risk of injury due to TV fall. With the advent of flat-panel TVs (FPTs) (such as LCD and plasma), these TVs are lighter and thinner, and are therefore thought to reduce the risk of tipovers significantly.[4] On the other hand, the slim design and lighter weight of the FPTs may allow children to grasp and move the TV, making it easier to knock over. Thus, whether the increase in FPTs continues or decreases, TV fall-related injury rates remain unclear.

In our study, there was an increased number of LCD TV-related injuries, especially after 2004. We think that this was due to the positioning of LCD TVs on unstable supports. One of the benefits of FPTs is that their flat shape allows them to be fastened to walls, out of the reach of children, or on a stable surface, which decreases the chance of tipping.

Our data show that the majority of children who sustained injuries from falling TVs were 3 years of age. In our study, the mechanisms of ‘falling/tipping 63

Ulus Travma Acil Cerrahi Derg

over’ and ‘pulling the furniture onto self’ accounted for 100% of deaths. The high incidence of injury in this age group is likely related to immature coordination.[10] On the other hand, toddlers have the motor skills to climb nearby objects and explore their environment. However, they may not possess the reflexive ability to avoid falling objects or the cognitive skills to deduce ensuing danger. TVs may be placed on furniture that was not designed to hold such weight, such as dressers and shelving units.[11] As a result, TVs are even more prone to tipping and falling when pulled or knocked by a child, and can bring their supporting furniture down as well. In our study, a variety of supportive structures were involved in the accidents, but dressers were the most common. Lack of parenteral knowledge of this injury mechanism may contribute to its incidence.[12] In conclusion, we can assume that almost all Turkish children are exposed to TV sets in their home environment.[13] TV fall-related injuries can lead to significant morbidity and mortality in children. As they are preventable injuries, restricted activity and improved supervision of children around the TV can potentially lead to fewer incidences.

REFERENCES 1. Brenner RA, Overpeck MD, Trumble AC, DerSimonian R, Berendes H. Deaths attributable to injuries in infants, United States, 1983-1991. Pediatrics 1999;103:968-74.

2. Marganitt B, MacKenzie EJ, Deshpande JK, Ramzy AI, Haller JA Jr. Hospitalizations for traumatic injuries among

64

children in Maryland: trends in incidence and severity: 1979 through 1988. Pediatrics 1992;89:608-13.

3. Scheidler MG, Shultz BL, Schall L, Vyas A, Barksdale EM Jr. Falling televisions: The hidden danger for children. J Pediatr Surg 2002;37:572-5.

4. DiScala C, Barthel M, Sege R. Outcomes from television sets toppling onto toddlers. Arch Pediatr Adolesc Med 2001;155:145-8.

5. Bernard PA, Johnston C, Curtis SE, King WD. Toppled television sets cause significant pediatric morbidity and mortality. Pediatrics 1998;102:E32.

6. Jea A, Ragheb J, Morrison G. Television tipovers as a significant source of pediatric head injury. Pediatr Neurosurg 2003;38:191-4.

7. Ota FS, Maxson RT, Okada PJ. Childhood injuries caused by falling televisions. Acad Emerg Med 2006;13:700-3.

8. Taras HL, Sallis JF, Nader PR, Nelson J. Children’s television-viewing habits and the family environment. Am J Dis Child 1990;144:357-9.

9. Tonge BJ. The impact of television on children and clinical practice. Aust N Z J Psychiatry 1990;24:552-60.

10. Rutkoski JD, Sippey M, Gaines BA. Traumatic television tip-overs in the pediatric patient population. J Surg Res 2011;166:199-204.

11. Gottesman BL, McKenzie LB, Conner KA, Smith GA. Injuries From furniture tip-overs among children and adolescents in the United States, 1990-2007. Clin Pediatr (Phila) 2009;48:851-8.

12. Murray KJ, Griffin R, Rue LW 3rd, McGwin G Jr. Recent trends in television tip over-related injuries among children aged 0-9 years. Inj Prev 2009;15:240-3.

13. Özkaya C, Vatandaş C, Aydın M, Tekin M, Can B, Arabacı C ve ark. Türkiye’de aile (Ailenin yapısal özellikleri, işlevleri ve değişimi). İstanbul: SEKAM Yayınları; 2011. s. 217-23.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):65-70

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.33427

Comparative results of percutaneous cannulated screws, dynamic compression type plate and screw for the treatment of femoral neck fractures Femur boyun kırıklarının tedavisinde perkütan kanüle vida, dinamik kompresyon plak ve vidanın karşılaştırmalı sonuçları Tolga KAPLAN,1 Burak AKESEN,2 Burak DEMİRAĞ,2 Sadık BİLGEN,2 Kemal DURAK2

BACKGROUND

AMAÇ

The purpose of this study was to compare the period of union, functional outcomes and complications of patients with femoral neck fracture treated with percutaneous cannulated screws versus dynamic hip screw (DHS).

Bu çalışmanın amacı, perkütan kanüle vida veya dinamik kalça vidası (DKV) ile tedavi edilen femur boyun kırıklı hastaların kaynama süresi, fonksiyonel sonuçlar ve komplikasyonlar açısından karşılaştırılmasıdır.

METHODS

GEREÇ VE YÖNTEM

Sixty-six patients with femoral neck fracture were treated with percutaneous cannulated screws (n=33) or with DHS (n=33) between August 1999 and October 2003. Functional outcome was measured using Harris Hip Score, and period of union, amount of bleeding and complications were also recorded.

Ağustos 1999 ile Ekim 2003 tarihleri arasında femur boyun kırığı bulunan altmış altı hasta perkütan kanüle vida (n=33) veya DKV (n=33) ile tedavi edildi. Fonksiyonel sonuçlar Harris kalça skoru ile değerlendirildi. Çalışmada ayrıca kayanama süreleri, kanama miktarı ve komplikasyon oranı ölçüldü.

RESULTS

BULGULAR

The period of union and functional outcomes were not different between the two groups. Risk of avascular necrosis (AVN) was associated mainly with the grade of fracture displacement. In the percutaneous cannulated screw group, duration of surgery was shorter and blood loss was less than in the other group.

Kaynama süreleri ve fonksiyonel sonuçlar açısından iki grup arasında anlamlı fark bulunmadı. Avasküler nekroz riski en çok kırığın kayma miktarı ile ilişkili bulundu. Perkütan kanüle vida uygulanan grupta ameliyat süresi ve kanama miktarı anlamlı olarak daha düşük bulundu.

SONUÇ

CONCLUSION

There was no superiority between cannulated screws and DHS according to union times and functional results. Risk of AVN is related to the degree of displacement. However, a prospective randomized study is needed to determine the outcome of each technique for patients suffering similar displacement rates.

Kayanama süresi ve fonksiyonel sonuç açısından perkütan kanüle vida ve DKV uygulamarının birbirlerine üstünlüğü bulunmamaktadır. Avasküler nekroz riski kırığın kayma miktarı ile ilişkilidir. Bununla birlikte aynı kayma miktarı bulunan hastlarda iki tekniğin birbirleri ile karşılaştırılması için prospektif randomize bir çalışma gereksinimi vardır.

Key Words: Dynamic hip screw; fractures of the femoral neck; percutaneous; cannulated screw.

Anahtar Sözcükler: Dinamik kalça vidası; femur boyun kırığı; perkütan; kanüle vida.

Department of Orthopaedics and Traumatology, Medical Park Hospital, Bursa; 2Department of Orthopaedics and Traumatology, Uludag University Faculty of Medicine, Bursa, Turkey.

1

Medical Park Hastanesi, Ortopedi ve Travmatoloji Kliniği, Bursa; 2 Uludağ Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Bursa.

1

Correspondence (İletişim): Burak Akesen, M.D. Uludağ Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Görükle 16059 Bursa, Turkey.

Tel: +090 - 224 - 295 28 23 e-mail (e-posta): akesenb@msn.com

65

Ulus Travma Acil Cerrahi Derg

The incidence of proximal femoral fractures tends to increase among the elderly as mean lifespan continues to increase. Increases in high-energy traffic accidents and popularization of extreme sports that exert limits make the young population also prone to such fractures.[1-6] One percent of all fractures occur around the femoral neck.[7] These fractures most commonly occur in individuals over 50 years of age.[8] Approximately 2-3% of femoral neck fractures occur in the population below 50 years of age.[9] Due to the distinguished arterial nutrition of the femoral head, avascular necrosis (AVN) is a common complication following these fractures.[10,11] Early anatomical reduction and stable fixation prevent complications like AVN of the femoral head and non-union, especially in young patients.[6,8,12] Direct or indirect stress may cause femoral neck fractures.

[7] In the indirect mechanism, fracture may occur due to the leaning of the femoral head against the acetabulum, with the effect of fourth forces when the thigh is in abduction. Falling on the greater trochanter when the thigh is in semi-flexion may cause fractures of the femoral neck by indirect forces.[13] In this study, we retrospectively evaluated the early-mid-term results of femoral neck fractures surgically treated by internal fixation with either percutaneous cannulated screws or dynamic hip screw (DHS).

MATERIALS AND METHODS Sixty-six patients (31 female, 35 male) with femoral neck fractures who were treated surgically with either percutaneous cannulated screws or DHS between August 1999 and October 2003 in our institution were enrolled in this retrospective study. The presence of multiple fractures, associated chest, abdominal or head injuries, and concurrent systemic diseases such as chronic renal failure, rheumatoid arthritis, systemic lupus erythematosus and malignancy were regarded as the exclusion criteria to this particular study. The

Fig. 2. Steps of cannulated screw application.

66

25

Group I (n=33) Group II (n=33)

20 15 10 5 0 Group I Group II

Type 1 22 6

Type 2 8 12

Type 3 3 13

Type 4 0 2

Fig. 1. Distribution of fracture types in Groups I and II.

patients were grouped according to the internal fixation devices used. Thirty-three patients operated with cannulated screws were regarded as Group I and 33 patients operated with DHS as Group II. The mean age of the patients at the time of surgery was 45 years (range: 18-68) in Group I and 46 years (range: 25-67) in Group II. According to the Gardenâ&#x20AC;&#x2122;s classification, 28 patients were type I, 20 were type II, 16 type III, and 2 were type IV (Fig. 1).

All patients received intravenous cefazolin sodium (1 g) and gentamicin sulfate (80 mg) before the operation and for three days after surgery. Low molecular weight heparin was administered to prevent deep vein thrombosis before the surgery and was continued for 21 days after surgery. Under regional or general anesthesia, closed hip reduction was ensured for patients in Group I under sterile conditions in the supine position followed by percutaneous fixation with three 7.3 mm cannulated screws. The first screw was applied inferiorly in the femoral neck, the second screw near the posterior cortex and the third in the anterior side of the femoral neck; all screws were in parallel position (Figures 2, 3).[14,15]

Fig. 3. Pre- and postoperative direct radiographs of a patient treated with cannulated screws.

Ocak - January 2012

Comparative results of percutaneous cannulated screws, dynamic compression type plate and screw

Fig. 4. Pre- and postoperative direct radiographs of a patient treated with DHS.

The proximal femur was exposed through the lateral approach in patients of Group II in the supine position. After fracture reduction under C-arm control without capsulotomy, fixation was achieved by DHS as in the original technique. One spongiosa screw was inserted as an anti-rotation screw (Fig. 4).

Operation times, amount of bleeding and need for transfusion in all patients were recorded. All patients were mobilized in the first day after the operation, without weight- bearing on the operated hip using crutches or walker. When follow-up radiographs showed sufficient healing and a pain-free hip was achieved clinically, patients were permitted controlled partial weight-bearing initially and full weight-bearing later, using crutches for four months. Patients were called for radiological follow-up and physical examination postoperatively in the 1st, 3rd, 6th, and 12th months and once a year thereafter. The scoring system of Pennsylvania University[16] and Garden Alignment Index[17] were utilized for radiological evaluation. Functional results were calculated by Harris Hip Score.[18] For statistical comparison of groups, Student’s t-test was used for parametric dispersions and Mann-Whitney U test, Fisher’s exact test and chi-square test for nonparametric dispersions.

RESULTS There was no significant difference statistically between operation times, blood loss during surgery, non-union rates, malalignments, AVN occurrence, and Harris Hip Scores of groups according to age and gender properties (p>0.05). Mean follow-up time was 33.6 months (range: 7-57) for all patients, 34.5 months (range: 7-57) for Group I, and 32.6 months (range: 8853) for Group II. The mechanisms of injury were classified as outdoor fall, indoor fall, fall from a height, fall from stairs, crush injury, traffic accident inside vehicle, and traffic accident outside vehicle, and they are summarized in Fig. 5.

Cilt - Vol. 18 Sayı - No. 1

According to Garden’s classification, 66.7% of patients in Group I were type I, while 39.3% and 36.3% of patients in Group II were type III and type II, respectively (Fig. 1). When the relationship between mechanism of injury and fracture type was evaluated, type I fractures were seen more frequently after a fall on stairs in both groups (p<0.005). Mean preoperative durations were 101 23 hours (range: 1-120) in Group I, and 41 hours (range: 6-240) in Group II. Mean preoperative duration as a variable did not cause any significant difference between groups statistically according to the occurrence of AVN (p>0.05).

Mean operation time was 46 minutes (range: 15-60) in Group I and 95 minutes (range: 50-240) in Group II. There was a significant difference between groups according to operation times (p<0.001). The amount of bleeding during the operation was 168 cc (range: 50-110) in Group I and 653 cc (range: 250-1120) in Group II. There was a statistically significant difference between groups according to blood loss during surgery (p<0.001). The mean healing time was 4 months (range: 3-5.1). The union rate was 97% in Group I and 91% in Group II. These rates did not reveal any significant difference statistically (p>0.05).

In Group I, evaluation of early and late complications revealed superficial wound infection of the incision site in 1 patient, a broken screw in 2 patients, and nonunion in 1 patient. Repeated trauma was detected in the postoperative second month in 2 patients who had broken cannulated screws. In these patients, fixation was revised with DHS. Union was achieved in both patients at the 6th month. For the patient who had non-union, cannulated screws were removed in the 8th month and Dickson[19] geometric osteotomy and fixation with DHS were performed. Union was achieved five months after the second operation in this patient.

In Group II, 6 patients had various complications: deep vein thrombosis (1 patient), implant failure (2 patients), and non-union (3 patients). After consultation 16

Group I (n=33) Group II (n=33)

14 12 10 8 6 4 2 0

Outdoor fall

Indoor fall

Fall from a height

Fall on stairs

Crush injury

Traffic accident inside vehicle

Traffic accident outside vehicle

Fig. 5. Mechanisms of injury of patients in Groups I and II. 67

Ulus Travma Acil Cerrahi Derg

with the Cardiovascular Surgery Department, proper medical treatment was begun for deep vein thrombosis of the patient. Implant failure occurred because of early uncontrolled weight-bearing in 2 patients. The one who had loosening of the compression screw was taken to the operating room and the screw was tightened.

In the other patient, loosening of the plate screw and loss of reduction were detected. In this patient, Dickson[19] geometric osteotomy and fixation with DHS were performed. Union was achieved four months after the second operation. Non-union was detected in 3 patients. Hemiarthroplasty was performed for a 64–year-old patient in whom non-union was detected eight months after the first operation. In the second patient, autogenous grafting was done, and in the last patient, Dickson[19] geometric osteotomy and fixation with DHS were performed. The grafted fracture united in two months and the other in five months. According to these complication rates, there was no statistically significant difference between groups (p>0.05). When AVN rates were evaluated, stage II or more advanced AVN was detected in 18% of patients in Group I and in 30% of patients in Group II. Patients who had this complication were operated 14 hours (range: 2-48) after the trauma in Group I and 20 hours (range: 8-48) after the trauma in Group II. Among these patients, fracture types according to Garden’s classification system were as follows: in Group I, 1 patient type I, 2 patients type II and 3 patients type III, and in Group II, 1 patient type II, 1 patient type IV and 8 patients type III. Mean time for diagnosis of AVN was 13 months (range: 9-21) in Group I and 8.6 months (range: 6-13) in Group II. Implants were removed in all patients of both groups who had a diagnosed AVN. Variables of age, gender, mechanism of injury, side of the fracture, American Society of Anesthesiologists (ASA) score, and preoperative waiting time did not cause any statistically significant difference between groups according to the occurrence of AVN (p>0.05). When the relationship between fracture type and occurrence of AVN was investigated, AVN frequency was greater in displaced fractures in both groups (p<0.001). When radiological results were evaluated, Garden Alignment Index[17] was 162° (range: 155°-170°) in Group I and 163° (range: 155°-170°) in Group II, and there was no significant difference between groups according to malalignment statistically (p>0.05). Evaluation of functional results according 151 to Harris[18] criteria revealed 91% excellent and good results, 6% fair and 3% bad results in Group I. Mean Harris[18] Hip Score in this group was 91 (range: 65-100). In Group II, the proportion of excellent and good results was 85% and of fair results 15%, and the mean Harris[18] Hip Score was 90 (range: 75-99). The patient with a bad result in Group I was known to have a broken screw and revision surgery with DHS; 2 patients with fair results in 68

Group I were complicated by AVN. In Group II, 1 of 5 patients with a fair result was re-operated because of non-union and the other 4 had AVN. There was no significant difference between groups statistically according to functional results (p>0.05).

DISCUSSION The main aim in the treatment of a femoral neck fracture is to facilitate a patient’s return to his normal activities as soon as possible. Internal fixation of these fractures is more important than arthroplasties today, because the patient’s native bone tissue is used and low costs are achieved.[6,20-25] While selecting a treatment method for these fractures, determination of the patient’s physiological and chronological age is important along with determination of fracture type.

