TJTES 2015-2 by KAREPUBLISHING

ISSN 1306 - 696X

TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi

Volume 21 | Number 2 | March 2015

www.tjtes.org

TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi Editor-in-Chief Recep Güloğlu Editors Kaya Sarıbeyoğlu (Managing Editor) M. Mahir Özmen Hakan Yanar Former Editors Ömer Türel, Cemalettin Ertekin, Korhan Taviloğlu Section Editors Anaesthesiology & ICU Güniz Meyancı Köksal, Mert Şentürk Cardiac Surgery Münacettin Ceviz, Murat Güvener Neurosurgery Ahmet Deniz Belen, Mehmet Yaşar Kaynar Ophtalmology Cem Mocan, Halil Ateş Ortopedics and Traumatology Mahmut Nedim Doral, Mehmet Can Ünlü Plastic and Reconstructive Surgery Ufuk Emekli, Figen Özgür Pediatric Surgery Aydın Yagmurlu, Ebru Yeşildağ Thoracic Surgery Alper Toker, Akif Turna Urology Ali Atan, Öner Şanlı Vascular Surgery Cüneyt Köksoy, Mehmet Kurtoğlu

www.tjtes.org

THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ President (Başkan) Vice President (Başkan Yardımcısı) Secretary General (Genel Sekreter) Treasurer (Sayman) Members (Yönetim Kurulu Üyeleri)

Recep Güloğlu Kaya Sarıbeyoğlu M. Mahir Özmen Ali Fuat Kaan Gök Hakan Teoman Yanar Gürhan Çelik Osman Şimşek

CORRESPONDENCE İLETİŞİM Ulusal Travma ve Acil Cerrahi Derneği Şehremini Mah., Köprülü Mehmet Paşa Sok. Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul, Turkey

Tel: +90 212 - 588 62 46 Fax (Faks): +90 212 - 586 18 04 e-mail (e-posta): travma@travma.org.tr Web: www.travma.org.tr

ISSUED BY THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ YAYIN ORGANI Owner (Ulusal Travma ve Acil Cerrahi Derneği adına Sahibi) Editorial Director (Yazı İşleri Müdürü) Managing Editor (Yayın Koordinatörü) Amblem Correspondence address (Yazışma adresi) Tel Fax (Faks)

Recep Güloğlu Recep Güloğlu M. Mahir Özmen Metin Ertem Ulusal Travma ve Acil Cerrahi Dergisi Sekreterliği Şehremini Mah., Köprülü Mehmet Paşa Sok., Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul +90 212 - 531 12 46 - 588 62 46 +90 212 - 586 18 04

p-ISSN 1306-696x • e-ISSN 1307-7945 • Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ, and Turkish Medical Index (Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ ve TÜBİTAK ULAKBİM Türk Tıp Dizini’nde yer almaktadır.) Publisher (Yayımcı): KARE Yayıncılık (KARE Publishing) • www.kareyayincilik.com • Design (Tasarım): Ali Cangül • Graphics (Grafikler): Edibe Çomaktekin • Linguistic Editor (İngilizce Editörü): Merve Şenol • Redaction (Redaksiyon): Erman Aytaç • Online Manuscript & Web Management (Online Dergi & Web): LookUs • Press (Baskı): Yıldırım Matbaacılık • Press date (Basım tarihi): March (Mart) 2015 • This publication is printed on paper that meets the international standard ISO 9706: 1994 (Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur.)

KARE www.tjtes.org

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.

tion, called “Upload Your Files”.

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.

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.

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. Open Access Policy: Full text access is free. There is no charge for publication or downloading the full text of printed material. 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” sec-

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.

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. Review articles: Only reviews written by distinguished authors based on the editor’s invitation will be considered and evaluated. Review articles must include the title, summary, text, and references sections. Any accompanying tables, graphics, and figures should be prepared as mentioned above. 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. Letters to the Editor: “Letters to the Editor” are only published electronically and they do not appear in the printed version of TJTES and PUBMED. The editors do not issue an acceptance document as an original article for the ‘’letters to the editor. The letters should not exceed 500 words. The letter must clearly list the title, authors, publication date, issue number, and inclusive page numbers of the publication for which opinions are released. 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.

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. Açık Erişim İlkesi: Tam metinlere erişim ücretsizdir. Yayınlanan basılı materyali tam metni indirmek için herhangi bir ücret alınmaz. 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 190210 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.

TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 21

Number - Sayı 2 March - Mart 2015

Contents - İçindekiler

Deneysel Review - Çalışma Derleme - Experimental Study 79-89 Guideline and treatment algorithm for burn injuries Yanık yaralanmaları tedavi algoritması Yastı AÇ, Şenel E, Saydam M, Özok G, Çoruh A, Yorgancı K

Experimental Study - Deneysel Çalışma 90-95 The effects of tibiofibularis anterior ligaments on ankle joint biomechanics Tibiofibularis anterior ligamanının ayak bileği eklemi biyomekaniğine etkisi Karakaşlı A, Erduran M, Baktıroğlu L, Büdeyri A, Yıldız DV, Havıtçıoğlu H 96-101 The effects of caffeic acid phenethyl ester on inflammatory cytokines after acute spinal cord injury Kafeik asit fenetil esterin akut spinal kord hasarı sonrasında enflamatuvar sitokinler üzerine etkisi Ak H, Gülşen İ, Karaaslan T, Alaca İ, Candan A, Koçak H, Atalay T, Çelikbilek A, Demir İ, Yılmaz T

Original Articles - Klinik Çalışma 102-106 Total leukocyte and neutrophil count as preventive tools in reducing negative appendectomies Total lökosit ve nötrofil sayısı negatif apandektomilerin azaltılmasını sağlayan belirteçlerdir Rafiq MS, Khan MM, Khan A, Ahmad B 107-112 A comparative study of small intestinal perforation secondary to foreign body and other non-traumatic causes Yabancı cisimle ince bağırsak perforasyonu ile diğer travma dışı nedenlerin karşılaştırmalı çalışması Chen Q, Huang Y, Wu Y, Zhao K, Zhu B, He T, Xing C 113-118 Proksimal humerus kırıklarının tedavisinde lateral deltoid split girişim ile deltopektoral girişimin karşılaştırılması Comparison of lateral deltoid splitting and deltopectoral approaches in the treatment of proximal humerus fractures Korkmaz MF, Erdem MN, Karakaplan M, Görmeli G, Selçuk EB, Maraş Z, Karataş T 119-126 Which modality is the best choice in distal radius fractures treated with two different Kirschner wire fixation and immobilization techniques? Hangi yöntem iki farklı Kirschner teli ile tespit ve immobilizasyon teknikleri ile tedavi edilen distal radius kırıklarında en iyi seçimdir? Günay C, Öken ÖF, Yavuz OY, Günay SH, Atalar H 127-133 Evaluation of autopsy reports in terms of preventability of traumatic deaths Travmatik ölümlerde otopsi raporlarının önlenebilirlik açısından değerlendirilmesi Eyi YE, Toygar M, Karbeyaz K, Kaldırım Ü, Tuncer SK, Durusu M

Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

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TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 21

Number - Sayı 2 March - Mart 2015

Contents - İçindekiler

134-138 Epidemiology of animal-related injuries in a high-income developing country Yüksek gelirli gelişmekte olan ülkelerde hayvanların neden olduğu yaralanmaların epidemiyolojisi Eid HO, Hefny AF, Abu-Zidan FM 139-142 Total oxidant status, total antioxidant status, and paraoxonase activity in acute appendicitis Akut apandisitte toplam oksitadif durum, toplam antioksidan durum ve paraoksonaz enzim aktivitesi Köksal H, Kurban S, Doğru O

Short Report - Kısa Rapor 143-148 Disaster medical assistance in super typhoon Haiyan: Collaboration with the local medical team that resulted in great synergy Süper Haiyan tayfunu felaketinde tıbbi yardım: Yerel sağlık ekipleriyle işbirliği büyük bir sinerji içinde gerçekleşmiştir Kim H, Ahn ME, Lee KH, Kim YC, Hong ES

Case Reports - Olgu Sunumu 149-151 Intrathoracic dislocation of the humeral head accompanied by polytrauma: How to treat it? Politravmanın eşlik ettiği humerus başının intratorasik dislokasyonu: Nasıl tedavi edilir? Chen J, Yan J, Wang S, Zhong H, Zhou H 152-156 Severe thoracic impalement injury: Survival in a case with delayed surgical definitive care Ağır toraks penetran yaralanması: Kesin cerrahi tedavisi gecikmiş olguda sağkalım Lunca S, Morosanu C, Alexa O, Pertea M 157-159 Bouveret syndrome: A fatal diagnostic dilemma of gastric outlet obstruction Bouveret sendromu: Mide çıkış yolu obstrüksiyonunda ölümcül bir tanısal ikilem Sağlam F, Sivrikoz E, Alemdar A, Kamalı S, Arslan U, Güven H 160-162 Nadir bir ince bağırsak tıkanıklık nedeni: Spontan strangüle transomental fıtık A rare cause of small intestinal obstruction: Spontaneous strangulated trans-omental hernia Ağca B, Karip AB, İşcan Y, Özcabı Y, Fersahoğlu MM, Memişoğlu K

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REVIEW

Guideline and treatment algorithm for burn injuries Ahmet Çınar Yastı, M.D.,1,2 Emrah Şenel, M.D.,3 Mutlu Saydam, M.D.,4 Geylani Özok, M.D.,5 Atilla Çoruh, M.D.,6 Kaya Yorgancı, M.D.7 1

Department of General Surgery, Hitit University Faculty of Medicine, Çorum;

Ankara Numune Training and Research Hospital, Burn Treatment Center, Ankara;

Department of Pediatric Surgery, Yıldırım Beyazıt University Faculty of Medicine, Ankara;

Department of Esthetic, Plastic and Reconstructive Surgery and Burns Unit, Yunus Emre Governmental Hospital, Eskişehir;

Department of Pediatric Surgery, Ege University Faculty of Medicine, İzmir;

Department of Esthetic, Plastic and Reconstructive Surgery, Erciyes University Faculty of Medicine, Kayseri;

Department of General Surgery, Hacettepe University Faculty of Medicine, Ankara

ABSTRACT As in many other countries, burn injuries are a challenging healthcare problem in Turkey. Initial management of burn patients is very important for future morbidity and mortality. Therefore, the Turkish Ministry of Health prepared “National Burns Treatment Algorithm” aided by the Scientific Burns Council. The basic aim of this algorithm is to guide physicians in the treatment of burn victims until they reach an experienced burns center. The content of this algorithm is first aid, initial management, resuscitation, and transfer policy. The Council started to work on this algorithm in 2011. Various consultants, including general surgeons, pediatric surgeons, aesthetic, plastic and reconstructive surgeons, anesthesiologists, and intensive care physicians, revised the first draft and it was sent to eight education and research hospitals of the Ministry of Health, four universities, and seven non-governmental organizations. In the last quarter of 2012, the algorithm was finalized and approved by the Scientific Council, after which, it was approved by the Ministry of Health and published. Key words: Algorithm; burn; guideline; treatment.

Determining Burn Severity and On-Site Medical Attention

2. Depth of the Burn: Burns are classified as superficial and deep dermal in clinical practice.

Determining Burn Severity Determining burn severity depends on the burned surface area, depth of burn and the involved body area.

In superficial burns, there is no or minimal dermal injury. These are first degree and superficial second degree burns, and usually heal in 3 weeks without any sequelae.

1. Burned Surface Area: The ‘rule of nines’ can roughly estimate adult burns (Fig. 1a). However, more accurate diagrams are available for adults (Fig. 1b) and children (see Lund Browder’s diagram), and a brief form of the diagram is shown in Fig. 2. For practical calculation, the outstretched palm with fingers together can be accepted as 1% of the body surface area for an individual (Fig. 3).

The dermis is partially or completely injured in deep dermal burns. They are classified as deep second, third and fourth degree regarding dermal injury and underlying deep tissues. These will usually heal in more than three weeks and usually require surgical intervention.

Address for correspondence: Ahmet Çınar Yastı, M.D. Vakif İş Hani, Çankırı Cad., No: 67/2, Dışkapı 06030 Ankara, Turkey Tel: +90 312 - 324 57 97 E-mail: cinaryasti@gmail.com Qucik Response Code

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First Degree:

Epidermis is intact, there is erythema, e.g.: sunburn Second Degree: Epidermal integrity is damaged. If the injury is limited to the upper layers of dermis, it is superficial second degree; however, involvement of the deeper (reticular) layers leads to deep second degree burn. While superficial is much more painful, there is less pain and a blunt pressure feeling in deep burns. Third Degree: All layers of the dermis are involved. The skin is hard, dark, dry, painless, thromboses 79

Yastı et al. Guideline and Treatment Algorithm for Burn Injuries

(a)

(b)

3.5%

9% 1%

18% 2% 9%

1.5%

13%

1.5%

4.5% 18%

13%

1.5%

4.5%

2.5%

4.5%

18%

4.%

1.5%

1.5% 1.5%

4.%

1.5%

Figure 1. (a) The rule of nines diagram. (b) Schema for estimation of body surface area in adults.

inside the vessels, and there is typical burn eschar. Fourth Degree: All layers of the skin, subcutaneous fat tissue and deeper tissues (muscles, tendons) are involved, and there is a carbonized appearance. 3. Burned Body Site: Burns of the eye, ear, face, hands, feet, and genitalia are ‘special area burns’ and should be treated at an experienced burns unit/center.

child d. Inhalation injury e. Electrical burns f. Burns with concomitant additional trauma (such as head trauma, intra-abdominal injury, fractures) g. Burns during pregnancy h. Co-morbidities adding significant risk to burns (such as Diabetes Mellitus, corticosteroid use, immune suppression) i. Burns of the eye, ear, face, hand, foot, major joint and genitalia.

Classification Burn Severity 1. Minor Burns a. Second degree adult burns less than 15% TBSA b. Second degree child burns less than 10% TBSA c. Third degree child or adult burns less than 2% TBSA 2. Moderate Burns a. Second degree adult burns involving 15 to 25% TBSA b. Second degree child burns involving 10 to 20% TBSA c. Third degree child or adult burns involving 2 to 10% TBSA 3. Major Burn a. In adults, second degree burns greater than 25% TBSA b. In children, second degree burns greater than 20% TBSA c. Third degree burns greater than 10% in an adult or a 80

Minor burns can be treated as an outpatient or in a burns room. Moderate and severe burns must be hospitalized and treated in a burns unit/center. On-Site Medical Attention 1. Airway, breathing and circulation should be assessed. In a multiple trauma patient, the ‘forget the burn’ principle is valid and the management of life threatening injury has priority. 2. Rescuing the victim from the burning premises and extinguishing the fire have priority. 3. In minor burns, the burned area should be kept under running tap water for 20 minutes within the first 15 minutes, and further burning should be stopped. 4. Hot liquid burns Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Yastı et al. Guideline and Treatment Algorithm for Burn Injuries

II 1%

2% 1.5%

1.5%

13%

1.5%

2.5%

2.5% 1%

III III

III III 1.5%

1.5% 1.5%

Age

1.5%

Adult

Front or back half

(%)

(Head)

9½

8½

6½

5½

4½

3½

(Thigh)

2¾

3¼

4¼

4½

4¾

III

(Leg)

2½

2¾

3¼

3½

Figure 2. Lund-Browder schema.

• All wet clothes are removed 5. Flame burns • The patient is removed from the heat source and moved from the scene to open-air; however, if not possible, the fire is extinguished. • Carbon monoxide or smoke intoxication is checked and the patient is administered 100% oxygen. • Requirement for endotracheal intubation is evaluated. 6. Electrical Burns • Health care provider should be aware that the patient is likely to be injured in three different ways: real electrical injury via electric current, arc burns, and flame burns as a consequence of the electric current ignition. • The electricity is turned off and/or the patient should be removed from the source, • Requirement for immediate cardiopulmonary resuscitation is evaluated (especially in low voltage injuries) • Sign or symptoms of multiple trauma, blunt or penetrating trauma must be checked, 7. Chemical Burns • Dry chemicals are firstly brushed off, and then, should Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

be rinsed with running water until the pain is relieved (this could take 60 minutes) • Neutralizing agents are not recommended (contra- indication as may cause further heat) A large intravenous line insertion is required for every major burn case and Ringer’s lactate solution should be the choice of fluid resuscitation. Circulation, respiration, and urinary output are observed if necessary. Detailed information regarding the event and the patient’s medical history should be obtained, and the emergency physician or burns surgeon where the patient is to be transferred should be informed of the burn severity and relevant medical history. 1% Due to the expected edema formation in large burns, jewelry, including bracelets, rings and necklaces should be removed. Burn wounds should not be covered Figure 3. Practical eswith medicaments or substances on- timation using palm. 81

Yastı et al. Guideline and Treatment Algorithm for Burn Injuries

Figure 4. Escharotomy and/or fasciotomy sites.

site. Wrapping the burn wounds with a clean cloth is sufficient during transfer to the nearest emergency department. If available, medical coolants can be applied to the injury site during the transfer. In order to prevent systemic hypothermia, unburned body parts are covered to maintain body heat. Informing the Relevant Facility About the Burns Patient After the first medical attention, the following information must be delivered to the facility before transfer: 1. Age of the patient 2. Gender 3. The place and means of injury 4. Burning agent 5. Time of injury 6. Width and depth of the burn including involved body areas 7. Associated injuries 8. Co-morbidities 9. General medical status of the patient and the medical interventions performed

Medical Attention in the Emergency Department The applications which should be attempted in the emergency department are summarized below: 1. Airway maintenance should be secured. Patient’s respiratory distress, if any, should be relieved immediately, and endotracheal intubation should be performed with no delay where necessary or suspected. If required, tracheostomy should be performed for airway maintenance. In case of inhalation injuries; please see section 9. 2. Insert intra venous route. • Wide burns require “central” catheterization. Subclavian vein is preferred to femoral catheterization. 82

• One or two effective peripheral venous line may provide sufficient venous access for children. However, for large burns requiring close monitoring, central catheterization is the optimum. • If central catheterization is not possible in children younger than 6 years of age, a 16-18 gauge needle (spinal needle is compatible) can be inserted from the distal femoral or proximal tibial bone marrow (attention to the epiphysis plaque) under local anesthesia, and 100 ml/hour fluid can be delivered. Meanwhile, other intravenous routes can be tried. • Temperature of the fluids should be close to the body temperature in order to avoid systemic hypothermia. 3. Associated traumas should be investigated and appropriately managed if present. If a multi-trauma patient has concomitant burns, the relevant department of the vital injury follows up the patient. In these patients, the participation of the burns surgeon in the management of the patient is as a consultant physician. 4. The patient’s weight, height, and total body surface area in m2 (especially in children) should be assessed (see Table 1). This assessment is the basis for fluid resuscitation and will also be a requirement for informing the burns facility regarding the severity of burn in case of a transfer. The “rule of nines” is generally reliable for calculating the burned body surface area in adults, but the Lund and Browder chart provides a better assessment for children. These charts should be placed in visible locations in the emergency departments where burns are managed. 5. Each burn case must be evaluated ‘forensically’ and if suspicious, should be reported to the police and/or forensic office. 6. In the pre-hospital period, covering the wounds with a clean dressing is sufficient. For a patient admitted to the emergency department, wound management will differ depending whether or not there is a requirement for hospitalization. Due to the expected edema formation in large burns, jewelry, including bracelets, rings and necklaces should be removed. Please see Section 3 outpatient burn wound management. Except for face burns, 1% silversulphadiazine is an option that can be considered for initiation without any disadvantage. 7. Intravenous fluid resuscitation should be initiated if the burned total body surface area is a. >10% in children b. >20% in adults 8. Fluid resuscitation in the emergency department: Table 1. Formulas proposed for child burns Estimating the body surface area in children: Body surface (m2)=[4x body weight (kg) +7] /[90+ body weight (kg)] Galveston’s formula: 2000 mL/m2 body surface area+5000 mL/m2 burned body surface area

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The suggested formulas are in fact just recommending guidelines. Readjustments are required according to the clinical course of the patient. • For adults, first 24 hours n The Parkland Formula: 4 mL/kg/ % burned TBSA, Ringer’s lactate solution n Modified Brooke’s Formula: 2 mL/kg / % burned TBSA

Half of the calculated amount is delivered over the first eight hours, and the remainder over the following 16 hours. • For children, first 24 hours 2 n Galveston’s formula: 2000 mL/m body surface area + 2 5000 mL/m burned TBSA, Ringer’s lactate solution Half of the calculated amount is delivered over the first eight hours, and the remainder over the following 16 hours. 9. Conditions requiring more fluid than calculated: • Associated trauma, • Alcoholic patient, • Inhalation injury, • Late onset or insufficient fluid resuscitation, dehydration, • Electrical burns. 10. Urinary catheter should be placed in large burns and/or perineal burns requiring close monitoring. Targeted urinary output is; Adult: 30-50 mL/hour Child: 1-2 mL/kg/hour

high risk co-morbidities and/or concomitant injuries, essential blood and urinary tests should be performed (cross match, Rh test, serum electrolyte, blood glucose, complete blood count, myoglobinuria/hemoglobinuria, at least) For patients with large burns, prophylaxis is applied according to general tetanus prophylaxis protocols. Patients Requiring Hospitalization • At all ages, second and third degree burns with burned TBSA >20% • At all ages, third degree burns with burned TBSA ≥5-10%, • Patients younger than 10 or older than 50 years of age with second and third degree burns and with burned TBSA ≥10% • Burns of the face, ear, hand and foot • Burns including major joints • Burns of genitalia and perineum • Chemical burns • Electrical burns • Lightning strike • Inhalation injuries • Associated multiple traumas • Chronic co-morbidities (diabetes, hypertension, cardiac disease, immune deficiency, neurologic disorders) • Pregnancy • Presence or suspicion of child abuse.

Targeted urinary density is 1015. In electrical burns and inhalation injuries, targeted urinary output should be twofold the above-mentioned volumes.

Local Wound Care for Burns

11. Applying pomades or creams containing local anesthetics to relieve pain is contraindicated. 12. The patient’s pain will be relieved after dressing the burn. Please see Section 8 for pain management. 13. In chemical substance burns, burning continues as long as the active substance is in contact with the skin. After completely undressing, the patient is showered with running water at body temperature, but should not be put in a bathtub. Hypothermia should be avoided during a long lasting bath. See Section 6. 14. Electrical burns, chemical substance burns, and large and/ or deep burns should be hospitalized. Serum electrolytes and arterial blood gas, and if necessary, ECG follow ups should be applied. 15. In high voltage electricity burns, intravenous (iv) fluid should be delivered until the urine clears and becomes alkaline. See Section 7. 16. In case of edema and/or eschar tissue formation, the thorax, abdomen, extremities, and neck should be evaluated for the requirement of escharotomy or fasciotomy. See Section 5. 17. There is gastro-paralysis and ileus risk for unconscious patients and/or patients with burned TBSA >30%, indicating nasogastric decompression when necessary. 18. In patients with moderate or large burns and patients with

Outpatient follow-up criteria to be considered for patient management in polyclinic settings:

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Primarily, indication for hospitalization or outpatient management of the patient should be determined (See Section 2). Burns requiring surgical debridement, escharoectomy or fasciotomy, complicated large burns indicating serious fluid resuscitation, and deep burns likely to need grafting will not be covered in this section. Therefore, application of sophisticated treatment modalities including synthetic temporary coverings will be left to the facilities experienced in burns management. The treatment modalities described below are for patients who will be managed in outpatient polyclinics or burns rooms.