Femoral neck fractures in the young population must be treated immediately and internal fixation must be performed after closed reduction.[26-29] In the elderly, sufficient bone stock is needed for internal fixation, and functional status before fracture must be kept in mind to select a treatment method.[6,22,30,31] Various types of fixation devices are reported for stabilization of femoral neck fractures.[32] The most important factor in selecting an implant is that it uses a minimally invasive technique and protects the vascular supply of the femoral head by preventing additional soft tissue injury. The implants that fit these criteria are cannulated screws and DHS, which we used in our study.

[15,22,33,34] As Garden classification is based on displacement of the 176 fractures, it has a strong effect on decision-making about the treatment option and prognosis.[35,36] In both groups, type I fractures were detected frequently after falling on stairs and the relationship was significant statistically (p<0.05). When evaluated according to the mechanism of injury, we think that undisplaced impaction fractures occur when the lateral side of the hip hits the edge of the stair during the fall. Our study revealed a difference between groups regarding operation times (p<0.001). In Group I, application of percutaneous screws lasted 46 minutes (range: 15-60). In Group II, the duration of DHS application was 95 minutes (range: 50-140). The percutaneous cannulated screw fixation method, which has lower operation times, also shortens anesthesia time and prevents the possible complications of anesthesia. Blood loss during cannulated screw fixation in Group I was lower than in the other group in which DHS was applied (p<0.001). It was also reported by Swiontkowski and Winquist[37] that use of cannulated screws for femoral neck fractures causes lower blood loss during operation. Madsen et al.[38] reported that application of DHS for these fractures causes prolonged operation and more blood loss, which supports the results of our study. In our study, there was no difference between groups according to occurrence of AVN (p>0.05), and Ocak - January 2012

Comparative results of percutaneous cannulated screws, dynamic compression type plate and screw

this complication was seen more in displaced fractures in both groups (p>0.05). Swiontkowski et al.[26] reported AVN rates of 20% in femoral neck fractures treated by cannulated screws, and they emphasized that this complication occurred in displaced fractures more frequently. This proportion is similar in Group I in our study, at 18%. However, there are studies that report 8-16% AVN in similar type of fractures.[5,30,39-41] Barnes et al.[8] reported an AVN rate of 22% and Ort et al.[42] reported an AVN rate of 24% in femoral neck fractures treated by DHS. We found higher rates (30% in our Group II patients with DHS), which may have been caused by selection bias. Zuckerman et al.[43] reported that this complication 201 will occur at an 11% lower rate in patients who are operated in the first 48 hours, regardless of the fixation technique used. Mean union time of all fractures was four months. Unlike our results, Shih and Wang[44] reported a union time of six months in 121 patients with a mean age of 36.8.

Rodriquez[45] reported a 95% union rate after fixation with cannulated screws, and Ort et al.[42] reported a 90.4% union rate after fixation of femoral neck fractures with DHS. Similarly, we found union rates of 97% and 91% in Groups I and II, respectively. We did not find any difference between groups according to union problems in our study (p>0.05). Non-union rates were 3% and 9% in Groups I and II, respectively. We think that the difference is a result of more displaced fractures scheduled in Group II rather than the fixation method used. The study of Frandsen et al.[46] supports our opinion, in that they found non-union problems more frequent in displaced fractures. As a result, the first choice of treatment for fractures of the femoral neck in young adults and older patients with good bone quality is anatomical reduction; internal fixation, cannulated screws and DHS show no superiority according to union times and functional results. Risk of AVN is related to the degree of displacement. Blood loss was significantly lower in Group I patients, as the cannulated screws were applied percutaneously. However, the decision of hardware to be implanted should be based on the anatomical features of the fracture and biomechanics. In Group II patients, DHS was applied through a longer incision and the operation time was longer. This may explain the difference between the two groups in terms of blood loss. However, a prospective randomized study is needed to determine the outcome of each technique for patients suffering similar displacement rates.

REFERENCES 1. Holmberg S, Thorngren KG. Statistical analysis of femoral neck fractures based on 3053 cases. Clin Orthop Relat Res 1987:32-41.

2. Jarnlo GB, Thorngren KG. Background factors to hip fractures. Clin Orthop Relat Res 1993;287:41-9.

3. Hedlund R, Lindgren U, Ahlbom A. Age- and sex-specific inCilt - Vol. 18 Sayı - No. 1

cidence of femoral neck and trochanteric fractures. An analysis based on 20,538 fractures in Stockholm County, Sweden, 1972-1981. Clin Orthop Relat Res 1987;222:132-9.

4. Askin SR, Bryan RS. Femoral neck fractures in young adults.

Clin Orthop Relat Res 1976;114:259-64.

5. Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE. Outcomes after displaced fractures of the femoral neck. A metaanalysis of one hundred and six published reports. J Bone Joint Surg Am 1994;76:15-25.

6. Shah AK, Eissler J, Radomisli T. Algorithms for the treatment of femoral neck fractures. Clin Orthop Relat Res 2002;399:28-34.

7. Kyle RF. Fractures of the proximal part of the femur. J Bone Joint Surg Am 1994;76:924-50.

8. Barnes R, Brown JT, Garden RS, Nicoll EA. Subcapital fractures of the femur. A prospective review. J Bone Joint Surg Br 1976;58:2-24.

9. Zetterberg C, Elmerson S, Andersson GB. Epidemiology of hip fractures in Göteborg, Sweden, 1940-1983. Clin Orthop Relat Res 1984;191:43-52.

10. Gautier E, Ganz K, Krügel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br 2000;82:679-83.

11. Catto M. A histological study of avascular necrosis of the femoral head after transcervical fracture. J Bone Joint Surg Br 1965;47:749-76.

12. Garden RS: Stability and union in subcapital fractures of the femur. J Bone Joint Surg Br 1964;46:630-47.

13. Aharonoff GB, Dennis MG, Elshinawy A, Zuckerman JD, Koval KJ. Circumstances of falls causing hip fractures in the elderly. Clin Orthop Relat Res 1998;348:10-4.

14. Kyle RF, Cabanela ME, Russell TA, Swiontkowski MF, Winquist RA, Zuckerman JD, et al. Fractures of the proximal part of the femur. Instr Course Lect 1995;44:227-53.

15. Bout CA, Cannegieter DM, Juttmann JW. Percutaneous cannulated screw fixation of femoral neck fractures: the three point principle. Injury 1997;28:135-9.

16. Steinberg ME, Hayken GD, Steinberg DR. A quantitative system for staging avascular necrosis. J Bone Joint Surg Br 1995;77:34-41.

17. Garden RS. Malreduction and avascular necrosis in subcapital fractures of the femur. J Bone Joint Surg Br 1971;53:18397.

18. Johnston RC, Fitzgerald RH Jr, Harris WH, Poss R, Müller ME, Sledge CB. Clinical and radiographic evaluation of total hip replacement. A standard system of terminology for reporting results. J Bone Joint Surg Am 1990;72:161-8.

19. DeLee CJ. Fractures and dislocations of the hip. Fractures of the neck of the femur. In: Rockwood AC, Green PD, Bucholz WR, editors. Fractures in adults. 3th ed. Philaedelphia: JB. Lippincott Company; 1991. p. 1481-538.

20. Schmidt AH, Swiontkowski MF. Femoral neck fractures. Orthop Clin North Am 2002;33:97-111, viii.

21. Eisler J, Cornwall R, Strauss E, Koval K, Siu A, Gilbert M. Outcomes of elderly patients with nondisplaced femoral neck fractures. Clin Orthop Relat Res 2002;399:52-8.

22. Bosch U, Schreiber T, Krettek C. Reduction and fixation of displaced intracapsular fractures of the proximal femur. Clin Orthop Relat Res 2002;399:59-71.

23. Thorngren KG, Ceder L, Svensson K. Predicting results of rehabilitation after hip fracture. A ten-year follow-up study.

Clin Orthop Relat Res 1993;287:76-81.

24. Pryor GA, Williams DR. Rehabilitation after hip fractures.

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Home and hospital management compared. J Bone Joint Surg Br 1989;71:471-4.

25. Holmberg S, Kalén R, Thorngren KG. Treatment and outcome of femoral neck fractures. An analysis of 2418 patients admitted from their own homes. Clin Orthop Relat Res 1987;218:42-52.

26. Swiontkowski MF. Current concept review: Intracapsuler fractures of the hip. J Bone Joint Surg 1994;76A:129-38.

27. Cserháti P, Kazár G, Manninger J, Fekete K, Frenyó S. Nonoperative or operative treatment for undisplaced femoral neck fractures: a comparative study of 122 non-operative and 125 operatively treated cases. Injury 1996;27:583-8.

28. Raaymakers EL, Marti RK. Non-operative treatment of impacted femoral neck fractures. A prospective study of 170 cases. J Bone Joint Surg Br 1991;73:950-4.

29. Strömqvist B, Hansson LI, Nilsson LT, Thorngren KG. Hookpin fixation in femoral neck fractures. A two-year follow-up study of 300 cases. Clin Orthop Relat Res 1987;218:58-62.

30. Hudson JI, Kenzora JE, Hebel JR, Gardner JF, Scherlis L, Epstein RS, et al. Eight-year outcome associated with clinical options in the management of femoral neck fractures.

Clin Orthop Relat Res 1998;348:59-66.

31. Springer RE, Lachiewicz FP, Gilbert J: Internal fixation of femoral neck fractures. Clin Orthop 1991;267:85-91.

32. Estrada LS, Volgas DA, Stannard JP, Alonso JE. Fixation failure in femoral neck fractures. Clin Orthop Relat Res 2002;399:110-8.

33. Blair B, Koval KJ, Kummer F, Zuckerman JD. Basicervical fractures of the proximal femur. A biomechanical study of 3 internal fixation techniques. Clin Orthop Relat Res 1994;306:256-63.

34. Bray TJ. Femoral neck fracture fixation. Clinical decision making. Clin Orthop Relat Res 1997;339:20-31.

35. Parker MJ. Garden grading of intracapsular fractures: meaningful or misleading? Injury 1993;24:241-2.

36. Frandsen PA, Andersen E, Madsen F, Skjødt T. Garden’s

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classification of femoral neck fractures. An assessment of inter-observer variation. J Bone Joint Surg Br 1988;70:58890.

37. Swiontkowski MF, Winquist RA. Displaced hip fractures in children and adolescents. J Trauma 1986;26:384-8.

38. Madsen F, Linde F, Andersen E, Birke H, Hvass I, Poulsen TD. Fixation of displaced femoral neck fractures. A comparison between sliding screw plate and four cancellous bone screws. Acta Orthop Scand 1987;58:212-6.

39. Asnis SE, Wanek-Sgaglione L. Intracapsular fractures of the femoral neck. Results of cannulated screw fixation. J Bone Joint Surg Am 1994;76:1793-803.

40. Parker MJ, Porter KM, Eastwood DM, Schembi Wismayer M, Bernard AA. Intracapsular fractures of the neck of femur. Parallel or crossed garden screws? J Bone Joint Surg Br 1991;73:826-7.

41. Swiontkowski MF, Winquist RA, Hansen ST Jr. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am 1984;66:837-46.

42. Ort PJ, LaMont J. Treatment of femoral neck fractures with a sliding compression screw and two Knowles pins. Clin Orthop Relat Res 1984;190:158-62.

43. Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am 1995;77:1551-6.

44. Shih CH, Wang KC. Femoral neck fractures. 121 cases treated

by Knowles pinning. Clin Orthop Relat Res 1991;271:195200.

45. Rodríguez-Merchán EC. In situ fixation of nondisplaced intracapsular fractures of the proximal femur. Clin Orthop Relat Res 2002;399:42-51.

46. Frandsen PA, Andersen PE Jr, Christoffersen H, Thomsen PB. Osteosynthesis of femoral neck fracture. The slidingscrew-plate with or without compression. Acta Orthop Scand 1984;55:620-3.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):71-74

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.07448

Immediate appendectomy for appendiceal mass Apendiküler kitlelerde erken apendektomi Bülent KAYA,1 Barış SANA,2 Cengiz ERİŞ,3 Rıza KUTANİŞ2

BACKGROUND

AMAÇ

The aim of this retrospective study was to evaluate the safety and effectiveness of immediate appendectomy in patients presenting with appendicular mass.

Bu retrospektif çalışmanın amacı, apendiküler kitle tespit edilen hastalarda erken apendektominin güvenirliğini ve etkinliğini araştırmaktır.

METHODS

GEREÇ VE YÖNTEM

Forty-seven patients with appendicular mass were operated within 24 hours after admission to Vakif Gureba Training and Research Hospital, General Surgery Department, from January 2004 to April 2010. The appendiceal mass was diagnosed with physical examination, abdominal ultrasonography, and computed tomography, or during surgical exploration. Age and sex, duration of symptoms, physical examination findings at admission, operation details, intraoperative and postoperative complications, and length of hospital stay were analyzed for each patient.

RESULTS

There were 25 males (53.2%) and 22 females (46.8%), with a mean age of 37.23±15.60 (range: 14-75) years. The mean time from the onset of the symptoms to operation was 4.06±2.50 (range: 1-15) days. A simple appendectomy was performed in 38 (80.9%) patients. Twenty-nine (61.8%) patients were discharged and followed up without any complication after surgery. Wound infection was detected in 13 (27.7%) patients.

Vakıf Gureba Eğitim ve Araştırma Hastanesi Genel Cerrahi Kliniği’ne Ocak 2004 ile Nisan 2010 tarihleri arasında başvuran 47 hasta apendiküler kitle nedeni ile 24 saat içerisinde ameliyat edildi. Apendiküler kitle tanısı fiziksel inceleme, karın ultrasonografisi, bilgisayarlı tomografi ya da ameliyat sırasında konuldu. Yaş ve cinsiyet, semptomların süresi, başvuruda fiziksel inceleme bulguları, ameliyat bulguları, intraoperatif ve postoperatif komplikasyonlar ile hastanede yatış süresi her hasta için analiz edildi.

BULGULAR

Çalışmaya 25 erkek (%53,2) ve 22 kadın (%46,8) hasta alındı. Ortalama yaş 37,23±15,60 (dağılım 14-75 yaş) idi.

Semptomların başlaması ile ameliyat arasında geçen ortalama zaman 4,06±2,50 gündü (dağılım 1-15 gün). Apendektomi 38 hastada (%80,9) uygulandı. Yirmi dokuz hasta (%61,8) cerrahi sonrası herhangi bir komplikasyon olmaksızın taburcu edildi. Yara yeri enfeksiyonu 13 hastada (%27,7) saptandı.

SONUÇ

CONCLUSION

Immediate appendectomy in appendicular mass is a safe and effective alternative to conservative management.

Erken apendektomi, apandiküler kitlelerde konservatif tedaviye alternatif güvenli ve etkili bir yöntemdir.

Key Words: Appendicitis; appendicular mass; immediate appendectomy.

Anahtar Sözcükler: Apandisit; apendiküler kitle; erken apendektomi.

1 Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul; 2Department of General Surgery, Bagcilar Training and Research Hospital, Istanbul; 3Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey.

Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul; 2Bağcılar Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul; 3Haydarpaşa Numune Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul.

1

Correspondence (İletişim): Bülent Kaya, M.D. Çubuklu Yazıcı Suyu Cad. N0: 3, Beykoz, İstanbul, Turkey.

Tel: +090 - 216 - 578 30 00 e-mail (e-posta): drbkaya@yahoo.com

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Acute appendicitis is one of the most common surgical emergencies worldwide. Appendiceal mass is detected in approximately 10% of patients with acute appendicitis.[1] The inflammatory mass results from untreated appendicitis and may represent a pathological spectrum ranging from phlegmon (a conglomeration of the inflamed appendix, adjacent viscera and the greater omentum) to periappendiceal abscess.[2] The surgical management of appendiceal mass remains controversial. An initial non-operative treatment introduced by Ochsner[3] in 1901 has became popular over the years. This approach involves the administration of intravenous fluids and broad-spectrum antibiotics. Non-operative management of the appendiceal mass requires continued assessment of the patient’s progress. Any appendix abscess should be drained during the follow-up. Elective appendectomy is recommended after the resolution of the appendiceal mass. An interval period of about 4-8 weeks is usually advised.

Immediate appendectomy in patients with appendiceal mass is an alternative to conventional conservative treatment. Early recovery and complete cure during the first admission are the main advantages of immediate appendectomy. On the other hand, it has a complication rate of approximately 36% in patients with appendiceal mass.[4] The common complications after immediate appendectomy are wound infection, intestinal fistula, small bowel obstruction, intra-abdominal abscess, and sepsis.[5,6] The aim of this study was to determine whether immediate appendectomy is a safe alternative to conservative management in patients with appendiceal mass.

Table 1. Characteristics of 47 patients with appendicular mass

Preoperative symptoms Abdominal pain in RIF Anorexia Nausea and vomiting Duration of symptoms Physical examination Abdominal tenderness Rebound tenderness Defense Leukocytosis >10.000/mm³ Duration of hospitalization

Number/ mean

Percentage (%)

47 32 30 4.06±2.50

100 68.1 63.8

45 37 15 38 5.48±5.21

95.6 78.7 31.9 80.8

RIF: Right iliac fossa.

age and sex, duration of symptoms, physical examination findings at admission, operation details, intraoperative and postoperative complications, and length of hospital stay. For statistical analysis, the statistical software package SPSS (Statistical Package for the Social Sciences) 11.0 for Windows (SPSS Inc., Chicago, IL) was used.