Need for intravenous fluid resuscitation should be dissolute n There should be no ongoing complication n Absence of sepsis must be verified n Sufficient oral nutrition should be maintained n Pain management should be provided with oral analgesics. n

Dressing change–wound cleaning: Wounds are rinsed with tap water or saline to clean the wound and remove debris, and except for neutral pH liquid 83

Yastı et al. Guideline and Treatment Algorithm for Burn Injuries

soaps, antiseptic solutions and brushing should not be used. Topical antimicrobial containing creams and pomades are not required for minor burns. Dressing with paraffin or ointment (e.g. nitrofurazone 0.2% pomade) impregnated gauze is adequate. Dressing materials should be prepared separately for each individual patient and should be for single use. In the presence of infection or eschar and large burns, 1% silver sulphadiazine can be used. Application of silver containing agents should be terminated with visible epithelialization as it delays epithelialization. First degree burns • No need for any dressing or topical antibacterial agent. • Moisturizing cream or ointment is sufficient. These agents will diminish inflammation and the feeling of pain aroused by the skin’s desiccation and stretching. Analgesics can be prescribed. • Patients with large first degree burns may require hospitalization for pain management and hydration. Second degree burns • Superficial Burns n Paraffin impregnated woven fabrics decrease the pain of dressing changes as they will not stick to the wound. n Polyurethane film sheets can be used in visible areas for aesthetics. n If these are not available, dressing with paraffin or greasy emulsion (e.g. 0.2% nitrofurazone) impregnated gauze is appropriate. Management of Blisters: Blisters which are small in size and/or unlikely to erupt may be left intact. Larger blisters should be drained or unroofing is followed up with scheduled dressing changing. • Deep Burns n Antibiotic containing creams (e.g., silver sulfadiazine, mupirocin, nitrofurazone) can be applied directly or underneath the paraffin impregnated gauze. n In case of a delayed wound healing and exceeding three weeks patients should promptly be referred to a burns unit/centre as discoloration, hypertrophic scarring, keloid formation or contractures are likely to occur. • Third and Fourth Degree Burns Spontaneous eschar separation occurs via the enzymatic products of the underlying bacteria. In sterile full thickness burns, eschar does not separate spontaneously. Spontaneous separation of the eschar is a sign of an infected wound. n These patients usually require surgical intervention and should be referred to a burns unit/centre for hospitalization. n

Transport of the Burns Patient Burns patient is a traumatized patient and it is vitally important that the transfer procedure is undertaken at the right time, to the right patient, and under the right conditions. Burns patient is transferred in two ways: 1. Transfer to a healthcare facility from the scene 2. Transfer from one healthcare facility to another more experienced facility The most important issues to be clarified before transferring a patient is the survival potential of the patient and the likelihood of the onset of a new life-threatening situation during transportation. Transportation is not a priority for a patient for whom survival is just subject to expectancies. Transportation of a patient with serious cardiopulmonary instability is also not a priority. However, there should never be a delay in transfer for a patient with the potential to survive, and transfer should be done as soon and quickly as possible. Patient Referral Criteria After determining burn severity, the decision is then taken as to which healthcare facility can manage the treatment (see Section 1). Healthcare facilities which manage burns treatment according to the severity of the burns are polyclinics, burns rooms, burns units and burns centers according to the national burns treatment directorate. Minor burns are treated at outpatient clinics or can be hospitalized in a burns room. Moderate burns are treated in burns units in the absence of accompanying co-morbidities or when other injuries do not complicate the patients’ general status. Severe/major burns are referred directly to a burns treatment center following their initial resuscitation at the first available healthcare facility. Nonetheless, if an existing co-morbidity or evolving situation complicates patient management during the clinical course, the patient should be referred to a higher level burns facility. It is unacceptable, for whatever reason, to have uncontrolled transfer of the burned patient without applying initial medical attention as summarized in the booklet. The two golden rules in patient transfer are good communication and effective team work. During the transfer: 1. Adequate stabilization of the burn patient should be secured before transferring. 2. The referred facility must be informed about the patient. 3. There must be direct communication between the physicians of the dispatching and accepting healthcare facilities. 4. The referral facility must confirm that they accept the patient. The dispatching facility physician must forward the patient’s information to the accepting facility physician, summarized as: 1. Age and gender 2. The place, time and source of injury Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Yastı et al. Guideline and Treatment Algorithm for Burn Injuries

3. 4. 5. 6. 7. 8. 9.

Extent and depth of the burn, and burned body areas Weight and height of the patient Vital signs of the patient Neurologic condition Laboratory test results if any Short medical history of the patient Medical efforts already made after the injury

After having been given verbally, detailed written information should also be put in the patient file. The issues listed below should be completed before the patient transfer: 1. A large venous catheter, or two if available, should be inserted preferably via upper extremities and stitched with sutures (burned skin can be used if necessary). 2. A spontaneously ventilating patient should have nasal oxygen support. In case of clinical suspicion of airway obstruction, the patient should be promptly intubated and ventilator settings should be applied. 3. A urinary catheter should be inserted to monitor urinary output (adults 30mL/hour, children 1 ml/kg/hour although twofold level is required in electrical burns and inhalation injury). 4. Oral intake should be stopped and a nasogastric tube should be inserted. 5. All narcotics should be ceased. 6. For patients transferred in the first 24 hours following a burns injury, only lactated Ringer’s solution is delivered (Ringer’s lactate solution with dextrose is preferred for children younger than 2 years of age). The pre-transfer amount of fluid resuscitation is determined by the dispatching physician according to the burned total body surface area. 7. Continuous ECG and respiratory monitoring is required during transfer. 8. Wet dressings are avoided during transfer. 9. The patient should be kept as warm as possible. Transfer options Patient transportation should always be undertaken in coordination with the emergency patient transfer coordinator center (Phone no: 112). Ground transportation is used for distances up to 100 km. However, helicopter transportation can be an option for shorter distances depending on the severity of the victim. Aeromedical transportation choice depends on the patient’s condition, distance, and specific risks related to air transportation. 1. Nasogastric tube should be inserted before departure 2. Pneumothorax should be investigated, and if present, a chest tube should be inserted. Helicopters are used for distances up to 220 km and fixed Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

wing aircraft should be preferred for longer distances. However, the availability of a heliport or airport has to be considered.

The First 24 Hours of Hospital Care for Severe Burns Systematic examination is mandatory, and first aid, pre-hospital and emergency department diagnostic efforts must be repeated. The topics below should be evaluated cautiously before the transfer of a high-risk patient to an experienced burns facility. The list below is a stepwise checklist for the first 24 hours: 1. Burned patients with associated trauma can be hospitalized at the burns unit/centre. However, if the associated trauma has a higher risk or is vital, the patient should be accepted in the related department or general surgical intensive care unit and monitored by the mortality risk related department. The burns surgeon should take role as a consultant. 2. Airway, circulation and respiration are revised at the time of admission. One special problem of the burns patient is that airway obstruction is likely to occur in the short term. The answer to the question ‘Which patients require intubation for a permanent airway?’ is clear. If the physician has any doubt, a permanent airway must be maintained. Otherwise edema may develop within hours, making it impossible to intubate or to perform a tracheostomy. 3. Respiration must be supported with nasal oxygen. Ventilator settings should be set by the physician for patients with a permanent airway. 4. Circulation is primarily examined by pulse and heart rate. 5. In the first 24 hours, resuscitative fluid volume is estimated by Parkland’s or modified Brooke’s formulas in adults and Galveston’s formula in children (Table 1). These formulas are just recommendations and are for initiation, and the infusion rate is modulated according to the patient’s clinical course. 6. Urinary output is one of the most reliable parameters for the assessment of circulation in the early stages. A urinary output level of 30 mL/hour in adults and 1 mL/kg/hour in children is the most important indicator of adequate circulation and resuscitation. 7. The suggested urinary output should be twofold in patients with electrical burns and inhalation injury. In severe electrical injuries in adults, 50 grams of mannitol and 2 ampoules of NaHCO3 should be administered intravenously as soon as possible. 8. More fluid delivery is required in patients with dehydration due to delayed fluid resuscitation and/or with inhalation injury. 9. Burns patients are prone to hypothermia. If it develops, it should be treated promptly and efficiently. 10. After admission, the patient should be examined systematically. Detailed re-examination can reveal possibly over85

YastÄą et al. Guideline and Treatment Algorithm for Burn Injuries

looked concomitant injuries. A detailed medical history is taken from the patient or relatives, keeping abuse, intent or neglect in mind, especially in cases of child burns, and a forensic consultation must be requested if appropriate. 11. When evaluating the neurological condition of the patient, the narcotic analgesic treatment which has already been administered should be considered. In patients who cannot maintain or will not maintain upper airway openness, a permanent airway must be provided. 12. A nasogastric tube is inserted to the patients with burned total body surface area (TBSA) >30%. Tube feeding should be started for stabilized patients in the early stage. It is sufficient to start with 10 ml/hour infusion of enteral nutrition which can be increased with patient toleration. 13. Severe burn injuries may cause acute gastrointestinal ulcers in adults. Severely burned adult patients are likely to develop acute gastrointestinal system ulcers; therefore, prophylaxis for acute mucosal lesion with H2 receptor antagonists should be initiated. Enteral nutrition is also added to the acute mucosal lesion prophylaxis. There is no need for prophylaxis for children tolerating oral nutrition. 14. Severely burned adult patients require prophylaxis for deep vein thrombosis. Either heparin or low molecular weight heparin can be given. 15. Pain management is important in burns patients. Narcotic analgesics are preferred in the early stage. See the related section of the booklet for dosage. 16. In circumferential thoracic, abdominal or extremity burns, escharotomy or fasciotomy is applied when necessary. Escharotomy should ideally be performed promptly when it is required. In emergency conditions when the patient cannot be transferred to a burns unit/centre, escharotomy or fasciotomy can be performed in the current healthcare facility (Fig. 4). 17. There is no indication for prophylactic or preemptive treatment in the early stage. Diagnosis of infection is difficult in burns patients. Therefore, antibiotics should only be used where infection has been proven or is highly probable. However, infection control precautions should be taken at every stage of the patientâ&#x20AC;&#x2122;s clinical course and treatment.

Chemical Burns Chemical burns are considered in two main groups of acid and alkaline. Alkaline burns cause liquefaction necrosis, and can exclusively progress to deeper tissues. Basic Treatment Principles Emergency Treatment: 1. Rapidly remove all clothing. 2. Contaminated areas should be washed with water. In order to avoid hypothermia, irrigate at room temperature with water at body temperature. The duration of rinsing with running tap water can be extended up to 60 minutes. 86

Pain relief or dissipation can be the end point of washing. 3. Neutralizing agents should never be applied. This application can lead to a deepening of the burn by chemical reaction itself or by the produced heat. 4. In burns of chemical powders, irrigation may have unfavorable effects. Water may activate chemical powders. In these conditions, after cleaning the chemical powder with a brush, a dry cloth or a vacuum cleaner, the area should be irrigated with copious water. 5. If there is an ocular injury, the eyes must be irrigated for a long time with copious amounts of water. The patient should consult an ophthalmologist. Some Chemical Burn Agents 1. Dry lime burns: To prevent heat generation, the agent is firstly cleaned with brushing and afterwards washed with water. 2. Mercury Compounds: As blister fluid contains mercury, they are unroofed. 3. Tar Burns: Tar causes burns both by its heat and by chemical irritation. A practical way to remove tar from the skin promptly and without causing additional damage is to apply ice cubes on the tarred area for 10-20 minutes. In the mean time, tar will freeze to a crusty layer and consequently can be peeled off. 4. Hydrofluoric Acid: These patients mostly work in the glass and steel industry or dry cleaners. Hydrofluoric acid penetrates the skin immediately and continues damaging until reaching a calcium rich tissue like bone. Even small, hydrofluoric acid burns can cause hypocalcaemia which would be enough for cardiac side effects to occur. Hydrofluoric acid burns larger than 10% may be fatal. Topical application of gel containing calcium gluconate is an effective, quick and non-invasive first step treatment, but if it is not effective, intravenous calcium gluconate infusion is indicated.

Radiation Burns Local radiation burns caused by high dose radiation (8-10 Gy) are similar to thermal injuries except for the delay which may extend from a few days to a few weeks. Progressive and intractable pain is a typical symptom and a challenging issue in the treatment of the patient. For this injury, the patient is referred to a burns unit/center under proper conditions.

Electrical Burns Although injuries at lower than 1000V are accepted as low voltage electrical burns and higher than 1000V as high voltage electrical burns, even in electrical burns at 250-1000V, patients can suffer from unconsciousness, compartment syndrome, myoglobinuria, and hemoglobinuria. Therefore, these patients should be followed up in the same way as for high voltage injuries. Emergency Treatment Algorithm 1. Within the context of a general trauma algorithm, the Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Yastı et al. Guideline and Treatment Algorithm for Burn Injuries

first priority is to check the circulation, assess airway, and breathing. 2. In low voltage electrical burns, atrial fibrillation with high ventricular response is the most encountered rhythm disorder and cause of death. Therefore, every patient with an electrical burn should have an ECG test. Cardiac monitoring and if possible, serum CPK-MB testing is indicated. Cardiac muscle necrosis may occur especially in a high voltage injury, and Troponin-1 levels should be examined. If the electric flow trace crosses the heart, 24 hours cardiac monitoring is indicated. 3. Circulation disorder or severe muscle damage may occur in the extremities. Developing edema can cause compression of the muscles and necrosis (compartment syndrome). In such a case, escharotomy is insufficient and fasciotomy is indicated. 4. Strong contraction of electricity may result in muscle avulsion or shearing. Bone fractures or joint dislocations may be seen. Intra-abdominal visceral damage may also occur. 5. Myoglobinuria or hemoglobinuria may occur and to prevent acute renal failure, fluid resuscitation and urinary output monitoring is essential. 6. If the urine is black or red, the amount of fluid delivery should be increased immediately. In these patients, targeted output is 100mL/h in adults and 3-4 mL/kg/hour in children. 7. In order to alkalinize the urine, NaHCO3 is intravenously delivered 2 ampoules in adults, 1 ampoule for children heavier than 10 kg and 1 mL/kg for children lighter than 10 kg. 8. Diuretics are contraindicated in the acute stage, fluid delivery should be increased. 9. If attempts to provide osmotic diuresis fail, mannitol can become an option. The intravenous bolus dose is 50 g for adults and 0.5 g/kg for children. 10. At high voltage electric burns, following the initial resuscitation, accompanying mortal injuries should be taken under control. After achieving complete control of mortal injuries or complications and full stabilization, the patient should be referred to the nearest available burns unit/center.

Maintaning Analgesia for the Burns Patient 1. Instillation of tap water (20-25°C) to the burned area is important for both pain relief and dispersion of the heat accumulated in the tissues. 2. Hypothermia should be prevented in extensively burned patients, and unburned body parts should be covered to keep the patient warm. Ice and other coolants should not be used. 3. Intravenous opioids are administered to relieve stress induced anxiety in the early stage. Due to local vasoconstriction, the intravenous route is the first choice, although if not possible intramuscular or subcutaneous Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

injections, respectively, can be used. 4. Morphine delivery with steady increments until relief of pain is the most-preferred method. In patients with respiratory injury, opioids can only be an option with close monitoring and/or mechanical ventilator. 5. Drugs should be titrated carefully and delivered by slow infusion to minimize probable respiratory and hemodynamic side effects while providing the adequate analgesic dose. 6. Tramadol and ketamine are reliable in various surgical approaches such as escharotomy of full thickness burns. Ideally, escharotomy/fasciotomy procedures should be applied at a burns unit/center. 7. In children or stressed adults, it is more convenient to make procedures requiring surgery under general anesthesia and in a burns unit/center. Acute Stage Analgesic Drugs and Intravenous Doses Drug

Dose Duration

Tramadol (12 years and older) 1mg/kg Ketamine 0.2-0.5 mg/kg Morphine or diamorphine 0.03-0.1 mg/kg child 0.1 mg/kg Fentanyl 1-1,5μgr/kg child 1 μgr/kg Meperidine 0.5-1 mg/kg

4-6 hours 15-25 minutes 4-6 hours 45-60 min 2-4 hours

Suggested Treatment Combinations 1. For adults and children, fentanyl 0.5-1 μgr/kg/hour + midazolam 0.03 mg/kg/hour can be an appropriate combination. 2. For adults with unstable respiration and hemodynamics, ketamine 0.5 mg/kg slow intravenous delivery is followed by tramadol 100-150 mg/2-4 hours infusion during transportation. 3. In children younger than 12 years of age, ketamine 0.5 mg/ kg slow intravenous and fentanyl 1μgr/kg/hour intravenous infusion is preferred. In children older than 12 years of age, ketamine 0.5 mg/kg slow intravenous and tramadol 100 mg/2-4 hours infusion is appropriate. 4. Doses should be repeated 15-20 minutes before the expected end of the analgesic effect time. Analgesic Drugs and Dose Recommendations for Outpatient Treatment Adult Patient: Non steroid anti-inflammatory drugs (i.e., naproxen, oxicam group) can be preferred. Child Patient: Paracetamol: 10-15 mg/kg, par oral Ibuprofen: After 2 years old, 20 mg/kg/day for 3-4 times a day, par oral. (Not suggested under 2 years old)

Yastı et al. Guideline and Treatment Algorithm for Burn Injuries

Diagnosing Inhalation Injury and Early Stage Treatment Inhalation injury is defined as three different injuries arising from the inhalation of thermal and/or chemical irritants: 1. Thermal injury affecting mostly the upper respiratory system 2. Chemical injury affecting the respiratory system as a whole 3. Systemic toxicities associated with the inhalation of toxic products such as carbon monoxide or cyanide. Although more frequent with indoor burns, breathing smoke can create a serious risk of inhalation injury even outdoors. Serious inhalation injury may occur in the absence of skin burn! Clinical signs of inhalation injury 1. Worsening of the general status of the patient, disordered consciousness, cyanosis, burns of the hair on the face, ear and nose, hoarseness, oral mucosal edema, carbon particles, and black sputum. 2. Perioral or facial burns, circumferential neck burns. 3. Signs of respiratory distress: tachypnea, dyspnea, stridor, wheezing 4. Signs of carbon monoxide intoxication: headache, dizziness, nausea, fatigue, distraction, chest pain, palpitation, visual disorders, abdominal pain, loss of consciousness. Clinical management of a patient with inhalation injury 1. First priority is to ensure safety of the environment by removal from the scene and decontamination of the patient. 2. Airway maintenance and security (resuscitation position, airway insertion, control of the tongue’s back sliding) 3. Breathing assessment (in case of superficial, apneic, and/ or obstructive breathing, support respiration with nasal cannulation/mask/endotracheal intubation) 4. Circulation assessment (fluid resuscitation, electrolyte replacement, warming, cardiovascular supportive medication) 5. During transportation, high flow (5-6 l/min) 100% oxygen support via nasal cannula/mask. 6. When airway safety is not provided (facial or perioral burns, circumferential burns of the neck, progressive hoarseness, respiratory depression, loss of consciousness or sub-glottal edema); endotracheal intubation and/or mechanical ventilation should be applied. Transferring a patient with inhalation injury A patient with spontaneous ventilation or under mechanical ventilation support can be transported in every ambulance vehicle in which the required monitoring and adequate resuscitation can be provided.

Clinician’s Medicolegal Power and Child Abuse 1. All burned patients should be evaluated forensically. It is 88

obligatory in our country to complete a forensic record for all patients at mortality risk and all injuries clearly or suspiciously non-accidental, and to report this to the relevant authorities. 2. If the family or patient himself does not give written consent for treatment of a burns victim (accidental or abuse), medical care cannot be applied as long as the patient is conscious. If the patient is conscious, lucid and has the ability to make his own declaration of intent, and even after being informed about all the risks, still has the right to reject treatment. However, a detailed consent form should be signed against possible future charges of malpractice or negligence. The patient should give a signed statement confirming that he has read and understood the facts and the risks, and if possible, (not compulsory) the signatures of two relatives, as witnesses, should be obtained. 3. Consent of the parents and/or legal guardian is mandatory for every sort of medical attention to children (except for emergent and life threatening conditions). 4. The family or official guardian or legal custodian of the child has the right to take their child to another healthcare facility after written consent. In cases of a help request, the available services should be provided. 5. If there is a life-threatening injury or the family insists on taking the child to another center even if there is no other available, the case should be reported to the forensic department and to the district attorney as there may be child abuse. (Patient rights regulation, section 24: Patient’s consent is required for medical attention. If the patient is a child or incapacitated then permission is taken from the parents or legal guardian. If the patient’s parents or legal guardian is absent or not available or the patient has no power of expression, this condition is not required. Under conditions where the legal representative does not give consent, if the intervention is essential, the decision is given by the court. If taking the parents’ or court’s permission will take time and the condition is vital or a vital organ is at risk and needs immediate medical intervention, permission is not required.) 6. The forensic approach to accidental and non-accidental injuries is no different. The case is reported to the hospital police if available, or if not, to the nearest forensic department. Child Abuse The general approach is to keep the possibility of abuse in mind. Indicators of possible abuse in medical history 1. Unexplained delay in getting the child to hospital 2. Discrepancy in medical history 3. Conflict between the medical history and physical examiUlus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Yastı et al. Guideline and Treatment Algorithm for Burn Injuries

nation findings 4. More than one suspicious trauma history and different explanations of the parents 5. Parents’ blaming a brother/sister or another third person for the accident 6. Blaming the child for the accident 7. Transporting the child to many different hospitals 8. Child accusing parents 9. Parents’ past history of being abused in childhood 10. Parents’ unreal expectations from the child. Indicators of possible abuse on physical examination: 1. Unique signs indicating punishment (ecchymosis on the back, legs, or genitalia). Different lesions at various healing stages. 2. Cigarette burns, scald burns on the hands or feet, perineum or hips 3. Abdominal trauma leading to rupture of the liver or spleen 4. Subdural hematoma with or without cranium fracture 5. Radiologic findings (subperiostal bleeding, decomposition of the metaphysis, periosteum ruptures or calcifications) Helpful indicators for diagnosis: 1. Delay in medical assistance request (sometimes parents may never consult a doctor) 2. Unreliable medical history lacking details, differences in between the people or a changing history at each telling.

3. History cannot explain the damage observed 4. Parents’ suspicious attitudes (mostly thinking about themselves, such as asking when they would be able to leave) 5. Parents’ hostile behavior 6. Abnormal outlook of the child and abnormal relationship between the child and the parents 7. Child’s explanations. A private interview with the child in an environment where the child can feel safe will be very helpful at diagnosis. It is very important to have a written record of the questions and answers at anamnesis. Pathognomonic signs of child abuse: 1. The child is extremely sensitive or inversely insensitive. He is not very sensitive to painful stimulus. 2. Clinical findings of the lesions indicating an occurrence time earlier than the proposed time. 3. Presence of different types of burns and incisions together. 4. Presence of various lesions of one source (i.e. many cigarette burns) 5. Attempts to hide lesions in different ways (covering the region with hair or bandage) 6. Lesions in unusual areas such as the tongue, lips, frenulum. Conflict of interest: None declared.

DERLEME - ÖZET OLGU SUNUMU

Yanık yaralanmaları tedavi algoritması Dr. Ahmet Çınar Yastı,1,2 Dr. Emrah Şenel,3 Dr. Mutlu Saydam,4 Dr. Geylani Özok,5 Dr. Atilla Çoruh,6 Dr. Kaya Yorgancı7 Hitit Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Çorum; Ankara Numune Eğitim ve Araştırma Hastanesi, Yanık Tedavi Merkezi, Ankara; 3 Yıldırım Beyazıt Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, Ankara; 4 Yunus Emre Devlet Hastanesi, Estetik Plastik ve Rekonstrüktif Cerrahi Kliniği ve Yanık Ünitesi, Eskişehir; 5 Ege Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, İzmir; 6 Erciyes Üniversitesi Tıp Fakültesi, Estetik Plastik ve Rekonstrüktif Cerrahi Anabilim Dalı, Kayseri; 7 Hacettepe Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Ankara 1 2

Yanık yaralanmaları diğer pek çok ülkede olduğu gibi Türkiye’de de üzerinde durulması gereken bir sağlık problemidir. Bu hastaların erken dönem yönetimleri sonraki dönem morbiditesi ve mortalitesi için çok önemlidir. Bu nedenle Sağlık Bakanlığı, Yanık Bilim Komisyonu katkılarıyla hazırlanan “Ulusal Yanık Tedavi Algoritması”nı hazırladı. Bu algoritmanın temel amacı, yanık kazazedeleri deneyimli yanık merkezlerine ulaşana değin klinisyenlere kılavuzluk yapmaktı. Bu algoritmanın içeriği ilk yardım, başlangıç yönetimi, resüsitasyon ve transfer politikasıdır. Konsey, algoritma üzerindeki çalışmalarına 2011 yılında başladı. Genel cerrahların, çocuk cerrahlarının, estetik plastik ve rekonstrüktif cerrahların, anestezistlerin ve yoğun bakım klinisyenlerini içeren çok sayıda konsültanlar ilk taslağı hazırladı ve bu sekiz Sağlık Bakanlığı eğitim ve araştırma hastanesine, dört üniversiteye ve yedi sivil toplum kuruluşuna iletildi. 2012 yılının son çeyreğinde, algoritmaya son şekli verildi ve Bilim Komisyonu tarafından onaylandı. Sonrasında Sağlık Bakanlığı tarafından onaylanarak yayınlandı. Anahtar sözcükler: Algoritma, kılavuz; tedavi; yanık. Ulus Travma Acil Cerrahi Derg 2015;21(2):79-89

doi: 10.5505/tjtes.2015.88261

Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

EXPERIMENTAL STUDY

The effects of tibiofibularis anterior ligaments on ankle joint biomechanics Ahmet Karakaşlı, M.D.,1 Mehmet Erduran, M.D.,1 Lütfü Baktıroğlu, M.D.,2 Aydın Büdeyri, M.D.,3 Didem Venüs Yıldız, M.D.,4 Hasan Havıtçıoğlu, M.D.1 1

Department of Orthopedics and Traumatology, Dokuz Eylul University Faculty of Medicine, Izmir;

Department of Orthopedics and Traumatology, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale

Department of Orthopedics and Traumatology, Private Sani Konukoglu Hospital, Gaziantep;

Department of Biomechanics, Institute of Health Science, University of Dokuz Eylul, Izmir

ABSTRACT BACKGROUND: The aim of this study was to evaluate the biomechanical behavior of anterior inferior tibiofibularis ligament (AITFL) deficient human ankle under axial loading of ankle at stance phase of gait. In order to investigate the contribution of AITFL to ankle stability, an in vitro sequential experimental setup was simulated. METHODS: The measurement of posterior displacement of distal tibia and anterior displacement of the foot, in neutral position, secondary to axial compression, was performed by two non-contact video extensometers. Eight freshly frozen, anatomically intact, cadaveric human ankle specimens were included and tested. An axial compression test machine was utilized from 0 to 800 Newtonswith a loading speed of 5 mm/min in order to simulate the axial weight-bearing sequence of the ankle at stance phase of human gait. RESULTS: There was a statistically significant difference between anteroposterior displacement values for AITFL-Intact and AITFLDissected specimens (p≤0.05). Mean AITFL-Intact and mean AITFL-Dissected ankle anteroposterior displacement was 1.28±0.47 mm and 2.06±0.7 mm, respectively. CONCLUSION: This study determined some numerical and quantitative data about the biomechanical properties of AITFL in neutral foot position. In the emergency department, diagnosis and treatment of AITFL injury, due to ankle distortion, is important. In AITFL injuries, ankle biomechanics is affected, and ankle instability occurs. Key words: Ankle biomechanics; anterior inferior tibiofibular ligament; axial compression test; displacement; non-contact measurement.