RESULTS There were 25 men (53.2%) and 22 women (46.8%), with a mean age of 37.23±15.60 (range: 1475 ) years. The major clinical symptoms were abdominal pain in the right iliac fossa in 47 (100%) patients, anorexia in 32 (68.1%), and nausea and vomiting in

MATERIALS AND METHODS Forty-seven patients with appendicular mass were operated in Vakıf Gureba Training and Research Hospital, General Surgery Department, from January 2004 to April 2010. The medical records of 47 patients were analyzed. The appendiceal mass was either diagnosed on the basis of physical examination with the help of abdominal ultrasonography and computed tomography (CT) (Fig. 1) or during surgical exploration. The diagnosis was confirmed by intraoperative findings of an inflammatory mass in the right iliac fossa. The patients were operated within 24 hours of admission.

McBurney or midline incision was used in all patients.

Two patients were operated with laparoscopic technique. Intravenous antibiotics were given for 7 days after surgery in uncomplicated cases. Patients were reviewed in the outpatient clinic between 1 and 4 weeks after discharge.

All medical charts were reviewed retrospectively.

The following data were collected for each patient: 72

Fig. 1. Computed tomography shows the appendix (A) with appendicular mass (B) in the right iliac fossa.

Ocak - January 2012

Immediate appendectomy for appendiceal mass

Table 2. Operations for appendiceal mass Operation Appendectomy Right hemicolectomy and ileocolic anastomosis Drainage (without appendectomy) Appendectomy and ileum resection Appendectomy and oophorectomy

n (%) 38 (80.9%) 5 (10.7%) 2 (4.2%) 1 (2.1%) 1 (2.1%)

Table 3. Postoperative surgical complications Complication Wound infection Wound dehiscence Postoperative ileus Intra-abdominal sepsis

n (%) 13 (27.7%) 1 (2.1%) 3 (6.3%) 1 (2.1%)

30 (63.8%). Thirty-eight patients had a leukocytosis of >10000/mm³. The mean time from the onset of the symptoms to operation was 4.06±2.50 (range: 1-15 ) days.

Patient demographics are summarized in Table 1.

A simple appendectomy was performed in 38 (80.9%) patients. Two of the appendectomies were performed laparoscopically. Right hemicolectomy was performed due to suspicion of cecal tumor or severe inflammation around the ileocecal region in 5 patients. One of the patients underwent appendectomy and ileum resection.

Another was treated with appendectomy and oophorectomy. The appendectomy could not be performed in 2 patients, and abdominal drainage was the surgical intervention (Table 2). The operation time was 30-60 minutes in 29 patients, 60-90 minutes in 10 patients and 90-150 minutes in 8 patients. Intra-abdominal drain was used in 35 (74.5%) patients. There was no malignancy in histopathological examination, including the patients operated with right hemicolectomy.

Twenty-nine (61.8%) patients were discharged and followed up without any complication after surgery.

Wound infection was detected in 13 (27.7%) patients.

Three patients were treated with postoperative ileus.

Conservative measures (stopping oral intake, nasogastric drainage, intravenous fluid replacement) were successful in these patients. One patient had open abdomen procedure due to intra-abdominal sepsis. The postoperative complications are shown in Table 3. The mean hospital stay was 5.48±5.21 (range: 1-30) days.

There was no mortality in the postoperative period.

DISCUSSION An appendiceal mass results from a walled-off appendiceal perforation, and it can be further complicated by formation of intra-abdominal abscess and generalized peritonitis. It is detected more frequently Cilt - Vol. 18 Sayı - No. 1

in women, the elderly and children, in whom delay in diagnosis of appendicitis is more common.[7] Patients are usually presented with fever, leukocytosis and abdominal pain. The appendiceal mass may be missed clinically in the obese and patients with muscular rigidity. Both ultrasonography and CT are helpful in diagnosing appendiceal mass.

Management of late-presenting appendicitis with appendiceal mass remains controversial.

There are three main treatment methods for managing appendiceal mass:[8] initial conservative management followed by interval appendectomy, immediate appendectomy in presentation and totally conservative approach without interval appendectomy. Each treatment modality has some advantages and disadvantages.

Currently, most surgeons prefer conservative management of appendiceal mass with or without interval appendectomy. The patients are treated with broadspectrum antibiotics at presentation. Interval appendectomy is usually performed in 4-8 weeks after resolution of the inflammatory mass. Appendiceal masses may have an abscess component, and 42-86% heal without any surgical approach.[4,9-11] Drainage may be necessary in case of unresolved periappendicular abscess despite antibiotherapy. Failure of conservative treatment may be encountered in 10-20% of the patients.[12] Sustained fever, tachycardia, peritoneal irritation signs, and increased leukocyte count under conservative therapy can indicate the surgery. It is also argued that some ileocecal pathologies other than appendicitis, like cecal malignancy and ileocecal tuberculosis, may be undiagnosed in patients treated with conservative management. Recurrent appendicitis and increased hospital costs are other disadvantages of a conservative approach.

Immediate appendectomy became an alternative treatment method for appendiceal mass in recent years.

[13,14] With the advent of antibiotics and supportive care, surgical intervention at any stage of appendicitis can be performed without major complications. Immediate appendectomy was shown to be safe and feasible with a shorter hospital stay. It also has advantages of cost-effectiveness and early diagnosis of unexpected pathologies like malignancy.[15] We performed appendectomy successfully in 40 (85.1%) patients. It was reported that the appendix cannot be resected in up to 30% of patients with appendiceal mass. Samuel et al.[13] compared the two groups of patients who were treated with either immediate appendectomy or interval appendectomy after non-surgical management.

They concluded that although serious adhesions were found in 100% of patients in the immediate appendectomy group, the appendix had been identified 73

Ulus Travma Acil Cerrahi Derg

and appendectomy could be performed in all patients.

Some authors reported that immediate appendectomy has a high complication rate.[15,16] It can cause dissemination of infection, intestinal injury and fecal fistula. Kumar et al.[17] reported longer operation time, higher incidence of adhesions and incision extension with more postoperative complications for early appendectomy in appendiceal mass. However, in a recent study reported by Cunnigaiper,[18] there were no major complications in 114 patients operated with appendiceal mass. No major complications such as bowel injury or intestinal fistula were detected in our series. One patient was managed with open abdomen due to intra-abdominal sepsis. There was also no mortality. Wound infection, as a minor problem, can be seen more frequently in patients with immediate appendectomy.[19,20] The rate of wound infection was found as 27.7% in our series, which is relatively high.

Arshad et al.[21] reported wound sepsis in 19.31% of their patients after immediate appendectomy due to appendiceal mass.

Post-operative ileus is a common problem after abdominal surgery. Three of our patients had adynamic ileus after surgery. All of these patients had been operated with midline laparotomy.

A conservative approach, including cessation of oral intake and nasogastric drainage with intravenous fluid resuscitation, was sufficient for treatment.

In conclusion, immediate appendectomy in appendicular mass is a safe and effective alternative to classical conservative management. The most important morbidity after immediate appendectomy is wound infection. Protection of the wound during surgery using broad-spectrum antibiotics may decrease the infection rate.

REFERENCES 1. Shipsey MR, O’Donnell B. Conservative management of appendix mass in children. Ann R Coll Surg Engl 1985;67:234.

2. Nitecki S, Assalia A, Schein M. Contemporary management of the appendiceal mass. Br J Surg 1993;80:18-20.

3. Ochsner AJ. The cause of diffuse peritonitis complicating appendicitis and its prevention. JAMA 1901;26:1747-54.

4. Bagi P, Dueholm S. Nonoperative management of the ultra-

74

sonically evaluated appendiceal mass. Surgery 1987;101:6025.

5. Kim JK, Ryoo S, Oh HK, Kim JS, Shin R, Choe EK, et al. Management of appendicitis presenting with abscess or mass. J Korean Soc Coloproctol 2010;26:413-9.

6. Swank HA, Eshuis EJ, van Berge Henegouwen MI, Bemelman WA. Short- and long-term results of open versus laparoscopic appendectomy. World J Surg 2011;35:1221-8.

7. Gibeily GJ, Ross MN, Manning DB, Wherry DC, Kao TC. Late-presenting appendicitis: a laparoscopic approach to a complicated problem. Surg Endosc 2003;17:725-9.

8. Garba ES, Ahmed A. Management of appendiceal mass. Ann Afr Med 2008;7:200-4.

9. Befeler D. Recurrent appendicitis. Incidence and prophylaxis. Arch Surg 1964;89:666-8.

10. Vargas HI, Averbook A, Stamos MJ. Appendiceal mass: conservative therapy followed by interval laparoscopic appendectomy. Am Surg 1994;60:753-8.

11. Yamini D, Vargas H, Bongard F, Klein S, Stamos MJ. Perforated appendicitis: is it truly a surgical urgency? Am Surg 1998;64:970-5.

12. Meshikhes AW. Management of appendiceal mass: controversial issues revisited. J Gastrointest Surg 2008;12:767-75.

13. Samuel M, Hosie G, Holmes K. Prospective evaluation of nonsurgical versus surgical management of appendiceal mass. J Pediatr Surg 2002;37:882-6.

14. Goh BK, Chui CH, Yap TL, Low Y, Lama TK, Alkouder G, et al. Is early laparoscopic appendectomy feasible in children with acute appendicitis presenting with an appendiceal mass? A prospective study. J Pediatr Surg 2005;40:1134-7.

15. Oliak D, Yamini D, Udani VM, Lewis RJ, Vargas H, Arnell T, et al. Nonoperative management of perforated appendicitis without periappendiceal mass. Am J Surg 2000;179:177-81.

16. Jordan JS, Kovalcik PJ, Schwab CW. Appendicitis with a palpable mass. Ann Surg 1981;193:227-9.

17. Kumar S, Jain S. Treatment of appendiceal mass: prospective, randomized clinical trial. Indian J Gastroenterol 2004;23:165-7.

18. Cunnigaiper ND, Raj P, Ganeshram P, Venkatesan V. Does Ochsner-Sherren regimen still hold true in the management of appendicular mass? Ulus Travma Acil Cerrahi Derg 2010;16:43-6.

19. Tingstedt B, Bexe-Lindskog E, Ekelund M, Andersson R. Management of appendiceal masses. Eur J Surg 2002;168:579-82.

20. Erdoğan D, Karaman I, Narci A, Karaman A, Cavuşoğlu YH, Aslan MK, et al. Comparison of two methods for the management of appendicular mass in children. Pediatr Surg Int 2005;21:81-3.

21. Arshad M, Aziz LA, Qasim M, Talpur KA. Early appendicectomy in appendicular mass-a Liaquat University Hospital experience. J Ayub Med Coll Abbottabad 2008;20:70-2.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):75-79

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2012.49354

Foreign body traumas of the eye managed in an emergency department of a single-institution Bir merkezin acil servisinde tedavi edilen gözün yabancı cisim travmaları Özlem YİĞİT, Aslıhan YÜRÜKTÜMEN, Savaş ARSLAN

BACKGROUND

AMAÇ

Superficial corneal foreign bodies (SCFB) are common injuries seen in the ED. The aim of this study was to describe the eye injuries caused by FBs and to determine clinical strategies for the prevention and management of ocular trauma.

Yüzeysel korneal yabancı cisimler acil servise sık başvuran olgulardır. Bu çalışmanın amacı, acil servise yabancı cisimlerle oluşan göz travmasıyla başvuran olguları tanımlamak ve göz travmasının önlenmesi ve acil servis yönetim stratejilerini tartışmaktır.

METHODS

GEREÇ VE YÖNTEM

This was a retrospective chart review of the previous two years. Demographic data, timing of the injury, injury type (open- or closed-globe injuries), source of the FB, hospital admission and ophthalmology consultation, treatments, and the long-term complications were recorded for each patient.

Çalışma geçmiş iki yılın kayıtları incelenerek geriye dönük olarak yapıldı. Demografik bilgiler, yaralanma zamanı, yaralanma tipi (açık veya kapalı glob yaralanması), yabancı cismin ne olduğu, hastane yatış ve oftalmoloji konsültasyonu varlığı, uygulanan tedaviler ve geç dönemde görülen kalıcı hasarlar kaydedildi.

RESULTS

BULGULAR

There were 476 patients, and 83% were male, with an average age of 34.16±14.02 years. 9.7% of the eyes had an open-globe injury, while the rest were closed-globe injuries with or without SCFB. The most common FBs were metal fragments (37.6%) and dust (31.1%). The majority of the patients (72.1%) sustained work-related injuries. 42.4% of the patients were consulted to ophthalmology, and the remaining were treated by the emergency physicians.

Only 10% of the patients required hospitalization, and complications were seen in 2.3% of the patients.

Toplam 476 hasta çalışmaya alındı, hastaların %83’ü erkekti, ortalama yaş 34,16±14,02 idi. Yaralanmaların %9,7’si açık glob yaralanması iken, kalanlar yüzeysel yabancı cisim bulunan veya bulunmayan kapalı yaralanmalardı. En sık görülen yabancı cisimler metal çapakları (%37,6) ve toz (%31,1) olarak saptandı. Hastaların çoğunda (%72,1) iş yerinde yaralanma söz konusuydu. Hastaların %42,4’ü oftalmoloji ile konsülte edilirken, diğer hastalar acil tıp asistan ve uzmanları tarafından tedavi edildi. Hastaların %10’u hastaneye yatırıldı ve %2,3’ünde uzun dönemde komplikasyon görüldü.

CONCLUSION

SONUÇ

Ocular FB involved mainly young healthy males who had sustained work-related injuries. In view of the large number of eye injuries seen in EDs, ED colleagues should train themselves in order to appropriately recognize, treat and refer the SCFB injuries seen in the ED.

Göz yabancı cisim travmaları en çok genç sağlıklı erkeklerin, iş nedenli yaralanmaları olarak oluşmaktadır. Çok sayıda göz travması acil servislerde görüldüğü için, acil servis hekimleri yüzeysel korneal yabancı cisimlerin tanınması, tedavisi ve yönetimi konusunda eğitilmelidir.

Key Words: Emergency department; eye; foreign body; treatment.

Anahtar Sözcükler: Acil servis; göz; yabancı cisim; tedavi.

Department of Emergency Medicine, Akdeniz University Faculty of Medicine, Antalya, Turkey.

Akdeniz Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Antalya.

Correspondence (İletişim): Özlem Yiğit, M.D. Akdeniz Üniversitesi Tıp Fakültesi Acil Tıp ABD, Dumlupınar Bulvarı Kampüs 07059 Antalya, Turkey.

Tel: +090 - 242 - 249 61 83 e-mail (e-posta): ozlemyigit@akdeniz.edu.tr

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Ulus Travma Acil Cerrahi Derg

Ocular trauma is a leading cause of visual impairment and impacts both the individual by affecting their quality of life and the community by causing loss of working capacity. The epidemiology of eye trauma has been well described in developed countries, and the lifetime prevalence of ocular injuries is estimated to be 14.4% to 19.8% in the United States.[1] Local epidemiological data on eye trauma in our country is limited.[2,3] Multiple types of ocular trauma, ranging in a spectrum from minor injuries treated on an outpatient basis to major eye injuries requiring hospitalization, present to the emergency department (ED). Superficial corneal foreign bodies (SCFB) are common injuries presenting to the ED.[4] SCFBs can be removed in the ED with minimal trauma in an aseptic method with adequate topical anesthesia.

The aim of this study was to describe the epidemiology of eye injuries caused by FBs, identify the nature and characteristics of the injuries and treatment(s) rendered, and determine the clinical strategies for the prevention and management of ocular trauma.

MATERIALS AND METHODS This study was carried out as a retrospective chart review in the ED of a tertiary care university hospital with an annual census of approximately 80,000 adult patient visits. The study was approved by the local ethics committee. The ED hospital records for the previous two years were searched to identify all patients visiting the ED with a complaint of eye trauma related to a FB. All patients in the hospital database, which were coded as FB of eye (T15) and ocular trauma (S05) according to the ICD-10 (International Classification of Diseases 10th revision and Clinical Modification) codes were enrolled into the study.

Demographic data including the patient’s age and

Data were analyzed with the SPSS 16.0 for Windows statistical package. The continuous data were presented as mean±SD and the categorical data were presented as frequencies and percentiles. Univariate analyses between two groups for categorical data were performed by chi-square test. A two-sided p value <0.05 was considered as significant.

RESULTS The hospital database identified 476 patients according to the specified ICD-10 codes. 83% (n=398) of the patients were male and 17% (n=78) female. The male-to-female ratio was 5:1. The mean age of the patients included in this study was 34.16±14.02 years (range: 1-88 years). The age groups were subdivided into children (0-18) and adult groups, and adults were subdivided into groups at 15-year intervals. The majority of the patients (77.4%, n=367) were aged 19 to 50 years, while 9.5% (n=45) were aged 18 years or younger (Fig. 1). With respect to the time interval from injury to presentation at the department, 52.9% (n=252) presented within 6 hours of the injury, and 34.4% (n=164) presented within 24 hours (Fig. 2).

Fifty percent (n=238) of the patients sustained injuries to the right eye, 47.9% (n=228) had injuries in-

200

200 Count

300

Count

300

100

0

100

0-18

19-34

35-50

51-65

≥66

Age group

Fig. 1. Distribution of patients by age groups at 15-year intervals.

76

sex, the affected eye, presence of bilateral injury, timing of the injury and presentation, type of injury (open- or closed-globe injuries), and source of FB were recorded. In addition to details about management in the ED, including the clinical findings on slitlamp examination, the need for hospital admission and ophthalmology consultation, the types of procedures done as part of the treatment (which could include procedures such as irrigation, FB removal and surgical operations), and the long-term complications were also recorded.