INTRODUCTION Ankle injuries are common in all levels of daily activities and sport traumas, varying in severity, degree and location. Most commonly, ankle injuries are located at the lateral ankle region, especially on anterior talofibular ligaments and anterior inferior tibiofibular ligaments (AITFL). Three quarters of ankle injuries involve the lateral ligamenAddress for correspondence: Ahmet Karakaşlı, M.D. Dokuz Eylül Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İnciraltı, İzmir, Turkey Tel: +90 232 - 412 33 53 E-mail: akarakasli@mailcity.com Qucik Response Code

tous complex.[1,2] Compared with the lateral ankle sprain, syndesmosis sprains are uncommon and noted less frequently. The incidence of syndesmosis injuries is reported 1% to 11% of all ankle injuries.[3-5] Although much research has focused on injury to lateral ankle ligaments and inversion ankle sprain, studies in the literature regarding the injury of the anterior inferior tibiofibular ligament are limited.[3] Syndesmotic injuries are still often undetected and diagnosed only after a simple ankle sprain fails to heal.[2] Syndesmosis injuries are a greater source of impairment than the typical lateral ankle sprain.[4] Partial disruption of syndesmosis is difficult to diagnose.[6] The leading cause of AITFL impingement lesions is posttraumatic ankle injuries, usually ankle sprains, resulting in chronic ankle pain.[7] Taking foot biomechanics into consideration is essential for clinicians during the treatment of ankle instability, which is especially the case for any surgical repair of injured ankle ligaments.[8] Biomechanical functions of the ligaments are to Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Karakaşlı et al. The effects of tibiofibularis anterior ligaments on ankle joint biomechanics

resist external load, guide relative movements of the two bones, and control the maximum range of joint motion. In determining the mechanical properties of the ligaments, tissue condition and test methods are particularly important (e.g. temperature, moisture content, strain rate, and previous loading history influence the tensile properties). Biomechanical research on distal tibiofibular syndesmosis injury mechanisms is also rare.[9] This kind of injury is difficult to evaluate and diagnose,[10] and has a longer recovery time than other ankle sprains.[9,11] A common ankle trauma mechanism usually initiates with an acute and inadequate axial loading trauma on the ankle, and then the load distribution on the ankle diverges to the medial and lateral ankle ligaments triggering the injury mechanism to the ankle syndesmosis. However, more often, while the lateral ankle region is the most commonly injured side, the medial is the least injured since the medial ligamentous complex is stronger and more resistant than the lateral complex.[3,12] This anatomic differentiation results in a relatively unbalanced moment distribution on the lateral and medial constraints. Center point of moment on ankle changes position towards the medial side of ankle and far to the lateral. This type of acute relative load distribution results in an increased energy concentration on the lateral side and higher incidence of lateral ankle injuries.[3] Distal fibula is firmly attached at the tibial notch of the tibia by several syndesmotic ligaments.[3,5] There are three main ligaments that add stability to distal tibiofibular syndesmosis including the anterior inferior tibiofibular ligament (AITFL), the posterior tibiofibular ligament (PITFL), and the interosseous ligament.[1-4] Anterior inferior tibia fibular ligament is a flat strong ligament that originates from the longitudinal tubercle on the anterior aspect of the lateral malleolus and fibers course superiorly and medially attaching on the anterolateral tubercle of tibia. This ligament, in addition to holding the fibula tight to the tibia, prevents excessive fibular movement and external talar rotation.[3,4] AITF ligament is the most frequently injured ligament in syndesmosis rupture of the AITF ligament that can lead to separation between the tibia and fibula. Most commonly, the AITFL is ruptured.[2,13] This anterior syndesmotic diastasis is an open book injury resulting from external rotation of the fibula. Tibia fibular ligament sprains are important since they have a longer recovery time, and they may develop subsequent chronic ankle instability. In most previous studies, syndesmosis and anterior inferior tibiofibular ligament biomechanical investigations were carried out under axial load.[5,14] In this study, talus anterior displacement was measured under axial load in two situations of intact anterior inferior tibioUlus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

fibular ligament and sectioned anterior inferior tibiofibular ligament. The aim of the present study was to examine the mechanical behavior of human ankle AITFL at same force (800 Newtons) and investigate the instability of talus biomechanically. In this study our aim was to investigate the talar instability in AITFL rupture. To measure the displacement and instability of ankle joint, talus was chosen to be a landmark as the major mechanical and anatomic constraint of the ankle joint.

MATERIALS AND METHODS In order to investigate the contribution of anterior inferior tibiofibularis ligament to ankle stability under axial compression force, in vitro measuring of the anterior foot displacement was sequentially simulated under experimental biomechanical setup. According to the procedure of this study, eight freshly frozen, cadaveric human ankle specimens, amputated 1 inch below the tibial tuberosity level, examined to have no incompatibility in any aspects of anatomical structures were included into the study. The specimens included were positioned neutrally in the experimental setup of axial compression test machine (AG-IS 10 kN, Shimadzu Corporation, Kyoto, Japan) in order to simulate axial weight-bearing of ankle at the stance phase of human gait. Moreover, two conditions for the human anterior inferior tibiofibular ligament (AITFL) were simulated, AITFL-Intact and AITFL-Dissected, to evaluate its contribution to anterior stability of ankle at this phase of human gait. Afterwards, distal tibia was marked 1 cm above ankle joint level and also neck of talus bone with pinned gauge marks of non-contact video extensometer (Non-contact Video Extensometer DVE-101/201, Shimadzu Corporation, Kyoto, Japan). Talus was chosen a landmark, which is the main anatomical and biomechanical constraint of the ankle joint. Subsequently, axial compression load of maximum 800 Newtons was applied gradually from 0 to 800 Newtons with a loading speed of 5 mm/min. Simultaneously, the resulting displacements of the gauge marks during the anterior spin of the foot and the posterior spin of the distal tibia were captured by perpendicularly lateral positioned noncontact CCD cameras and were measured via non-contact video extensometer (Non-contact Video Extensometer DVE-101/201, Shimadzu Corporation, Kyoto, Japan). The inbuilt double camera which has an absolute accuracy depending on the smaller field of view, is able to measure the minor displacements with a low standard error. In our study absolute error is +/- 3x10-3 mm and the relative error is +/- 1% of the elongation (room temperature).

Specimens Eight freshly frozen, cadaveric human ankle specimens, amputated 1 inch below the tibial tuberosity level, examined to have no incompatibility in any aspects of the anatomical structures were included into the study. The specimens included were positioned neutrally in the experimental setup 91

Karakaşlı et al. The effects of tibiofibularis anterior ligaments on ankle joint biomechanics

of axial compression test machine (AG-IS 10 kN, Shimadzu Corporation, Kyoto, Japan) in order to simulate axial weightbearing of ankle at stance phase of human gait. Researchers were blind to all human subjects of the specimens. Seven of the specimens were from men and one was from a woman. Median age of the patients to whom the specimens belonged was 66 years (range, 54-80) at the time of operation. There were no ligamentous pathology, joint pathology, and osteoarthritis in the ankles of the patients. The specimens were noted to have intact ligaments by direct visualization after dissection. After the tests were performed for intact ligaments of human ankles, anterior tibiofibular ligament of each specimen was dissected.

Test Machine The test machine (AG-IS 10 kN, Shimadzu Corporation, Kyoto, Japan) which was set up in our biomechanics laboratory could apply axial compression to the ankle with foot. The test machine consisted of load cell (max. 5 kN) attached to the crosshead of the main body, compression plates (upper plate and lower plate), adapter for compression including screw, table (support) of bending and controller. The test device had data processing software (TRAPEZIUM2, Shimadzu Corporation, Kyoto, Japan) and non-contact video extensometer (DVE-101/201, Shimadzu Corporation, Kyoto, Japan) which was an elongation meter that enabled elongation measurement without making contact with the test specimen. Figure 1 illustrates the test arrangement.

Methods This laboratory based study was carried out in the Biomechanical Laboratory of Institute of Health Sciences of Faculty of Medicine of Dokuz Eylul University. In this study, axial loads were applied vertically to eight specimens during foot at neutral position. The study was conducted in two phases. In the first phase, the specimens with intact anterior inferior tibiofibular ligaments were tested. Longitudinal axis of the amputee was vertical to ground surface. Suitable gauge marks (diamond mark for high accuracy) for specimens were applied to test specimens with pins due to the sliding surface of test specimens. One of the gauge marks was placed to

Lateral view Gauge marks in sagittal plane

Transected AITFL

Figure 2. Transected Anterior Inferior Tibiofibular Ligament (AITFL) of a specimen and lateral view of upper and lower gauge marks in saggital plane.

distal tibia anteriorly 1 cm proximal from ankle joint level and the other one was attached to the neck of talus bone parallel with the proximal gauge mark in the same sagittal plane that was perpendicular with cameras. Axial compression load of maximum 800 Newtons was applied to each amputee material with a loading speed of 5 mm/min. Operating temperature was room temperature of 25 °C. Non-contact measurements were carried out by two noncontact cameras that grabbed image of the gauge marks attached to the test specimens. Personal computer processed grey-scale image and measured the displacement of the gauge marks of each camera image from the initial processing result. The gauge length was measured as the distance between centers of the upper and lower gauge marks (Fig. 2). The gauge length on the CCD screen was converted into the actual distance to calculate the displacement of the test specimen. Converting ratio was calculated during calibration before measurement. The second phase involved the division of the anterior inferior tibiofibular ligaments. The entire anterior inferior tibiofibular ligament was sectioned in its mid-substance (Fig. 2), 3 2.5

Personel Computer Load Cell

2 1.5 1

Two non-contact cameras

0.5 Test Machine

Figure 1. Schematic diagram of axial compression test includes axial compression test machine, amputee, double non-contact cameras, computer.

Measurement 1

Measurement 2

Figure 3. Mean displacement values of measurements of biomechanical test. Measurement 1 was mean displacement value of specimens in intact situation. Measurement 2 was mean displacement value of specimens after sectioning of ATIF ligament.

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Karakaşlı et al. The effects of tibiofibularis anterior ligaments on ankle joint biomechanics

RESULTS

Table 1. Displacement values of biomechanical measurements of the specimens. Patient

Displacement Values (mm) Intact

AITFL sectioned

No. 1

4.45

6.91

No. 2

0.85

2.09

No. 3

0.55

0.60

No. 4

0.50

0.16

No. 5

1.72

3.76

No. 6

0.47

0.71

No. 7

0.71

1.08

No. 8

1.00

1.21

AITFL: Anterior inferior tibiofibularis ligament

and measurements were made with an external load of 800 Newtons. The same procedure of biomechanical axial compression test was carried out as in the first phase. For both phases, the results of displacement values were recorded on personnel computer connected with test machine and two non-contact cameras. The software produced the results of displacement and force on charts and the results were displayed on personnel computer screen. After the tests were performed, medial ligaments of the specimens were checked if they were intact ligaments by direct visualization after dissection. Clinically displacements of 2 mm and above are known as instability of ankle. The anterior displacement of fibula was reported to be an average of 1.2 mm, with a sectioned AITFL.[2,6,14]

Statistical Analysis Descriptive statistics and confidence limits were calculated with SPSS software (SPSS 15.0). Paired data analysis correlated with the biomechanical evaluation was performed to compare the displacement values of the specimens with AITFL intact and specimens with AITFL sectioned. Comparisons of the results of the two phases were made by Wilcoxon signed rank test. Differences were considered statistically significant when P was less than or equal to 0.05 (0.05 ≥ P).

In both phases of this study, 800 Newtons axial loads were applied to intact AITFL of ankle at neutral position. According to the results of this biomechanical study, talus anterior displacement values were shown in Table 1. Displacement results of the gauge marks under compression during the anterior spin of the foot and the posterior spin of the distal tibia were measured by laterally placed noncontact CCD video extensometer cameras positioned in a perpendicular fashion to the ankle and gauge marks. Mean AITFL-Intact ankle anteroposterior gauge displacement was 1.28±0.47 mm (Fig. 3). Mean AITFL-Dissected ankle anteroposterior gauge displacement was 2.06±0.7 mm (Fig. 3). In general, all displacement results of the specimens were similar but the displacement result of specimen number five was obviously different. There was a statistically significant difference between the anteroposterior displacement values for AITFL-Intact and AITFL-Dissected specimens (p≤0.05). Vertical stiffness values (MPa) for amputees with intact AITFL and dissected AITFL were presented in Table 2. There was no difference in stiffness between AITFL-Intact and AITFL-Dissected specimens (p≤0.05).

DISCUSSION Ankle injury, which is currently a very important problem affecting many people, is the most common sports injury. After ankle sprain, some patients continue to experience the following complaints: intermittent ankle pain, swelling, sense of instability, and recurring pain.[2,4,13,15,16] It is calculated that the likelihood of a new sprain following lateral injury is increased twice or three times.[13,15] Ankle stability is dependent upon load level direction of forces applied and ligament integrity.[14] Most commonly, the AITFL is ruptured. This anterior syndesmotic diastasis is an open book injury resulting from external rotation of fibula. In the external rotation of the ankle, a greater strain occurs on the AITFL. In this injury, application of plaster provides recovery; however, if a proper treatment is not given in the early stage, chronic instability and pain may occur in the late period. In our study, the lateral displacement of talus was measured under 800 Newtons axial loads with an intact AITFL after its

Table 2. Vertical stiffness values (kvert) for amputees with intact ATIFL and amputees with dissected ATIFL (N/mm)

No 1.

No 2.

No 3.

No 4.

No 5.

No 6.

No 7.

No 8.

Stiffness values (kvert) of amputees

179.78

941.18

1454.55

1600

465.12

1702.13

1126.76

800

115.77

382.78

1333.33

5000

212.77

1126.76

740.74

661.16

with intact ATIFL (n=8) Stiffness values (kvert) of amputees with dissected ATIFL (n=8) Formula for calculating stiffness : VERTICAL STIFFNESS (kvert) → kvert = Fmax / ∆y (McMahon and Cheng,1990) where Fmax = maximum vertical force; ∆y = maximum vertical displacement measured by test machine (AG-IS 10 kN, Shimadzu Corporation, Kyoto, Japan)

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Karakaşlı et al. The effects of tibiofibularis anterior ligaments on ankle joint biomechanics

sectioning in the human ankle at neutral position. The displacement values of AITFL intact and AITFL sectioned were compared. It was found that measured anterior displacement values at AITFL sectioned were about twofold more than from AITFL intact values. The displacement values found in our study for the anterior displacement of talus were close to the measured values in the literature. Beumer et al.[14] have measured anterior fibular displacement under axial load after the sectioning of AITFL, and their measurements have been taken with the ankle at neutral position. They have found 1.1 mm - 2.6 mm, which are similar values to our study. In AIFTL isolate rupture, the lateral displacement of the fibula is reported in the average 1.2 mm since other ligaments are intact and the fibula cannothave excessive displacement.[6,7,14] In this study, the anterior displacement and anterior instability of the talus was investigated under axial load at neutral position. Beumer et al.[14] have reported that it is of interest that in the neutral situation, displacements were found after sectioning the ligaments because the level of the distal tibiofibular syndesmosis in the horizontal plan may be considered to be a ring. The ring is composed of anterior tibiofibular ligament, fibula, posterior tibiofibular ligament and tibia.[14] The talus is located in the center of the ring. When the ring is disrupted at one level, for example AITFL, the rest tension of the ring cannot be maintained, and there will be a relaxation at the posterior tibiofibular ligament and posterior capsule. In this situation, the fibula will be displaced.[14] In our study, the anterior displacement of the talus was measured mean 1.4 mm. Since the values found were very small, AITFL injuries were difficult to detect in acute stage. This situation constitutes ankle stability and some patients may experience ankle pain while walking and doing some activity.[7,17] Post traumatic anterolateral instability due to an injured and torn AITFL results in anterolateral extorsion of the talar dome, and it may cause impingement syndromes of the ankle. Unstable ankles may lead to the formation of fibrosis granulation tissue.[7] In the current study, when the AITFL was sectioned, the anterior displacement of the talus was measured 0.45 mm to 2.45 mm. It is similar to previous studies where the anterior displacement of fibula was reported to be an average of 1.2 mm, with a sectioned AITFL.[2,6,14] Watanabe et al.[18] have shown that under external load of the ankle, peak strains in the AITFL occur prior to peak strain in the AITFL. Deltoid ligament rupture occurs after AITFL rupture. Posterior displacement of the distal tibia in this biomechanical axial compression setup should be considered as the anterior instability of the ankle joint during axial weight-bearing phase of human gait stance phase. In order to understand antero-posterior instability due to AITFL injuries during all phases of human gait, advanced new dynamic studies including not only human gait at stance phase as measured in this study but also all phases of human gait, were required. This study was a pilot study for the require94

ment of data on AITFL biomechanics,and new studies are required for understanding AITFL biomechanics. Our limitation in this study was the median age of the patients to whom the specimens belonged to, which was 66 years of age (range 54-82). Therefore, biomechanical study didn’t evaluate the young population. However, the situation of old population didn’t affect the results as this was a comparison of two groups in biomechanical study. Instead of static position, dynamic or different foot positions may give more information about the biomechanics of AITF ligaments.

Conclusion In living humans, it may be crucial in understanding the ankle function and injury mechanisms.[17,19] It may be explained why AITFL is injured more than the other ligaments in the ankle under external rotation load. Our findings in this study showed that talus instability and talus displacement may occur in AITFL injuries of the ankle. In the emergency department, diagnosis and treatment of AITFL injury due to ankle distortion is important. In AITFL injuries, ankle biomechanics is affected and ankle instability occurs. Displacement values for AITFL-Dissected specimens may be evidence for tendency to anteroposterior displacement and biomechanical insufficiency under axial compression during foot in neutral position, giving the impression that AITFL deficient-ruptured patients are being exposed to more instable and degenerative processes during axial weight-bearing of ankle at stance phase of gait. Since distal tibial joint surface has an anteroposterior inclination at horizontal axis, AITFL plays an important stabilizer role during axial loading of ankle joint. Randomized, controlled, dynamically measured further trials are necessary to identify more real-time biomechanical behavior of AITFL contributing to ankle stability during all phases of human gait and axial ankle loading. This study will provide basic knowledge for future studies of ankle joint biomechanics, which will shed light on clinical studies relevant to ankle. Conflict of interest: The authors confirm that there is no conflict of interest regarding the publication of this manuscript. We had no financial and personal relationships with other people or organizations that could inappropriately influence (bias) our work.

REFERENCES 1. Chan KW, Ding BC, Mroczek KJ. Acute and chronic lateral ankle instability in the athlete. Bull NYU Hosp Jt Dis 2011;69:17-26. 2. Title CI, Katchis SD. Traumatic foot and ankle injuries in the athlete. Orthop Clin North Am 2002;33:587-98. 3. Norkus SA, Floyd RT. The anatomy and mechanisms of syndesmotic ankle sprains. J Athl Train 2001;36:68-73. 4. Clanton TO, Paul P. Syndesmosis injuries in athletes. Foot Ankle Clin

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Karakaşlı et al. The effects of tibiofibularis anterior ligaments on ankle joint biomechanics 2002;7:529-49. 5. Beumer A, van Hemert WL, Swierstra BA, Jasper LE, Belkoff SM. A biomechanical evaluation of the tibiofibular and tibiotalar ligaments of the ankle. Foot Ankle Int 2003;24:426-9. 6. Xenos JS, Hopkinson WJ, Mulligan ME, Olson EJ, Popovic NA. The tibiofibular syndesmosis. Evaluation of the ligamentous structures, methods of fixation, and radiographic assessment. J Bone Joint Surg Am 1995;77:847-56. 7. van den Bekerom MP, Raven EE. The distal fascicle of the anterior inferior tibiofibular ligament as a cause of tibiotalar impingement syndrome: a current concepts review. Knee Surg Sports Traumatol Arthrosc 2007;15:465-71. 8. Hintermann B. Biomechanics of the ligaments of the unstable ankle joint. [Article in German] Sportverletz Sportschaden 1996;10:48-54. [Abstract] 9. Taylor DC, Englehardt DL, Bassett FH 3rd. Syndesmosis sprains of the ankle. The influence of heterotopic ossification. Am J Sports Med 1992;20:146-50. 10. Taylor DC, Bassett FH. Syndesmosis ankle sprains: diagnosing the injury and aiding recovery. Physician Sportsmed 1993;21:39-46. 11. Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports Med 1991;19:294-8. 12. Wang Q, Whittle M, Cunningham J, Kenwright J. Fibula and its ligaments in load transmission and ankle joint stability. Clin Orthop Relat Res 1996;330:261-70.

13. Kumar V, Triantafyllopoulos I, Panagopoulos A, Fitzgerald S, van Niekerk L. Deficiencies of MRI in the diagnosis of chronic symptomatic lateral ankle ligament injuries. Foot and Ankle Surgery 2007;13:171-6. 14. Beumer A, Valstar ER, Garling EH, Niesing R, Ginai AZ, Ranstam J, et al. Effects of ligament sectioning on the kinematics of the distal tibiofibular syndesmosis: a radiostereometric study of 10 cadaveric specimens based on presumed trauma mechanisms with suggestions for treatment. Acta Orthop 2006;77:531-40. 15. Urgüden M, Kızılay F, Sekban H, Samancı N, Ozkaynak S, Ozdemir H. Evaluation of the lateral instability of the ankle by inversion simulation device and assessment of the rehabilitation program. Acta Orthop Traumatol Turc 2010;44:365-77. 16. Bonnel F, Toullec E, Mabit C, Tourné Y; Sofcot. Chronic ankle instability: biomechanics and pathomechanics of ligaments injury and associated lesions. Orthop Traumatol Surg Res 2010;96:424-32. 17. Wei F, Braman JE, Weaver BT, Haut RC. Determination of dynamic ankle ligament strains from a computational model driven by motion analysis based kinematic data. J Biomech 2011;44:2636-41. 18. Watanabe K, Kitaoka HB, Berglund LJ, Zhao KD, Kaufman KR, An KN. The role of ankle ligaments and articular geometry in stabilizing the ankle. Clin Biomech (Bristol, Avon) 2012;27:189-95. 19. Stufkens SA, van Bergen CJ, Blankevoort L, van Dijk CN, Hintermann B, Knupp M. The role of the fibula in varus and valgus deformity of the tibia: a biomechanical study. J Bone Joint Surg Br 2011;93:1232-9.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Tibiofibularis anterior ligamanının ayak bileği eklemi biyomekaniğine etkisi Dr. Ahmet Karakaşlı,1 Dr. Mehmet Erduran,1 Dr. Lütfü Baktıroğlu,2 Dr. Aydın Büdeyri,3 Dr. Didem Venüs Yıldız,4 Dr. Hasan Havıtçıoğlu1 Dokuz Eylül Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İzmir; Çanakkale Onsekiz Mart Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Çanakkale; Özel Sani Konukoglu Hastanesi, Ortopedi ve Travmatoloji Kliniği; Gaziantep; 4 Dokuz Eylül Üniversitesi Sağlık Bilimleri Enstitüsü, Biyomekanik Anabilim Dalı, İzmir 1 2 3

AMAÇ: Bu çalışmanın amacı duruş fazında aksiyel yüklenme altında insan ayak bileğinin anterior inferior tibiofibularis ligamanının (AITFL) biyomekanik davranışını değerlendirmektir. Duruş fazında ayak bileği stabilitesine AITFL’nin etkisini araştırmak için in vitro ardaşık deneysel bir düzenek simüle edildi. GEREÇ VE YÖNTEM: Aksiyel kompresyon gerçekleşirken nötral posizyonda ayağın anterior yerdeğişimi ve distal tibianın posterior yerdeğişimi ölçümü iki non-kontakt vidyo ekstansiyometre ile gerçekleştirildi. Sekiz taze donmuş ve anatomik olarak sağlam insan kadavra ayak bileği örnekleri test edildi. Aksiyel kompresyon test makinesi, duruş fazında aksiyel ayak bileği yüklenmesini simüle etmek için 0’dan 800 Newton’a kadar yüklenme ile ve 5 mm/dk yükleme hızında kullanıldı. BULGULAR: AITFL-sağlam ve AITFL-kesilmiş örneklerde anteroposterior yerdeğiştirme arasında istatistiksel olarak anlamlı fark gözlendi. Ortalama AITFL-sağlam ayak bileği anteroposterior yerdeğişimi 1.28±0.47 mm idi. Ortalama AITFL-kesik ayakbileği anteroposterior yerdeğişimi 2.06±0.7 mm idi. TARTIŞMA: Sonuç olarak, ayak bileği nötral pozisyondayke AITFL’nin biyomekanik özellikleri hakkında bazı nümerik ve kantitatif bilgi vermektedir. Acil serviste ayakbileği distorsiyon sonrası AITFL yaralanması teşhisi ve tedavisi önemlidir. Ayak bileği biyomekaniği AITFL yaralanmaları sonrası etkilenmekte ve instabilite gelişmektedir. Anahtar sözcükler: Aksiyel kompresyon testi; anterior inferior tibiofibular ligamanı; ayak bileği biyomekaniği; yer değiştirme. Ulus Travma Acil Cerrahi Derg 2015;21(2):90-95

doi: 10.5505/tjtes.2015.27163

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EXPERIMENTAL STUDY

The effects of caffeic acid phenethyl ester on inflammatory cytokines after acute spinal cord injury Hakan Ak, M.D.,1 İsmail Gülşen, M.D.,2 Tamer Karaaslan, M.D.,3 İlker Alaca, M.D.,3 Aydın Candan, M.D.,4 Havva Koçak, M.D.,5 Tugay Atalay, M.D.,1 Asuman Çelikbilek, M.D.,6 İsmail Demir, M.D.,7 Tevfik Yılmaz, M.D.8 1