0

0-6

7-12

13-24

25-72

≥72

Time

Fig. 2. Time interval between injury and presentation.

Ocak - January 2012

Foreign body traumas of the eye managed in an emergency department of a single-institution

Table 1. Injury types among patients Injury type Affected eye Right Left Bilateral Open-globe injury Intraocular foreign body Closed-globe injury Superficial corneal foreign body Under eyelid No foreign body Corneal epithelial defect Yes No

n (%) 238 (50) 228 (47.9) 10 (1.6) 46 (9.7) 42 (8.8) 430 (90.3) 360 (72.6) 28 (5.9) 42 (11.8) 278 (58.4) 198 (41.6)

Table 2. Foreign bodies found in eyes Foreign body Metal fragments Dust Wood splinter Household chemicals Finger and nail tap 25 (5.3) Plastic Glass Plant Stone fragments Insects

n (%) 179 (37.6) 148 (31.1) 49 (10.3) 26 (5.5) 14 (2.9) 11 (2.3) 11 (2.3) 9 (1.9) 4 (0.8)

Table 3. Long-term complications seen after treatment Complication

n (%)

Keratitis Cataract Decreased visual acuity Retinal detachment Hyphema

4 (0.8) 3 (0.6) 2 (0.4) 1 (0.2) 1 (0.2)

volving the left eye, and 1.6% (n=10) of the patients had bilateral injuries. 9.7% (n=46) of the eyes were diagnosed to have an open-globe injury with perforation, and 8.8% (n=42) had intraocular FBs, while the rest (90.3%, n=430) were closed-globe injuries with or without SCFBs. In the eye examination, 72.6% (n=360) of the patients had a SCFB: 18.5% (n=88) of them were in the central area of the cornea and 5.9% (n=28) were under the eyelid; 3.4% (n=16) of the patients had more than one FB. Slit-lamp examination with cobalt blue filter after coloring the eye with fluorescein dye revealed corneal epithelial defects in 58.4% (n=278) of the patients (Table 1).

Cilt - Vol. 18 Sayı - No. 1

The most common FBs causing an injury were metal fragments (37.6%, n=179) and dust (31.1%, n=148). The other FBs and injury mechanisms are shown in Table 2. The majority of the patients (72.1%, n=369) had sustained work-related injuries. Some patients had chemical exposure. Since these patients had symptoms of FB sensation, they were coded as T15 according to the ICD-10 codes and were included in the study group. Most of the chemicals were household cleaning products and soaps.

In the ED, 42.4% (n=202) of the patients were consulted to ophthalmology, and the remaining patients were treated by the emergency physicians. The most common procedure was the removal of FBs, and the most common methods were removal of the FB with a sharp needle after achieving topical anesthesia (48.3%, n=230) and irrigation of the eye (25.4%, n=121). All patients were prescribed topical ��������������������� antibiotics���������� upon discharge from the ED. Only 10% (n=48) of the patients required hospital admission for their eye injury, and 8.7% (n=42) of them required operative management.

Long-term complications were seen in 2.3% (n=11) of the patients, and are listed in Table 3. All patients in whom a complication occurred were consulted to ophthalmology, and none of the patients with FBs treated by the emergency physicians resulted in a long-term complication (p=0.008). Most of the complications (9 of 11) occurred in patients with globe perforation. The effects of other factors on the complication rate were not statistically significant (Table 4).

DISCUSSION Injury is the most common reason for eye-related ED visits, and most eye injuries seen in the ED are Table 4. Factors that can affect the complication rate Complication Corneal abrasion Yes No Globe perforation Yes No Defect location Central (on pupil) Non-central Foreign body Solitary Multiple None Consultation Yes No

Yes (%)

p

6 (1.3) 5 (1.1)

0.793

9 (1.9) 2 (0.4)

0.000

4 (0.8) 7 (1.5)

0.339

7 (1.5) 1 (0.2) 3 (0.6)

0.547

11 (2.3) 0

0.008

77

Ulus Travma Acil Cerrahi Derg

minor. Approximately 1 million eye injury-related ED visits occur each year in the United States, representing less than 2% of all ED visits; most of these injuries do not require hospitalization and likely result in no visual impairment.[4] Since the injuries are commonly superficial, it would seem reasonable to suggest that the burden of eye injuries was more commonly on the health system and economy rather than on the patientâ&#x20AC;&#x2122;s quality of life. However, despite their minimal long-term morbidity, ocular trauma is associated with psycho-morbidity and problems of adjustment.[5] Thus, it is important to consider the full spectrum of eye injuries.

It is commonly recognized that young adult males are more prone to ocular trauma because of the relatively higher tendency for risk-taking behavior and the higher proportion of work-, assault- and sports-related eye injuries, in which there is a significant male preponderance. Most studies in the existing literature have shown that male patients formed the overwhelming majority of patients presenting with eye injuries, ranging from 70% to 87% of all ocular trauma.[6-11] Similar to the literature, 83% of the patients in the present study were male and the mean age was 34.16 years, and this corresponds to most other studies, which reported a mean age of about 30 years.[4,6,10,11] When we considered the setting of the injury, 72.1% of the patients had work-related injuries, and this result is similar to the preexisting literature.[6,10,11] It is also well-known that most eye injuries are preventable with the appropriate use of protective eyewear, yet the use of such equipment is often infrequent. The use of eye protection was not determined in the present study; however, it was thought to be low because of the high work-related injury incidence.

Many studies in the literature have focused on eye injuries that were serious enough to require hospital admission. While those injuries are the most likely to be visually disabling, they are also rare and therefore represent only a small part of the problem.[12-15] Our study has presented the epidemiology of eye injuries treated in the ED. In contrast to existing studies that provide estimates of the rate of severe eye injury only, our study provides a more comprehensive estimate by including a preponderance of such injuries, that is, those not requiring hospitalization. Our results were similar to the other studies including ED patients.[4] Only 10% of the patients required hospital admission for their eye injury, and long-term complications were seen in only 2.3% of the patients in the present study.

The great majority of SCFBs are metallic, followed by stone fragments and wood.[16] The present study revealed similar results. Since the majority of injuries occurred at work while cutting and welding metals, the commonest FBs were metal fragments, which 78

sprayed into the eyes of workers who were not wearing protective devices.

The exact proportion of all eye injuries seen directly by ophthalmologists in EDs is unknown; however, it would not be surprising if the number is low.

In the present study, 57.6% of the patients were treated by emergency physicians without any complication. When evaluating a patient with FB in the eye, two major questions to be answered by the physician are: whether the FB is superficial or intraocular and whether the SCFB can be removed in the ED. If an intraocular FB is suspected, ophthalmology consultation should be done immediately.[17] All patients with perforated eye injury with or without FB were consulted to ophthalmology in the present study. If an uncomplicated SCFB is discovered and the visual acuity and other findings in the slit-lamp examination are normal, the emergency physician should attempt the removal.

After the eye is anesthetized with topical anesthetic, successful removal can often be achieved by irrigation or with a 25-gauge needle.[17] While multiple nondeeply embedded FBs such as dust can be removed successfully with irrigation, the metal fragments usually require needle manipulation. In the present study, 48.3% of patients required needle removal.

If dealt with appropriately, there are usually no long-term sequelae and recovery is rapid, over 24-72 hours. It has been shown that delay in rehabilitation following non-penetrating SCFB is related to two factors: the size of the corneal epithelial defect following FB removal and inadequate removal of corneal rust.

[18] In the present study, corneal epithelial defects were found in 58.4% of the patients; however, the size of the defects and the adequacy of rust removal were not determined.

Once the FB is removed, topical antibiotics may be given for all patients with or without corneal abrasions. In a prospective study, removed FBs were cultured and 32.7% showed positive results, mostly staphylococcal and streptococcal species, therefore mandating treatment with broad-spectrum antibiotics.

[16] Patching is not generally recommended, because studies have shown no significant difference in patient comfort or the healing rate.[19,20] Topical anesthetics should also be avoided, because these agents may hide pain associated with retained FB or corneal ulceration.

[21] In the present study, all patients were prescribed topical antibiotics upon discharge from the ED, and no long-term complications were seen in patients treated by the ED physicians.

In conclusion, ocular trauma in this study involved mainly young healthy males who had sustained workrelated injuries, which can cause significant morbidity. Nevertheless, most occupational accidents can be Ocak - January 2012

Foreign body traumas of the eye managed in an emergency department of a single-institution

avoided with utilization of better protective devices in order to reduce the incidence of injuries and socioeconomic damage. Finally, given the large number of eye injuries seen in EDs, emergency medicine colleagues should train themselves in order to appropriately recognize, treat and refer the SCFB injuries seen in the ED.

REFERENCES 1. Wong TY, Klein BE, Klein R. The prevalence and 5-year incidence of ocular trauma. The Beaver Dam Eye Study. Ophthalmology 2000;107:2196-202.

2. Akdur O, Ozkan S, Erkılıc K, Durukan P, Duman A, Ikizceli I. Evaluation of ocular trauma cases presenting to the emergency department JAEM 2009;8:47-50 3. Ustundag M, Orak M, Guloglu C, Sayhan MB, Ozhasenekler A. Retrospective evaluation of eye injury victims presented to emergency department. Turk J Emerg Med 2007;7:64-7.

4. McGwin G Jr, Owsley C. Incidence of emergency department-treated eye injury in the United States. Arch Ophthalmol 2005;123:662-6.

5. Alexander DA, Kemp RV, Klein S, Forrester JV. Psychiatric sequelae and psychosocial adjustment following ocular trauma: a retrospective pilot study. Br J Ophthalmol 2001;85:560-2.

6. Woo JH, Sundar G. Eye injuries in Singapore-don’t risk it.

Do more. A prospective study. Ann Acad Med Singapore 2006;35:706-18.

7. Glynn RJ, Seddon JM, Berlin BM. The incidence of eye injuries in New England adults. Arch Ophthalmol 1988;106:7859.

8. Katz J, Tielsch JM. Lifetime prevalence of ocular injuries from the Baltimore Eye Survey. Arch Ophthalmol 1993;111:1564-8.

9. Wong TY, Smith GS, Lincoln AE, Tielsch JM. Ocular trauma

Cilt - Vol. 18 Sayı - No. 1

in the United States Army: hospitalization records from 1985 through 1994. Am J Ophthalmol 2000;129:645-50.

10. Schein OD, Hibberd PL, Shingleton BJ, Kunzweiler T, Frambach DA, Seddon JM, et al. The spectrum and burden of ocular injury. Ophthalmology 1988;95:300-5.

11. Macewen CJ. Eye injuries: a prospective survey of 5671 cases. Br J Ophthalmol 1989;73:888-94.

12. Desai P, MacEwen CJ, Baines P, Minassian DC. Incidence of cases of ocular trauma admitted to hospital and incidence of blinding outcome. Br J Ophthalmol 1996;80:592-6.

13. Klopfer J, Tielsch JM, Vitale S, See LC, Canner JK. Ocular trauma in the United States. Eye injuries resulting in hospitalization, 1984 through 1987. Arch Ophthalmol 1992;110:83842.

14. Fong LP. Eye injuries in Victoria, Australia. Med J Aust.

1995;162:64-8.

15. Wong TY, Tielsch JM. A population-based study on the incidence of severe ocular trauma in Singapore. Am J Ophthalmol 1999;128:345-51.

16. Macedo Filho ET, Lago A, Duarte K, Liang SJ, Lima AL, Freitas D. Superficial corneal foreign body: laboratory and epidemiologic aspects. Arq Bras Oftalmol 2005;68:821-3.

17. Babineau MR, Sanchez LD. Ophthalmologic procedures in the emergency department. Emerg Med Clin North Am 2008;26:17-34, v-vi.

18. Jayamanne DG, Bell RW. Non-penetrating corneal foreign body injuries: factors affecting delay in rehabilitation of patients. J Accid Emerg Med 1994;11:195-7.

19. Arbour JD, Brunette I, Boisjoly HM, Shi ZH, Dumas J, Guertin MC. Should we patch corneal erosions? Arch Ophthalmol 1997;115:313-7.

20. Wilson SA, Last A. Management of corneal abrasions. Am Fam Physician 2004;70:123-8.

21. Newell SW. Management of corneal foreign bodies. Am Fam Physician 1985;31:149-56.

79

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):80-82

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.00908

Vertebra kırığı veya çıkığı olmaksızın gelişen çift seviyeli omurilik yaralanması: Olgu sunumu Double-level spinal cord injury without vertebral fracture or dislocation: A case report Mehmet ATILGAN

Direkt radyografi veya bilgisayarlı tomografide (BT) vertebralarda kırık veya çıkık bulguları olmaksızın görülen omurilik yaralanmaları SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) olarak adlandırılmaktadır. Bu tür yaralanmalar, omurganın kendine özgü anatomik ve fonksiyonel özellikleri nedeniyle çocuklarda daha sık görülür. Bu yazıda, anatomik olarak tam kat kesi ile birlikte ve iki seviyede aynı anda olarak görülen nadir bir SCIWORA olgusunun sunulması ve SCIWORA’nın adli tıp açısından öneminin vurgulanması amaçlandı. Üç yaşında bir erkek çocuğu otomobil çarpması sonrasında paraplejik halde acil servise getirıldi, BT’de ve direkt radyografik incelemelerde herhangi bir kemik kırığı veya çıkık olmamakla birlikte manyetik rezonans görüntülemede T3-4 ve T6-7 seviyelerinde omurilikte tama yakın ve tam kat kesi ile bütünlük kaybı izlendi. Bugüne kadar literatürde sadece iki adet çift seviyeli SCIWORA olgusu bildirilmiştir. Ancak bu olgu çift seviyeli SCIWORA’nın tam kat kesi ile birlikte görüldüğü ilk olgudur. Trafik kazasının adli tıp açısından rekonstrüksiyonu ile ilgili olarak bu olgudaki yaralanma mekanizması tam anlaşılamamıştır.

Spinal cord injuries without evidence of vertebral fracture or dislocation on plain radiographs and computed tomography are referred to as SCIWORA (Spinal Cord Injury without Radiological Abnormality). This entity is seen more often in children due to the specific anatomical and functional properties of the pediatric spine. The aim of this study was to present a rare case in which SCIWORA occurred at two levels simultaneously with complete anatomic transection and to emphasize the importance of SCIWORA in forensic medicine. A three-year-old boy was admitted to the emergency department with paraplegia after being hit by a car.

Computed tomography and plain radiographs failed to reveal any bone fracture or dislocation. However, magnetic resonance imaging showed loss of continuity with nearcomplete and complete anatomic transection of the spinal cord at the T3-4 and T6-7 levels. According to the literature, only two cases of double-level SCIWORA have been reported previously. However, this is the first case of double-level SCIWORA with complete anatomic transection.

The mechanism of injury in the case reported here remains obscure regarding the forensic reconstruction of the event.

Anahtar Sözcükler: SCIWORA, omurilik yaralanması, adli tıp

Key Words: SCIWORA; spinal cord injury; forensic medicine.

Direkt radyografi ve bilgisayarlı tomografide (BT) vertebralarda kırık veya çıkık bulguları olmaksızın görülen omurilik yaralanmaları ilk olarak 1982’de Pang ve Wilberger tarafından SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) olarak adlandırılmıştır.[1] Çocuk vertebralarının faset ek-

lem yüzeylerinin daha yatay olması, vertebraların öne doğru kamalaşma göstermesi ve eklem kapsülleri ile bağların daha elastik olması gibi omurgalarının erişkinlere oranla daha esnek olmasını sağlayan kendine özgü anatomik ve fonksiyonel özellikleri nedeniyle bu tür yaralanmalar çocuklarda daha sık görülür.[2,3]

8. Adli Bilimler Kongresi’nde poster bildirisi olarak sunulmuştur (15-18 Mayıs 2008, Kocaeli).

Presented at the 8th Forensic Sciences Congress (May 15-18, 2008, Kocaeli, Turkey).

Akdeniz Üniversitesi Tıp Fakültesi, Adli Tıp Anabilim Dalı, Antalya.

Department of Forensic Medicine, Akdeniz University Faculty of Medicine, Antalya, Turkey.

İletişim (Correspondence): Dr. Mehmet Atılgan. Akdeniz Üniversitesi Tıp Fakültesi Hastanesi, C Blok, Zemin Kat, Arapsuyu, Antalya, Turkey.

Tel: +90 - 242 - 249 63 75 e-posta (e-mail): atilgan@akdeniz.edu.tr

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Vertebra kırığı veya çıkığı olmaksızın gelişen çift seviyeli omurilik yaralanması

nografisinde, BT’de ve direkt radyografilerde herhangi bir patoloji veya kırık-çıkık saptanmamasına karşın servikal-torakal MRG’de T3-4 ve T6-7 vertebralar seviyesinde omurilikte tama yakın ve tam kat kesi ile bu iki seviye arasında sinyal intensitesinde artış ve bütünlük kaybı izlenmişti (Şekil 1a, b ve 2a, b). Beyin cerrahi servisinde 15 gün takip edildikten sonra T4 vertebra altı seviyeden paraplejik halde önerilerle taburcu edilmişti. Olgunun son kontrolünde paraplejisi devam ediyordu.

(a)

(b)

Şekil 1. (a) Servikal-torakal manyetik rezonans görüntülemede T1 ağırlıklı sagittal kesitte T3-4 ve T6-7 vertebralar seviyesinde omurilikte tama yakın ve tam kat kesi. (b) T2 ağırlıklı sajital kesitte posttravmatik intensite değişiklikleri.

TARTIŞMA Olguda torakal seviyedeki omurilikte saptanan, iki ayrı yerde ve biri tama yakın diğeri tam kat kesi şeklindeki yaralanma, aracın şiddetli bir şekilde çarpmasının göstergesi olabilir. Omurganın aşırı fleksiyon ve ekstansiyonu olası bir mekanizma gibi görülmekle birlikte çocukta ayrıca ölümcül yaralanmanın olmaması bu travmadaki mekanizmayı açıklamakta güçlük yaratmaktadır. Literatürde bu güne kadar iki seviyede aynı anda görülen sadece iki adet SCIWORA olgusu bildirilmiş,[3,8] ancak biri tam kat kesi şeklinde olan olguya rastlanmamıştır.

Çocukluk çağında görülen tüm omurilik yaralanmalarının %19-34’ünün SCIWORA şeklinde olduğu bildirilmiştir.[4] Trafik kazaları başta olmak üzere yüksekten düşmeler, spor kazaları, doğum travmaları ve çocuk istismarı olguları SCIWORA nedenleri arasında yer almaktadır.[2,4-6] SCIWORA olgularında direkt radyografilerin ve BT’nin tanısal değeri olmamasına karşın, manyetik rezonans görüntüleme (MRG) tanı koydurucudur.[2,7] Omuriliğin her seviyesinde görülmekle birlikte bu güne kadar literatürde iki seviyede birden görülen sadece iki adet SCIWORA olgusu bildirilmiştir.[3,8]

(a)

Bu yazıda, anatomik olarak tam kat kesi birlikte ve iki seviyede aynı anda gelişmiş nadir bir SCIWORA olgusu literatür eşliğinde sunuldu, ayrıca SCIWORA’nın adli tıp açısından önemi tartışıldı.

OLGU SUNUMU Araç dışı trafik kazası nedeniyle acil servise getirilen 3 yaşında bir erkek çocuğunun yapılan fiziksel incelemesinde; bilincinin bulanık, genel durumunun kötü olduğu gözlenmiş, alında sıyrıklar, çenede 3 cm’lik, göğsün sol ön yüzünde 5. kot orta hatta genişliği 2 cm, derinliği 1,5 cm toraks boşluğu ile ilişkisiz, sol önkol arka yüzde 2 cm’lik kesiler saptanmıştı. Nörolojik incelemesinde alt ekstremitelerde kuvvet kaybı tespit edilmiş, spontan ve ağrılı uyarana herhangi bir motor yanıt alınamadığı, derin tendon reflekslerinin alt ekstremitede negatif ve Babinski refleksinin iki taraflı lakayıt olduğu belirlenmiş, karın ultrasoCilt - Vol. 18 Sayı - No. 1

(b) Şekil 2. (a) Manyetik rezonans görüntülemede T2 ağırlıklı transvers kesitlerde omurilikte T3-4 seviyesinde tama yakın, (b) T6-7 seviyesinde tam kat kesi bulguları.

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Vertebralarda kırık veya çıkık bulguları olmaksızın görülen omurilik yaralanmalarının meydana geldiği olgular adli tıp açısından özel önem taşıyabilir.

[5,6,9] Ergun ve Oder tarafından yapılan bir çalışmada 12 yaşındaki bir kız çocuğunda olaydan 2 yıl sonra tanısı konmuş bir SCIWORA olgusundan bahsedilmiştir. Bu olguda bir sigorta şirketi tarafından omurilikteki iskemik tarzdaki lezyonun çocuğun kendisinde önceden var olan damar anomalisi gibi bir hastalığa mı yoksa kaza sonucu travmaya mı bağlı olduğunun araştırılması istenmiş, yapılan incelemede okuldan eve dönerken yolda kayarak dizlerinin üzerine düşme gibi önemsenmeyen küçük bir travma sonucunda olduğu ortaya çıkarılmıştır.[9] SCIWORA’nın ayırıcı tanısında damar anomalisi yanı sıra vertebral arterin travmatik olmayan tromboembolizmi, omuriliğin akut ya da kronik enflamasyonu da düşünülmeli, minör travmalardan sonra bile vertebralarda kırık veya çıkık bulguları olmadan omurilik lezyonu görülebileceği akla gelmelidir.[9,10] Adli tıp açısından önemli diğer bir konu SCIWORA’nın fiziksel çocuk istismarı olgularında da görülebilmesidir. Pang tarafından SCIWORA olgularının incelendiği bir çalışmada 95 olgunun 4’ünde, Launay ve arkadaşlarının meta-analiz çalışmasında ise %3 oranında yaralanma nedeninin çocuk istismarı olduğu bildirilmiştir.[2,4] SCIWORA fiziksel çocuk istismarında postmortem incelemelerde öldürücü kafa ve karın travmalarıyla birlikte tespit edilebildiği gibi, canlı olgularda ve izole olarak da görülebilir.[5,6] SCIWORA olgularının %20-50’sinde nörolojik bulguların ortaya çıkması 30 dakikadan başlayarak 4 güne kadar gecikebilir.[11] Bu nedenle nörolojik incelemeler belirli aralıklarla tekrarlanmalı ve tanıda MRG’nin önemi unutulmamalıdır.[2,7] Direkt radyografi ve BT’de vertebralarda kırık

82

veya çıkık bulguları olmaksızın görülen omurilik yaralanmaları (SCIWORA), gerek yaralanma mekanizması ve olayın rekonstrüksiyonu gerekse nedenleri bakımından medikolegal açıdan önemlidir. Özellikle bilinç kaybı olan küçük çocuklarda birlikte görülebilecek diğer yaralanmaların bulguları maskeleyebileceği ve SCIWORA’nın fiziksel çocuk istismarının bir göstergesi olabileceği akılda tutulmalıdır.

KAYNAKLAR. 1. Pang D, Wilberger JE Jr. Spinal cord injury without radiographic abnormalities in children. J Neurosurg 1982;57:11429.

2. Pang D. Spinal cord injury without radiographic abnormality in children, 2 decades later. Neurosurgery 2004;55:1325-43.

3. Duprez T, De Merlier Y, Clapuyt P, Clément de Cléty S, Cosnard G, Gadisseux JF. Early cord degeneration in bifocal SCIWORA: a case report. Spinal Cord Injury Without Radiographic Abnormalities. Pediatr Radiol 1998;28:186-8.

4. Launay F, Leet AI, Sponseller PD. Pediatric spinal cord injury without radiographic abnormality: a meta-analysis. Clin Orthop Relat Res 2005:166-70.

5. Piatt JH Jr., Steinberg M. Isolated spinal cord injury as a presentation of child abuse. Pediatrics 1995;96:780-82.

6. Gosnold JK, Sivaloganathan S. Spinal cord damage in a case of non-accidental injury in children. Med Sci Law 1980;20:54-7.

7. Leventhal MR. Fractures, dislocations, fracture-dislocations of spine. In: Canale ST, editor. Campbell’s operative orthopaedics. 9th ed. St. Louis: Mosby; 1998. p. 2704-90.

8. Pollina J, Li V. Tandem spinal cord injuries without radiographic abnormalities in a young child. Pediatr Neurosurg 1999;30:263-6.

9. Ergun A, Oder W. Pediatric care report of spinal cord injury without radiographic abnormality (SCIWORA): case report and literature review. Spinal Cord 2003;41:249-53.

10. Yamaguchi S, Hida K, Akino M, Yano S, Saito H, Iwasaki Y. A case of pediatric thoracic SCIWORA following minor trauma. Childs Nerv Syst 2002;18:241-3.

11. Ruge JR, Sinson GP, McLone DG, Cerullo LJ. Pediatric spinal injury: the very young. J Neurosurg 1988;68:25-30.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):83-86

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.97820

Repair of an extensive iatrogenic tracheal rupture with a pleural patch and a vascular graft Geniş iyatrojenik trakea rüptürünün vasküler ve plevral yama ile onarımı Erdal Birol BOSTANCI,1 İlter ÖZER,1 Feza EKİZ,1 Ali Emre ATICI,1 Enver REYHAN,1 Musa AKOĞLU,1 Atakan ERKILINÇ,2 Cevat YAKUT3

Here we describe a 48-year-old woman who suffered a 7-cm rupture in the lower trachea after intubation with a double-lumen tube. We repaired the rupture with a new technique using a pleural patch reinforced by a ringed vascular graft. This technique appears to be appropriate for use in patients who have large tracheal ruptures to avoid tracheal stenosis.

Biz burada çift lümenli endotrakeal tüp ile entübasyon sonrasında 7 cm’lik trakeal rüptür oluşan 48 yaşındaki hastayı sunmak istiyoruz. Ringli vasküler greft ile desteklenmiş plevral yama kullanılarak yeni bir teknik ile trakea yaralanması onarıldı. Bu tekniğin büyük trakea yaralanması olan hastalarda kullanımı trakea stenozunu önleme açısından uygun olabilir.

Key Words: Double-lumen endotracheal tube; pleural patch; tracheal rupture.

Anahtar Sözcükler: Çift lümenli endotrakeal tüp; plevral yama; trakea rüptürü.

Tracheobronchial rupture occurs rarely after single- or double-lumen endobronchial intubation, but is a life-threatening injury because it can lead to respiratory failure. The diagnosis is not difficult if the injury obviously impairs the respiratory parameters and the physician is aware of the possibility that a tracheobronchial rupture has occurred.

CASE REPORT A 48-year-old woman (weight 64 kg, height 1.61 m) was admitted to our hospital with a diagnosis of adenocarcinoma in the middle part of the intrathoracic esophagus. No distant metastases were found during the preoperative evaluation, and the patient underwent a three-stage esophagectomy.

We describe herein a 48-year-old woman who experienced a rupture in the lower trachea after intubation with a double-lumen tube. We repaired the rupture with a new technique using a pleural patch reinforced by a ringed vascular graft.

A left-sided double-lumen endobronchial tube (37 French) was placed with some difficulty with the use of a stylet. Dissection of the esophagus was performed without difficulty and the adjacent organs were not found to be invaded. The tumor was located in the

Presented at the 18th World Congress of the International Association of Surgeons, Gastroenterologists and Oncologists (October 8-11, 2008, Istanbul, Turkey).

Uluslararası Cerrahlar, Gastroenterologlar ve Onkologlar Birliği 18. Dünya Kongresi’nde sunulmuştur (8-11 Ekim 2008, İstanbul, Türkiye).

Departments of 1Gastrointestinal Surgery, Anesthesiology and Reanimation, 3Cardiovascular Surgery, Kartal Kosuyolu Yuksek Ihtisas Training and Research Hospital, Istanbul, Turkey.

Kartal Koşuyolu Yüksek İhtisas Hastanesi Eğitim ve Araştırma Hastanesi, 1 Gastroenteroloji Cerrahisi Kliniği, 2 Anesteziyoloji ve Reanimasyon Kliniği, 3Kardiovasküler Cerrahi Kliniği, İstanbul.

2

Correspondence (İletişim): Ali Emre Atıcı, M.D. Kentplus Sitesi, D6 Blok D: 11, Batı Ataşehir, İstanbul, Turkey.

Tel: +90 - 216 - 459 44 40 e-mail (e-posta): aeatici@gmail.com

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Ulus Travma Acil Cerrahi Derg

middle third of the esophagus, inferior to the carina.

The abdominal, thoracic and cervical steps of the operation were uneventful. A chest tube was inserted in the right hemithorax. The patient’s physiologic parameters were normal throughout the operation.

Just after the operation, while the patient was still on the operating table, the double-lumen tube was replaced by a standard single-lumen endotracheal tube, and subcutaneous emphysema occurred in the upper region of the right hemithorax.

While the patient was being transported to the intensive care unit, the chest tube was clamped, and therefore air leakage from the tube was not apparent. However, by the time the patient arrived in the unit, her subcutaneous emphysema had increased obviously. She had severe cyanosis and her ventilatory parameters were deteriorating. Blood gas evaluation revealed an increased PCO2 (76 mmHg), a decreased PO2 (53 mmHg), and severe acidosis (pH 7.12). When the chest tube clamp was removed, a large amount of gas leakage was noted. The patient’s hemodynamic status deteriorated due to hypoventilation and the resulting hypoxia.

A chest X-ray showed severe right-sided pneumothorax despite the presence of the chest tube in the right hemithorax. Because the patient’s condition had markedly worsened after placement of the singlelumen endotracheal tube, this was replaced with a left-sided double lumen tube, as had been used previously. As soon as the left lumen balloon was inflated, the leakage of air from the chest tube ceased. When the balloon was deflated, the leakage was observed again, and upon reinflation the leakage stopped. After placement of the double-lumen tube, the patient’s physiologic parameters improved; PCO2 decreased to 46 mmHg, PO2 increased to 93 mmHg, and pH increased from 7.12 to 7.3. Her blood pressure returned to normal. Bronchoscopy, which could have been used to confirm the rupture, was unfortunately not available at the time.

Collectively, the patient’s findings indicated a tracheal and/or bronchial rupture on the right side. The patient was evaluated by cardiothoracic surgeons, and as her general condition and hemodynamic status were stable after the insertion of the double-lumen tube, reoperation to repair the rupture was performed the following morning to provide better conditions. The patient’s general condition and hemodynamic parameters remained stable until the reoperation. For this second operation, the right thoracotomy incision was reopened. A 7-cm long rupture in the posterior (membranous) aspect of the trachea was found just above the carina. To repair the tracheal injury, an 8 cm x 2 cm patch was harvested from the pleura. This was hard84

ened by exposure to glutaraldehyde as follows. The patch was spread flat; 1 ml of a 25% solution of glutaraldehyde was mixed with 1 ml of physiologic saline, and this mixture was squirted onto the patch with a syringe. After a few seconds, the patch was washed 3 times with physiologic saline.

Around the tracheal rupture site, interrupted 3-0 polypropylene sutures (Prolene®, Ethicon, Inc., Somerville, NJ, USA) were placed at a distance of 5 mm from the edge of the wound, and separated from each other by intervals of 1 cm. These sutures were left untied. The pleural patch was then trimmed to a spindle shape so as to cover the tracheal rupture site and was attached to the edges of the wound with continuous 5-0 polypropylene sutures. A ringed vascular graft made of polytetrafluoroethylene (Gore-Tex®, W. L. Gore & Associates, Inc., Flagstaff, AZ, USA) was then bisected along the long axis, with one half being further cut into shape so as to provide a slightly arched structure over the pleural patch for reinforcement. The shaped vascular graft was then placed over the pleural patch, and the two ends of each previously placed, as yet untied suture were then passed through the nearest part of the vascular graft, with one of the ends being on either side of a ring in the graft (Fig. 1). Thus, when the ends were tied, the knot was located on the ring in the graft. This was repeated for the other remaining sutures around the perimeter of the graft.

Fig. 1. After being trimmed into shape, the ringed vascular graft was positioned over the pleural patch and was sutured with the previously placed, as yet untied polypropylene sutures, with the two ends of each suture passing on opposite sides of a ring in the graft.

Ocak - January 2012

Repair of an extensive iatrogenic tracheal rupture with a pleural patch and a vascular graft

Two chest tubes were placed in the right hemithorax and the incision was closed. The patient’s postoperative course was uneventful and she was extubated the following day. The patient began oral feeding on postoperative day 10, and the chest tubes were removed on postoperative day 14. She experienced pneumonia, which was treated with systemic antibiotics, and she was discharged on postoperative day 21 with no respiratory or swallowing problems.

At a follow-up visit two months after the patient was discharged from the hospital, computed tomography and bronchoscopy showed no tracheal stenosis, and granulation tissue was observed on bronchoscopy (Fig. 2). The patient is now in the 9th month of followup and has had no further complaints.

DISCUSSION Tracheobronchial rupture is a rare complication of procedures that involve the placement of instruments in the trachea or bronchi, such as bronchoscopy or intubation, especially intubation with double-lumen tubes.[1] Risk factors include emergency intubation, multiple and vigorous attempts at intubation, inexperience in intubation, overinflation of the tube cuff, malposition of the tube, improper tube size, inappropriate use of stylets, abrupt movement by the patient, excessive coughing, female gender, and short stature.

[1,2] Our patient was female and of short stature, a stylet was used during her initial intubation, and the intubation was difficult.

The main clinical manifestations of tracheobronchial rupture are subcutaneous emphysema, hemoptysis and dyspnea. However, the diagnosis can be delayed because of varying intervals between occurrence of the rupture and onset of clinical symptoms.[3] Intervals of up to 126 hours between injury and diagnosis have been reported.[4] In our patient, tracheal rupture was diagnosed immediately because of the acute onset of severe symptoms and deterioration of respiratory parameters. As soon as a tracheal injury was suspected, the patient was reintubated with a left-sided double-lumen tube, the cuff was inflated, and the patient’s general condition, blood gas values and hemodynamic parameters improved immediately.

While the patient was being transported to the intensive care unit, the chest tube was clamped, thus no air leak was seen. A clamped chest tube is dangerous in mechanically ventilated patients who undergo pulmonary surgery. In this patient, esophageal resection was performed. The right lung was inflated before the thoracotomy was closed, and no air leak was observed. We perform 20-25 esophagectomies per year and have not experienced any problem due to clamping. However, after this unexpected experience, we do not clamp the chest tubes, although we can transfer Cilt - Vol. 18 Sayı - No. 1

Fig. 2. Bronchoscopy image obtained two months after discharge from the hospital.

our patients to the intensive care unit in only a few minutes. Chest tubes should be left open against potential tracheobronchial or pulmonary injuries. This case emphasizes the importance of patient transfer after esophageal surgery.