Department of Neurosurgery, Bozok University Faculty of Medicine, Yozgat;

Department of Neurosurgery, Yüzüncü Yıl University Faculty of Medicine, Van;

Department of Neurosurgery, Süleyman Demirel University Faculty of Medicine, Isparta;

Department of Histology and Embryology, Süleyman Demirel University Faculty of Medicine, Isparta;

Department of Biocehmistry, Dumlupınar University Faculty of Medicine; Kütahya;

Department of Neurology, Bozok University Faculty of Medicine, Yozgat;

Department of Neurosurgery, Van Regional Training and Teaching Hospital, Van;

Department of Neurosurgery, Dicle University Faculty of Medicine, Diyarbakır

ABSTRACT BACKGROUND: The purpose of this study was to investigate the effects of Caffeic Acid Phenethyl Ester (CAPE) on proinflammatory cytokines, IL-1β and TNF-α, and explore its healing effect after acute spinal cord injury. METHODS: Forty-eight male Wistar-Albino rats were used in this study which was planned as three groups. All groups were divided into two sub-groups. Group 1a was the control group, in which only lower segment thoracic laminectomy was performed. In group 1b, spinal cord trauma was performed with aneurysm clip. In the second group, serum physiologic was given systemically thirty minutes after trauma, and rats were sacrificed after the first and sixth hour. In the third group, CAPE was given systemically thirty minutes after trauma, and rats were sacrificed after the first and sixth hour. Serum IL-1β and TNF-α levels were analyzed by ELISA in the serum. Histopathological analysis was performed in damaged cord tissues. RESULTS: CAPE suppressed TNF-α and IL-1β levels in the serum. In histopathological evaluation, it was detected that CAPE decreased hemorrhage and necrosis. CONCLUSION: CAPE suppresses the levels of proinflammatory cytokines, TNF-α and IL-1β, after acute spinal cord injury in the early phase and contributes to the healing process. Key words: CAPE; IL-1β; inflammation; spinal cord injury; TNF-α.

INTRODUCTION Spine injury is a serious health problem having detrimental effects on the patient, family, and economy of the country.

Address for correspondence: Hakan Ak, M.D. Bozok Üniversitesi Araştırma ve Uygulama Hastanesi, 66100 Yozgat, Turkey Tel: +90 354 - 212 70 60 / 3671 E-mail: nrsdrhakanak@yahoo.com Qucik Response Code

Its general incidence is about 20-40/1.000.000 in many countries around the world.[1] In the pathophysiology of acute spinal cord injury (SCI), primary and secondary mechanisms of the injury have been proposed. There are four characteristic mechanisms in primary injury, which are impact plus persistent compression, impact alone with transient compression, distraction, and laceration/transaction. However, secondary mechanisms of injury, extending from primary injury, involve neurogenic shock, vascular insults, excitotoxicity, calciummediated secondary injury and fluid-electrolyte disturbances, immunologic injury, apoptosis, disturbances in mitochondrion function, and other miscellaneous processes.[2] Caffeic acid phenethyl ester (CAPE) is one of the active components of propolis, which is a substance found in the plant extracts collected by honeybees. Antimicrobial, anti-inflamUlus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Ak et al. The effects of caffeic acid phenethyl ester on inflammatory cytokines after acute spinal cord injury

matory, immunomodulatory, antimutagenic, and antioxidant effects of propolis have been revealed in several studies. CAPE, specifically by blocking NF-κB and oxygen radicals, inhibits many inflammatory agents, especially the TNF-α. It has been shown that CAPE induces apoptosis in inflammatory cells independently from glucocorticoid receptors. Protective effects of CAPE in the nervous system have been reported in cerebral ischemic reperfusion injury, ischemic damage of the spinal cord, Parkinson’s disease, convulsions, multiple sclerosis, brain tumors, hepatic encephalopathy, and against toxic effects of therapeutic agents in anticancer therapy.[311] Moreover, studies evaluating its protective effect in spinal cord ischemia-reperfusion models and hemi-transection model have been reported; however, there is no study investigating the acute effects of CAPE in traumatic acute spinal cord injury in clip compression model. Therefore, this study was conducted to evaluate the early anti-cytotoxic effects of CAPE in acute spinal cord injury.

MATERIALS AND METHODS After the approval of Süleyman Demirel University (SDÜ) Local Ethical Committee on Animal Experiments (121531123153855-136), surgical procedure was performed in the experimental animals’ research laboratory of the medical faculty of the same university. Forty-eight Wistar albino adult male rats, weighing 250±40 gr, were used. They were divided into three main groups, and each group was divided into two subgroups including eight animals. All animals were weighed before the operation and sacrification. Biochemical and pathological examinations were performed in the laboratories of biochemistry and histology-embryology departments of SDU.

tissues including lesion site and blood were taken for histopathological and biochemical evaluation before the rats were sacrificed with high dose of anesthesia. In Group 1b (n=8), spinal cord tissues including lesion site and blood were taken one hour after laminectomy and trauma. In Group 2a (n=8), 1cc saline was given intraperitoneally thirty minutes after trauma. One hour after trauma, blood and spinal cord tissue were taken. In Group 2b (n=8), the same steps as those of 2a were followed, but blood and tissue samples were taken six hours after trauma. In Group 3a (n=8), CAPE was given intraperitoneally (10 µg/kg) thirty minutes after trauma. One hour after trauma, blood and tissue samples were taken. In Group 3b (n=), same dosage of CAPE was given intraperitoneally thirty minutes after trauma; however, blood and tissue samples were taken six hours later. Interleukin 1β and tumor necrosis factor-α levels were measured in the blood with ELISA kits. For light microscopy, spinal cord tissue samples were fixed with 10% formalin.

Statistical Analysis Statistical analyses were performed using SPSS 15.0 software (SPSS Inc., Chicago, IL, USA). Parametric values were given

(a)

In total, rats were divided into six groups; Group 1a (n=8) only laminectomy (1st h), Group 1b (n=8) laminectomy + trauma (1st h), Group 2a (n=8) laminectomy + trauma + saline (1st h) Group 2b (n=8) laminectomy + trauma + saline (6th h) Group 3a (n=8) Laminectomy +trauma +CAPE (1st h) Group 3b (n=8) Laminectomy + trauma +CAPE (6th h)

Anesthesia General anesthesia was achieved with an intraperitoneal administration of 8 mg/100 gr ketamine (Alfamine 10%, Ege Vet Hayvancılık Bornova-İzmir, Alfasan International BV Holland) and 1 mg/100 gr xylazine (Alfazyne 2%, Ege Vet Hayvancılık Bornova-İzmir, Alfasan International BV Holland).

(b)

Surgical Procedure Laminectomy was performed between the thoracic vertebrae Th8 and Th12. Aneurysm clip (Sugita no: 07-934-11, closure pressure: 1.37-1.72 N) was used to create trauma for one minute (Figs 1a, b). In Group 1a (n=8), one hour after laminectomy, spinal cord Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Figure 1. (a) Creating spinal cord injury with an aneurysm clip. (b) External view of spinal cord after creating injury.

Ak et al. The effects of caffeic acid phenethyl ester on inflammatory cytokines after acute spinal cord injury

Histological evaluation

Table 1. Mean TNF-α and IL-1β values of each group

Mean

10.7798

13.0727

10.4561

10.0711

9.2311

9.3185

32.6550

33.8704

25.4870

30.7100

23.8298

21.1215

TNF-α

IL-1β

Stained tissue samples were examined under binocular microscope (Olympus BX50, NY), and microphotographs of the sections were evaluated. For histopathological evaluation, a semi-quantitative scoring system which was previously used by Ercan et al. was selected.[12] According to this system; (-) score (negative score): no structural change (+) score (1 positive score): slight changes. (++) score (2 positive score): moderate changes

(a)

as mean±standard deviation and non-parametric values were given as percentage. In order to compare parametric continuous variables, Student’s t-test was used, and Mann-Whitney U-test was used to compare nonparametric continuous variables. Two-tailed P-values of less than 0.05 were considered statistically significant.

RESULTS

(b)

Biochemical Evaluation Mean serum TNF-α levels were 10.7798 pg/ml in Group 1a, 13.0727 pg/ml in Group 1b, 10,456 pg/ml in Group 2a, 10.0711 pg/ml in Group 2b, 9.2311 pg/ml in Group 3a, and 9.3185 pg/ ml in Group 3b (Table 1). TNF-α levels were increased in Group 1b when compared to Group 1a; however, no statistically significant difference was observed (p=0.070). There was not a statistically significant difference between Groups 1a, 2a, and 2b (p=0.999 and p=0.949, respectively). Similarly, there was not a significant difference between Groups 1a, 3a, and 3b (p=0.404 and p=0.469, respectively). Significant differences were detected between Groups 1b and Groups 2a or 2b, and Groups 3a and 3b (p=0.026, 0.007, 0.001, and 0.001, respectively). No difference was observed between Groups 2, 3 and their subgroups (Table 2). Mean serum IL-1β levels were 32.6550 pg/ml in Group 1a, 33.8704 pg/ml in Group 1b, 25.4870 pg/ml in Group 2a, 30.7100 pg/ml in Group 2b, 23.8298 pg/ml in Group 3a, and 21.1215 pg/ml in Group 3b (Table 1). IL-1β level was decreased in Groups 3a and 3b when compared to Group 1b; however, no significant difference was observed between these groups (p=0.539 and 0.278, respectively). In addition, no statistically significant difference was detected between all groups and their subgroups (Table 3). 98

(c)

Figure 2. (a) Microscopic appearance in group 1a (H&E, x100). (b) Microscopic appearance in group 2a (H&E, x100). (c) Microscopic appearance in group 3a (H&E, x100).

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Ak et al. The effects of caffeic acid phenethyl ester on inflammatory cytokines after acute spinal cord injury

Table 2. Statistical comparisons of TNF-α among the groups

Table 3. Statistical comparisons of IL-1β among the groups

Dependant variable

(I) group

TNF-α

(J) group

(I) group

(J) group

1b 0.070

IL-1β

2a 0.999

2a .828

2b .949

2b .999

3a .404

3a .670

3b .469

3b .386

1a .070

1a 1.000

2a .026

2a .715

2b .007

2b .994

3a .001

3a .539

3b .001

3b .278

1a .999

1a .828

1b .026

1b .715

2b .997

2b .948

3a .654

3a 1.000

3b .720

3b .976

1a .949

1a .999

1b .007

1b .994

2a .997

2a .948

3a .901

3a .851

3b .935

3b .588

1a .404

1a .670

1b .000

1b .539

2a .654

2a 1.000

2b .901

2b .851

3b 1.000

3b .997

1a .469

1a .386

1b .001

1b .278

2a .720

2a .976

2b .935

2b .588

3a 1.000

3a .997

1b 1.000

Table 4. Histopathological findings of each group Group number

Degeneration or hemorrhage in central canal

Necrosis in gray and white matter

–

Hemorrhage in gray and white matter

Liquefaction necrosis

+ + –

+++

+++ +++ +++

+++

+++ +++ +++

+++

+++ +++ +++

+ + +

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Ak et al. The effects of caffeic acid phenethyl ester on inflammatory cytokines after acute spinal cord injury

(+++) score (3 positive score): prominent changes. Group 1a: Slight hemorrhage was detected in gray and white matter (+). Also, slight necrosis was seen in both matters (+). Degeneration, hemorrhage, and liquefaction necrosis were not observed in the central canal (Fig. 2a). Group 1b: Prominent hemorrhage and necrosis were observed in both matters (+++). Also, degeneration, hemorrhage, and liquefaction necrosis were prominent in the central canal (+++). Group 2a: Prominent hemorrhage and necrosis were observed in both matters (+++). Also, degeneration, hemorrhage, and liquefaction necrosis were prominent in central canal (+++) (Fig. 2b). Group 2b: Similar findings were observed as those of Groups 1b and 2a. Group 3a: There was slight hemorrhage and liquefaction necrosis around central canal. Moderate hemorrhage and necrosis were observed in white and gray matter less than previous groups (Fig. 2c). Group 3b: Similar findings were observed as those of Group 3a (Table 4).