Treatment for tracheobronchial rupture depends on the size and location of the injury and the patient’s clinical presentation and general condition.[5] Surgery is the main choice of treatment for the majority of patients. The outcome of treatment depends on the rapidity of diagnosis, because early treatment helps to minimize mediastinitis. Ruptures larger than 2 cm, injuries involving the paracarinal region, presence of respiratory distress, rapidly increasing subcutaneous and mediastinal emphysema, and pneumothorax showing continuous air leak are indications for surgery.[1,5] For the surgical repair of tracheal ruptures, various methods have been described, involving direct suturing of the trachea,[6] which may be reinforced by flaps from nearby tissues such as the pectoralis muscle.[7] A method using a pericardial flap reinforced by a GoreTex® soft tissue patch has been described,[8] and free pericardial patch repair has also been used, with reinforcement provided by a pedicled muscle flap.[9] A potential consequence of tracheal rupture and repair is tracheal stenosis, particularly in patients with small-caliber tracheas. In the repair of large tracheal 85

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ruptures, direct suturing of the torn edges of the rupture might therefore be less appropriate than the use of methods that do not involve direct apposition of the edges. For our patient, who had a small-caliber trachea and a large rupture, we preferred to use a pleural patch reinforced with a ringed polytetrafluoroethylene vascular graft to help avoid later tracheal stenosis. We considered a pleural patch to be more appropriate than one taken from the pericardium, because the presence of the right thoracotomy provided ready access to the pleura, whereas harvesting a pericardial graft would have required an additional procedure, possibly leading to further complications. The reason for using the pleura at all was to reduce the possibility of air leak, which would likely occur if the vascular graft was used alone. With this in mind, the pleural patch was attached to the torn tracheal edges with continuous sutures. The use of glutaraldehyde to harden the pleura made suturing easier. The rationale for using a ringed vascular graft was that it provides a slightly arched, reinforced structure to help prevent collapse of the pleural patch into the trachea. The rings also help prevent the sutures from pulling through the graft, a problem that can occur with other types of polytetrafluoroethylene grafts. Two months after the patient was discharged, a bronchoscopy was carried out to evaluate the results of our repair, and no stenosis was observed.

To our knowledge, this is the first reported use of a ringed vascular graft in the repair of a tracheal rupture.

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This technique appears to be appropriate for use in patients who have large tracheal ruptures.

REFERENCES 1. Leinung S, Möbius C, Hofmann HS, Ott R, Rüffert H, Schuster E, et al. Iatrogenic tracheobronchial ruptures - treatment and outcomes. Interact Cardiovasc Thorac Surg 2006;5:303-6.

2. Liu H, Jahr JS, Sullivan E, Waters PF. Tracheobronchial rupture after double-lumen endotracheal intubation. J Cardiothorac Vasc Anesth 2004;18:228-33.

3. Miñambres E, González-Castro A, Burón J, Suberviola B, Ballesteros MA, Ortiz-Melón F. Management of postintubation tracheobronchial rupture: our experience and a review of the literature. Eur J Emerg Med 2007;14:177-9.

4. Massard G, Rougé C, Dabbagh A, Kessler R, Hentz JG, Roeslin N, et al. Tracheobronchial lacerations after intubation and tracheostomy. Ann Thorac Surg 1996;61:1483-7.

5. Borasio P, Ardissone F, Chiampo G. Post-intubation tracheal rupture. A report on ten cases. Eur J Cardiothorac Surg 1997;12:98-100.

6. Hofmann HS, Rettig G, Radke J, Neef H, Silber RE. Iatrogenic ruptures of the tracheobronchial tree. Eur J Cardiothorac Surg 2002;21:649-52.

7. Kaloud H, Smolle-Juettner FM, Prause G, List WF. Iatrogenic ruptures of the tracheobronchial tree. Chest 1997;112:774-8.

8. Hasse J. Patch-closure of tracheal defects with pericardium/ PTFE. A new technique in extended pneumonectomy with carinal resection. Eur J Cardiothorac Surg 1990;4:412-6.

9. Foroulis CN, Simeoforidou M, Michaloudis D, Hatzitheofilou K. Pericardial patch repair of an extensive longitudinal iatrogenic rupture of the intrathoracic membranous trachea.

Interact Cardiovasc Thorac Surg 2003;2:595-7.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):87-88

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.04874

Traditional Kehr’s sign: Left shoulder pain related to splenic abscess Geleneksel Kehr bulgusu: Splenik apseye bağlı sol omuz ağrısı Seçgin SÖYÜNCÜ, Fırat BEKTAŞ, Yıldıray ÇETE

Kehr’s sign was originally described by the German surgeon Hans Kehr (1862-1916). It is a classical example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the clavicle.

We present a case of a 21-year-old woman admitted to the emergency department with the chief complaint of left shoulder pain related to splenic abscess.

Kehr bulgusu ilk olarak Alman cerrah Hans Kehr (1862– 1916) tarafından tanımlanmıştır. Kehr bulgusu yansıyan ağrının klasik bir örneğidir. Diyafram irritasyonu klavikulanın üzerindeki bir bölgede ağrı duyusu olarak frenik sinir tarafından oluşturulur. Acil servise sol omuz ağrısı nedeniyle başvuran ve splenik apse tanısı konulan 21 yaşındaki kadın olguyu sunduk.

Key Words: Kehr’s sign; referred pain; splenic abscess.

Anahtar Sözcükler: Kehr işareti; yansıyan ağrı; dalak apsesi.

Kehr’s sign was originally described by the German surgeon Hans Kehr (1862-1916).[1] It is a classical example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the clavicle.

intact. Abdominal and other physical examinations were normal. Her white blood cell count was 18.4 x 103/mm3 (4.8-10.8 x 103/mm3). Since she had been operated recently, the pain was thought to be Kehr’s sign, and an abdominal computed tomography (CT) was ordered. As can be seen in the abdominal tomography, the cause of Kehr’s sign in this patient was the splenic abscess (Fig. 1). The patient was hospitalized and splenectomy was performed under general anesthesia. She was discharged from the hospital 10 days postoperatively, during which she was tolerating a full liquid diet and had resumed bowel function.

We present a case of a 21-year-old woman admitted to the emergency department with the chief complaint of left shoulder pain related to splenic abscess.

CASE REPORT A 21-year-old woman presented to the emergency department (ED) with the chief complaint of left shoulder pain. The pain had lasted for one week without any other complaint. Her medical history revealed that she had been operated for achalasia one month ago. Her vital signs were as follows: blood pressure 125/75 mmHg, pulse rate 96 beats/minute, respiratory rate 18 breaths/minute, axillary temperature 37ºC, and SPO2 98% by pulse-oximeter in room air. Left shoulder joint movements and range of motion were fully normal and painless in the physical examination.

Neurovascular findings of the upper extremity were

Department of Emergency Medicine, Akdeniz University Faculty of Medicine, Antalya, Turkey.

DISCUSSION The review of the literature showed a number of case reports mentioning “Kehr’s sign”.[2,3] One report was about splenic rupture and the other was phrenic artery rupture. Kehr’s sign due to splenic abscess was not reported in the past articles. Although splenic abscess is rare, it has a high mortality rate if there is a delay in diagnosis and treatment. The clinical triad of splenic abscess is fever, left upper abdominal pain and

Akdeniz Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Antalya.

Correspondence (İletişim): Fırat Bektaş, M.D. Akdeniz Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Kampüs 07059 Antalya, Turkey.

Tel: +90 - 242 - 249 61 78 e-mail (e-posta): fbektas@akdeniz.edu.tr

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Fig. 1. Abdominal tomography demonstrates splenic abscess causing Kehr’s sign.

leukocytosis. With the combination of the clinical triad and imaging findings, the diagnostic rate increased to 86.7%.[4] The only positive component in our patient from this triad was the leukocytosis, and she had no left abdominal pain or fever. The nonspecific clinical presentation as described in our patient should be thoroughly investigated, and CT, the most sensitive diagnostic tool, should be used whenever splenic abscess is suspected.[4]

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Since the technologic development of new devices and diagnostic modalities are growing rapidly, the detailed medical history and physical examination have lessened in importance. Many physicians waive a detailed examination and conduct many more laboratory tests and imaging studies. The responsibility of caring for many different kinds of patients at the same time and overcrowding in the EDs have given rise to the use of more diagnostic modalities despite indications, and this approach decreases cost-effectiveness. The art of medicine and of traditional physical processes should never be forgotten as a result of technologic development, and every physician should teach this art skillfully to young practitioners.

REFERENCES 1. Russell RCG. Spleen. In: Mann CV, Russell RCG, editors.

Bailey and Loves’ short practice of surgery. London: Chapman & Hall; 1992. p. 1038.

2. Sutton CD, Marshall LJ, White SA, Berry DP, Dennison AR. Kehr’s sign - a rare cause: spontaneous phrenic artery rupture. ANZ J Surg 2002;72:913-4.

3. Lowenfels AB. Kehr’s sign-a neglected aid in rupture of the spleen. N Engl J Med 1966;274:1019.

4. Ng KK, Lee TY, Wan YL, Tan CF, Lui KW, Cheung YC, et al. Splenic abscess: diagnosis and management. Hepatogastroenterology 2002;49:567-71.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):89-91

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.90912

A fish bone causing ileal perforation in the terminal ileum Balık kılçığının neden olduğu terminal ileum perforasyonu Ayhan MUTLU,1 Ender UYSAL,2 Levent ULUSOY,1 Cihan DURAN,1 Derya SELAMOĞLU1

Foreign body perforation of the gastrointestinal (GI) tract has diverse clinical manifestations, and the correct preoperative diagnosis is seldom made. We report the case of a 69-year-old woman who experienced severe pain in the right iliac fossa. The presumptive diagnosis was acute purulent appendicitis or diverticulitis. Multidetector computed tomography (MDCT) imaging showed the fish bone perforation of the terminal ileum. A high index of suspicion should always be maintained in order for the correct diagnosis to be made.

Gastrointestinal sistemin yabancı cisimlerle perforasyonu farklı klinik tablolarla kendini gösterebilir ve operasyon öncesi doğru tanı nadiren konulur. Biz hastanemize sağ alt karın ağrısı ile başvuran, klinik olarak akut apandisit ve divertikülit öntanıları düşünülen, 69 yaşındaki kadın hastanın multidedektör bilgisayarlı tomografi incelemesinde balık kılçığına bağlı terminal ileum perforasyonu saptadık. Bu gibi olgularda doğru tanı koyabilmek için öncelikle klinik olarak şüphelenmek gerekir.

Key Words: Bowel perforation; fishbone; multidetector computed tomography.

Anahtar Sözcükler: Bağırsak perforasyonu; balık kılçığı; multidedektör bilgisayarlı tomografi.

Foreign body (FB) ingestion is a common clinical problem seen in emergency departments. Most ingested FBs pass through the gastrointestinal (GI) tract uneventfully within one week,[1] and GI perforation is rare, occurring in less than 1% of patients.[2,3] Fish bones are the most commonly ingested objects and the most common cause of FB perforation of the GI tract. FB perforation of the GI tract has diverse clinical manifestations, and the correct preoperative diagnosis is seldom made.

revealed a body temperature of 38.2°C. An abdominal examination showed localized tenderness in the lower right quadrant with rebound and voluntary guarding. Laboratory tests indicated an elevated white cell count of 12,400 with 88% neutrophils. A plain X-ray of the abdomen showed local ileus in the lower right quadrant. Sonography of the whole abdomen revealed minimal fluid collection in the pelvic region. The appendix could not be visualized due to the overlying small intestinal loops. The presumptive diagnosis was acute purulent appendicitis and an emergency appendectomy was planned. Before the emergency operation, abdominal multidetector computed tomography (MDCT) imaging was planned for the patient. MDCT showed a localized pneumoperitoneum surrounded by inflammatory mesenteric fat that was found in the vicinity of a short focally thickened ileal segment impacted by the fish bone (Figs. 1, 2). The appendix appeared normal and there was a minimal pelvic fluid collection. The patient was unaware of having ingested a FB, and only the retrospective alimentary inquiry

We report the case of fish bone perforation of the distal ileum, resulting in a clinical presentation mimicking acute appendicitis.

CASE REPORT A 69-year-old woman, with no previous abdominal complaints, was admitted to our emergency department with acute abdominal pain in the lower right quadrant for the preceding two days. There was no nausea, vomiting or diarrhea. Physical examination Department of Radiology, Sisli Florence Nightingale Hospital, Istanbul; 2 Department of Radiology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey.

1

Şişli Florence Nightingale Hastanesi, Radyoloji Bölümü, İstanbul; 2 Şişli Etfal Eğitim ve Araştırma Hastanesi, Radyoloji Bölümü, İstanbul.

1

Correspondence (İletişim): Ayhan Mutlu, M.D. Şişli Florence Nightingale Hastanesi Radyoloji Bölümü, İstanbul, Turkey.

Tel: +90 - 212 - 224 49 50 e-mail (e-posta): drmutlu@yahoo.com

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clinical presentations, it is not surprising that FB perforation is seldom diagnosed preoperatively.[8]

Fig. 1. A localized inflammatory mesenteric fat (arrowhead) is found in the vicinity of a short focally thickened ileal segment impacted by a fish bone (arrow).

revealed the consumption of fish two days before the perforation.

DISCUSSION Perforation of the GI tract by ingested FBs is uncommon, and less than 1% of ingested FBs perforate the bowel.[4,5] Those that cause perforation are usually either sharp, pointed or elongated.[4] They are usually fish bones, toothpicks and chicken bones. FB perforation occurs in all segments of the GI tract, although it tends to occur in regions of acute angulation, such as the ileocecal and rectosigmoid junctions.[2,6] FBs may also perforate through a hernia sac, Meckelâ&#x20AC;&#x2122;s diverticulum, or the appendix.[7] FB perforation of the GI tract has a wide spectrum of clinical presentations, which can be acute or chronic. Patients occasionally present with unusual or even bizarre clinical manifestations, including hemorrhage, bowel obstruction, and even ureteric colic.[2,7] With these varied and nonspecific

Fig. 2. A localized pneumoperitoneum (arrowhead) surrounded by inflammatory mesenteric fat (white arrow) is also found in the vicinity of the ileal segment.

90

Voluntary ingestion of one or more FBs is relatively rare and is most common among prisoners and in people who attempt suicide.[6] In most cases of FB ingestion, the patients are unaware and/or the ingestion is accidental, and such ingestions are more common in the extremes of life (children and the elderly,[6] among those with mental disorders and in professionally exposed people (carpenters, dressmakers and upholsterers). Predisposing factors include psychiatric disorders, anti-inflammatory treatments, alcohol or drug abuse, ingestion of extremely cold liquids, poor vision, and rapid eating;[6,9,10] the population most susceptible to FB ingestion is people who wear dentures, because the tactile sensitivity of the soft palate that is vital for the detection and recognition of small intra-oral objects is diminished by the presence of dentures.[4] Non-metallic FBs, especially fish bones and other bone fragments, pose a unique problem in the diagnosis of FB perforation. The number of occasions on which these objects are swallowed are numerous and underreported.[7] Accidental ingestion of nondietary FBs is a more dramatic event and impresses itself vividly on the patientâ&#x20AC;&#x2122;s memory.[7] The inability to obtain a history of FB ingestion and its wide spectrum of nonspecific clinical presentations make diagnosis of dietary FB perforation extremely difficult.

Radiography is unreliable in the diagnosis of fish bone perforation.[11,12] This problem has been illustrated in studies of fish bone ingestion showing that the degree of radiopacity of the bone depends on the species of fish.[13,14] In contrast, chicken bones are almost always radiopaque. Even when fish bones are sufficiently radiopaque to be visualized on radiographs, large soft-tissue masses and fluid can obscure the minimal calcium content of the bone, particularly in altered or obese patients.[9,11] Another reason for not identifying fish bones on radiographs is use of the peak kilovoltage setting. Subtle calcifications are more easily identified on low-kilovoltage (70 kV) supine films. In contrast, use of 90 kV makes it more difficult to see the offending FB. Results of a prospective study with 358 patients who had swallowed fish bones revealed that radiography had a sensitivity of only 32%.[15] Another difficulty is that the presence of free gas under the diaphragm is almost never seen in FB perforation of the GI tract.[6] Because the perforation is caused by impaction and progressive erosion of the FB through the intestinal wall, the site of perforation becomes covered by fibrin, omentum or adjacent loops of bowel. This limits the passage of large amounts of intraluminal air into the peritoneal cavity.[6] The potential role of CT scanning for detecting Ocak - January 2012

A fish bone causing ileal perforation in the terminal ileum

non-metallic FB perforation has been demonstrated by two case series.[11,16] Coulier et al.[11] reported the use of CT for diagnosing seven patients with non-metallic FB perforation, including three patients with fish bone perforations. The region of perforation can be identified on CT scans as a thickened intestinal segment, localized pneumoperitoneum, regional fatty infiltration, or associated intestinal obstruction. However, none of these findings is specific, and the definitive diagnosis is made by identification of the calcified FB.[11] Fish bone perforation typically appears on CT scans as a linear calcified lesion surrounded by an area of inflammation, as shown in our case.

Despite its superiority over radiography in the diagnosis of fish bone perforation, CT has potential limitations in the detection of intraabdominal fish bones.

Goh et al.[16] reported the sensitivity of CT in the detection of intraabdominal fish bones as 71.4% (5/7) for initial reports but this improved to 100% (7/7) on retrospective review of CT scans. The main limitation of CT in the detection of FBs in that study was lack of observer awareness. Their study showed that without a high index of suspicion, an FB can be missed or mistaken for another structure, such as a blood vessel.[11] Another potential limitation of CT is scanning thickness. Use of thinner CT slices allows reviewers to better trace structures such as blood vessels and differentiate them from calcified FBs. Coulier et al.[11] emphasized the importance of the thickness of CT slices in the detection of FBs. In their series, FBs were identified preoperatively with CT in all seven patients.

In that study, single-detector helical CT with 3-mm or 1.5-mm slices and MDCT with 1.25-mm or 0.65-mm slices were used, and the images were examined with multiplanar reconstructions and cine mode on workstations. In our case, we used 1.25-mm slices, and images were evaluated on a workstation as our clinical routine. It is not practical for most institutions to use such fine-cut CT scans with 3D reconstruction to examine all patients presenting with an acute abdomen.

Nonetheless, it would not be unreasonable for institutions with single-detector equipment to rescan the abscess region in thinner sections to identify a subtle FB. The orientation of an FB with respect to an axial CT scan also can affect the perception of the viewer.

Coronal reconstruction would be especially useful in overcoming this limitation.

The use of oral and intravenous (IV) contrast material during CT can cause difficulty in identifying fish bones. Goh et al.[16] reported that oral contrast media can obscure fish bones in the intestinal lumen, causing

Cilt - Vol. 18 Sayı - No. 1

them to be missed. This problem can be ameliorated with the use of 16-MDCT, in which only water is used to distend the stomach and bowel loops. They also noted that fish bones appear more attenuated and can be appreciated with careful windowing of CT images.

Perforation of intestinal structures by ingested FBs is a challenging diagnosis that should always be kept in mind in cases of acute abdominal symptoms; this case study showed the utility of MDCT in the detection of fish bone perforation of the GI tract.

REFERENCES 1. McCanse DE, Kurchin A, Hinshaw JR. Gastrointestinal foreign bodies. Am J Surg 1981;142:335-7.

2. Maleki M, Evans WE. Foreign-body perforation of the intestinal tract. Report of 12 cases and review of the literature.

Arch Surg 1970;101:475-7.

3. McPherson RC, Karlan M, Williams RD. Foreign body perforation of the intestinal tract. Am J Surg 1957;94:564-6.

4. Noh HM, Chew FS. Small-bowel perforation by a foreign body. AJR Am J Roentgenol 1998;171:1002.

5. Rasheed AA, Deshpande V, Slanetz PJ. Colonic perforation by ingested chicken bone. AJR Am J Roentgenol 2001;176:152.

6. Pinero Madrona A, Fernández Hernández JA, Carrasco Prats M, Riquelme Riquelme J, Parrila Paricio P. Intestinal perforation by foreign bodies. Eur J Surg 2000;166:307-9.

7. Ginzburg L, Beller AJ. The clinical manifestations of nonmetallic perforating intestinal foreign bodies. Ann Surg 1927;86:928-39.

8. Ashby BS, Hunter-Craig ID. Foreign-body perforations of the gut. Br J Surg 1967;54:382-4.

9. Maglinte DD, Taylor SD, Ng AC. Gastrointestinal perforation by chicken bones. Radiology 1979;130:597-9.

10. Coulier B. Diagnostic ultrasonography of perforating foreign bodies of the digestive tract. [Article in French] J Belge Radiol 1997;80:1-5.

11. Coulier B, Tancredi MH, Ramboux A. Spiral CT and multidetector-row CT diagnosis of perforation of the small intestine caused by ingested foreign bodies. Eur Radiol 2004;14:191825.

12. Goh BK, Jeyaraj PR, Chan HS, Ong HS, Agasthian T, Chang KT, et al. A case of fish bone perforation of the stomach mimicking a locally advanced pancreatic carcinoma. Dig Dis Sci 2004;49:1935-7.

13. Kumar M, Joseph G, Kumar S, Clayton M. Fish bone as a foreign body. J Laryngol Otol 1998;112:360-4.

14. Ell SR, Sprigg A. The radio-opacity of fishbones--species variation. Clin Radiol 1991;44:104-7.

15. Ngan JH, Fok PJ, Lai EC, Branicki FJ, Wong J. A prospective study on fish bone ingestion. Experience of 358 patients. Ann Surg 1990;211:459-62.

16. Goh BK, Tan YM, Lin SE, Chow PK, Cheah FK, Ooi LL, et al. CT in the preoperative diagnosis of fish bone perforation of the gastrointestinal tract. AJR Am J Roentgenol 2006;187:710-4.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):92-94

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.76402

Late-diagnosed bilateral intertrochanteric femur fracture during an epileptic seizure Epilepsi nöbeti sırasında gelişmiş geç tanı konmuş, iki taraflı intertrokanterik femur kırığı Cem ÇOPUROĞLU, Mert ÖZCAN, Hakan DÜLGER, Erol YALNIZ

Although spontaneous and simultaneous bilateral hip fractures without trauma are seen rarely, epileptic seizures may lead to these fractures. We present an 82-year-old female patient with poor bone quality and a 20-year history of epilepsy. She had been using anticonvulsant drugs for almost 20 years. Following a convulsive epileptic attack, bilateral intertrochanteric femur fractures occurred (causing bilateral hip pain), which was diagnosed on the 12th day. An earlier pelvic anteroposterior roentgenogram would be helpful for early diagnosis. It should not be forgotten that bone fractures may be observed without trauma in epilepsy patients.

Travma olmadan iki taraflı kalça kırıkları nadirdir, fakat epileptik nöbetler bu tip kırıklara neden olabilir. Bu olgu sunumunda, 82 yaşında, kemik kalitesi kötü olan ve 20 yıllık epilepsi hastası olduğu bilinen bir kadın olgu sunuldu.

Hasta yaklaşık 20 yıldır antikonvülzan ilaçlar kullanmaktaydı; bir epilepsi atağı sırasında her iki kalçasında intertrokanterik femur kırığı oluştuğu, fakat tanının 12. gün sonra konulabildiği öğrenildi. Daha erken çekilen bir pelvis ön-arka grafisi erken tanı için yardımcı olabilirdi. Epilepsi hastalarında travma olmaksızın kırıklar olabileceği akılda tutulmalıdır.

Key Words: Epileptic seizure; hip fracture/bilateral.

Anahtar Sözcükler: Epileptik nöbet; kalça kırığı/iki taraflı.

Although hip fractures are frequent in the elderly population, simultaneous and spontaneous (atraumatic) bilateral hip fractures are very rare. Fractures and dislocations of major joints are usually caused by severe external trauma,[1] or such cases may occur secondary to several metabolic disorders.[2] Seizures may cause significant muscular tension capable of fracturing bones.[3] Sudden forceful tonic muscular contractions of seizure activity are a lesser known cause of fractures and dislocations. Seizures caused by a wide variety of other disorders have been reported to cause skeletal lesions, predominantly fractures of the vertebrae and fractures and dislocations in the regions of the shoulder and hip.[1]

her last epileptic convulsive attack, bilateral intertrochanteric femur fractures were not diagnosed until the 12th day, although she was taken to the emergency room several times. Why so late?

We present the case of an 82-year-old female epileptic patient with bilateral intertrochanteric femur fractures. She had been observed and under medical treatment for epilepsy for almost 20 years. Following

Department of Orthopaedics and Traumatology, Trakya University, Faculty of Medicine, Edirne, Turkey.

CASE REPORT We present an 82-year-old epileptic female patient with bilateral intertrochanteric femur fractures. She had been referred to our clinic from another hospital due to her fractures and concomitant cardiac problems.

She suffered from cardiac arrhythmias and had a 20year history of epilepsy. She had been under medical treatment for epilepsy, although intermittently. During the last five years, she was able to move indoors with crutches, despite great difficulty.

On the day of the event, her sleep was interrupted by severe bilateral hip pain and general muscle pain in the morning, which she reportedly experienced once

Trakya Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Edirne.

Correspondence (İletişim): Cem Çopuroğlu, M.D. Trakya Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Edirne, Turkey.

Tel: +90 - 284 - 235 76 41 e-mail (e-posta): cemcopur@hotmail.com

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Late-diagnosed bilateral intertrochanteric femur fracture during an epileptic seizure

or twice a year due to a tonic-clonic seizure. She experienced difficulty moving her legs and suffered from generalized muscle pain, especially localized around both buttocks and knees. The seizure was followed by a postictal state that resolved spontaneously, and was reported to have lasted for approximately 1 minute.

The patient was in her familyâ&#x20AC;&#x2122;s company during the entire seizure, and the family reported no fall from the couch or experience of any trauma.

Following the seizure, the patient, who lives with her daughter in a village, informed her daughter of her aches. Guided by her motherâ&#x20AC;&#x2122;s previous experience with a convulsive attack that was followed by aches, the daughter offered analgesics and muscle relaxants to ease the pain. As the physical immobility and pain (the patient could not rise from the bed) continued for two days, she was taken to the nearest town hospital. Bilateral knee plain roentgenograms were taken for the lower extremity pain. As no emergent osseous pathology could be obtained, bed rest, analgesics and muscle relaxants were prescribed for general muscle aches. She used the prescribed medication for 10 days; however, no recovery was observed. As the pain had become unbearable, she was taken to the nearest city hospital. She reported pain in her entire lower extremity, which began after a convulsive attack, and that she had not been able to walk since the seizure. After physical examination, the doctor evaluated her pelvis anterior-posterior (AP) roentgenogram, which led to the diagnosis of bilateral intertrochanteric femur fractures 12 days after the generalized tonic-clonic seizure (Fig. 1a). Due to the risks related to anesthesia, she was not operated in the city hospital and was referred to our hospital, which has an intensive care unit if needed.

Carried in a litter to our emergency room, she was known to be epileptic for almost 20 years. Her seizures consisted of daily early morning myoclonus and occasional generalized tonic-clonic seizures. She was prescribed a twice-daily dose of phenytoin 100 mg; however, she was not compliant with the prescription.

(a)

In her physical examination, both legs were in external rotation, she was unable to move her legs because of pain, and hip range of movements could not be examined. No neurovascular deficiency could be determined in the lower extremities.

Laboratory findings revealed the following: hemoglobin concentration 11.9 g/dl (normal: 12.2-17.2 g/ dl), urea level 233 mg/dl (normal: 10-50 mg/dl), creatinine level 4.02 mg/dl (normal: 0.44-1.03 mg/dl), total protein level 5.6 g/dl (normal: 6.4-8.3 g/dl), albumin level 2.4 g/dl (normal: 3.5-4.8 g/dl), lactate dehydrogenase activity 541 U/L (normal: 98-192 U/L), alkaline phosphatase activity 218 U/L (normal: 32-91 U/L), creatinine kinase activity 1708 U/L (normal: 38-204 U/L), serum calcium level 3.9 mg/dl (normal: 8.9-10.3 mg/dl), intact parathormone level 757.5 pg/ ml (normal: 12-88 pg/ml), homocysteine level 31.7 uMol/L (normal: 5-15 uMol/L), and serum phenytoin level 0.9 ug/ml (normal: 10-20 ug/ml).

Under general anesthesia, on the 14th day of the trauma, she was operated bilaterally in one session.

First, for the right hip, bipolar hemiarthroplasty with cementation was applied in the lateral decubitus position, with lateral incision (by using the modified Hardinge approach). Then, the exact procedure was repeated for the left hip (Fig. 1b). After the operation, she was monitored in the intensive care unit for the first 24 hours. On the 2nd day of operation, she was mobilized and was able to walk with crutches. After consultation to the Neurology Department, her epilepsy treatment was re-organized. For hypocalcemia, a medical treatment was arranged following consultation to the Endocrinology Department. On the 5th day after the operation, she was discharged from the hospital.

DISCUSSION Simultaneous bilateral hip injuries, including bilateral intertrochanteric femur fractures, are seen rarely.

Most occur as a result of epileptic seizures, are electrically induced, or have hypocalcemic or uremic ori-

(b)

Fig. 1. (a) Preoperative roentgenogram. (b) Postoperative roentgenogram.

Cilt - Vol. 18 SayÄą - No. 1

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gin.[5] Several factors may contribute to the increased fracture risk in seizure patients. Muscular contraction generated by seizures may directly fracture bone; however, indirect mechanisms may also elevate fracture risk. Several reports emphasize bone disease as a major precipitating factor, and there is an increased incidence of fracture in chronic epilepsy.[1] Antiepileptic medications may affect intestinal calcium absorption and can induce anticonvulsant osteopathy.[3] When used for long periods, anticonvulsant drugs cause osteomalacia. Anticonvulsant drugs block mineralization of the bone matrix, decrease peripheral response to the active vitamin D, help to degrade vitamin D by inducing hepatic enzymes, and decrease calcium intake from the gastrointestinal tract. For these reasons, anticonvulsant drug usage may cause osteomalacia.[2] Postmenopausal osteoporosis and immobilization for long durations are other causes of osteomalacia.

Active mobilization results in rapid return of blood supply to both the bone and soft tissues and improves articular cartilage nutrition. Further, when combined with weight-bearing, active mobilization greatly decreases post-traumatic osteoporosis and enhances bone formation.[4] Our case concerns an 82-year-old osteoporotic female who had been on anticonvulsant drugs for almost 20 years.

Thirty to 35% of seizure patients have experienced a secondary injury as a result of seizure during their lifetime. These observations support the importance of the evaluation of secondary injury in patients presenting to the emergency department. Fractures are less common complications in seizure patients who experience seizure; however, they have been reported to occur in 0.25% to 2.4% of this group of patients. Patients with epilepsy are 33% more likely to sustain a fracture in their lifetime than those without epilepsy.[3] The proximal humerus was the most common site of fractures in the atraumatic group.[3,6] Some seizure-induced fractures, such as compression fracture of the vertebrae and fractures of the humerus or the head or neck of the femur, resemble more common fractures caused by external trauma. If a patient is not known to have epilepsy or if the seizure was not witnessed, the unexpected finding of such a fracture may lead to a suspicion of assault, particularly if the patient is not in a condition to give a clinical history.[1] There are some reported cases of acute fractures of the acetabulum secondary to a convulsive sei-

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zure. Seizures could also lead to acute periprosthetic fractures of the acetabulum in patients with osteopenia after total hip arthroplasty.[7] Seizure-related fractures, which most frequently involve the head and neck of the femur and the proximal humerus, may sometimes present diagnostic difficulties, but usually are evident due to pain or deformity and the history of seizure.[1] Physicians should be alert to the possibility of fractures in patients with epileptic seizures. Pain in any part of the body should signal the need for immediate radiographic examination.[5] To avoid unrecognized injuries in postconvulsive patients, a thorough evaluation must be performed prior to dismissal of the injury as a ligament sprain or muscle strain.[5] Certain reports indicate that recognition of the injury may be delayed or found incidentally on imaging for unrelated reasons.[1] Bilateral simultaneous trochanteric fractures are rare and potentially life-threatening injuries, associated with high morbidity. They should be diagnosed and treated as soon as possible.

In conclusion, evaluation of extremity pain, deformity, ecchymosis, and crepitus should help in the identification of bony injury following a seizure and should always be tracked by radiographs of the affected area. Likewise, an A-P radiograph of the pelvis should be obtained for any seizure patient suffering from hip or groin pain.

REFERENCES 1. Hughes CA, O’Briain DS. Sudden death from pelvic hemorrhage after bilateral central fracture dislocations of the hip due to an epileptic seizure. Am J Forensic Med Pathol 2000;21:380-4.

2. Yercan H, Özalp T, Vatansever A, Okçu G, Öziç U. Spontaneous bilateral hip fractures following a seizure: a case report. Joint Dis Rel Surg 2005;16:71-3.

3. Friedberg R, Buras J. Bilateral acetabular fractures associated with a seizure: a case report. Ann Emerg Med 2005;46:260-2.

4. Rahman MM, Awada A. Bilateral simultaneous hip fractures secondary to an epileptic seizure. Saudi Med J 2003;24:1261-3.

5. Suh KT, Kang DJ, Lee JS. Bilateral intertrochanteric fractures after surgical treatment of bilateral femoral neck fractures secondary to hypocalcemic convulsions with chronic renal failure: a case report and review of the literature. Arch Orthop Trauma Surg 2006;126:123-6.

6. Copuroglu C, Aykac B, Tuncer B, Ozcan M, Yalniz E. Simultaneous occurrence of acute posterior shoulder dislocation and posterior shoulder-fracture dislocation after epileptic seizure. Int J Shoulder Surg 2009;3:49-51.

7. Atilla B, Caglar O, Akgun RC. Acute fracture of the acetabulum secondary to a convulsive seizure 3 years after total hip arthroplasty. Orthopedics 2008;31:283.

Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2012;18 (1):95-98

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2012.79663

Künt travmaya bağlı diyafram yırtığına sekonder akut mekanik intestinal obstrüksiyon olgusu Evaluation of an acute mechanic intestinal obstruction case secondary to diaphragma rupture due to a blunt trauma Selim SÖZEN,1 Feridun AYSU,1 Hasan ELKAN,1 Atilla ÇAKMAK,1 Fahrettin YILDIZ2

Künt travma sonrası diyafram yırtığı nadir görülür. Bu yazıda, trafik kazası geçirdikten 3 yıl sonra acil servisimize başvurup bağırsak tıkanıklığı nedeniyle laparatomi yapılan 24 yaşlarındaki erkek olgu sunuldu. Diyafram yırtıklarının karın içi organların fıtıklaşmaları ya da mekanik intestinal tıkanıklık nedeni olabileceğini, tanısı konduğunda bu olguların zaman geçirmeden ameliyat edilmesi gerektiğini düşünüyoruz.

Rupture of the diaphragm after blunt trauma is uncommon.

In this report, a 24-year-old male with intestinal obstruction who underwent laparotomy is presented; he had been involved in a traffic accident three years prior to presentation to our emergency service. We conclude that diaphragma ruptures may cause herniation of abdominal organs and intestinal obstruction, and thus should be repaired when diagnosed.

Anahtar Sözcükler: Diyafram yırtığı; ileus; künt travma.

Key Words: Diaphragma rupture; ileus; blunt trauma.

Diyafram göğüs ve karın boşluklarını birbirinden ayıran, kubbe şeklinde, kas ve tendondan oluşmuş anatomik bir yapıdır.[1] Karın içi organların, travma sonucu diyaframda oluşan yırtıktan toraksa geçmesi, travmatik diyafram yırtığı olarak isimlendirilir.[2] Diyafram yırtığı, ilk olarak 1541 yılında Sennertius tarafından tanımlanmış ve ilk başarılı diyafram onarımı Walker tarafından 1889 yılında yapılmıştır.[3] Künt travma sonrası diyafram yırtığı gelişme oranı %1-2’dir.

[4] Otopsi serilerinde ise diyafram yırtığı insidansının %5,2-17 olduğu bildirilmiştir.[5,6] Diyafram yırtıklarının %75’i solda, %23’ü sağda görülür. Diyafram yırtığının tanısında diyagnostik periton lavajı, ultrasonografi (USG), bilgisayarlı tomografi (BT), tanısal laparoskopi uygulanabilir. Ancak olgular karşımıza kronik olarak geldiğinde genellikle BT’den faydalanılır.

Travmatik diyafram yırtıkları sol diyaframda sağ diyaframa göre 10 kat daha fazla görülmektedir.[7,8]

ve karacigerin tamponlayıcı etkisi nedeniyle travmalarda daha az yaralanmaktadır.[7] Travmayı izleyen dönemde spesifik semptomlar ve radyolojik bulguların olmadığı durumlarda tanı konamayabilir. Bu özellik nedeniyle yıllar içinde travmatik diyafram yırtıklarının morbitide ve mortalitesi artabilir.

Yırtıkların solda daha çok olmasının nedeni diyaframın sol medial posterolateral tendinomüsküler alanının embriyolojik gelişmede diyaframın en zayıf bölgesi olmasıdır. Sağ diyafram doğuştan daha güçlüdür 1 Balıklıgöl Devlet Hastanesi, Genel Cerrahi Kliniği, Şanlıurfa; Harran Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Şanlıurfa.

2

Sonuç olarak, diyafram yırtıklarının mekanik intestinal tıkanıklık nedeni olabileceğini akıldan çıkarmamak gerektiğini düşünüyoruz. Akut karın veya mediastinit bulguları olan olgular zaman geçirmeden ameliyat edilmeli ve karından yaklaşım tercih edilmelidir.

Bu yazıda, trafik kazası geçirdikten 3 yıl sonra acil servisimize başvurup bağırsak tıkanıklığı nedeniyle laparatomi yapılan olgu sunuldu.

OLGU SUNUMU Karın ağrısı yakınması ile acil polikliniğimize başvuran 24 yaşındaki erkek hasta, bir haftadır gaz ve gaita çıkaramadığını ve son bir gündür karın ağrısının başladığını belirtti. Fiziksel incelemesinde, genel durum iyi, bilinç açık koopere ve oryanteydi. Ödem, ikter, siyanoz ve çomak parmak saptanmadı. Kan ba1 Department of General Surgery, Balikligol State Hospital, Sanliurfa; Department of General Surgery, Harran University Faculty of Medicine, Sanliurfa, Turkey.

2

İletişim (Correspondence): Dr. Selim Sözen. Yurt Mah., 71335 Sok., No: 13/19 Çukurova, Adana, Turkey.

Tel: +90 - 414 - 314 84 10 e-posta (e-mail): selimsozen63@yahoo.com

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sıncı 120/80 mmHg, nabız 84/dak. ve solunum sayısı ise 22/dak. olarak tespit edildi. Palpasyonda her iki hemitoraks solunuma eşit katılıyordu, vibrasyon torasik solda hafif azalmıştı. Rutin hemogramda lökosit 12000 %68 parçalı hakimiyeti saptandı. Sedimentasyon ve biyokimyasal incelemelerinde patoloji saptanmadı. Hastanın başvurusunda, fiziksel incelemede karın distansiyonu ve karında yaygın hassasiyet mevcuttu. Karın USG’sinde dilate ve ödemli ince bağırsak ansları arasında az miktarda serbest sıvı rapor edildi.

Karın BT’sinde ileal anslara uyan seviyede dilatasyon ve ileokolik segmentlerde hava sıvı seviyelenmeleri mevcuttu. Ayrıca rektal yoldan verilen kontrast maddenin splenik fleksuradan daha öteye geçmediği gözlendi (Şekil 1). Hasta ileus tanısıyla acil olarak ameliyata alındı. Göbek üstü orta hat kesisi ile eksplorasyon yapıldı. Karın içinde bağırsak ansları arasında az miktarda reaksiyonel serbest sıvı mevcuttu Sol diyaframdaki 2 cm’lik yırtıktan toraks içine omentumun fıtıklaştığı gözlendi, ancak fıtık kesesi mevcut değildi. Omentum spelenik fleksura seviyesinde kolona bası yapıyordu. Kolon segmenti retroperitoneal yapılar ile fıtıklaşan omentum arasında sıkışmıştı. Kanlanması bozulmamıştı. Fakat gelişen kısmi ödemden dolayı geçişe izin vermiyordu. Diyaframdaki defekt genişletilerek omentum karın içine alındı. Diyaframdaki defekt “0” numaralı prolen kullanılarak U dikişleri ile onarılarak ameliyat sonlandırıldı. Ameliyat sonrası 4. gün hasta taburcu edildi. Özgeçmişinde 3 yıl önce araç içi trafik kazasıa maruz kaldığını, hastaneye başvurmadığını ve göğüs bölgesinde bir süre ağrı hissettiğini, sonra da bu ağrının kendiliğinden geçtiğini ifade etti. Karın BT’sinde ince bağırsak anslarında ve çıkan kolonda dilatasyon saptanmıştı (Şekil 2). Akciğer grafisinde herhangi bir patoloji saptanmamıştı.

TARTIŞMA Klinik serilerde künt travma sonrası sol taraf di-

Şekil 1. Kontrast madde sigmoid kolondan öteye geçmiyor.

96

yafram yırtıkları daha yüksek oranda bildirildigi halde, otopsi serilerinde sağ ve sol taraf yırtıklarının eşit oranda görüldügü saptanmıştır.[9] Bunun nedeni sağ diyafram yırtıklarının genellikle majör travmalar ile birlikte olması dolayısıyla mortalitesinin yüksekliğinden kaynaklanmaktadır.[10] Travmatik diyafram yırtıklarında optimal tedavi erken tanı konan olgularda, yani inisiyal dönemde defektin onarılmasıdır. Bu dönemdeki girişimlerde yandaş organ yaralanmalarının da olabileceği düşünülerek cerrahi girişim için karın yolu tercih edilmelidir.

Diyaframın non-absorbabl dikişlerle primer onarımı genellikle tercih edilen yöntemdir. Defektin büyük olması ve primer kapatmanın mümkün olmadıgı durumlarda ise uygun bir greft kullanılarak defektin kapatılması önerilmektedir.[11] İnisiyal travmadan sonra ilk 2 hafta içerisinde tanı konulanlar akut, akut yaralanmadan sonra herniye olan organda strangülasyon gelişmeden önce tanı konulan olgular latent ve strangülasyona bağlı katastrofik olaylar geliştikten sonra tanı konulan olgular ise obstrüktif grubu oluştururlar.[12] Operasyon gerektirmeyen torakoabdominal travmalı olguların %12-60’ında, akut dönemde tanı konulamamakta ve latent dönemde veya strangülasyon döneminde diyafram yırtığı saptanmaktadır.[10] Bu özellik nedeniyle yıllar içinde travmatik diyafram yırtıklarının morbitide ve mortalitesi artabilir.

Carter ve Giuseffi 1950’li yıllarda diyafram yırtıklarının klinik evrelerini üç aşamada tanımlamışlardır. Başlangıç dönemi; yaralanmadan hemen sonra başlayan ve primer yaraların iyileşmesine kadar geçen süredir ve ciddi olgularda genellikle respiratuvar ve kardiyak sorunlar tabloya eşlik ederken minör yaralanmalarda ise sessiz geçer. Latent dönem; genellikle asemptomatik seyreden dönemdir ve ancak komplikasyon ortaya çıktıgında semptomlar gözlenerek üçüncü döneme geçilir. Obstrüktif dönem; bu dönem

Şekil 2. İnce bağırsak çıkan ve transvers kolonda hava sıvı seviyesi.

Ocak - January 2012

Künt travmaya bağlı diyafram yırtığına sekonder akut mekanik intestinal obstrüksiyon olgusu

bağırsak ve/veya visseral fıtıklaşmanın, obstrüksiyon, inkarserasyon strangülasyon veya olası yırtıkların oldugu dönemdir. Bu dönemde mutlak cerrahi tedavi endikasyonu mevcuttur. Olgumuzda tıkanıklığın nedeni kolon segmentinin diyaframdaki defektten fıtıklaşması değildi. Bu yüzden çekilen akciğer grafisinde patoloji yoktu. Omental fıtıklaşmaya sekonder gelişen kolonik tıkanıklıktı.

Diyafram olgumuzda primer olarak tamir edildi. 10 cm’yi geçmeyen yaralanmalar primer olarak U şeklinde veya matris dikişlerle non-absorbabl materyal ile tamir edilmektedir. Bu olguda da aynı yöntemi izledik.

Yaralanma 25 cm’den geniş ise prostetik materyali tercih eden yazarlar vardır.[13,14] Akut dönemde multipl travmaya bağlı diğer organ yaralanmaları, tanıda gecikilen olgularda ise pulmoner komplikasyonlar ölümlerin nedenleridir. Akut dönemden, fıtıklaşan organ strangüle olana kadar geçen süre latent dönem olarak adlandırılmaktadır. Latent dönemin süresi değişkendir. Literatürde latent dönemin 20 gün-28 yıl, ortalama 4.1 yıl sürdüğü bildirilmiştir.[6] Olgumuzda künt yaralanmanın üzerinden 3 yıl geçmesine rağmen, hala latent dönem devam etmekteydi. İzole travmatik diyafram yırtıklarının tablosu asemptomatik olduğu için bu olguların kesin tanısında güçlükler yaşanır. Bu tür yaralanmaların %12-69’unda ameliyat öncesi dönemde tanı konamamaktadır.[10] Direk grafideki radyolojik bulgular arasında; diyafram bütünlüğünün bozulması, bağırsak haustralarının ve gaz gölgelerinin toraks içinde görülmesi, diyaframın normal anatomik pozisyonundan yüksekte izlenmesi, mediastinal kayma, atelektazi, akciğerde kitle görünümü, plevral effüzyon, pnömotoraks ve hidropnömotoraks yer alır. Travmatik diyafram yırtıklarının tanısında karın USG’si, floroskopi, torako-abdominal BT, MRG, dalak ve karaciğer sintigrafileri, torakoskopi ve laparoskopi gibi incelemeler gerektiğinde başvurulacak diğer tanı yöntemleri olmalıdır. Laparaskopi ve torakoskopi ise tanıda altın standarttır. Torakoskopi tanıda başarılı olmasının yanı sıra, tedavi amaçlı da kullanılabilmektedir.[6,15,16] Minör yaralanma bile olsa, solunum sırasında, abdomen ve toraks arasında 100 mmHg’ye ulaşan basınç farkı, karın organlarının toraksa fıtıklaşmasını kolaylaştıran en önemli faktördür. Fıtıklaşan organlar; diyaframdaki defektin çapına ve defekte komşu olan organların özelliklerine göre degişmektedir. Diyaframdaki defektten en sık mide, ince bağırsak ve kolon, nadiren de karaciğer ve dalak fıtıklaşmaktadır. Fıtıklaşan organa ait spesifik klinik bulgular görülebilecegi gibi solunum ve kardiyak bulgularda ön planda olabilir. Bizim olgumuzda ise fıtıklaşan organ ise omentumdu. Obstruksiyon semptomları omentum ile retroCilt - Vol. 18 Sayı - No. 1

periton arasında sıkışan splenik fleksuradan kaynaklanmaktaydı.

Sol diyafram yırtıkları daha sık olarak komplike olmaktadır.[4,17-19] Bu komplikasyonlar karın içi organların fıtıklaşmasına bağlı olarak gelişebilir. Fıtıklaşma bulguları arasında karında bitkinlik ve bağırsak tıkanıklığı bulguları nefes darlığı, plevral effüzyon sayılabilir. Lökositoz, ateş, nefes darlığı, karında defans ve periton irritasyon bulguları varlığında en tehlikeli komplikasyon olan strangüle olmuş intestinal yapıların perforasyonu akla gelmelidir. Bu gibi durumlarda acil operasyon endikasyonu vardır.

Travmatik diyafram yırtıklarında optimal tedavi erken tanı konan olgularda, yani inisiyal dönemde defektin onarılmasıdır. Bu dönemdeki girişimlerde yandaş organ yaralanmalarının da olabileceği düşünülerek cerrahi girişim için karından yaklaşım tercih edilmelidir. Bu yolla onarımın yapılamadıgı durumlarda, torakoabdominal veya ayrı torakal kesiler gerekebilir. Diyaframın non-absorbabl dikişlerle primer onarımı genellikle tercih edilen yöntemdir. Defektin büyük olması ve primer kapatmanın mümkün olmadıgı durumlarda ise uygun bir greft kullanılarak defektin kapatılması önerilmektedir. Özet olarak, tüm torakoabdominal travmalı olgularda diyafram yırtıklarından şüphelenilmelidir. İlk akciğer grafisinin normal olabileceği unutulmamalıdır. Diyafram yırtıklarının mekanik intestinal tıkanıklık nedeni olabileceğini akıldan çıkarmamak gerektiğini düşünüyoruz. Akut karın veya mediastinit bulguları olan olgular zaman geçirmeden ameliyat edilmeli ve karından yaklaşım tercih edilmelidir.

KAYNAKLAR 1. Erem T, Oygucu İH. Akciğerin anatomisi.In: Özyardımcı N, editör. Nonspesifik akciğer hastalıkları. Bursa: Uludağ Üniversitesi Basımevi; 1999. s. 14-35.

2. Yüksel M, Kalaycı G. Diyafragma. In: Yüksel M, Kalaycı G editör. Göğüs cerrahisi. İstanbul: İlmedya Grup; 2001. s.

747-71.

3. Arrendrup CH, Arrendrup D. Traumatic diaphragmatic hernia. In: Nyhus L, Condon ER, editors. Hernia. 3rd ed. Philadelphia: Lippincott; 1989. p. 708-16.

4. Atagenç F. Diyafragma hastalıkları. Kalaycı G, editör. Genel cerrahi. İstanbul: Nobel Kitabevi; 2002.

5. Ward RE, Flynn TC, Clark WP. Diaphragmatic disruption secondary to blunt abdominal trauma. J Trauma 1981;21:358.

6. Reber PU, Schmied B, Seiler CA, Baer HU, Patel AG, Büchler MW. Missed diaphragmatic injuries and their longterm sequelae. J Trauma 1998;44:183-8.

7. Boulanger BR, Milzman DP, Rosati C, Rodriguez A. A comparison of right and left blunt traumatic diaphragmatic rupture. J Trauma 1993;35:255-60.

8. Orsi P, Rollo S, Montanari M, Rossi G. Rupture of the diaphragm caused by closed thoraco-abdominal trauma. Case contribution and anatomo-clinical considerations. G Chir 1998;19:13-7.

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9. Puffer P, Gaebler M. Traumatic diaphragmatic rupture in a forensic medicine autopsy sample. [Article in German] Beitr Gerichtl Med 1991;49:149-52.

10. Guth AA, Pachter HL, Kim U. Pitfalls in the diagnosis of blunt diaphragmatic injury. Am J Surg 1995;170:5-9.

11. Sattler S, Canty TG Jr, Mulligan MS, Wood DE, Scully JM, Vallieres E, et al. Chronic traumatic and congenital diaphragmatic hernias: presentation and surgical management. Can Respir J 2002;9:135-9.

12. Grimes OF. Traumatic injuries of the diaphragm. Diaphragmatic hernia. Am J Surg 1974;128:175-81.

13. Lucas CE, Ledgerwood AM. Diaphragmatic injury. In: Cameron JL, editor. Current surgical therapy. 2nd ed., St Louis: Mosby; 1998. p. 921-4.

14. Montresor E, Bortolasi L, Modena S, Ragni E, Attino M, Mangiante G, et al. Delayed traumatic hernia of the dia-

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phragm presenting with hypertensive pneumothorax. Case report and review of the literature. G Chir 1997;18:295-6.

15. Shah R, Sabanathan S, Mearns AJ, Choudhury AK. Traumatic rupture of diaphragm. Ann Thorac Surg 1995;60:1444-9.

16. Kocher TM, G端rke L, Kuhrmeier A, Martinoli S. Misleading symptoms after a minor blunt chest trauma. Thoracoscopic treatment of diaphragmatic rupture. Surg Endosc 1998;12:879-81.

17. Flint L, Jorge LR. Management of thoracic injury. In: Nyhus LM, Baker JR, editors. Mastery of surgery. Vol 1, 2nd ed., 1992. p. 343-53.

18. Al-Mashat F, Sibiany A, Kensarah A, Eibany K. Delayed presentation of traumatic diaphragmatic rupture. Indian J Chest Dis Allied Sci 2002;44:121-4.

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