DISCUSSION In the present study, CAPE was detected to decrease TNF-α and IL-1β levels after spinal cord injury in the early period. Furthermore, it reduces hemorrhage and necrosis in gray and white matter, as well as in the central canal. Two known mechanisms of spinal cord injury are primary mechanical injury and secondary injury. Underlying mechanisms of pathophysiology in these injuries include acute hemorrhage, ischemia, inflammation, abnormal intracellular ion shifts (Na+, Ca +2), lipid peroxidation of cell membrane induced by free radicals, edema, leukocyte infiltration, and excitotoxic cell death.[13] Inflammation begins immediately after spinal cord injury. Edema, hemorrhage, accumulation of neuroexcitotoxin, and biochemical changes beginning after injury create difficulties on determining the main effects of inflammation on central nervous system. Although inflammation includes vascular, neurologic, humoral, and cellular responses around the injury site, it is a process to remove harmful stimuli and “contribute to tissue repair”.[14] The cellular source of IL-1 β and TNF-α after acute spinal cord injury is controversial. Some authors believe that these cytokines are the primary products of neutrophils and macrophages. However, other studies have shown that endogen central nervous system cells (microglia) secrete pro-inflammatory cytokines in many injury models.[15] 100

This study utilized CAPE which inhibits lipid peroxidation by suppressing protein tyrosine kinase, cyclooxygenase (nonspecifically), and lipoxygenase. Anti-inflammatory activity of CAPE was found equivalent with diclofenac and hydrocortisone.[16] It has also been suggested that CAPE induces apoptosis independently from glucocorticoid receptors.[17] The protective effects of CAPE have been practiced in various studies dealing with cerebral ischemia-reperfusion injury, spinal cord ischemia-reperfusion injury, Parkinson’s disease, hypoxic ischemic brain damage in newborns, multiple sclerosis, convulsions, brain tumors, toxic effects of therapeutic agent in anticancer therapies, and hepatic encephalopathy.[3-11] There are only five studies in the literature evaluating the effects of CAPE in the spinal cord.[5,8,11,18,19] Two of these studies have been performed to evaluate the protective effects of CAPE against experimental allergic encephalomyelitisinduced oxidative stress, and in methotrexate administered rats.[8,11] Kasai et al. have reported that CAPE might be a promising therapeutic agent for reducing secondary neural damage in their hemi-transection model.[18] In the remaining two studies, researchers have evaluated the effects of CAPE in ischemia-reperfusion injury model. Authors have reported that CAPE decreases injury more than methylprednisolone with its antioxidant and anti-inflammatory effects.[5,19] In the present study, clip compression model, which suits more to the trauma model in humans, was used. This is the first study evaluating the effects of CAPE in this model. Same dosage of CAPE (10 µg/kg) with the previous reports was administered. It was found that CAPE decreased the levels of proinflammatory cytokines but not in significant levels, which may be due to the fact that the evaluation process was conducted in serum, not in tissue. This may be a limitation of our study.

Conclusion CAPE decreases inflammation, necrosis and hemorrhage in the injured spinal cord tissue. It may become a promising agent in the management of spinal cord injury with further studies. Conflict of interest: None declared.

REFERENCES 1. Selvarajah S, Hammond ER, Haider AH, Abularrage CJ, Becker D, Dhiman N, et al. The burden of acute traumatic spinal cord injury among adults in the united states: an update. J Neurotrauma 2014;31:228-38. 2. Dumont RJ, Okonkwo DO, Verma S, Hurlbert RJ, Boulos PT, Ellegala DB, et al. Acute spinal cord injury, part I: pathophysiologic mechanisms. Clin Neuropharmacol 2001;24:254-64. 3. Khan M, Elango C, Ansari MA, Singh I, Singh AK. Caffeic acid phenethyl ester reduces neurovascular inflammation and protects rat brain following transient focal cerebral ischemia. J Neurochem 2007;102:365-77. 4. Tsai SK, Lin MJ, Liao PH, Yang CY, Lin SM, Liu SM, et al. Caffeic acid phenethyl ester ameliorates cerebral infarction in rats subjected to focal

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Ak et al. The effects of caffeic acid phenethyl ester on inflammatory cytokines after acute spinal cord injury cerebral ischemia. Life Sci 2006;78:2758-62. 5. Ilhan A, Koltuksuz U, Ozen S, Uz E, Ciralik H, Akyol O. The effects of caffeic acid phenethyl ester (CAPE) on spinal cord ischemia/reperfusion injury in rabbits. Eur J Cardiothorac Surg 1999;16:458-63. 6. Noelker C, Bacher M, Gocke P, Wei X, Klockgether T, Du Y, et al. The flavanoide caffeic acid phenethyl ester blocks 6-hydroxydopamine-induced neurotoxicity. Neurosci Lett 2005;383:39-43. 7. Wei X, Zhao L, Ma Z, Holtzman DM, Yan C, Dodel RC, et al. Caffeic acid phenethyl ester prevents neonatal hypoxic-ischaemic brain injury. Brain 2004;127(Pt 12):2629-35. 8. Ilhan A, Akyol O, Gurel A, Armutcu F, Iraz M, Oztas E. Protective effects of caffeic acid phenethyl ester against experimental allergic encephalomyelitis-induced oxidative stress in rats. Free Radic Biol Med 2004;37:38694. 9. Ilhan A, Iraz M, Gurel A, Armutcu F, Akyol O. Caffeic acid phenethyl ester exerts a neuroprotective effect on CNS against pentylenetetrazolinduced seizures in mice. Neurochem Res 2004;29:2287-92. 10. Lin YH, Chiu JH, Tseng WS, Wong TT, Chiou SH, Yen SH. Antiproliferation and radiosensitization of caffeic acid phenethyl ester on human medulloblastoma cells. Cancer Chemother Pharmacol 2006;57:525-32. 11. Uzar E, Sahin O, Koyuncuoglu HR, Uz E, Bas O, Kilbas S, et al. The activity of adenosine deaminase and the level of nitric oxide in spinal cord of methotrexate administered rats: protective effect of caffeic acid phenethyl ester. Toxicology 2006;218:125-33. 12. Ercan I, Cakir BO, Başak T, Ozbal EA, Sahin A, Balci G, et al. Effects of

topical application of methotrexate on nasal mucosa in rats: a preclinical assessment study. Otolaryngol Head Neck Surg 2006;134:751-5. 13. Zhang N, Yin Y, Xu SJ, Wu YP, Chen WS. Inflammation & apoptosis in spinal cord injury. Indian J Med Res 2012;135:287-96. 14. Beck KD, Nguyen HX, Galvan MD, Salazar DL, Woodruff TM, Anderson AJ. Quantitative analysis of cellular inflammation after traumatic spinal cord injury: evidence for a multiphasic inflammatory response in the acute to chronic environment. Brain 2010;133:433-47. 15. Herx LM, Rivest S, Yong VW. Central nervous system-initiated inflammation and neurotrophism in trauma: IL-1 beta is required for the production of ciliary neurotrophic factor. J Immunol 2000;165:2232-9. 16. Koksel O, Ozdulger A, Tamer L, Cinel L, Ercil M, Degirmenci U, et al. Effects of caffeic acid phenethyl ester on lipopolysaccharide-induced lung injury in rats. Pulm Pharmacol Ther 2006;19:90-5. 17. Zaeemzadeh N, Hemmati A, Arzi A, Jalali M, Rashidi I. Protective Effect of Caffeic Acid Phenethyl Ester (CAPE) on Amiodarone-Induced Pulmonary Fibrosisin Rat. Iran J Pharm Res 2011;10:321-8. 18. Kasai M, Fukumitsu H, Soumiya H, Furukawa S. Caffeic acid phenethyl ester reduces spinal cord injury-evoked locomotor dysfunction. Biomed Res 2011;32:1-7. 19. Sahin S, Sogut S, Ozyurt H, Uz E, Ilhan A, Akyol O. Tissue xanthine oxidase activity and nitric oxide levels after spinal cord ischemia/reperfusion injury in rabbits: comparison of caffeic acid phenethyl ester (CAPE) and methylprednisolone. Neuroscience Research Communications 2002;31:111-21.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Kafeik asit fenetil esterin akut spinal kord hasarı sonrasında enflamatuvar sitokinler üzerine etkisi Dr. Hakan Ak,1 Dr. İsmail Gülşen,2 Dr. Tamer Karaaslan,3 Dr. İlker Alaca,3 Dr. Aydın Candan,4 Dr. Havva Koçak,5 Dr. Tugay Atalay,1 Dr. Asuman Çelikbilek,6 Dr. İsmail Demir,7 Dr. Tevfik Yılmaz8 Bozok Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Yozgat; Yüzüncü Yıl Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Van; 3 Süleyman Demirel Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Isparta; 4 Süleyman Demirel Üniversitesi Tıp Fakültesi, Histoloji ve Embriyoloji Anabilim Dalı, Isparta; 5 Dumlupınar Üniversitesi Tıp Fakültesi, Biyokimya Anabilim Dalı, Kütahya; 6 Bozok Üniversitesi Tıp Fakültesi, Nöroloji Anabilim Dalı, Yozgat; 7 Van Bölge Eğitim Araştırma Hastanesi, Nöroşirürji Kliniği, Van; 8 Dicle Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Diyarbakır 1 2

AMAÇ: Bu çalışmada, akut spinal kord hasarı sonrası erken dönemde kafeik asit fenetil esterin (KAFE) enflamatuvar sitokinlerden interlökin 1 beta (IL-1β) ve tümör nekrotizan faktor alfa (TNF-α) üzerine etkisini ve histopatolojik olarak KAFE’nin olası iyileştirici etkisini araştırmak amaçlandı. GEREÇ VE YÖNTEM: Çalışmada ağırlıkları 250-300 gram arasında değişen 48 Wistar-Albino cinsi sıçan kullanıldı. Denekler üç gruba ayrıldı. Her grup kendi altında iki alt gruba ayrıldı. 1a grubu kontrol grubu olup bu grupta yalnızca laminektomi yapıldı. Grup 1b’de laminektomi sonrası anevrizma klibi ile travma oluşturuldu. İkinci gruptaki deneklerde travma oluşturulduktan yarım saat sonra serum fizyolojik sistemik olarak verilip birinci ve altıncı saatte denekler sakrifiye edildi. Üçüncü grupta travma oluşturulmuş deneklere yarım saat sonra sistemik yoldan KAFE verildi ve bu denekler birinci ve altıncı saatte sakrifiye edildi. Sakrifikasyon öncesi kalpten alınan kanda ELİSA kitleri ile serum IL-1β ve TNF-α düzeyleri ölçüldü. Hasarlanmış kordan alınan doku örneklerinde histopatolojik değerlendirme yapıldı. BULGULAR: Kafeik asit fenetil esterin verilen grupta TNF-α ve IL-1β düzeylerinin azaldığı tespit edildi. Histopatolojik değerlendirmede KAFE verilen grupta hemoraji ve nekroz oranında azalma tespit edildi. TARTIŞMA: Akut spinal kord hasarı sonrası erken dönemde KAFE enflamatuvar sitokinlerden TNF-α ve IL-1β düzeylerini baskılamaktadır ve hasar sonrası iyileşmeye katkıda bulunmaktadır. Anahtar sözcükler: Enflamasyon; interlökin-1β; kafeik asit fenetil ester; spinal kord hasarı; tümör nekrotizan faktör-α. Ulus Travma Acil Cerrahi Derg 2015;21(2):96-101

doi: 10.5505/tjtes.2015.33848

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ORIG I N A L A R T IC L E

Total leukocyte and neutrophil count as preventive tools in reducing negative appendectomies Muhammad Salman Rafiq, M.D., Mah Muneer Khan, M.D., Ataullah Khan, M.D., Bilal Ahmad, M.D. Department of Surgical, Khyber Teaching Hospital, Peshawar, Pakistan

ABSTRACT BACKGROUND: Negative appendectomies result in unnecessary admissions, health care burden, and cost. This study was conducted to assess total leukocyte and neutrophil counts as preventive tools in reducing negative appendectomies. METHODS: Data of admitted patients who underwent appendectomies was analyzed. Receiver operator characteristic (ROC) curve analysis of total leukocyte and neutrophil counts was calculated for various cut-off points. Optimum sensitivity, specificity, overall accuracy, and area under the curve was determined. RESULTS: Of the four hundred and eightpatients, true and negative appendicitis by operative assessment was 294 (72.1%) and 114 (27.9%) compared to 311 (76.2%) and 97 (23.8%) by histopathology, respectively. Optimal cut-off for total leukocyte count was >11.9x109/Liter with 87.14% sensitivity and 91.75% specificity. Optimal cut-off point for neutrophil count was >7.735x109/Liter with 98.71% sensitivity and 91.75% specificity. Area under the curve for total leukocyte and neutrophil counts was 0.9603 and 0.9872, respectively with overall accuracy of 91.2% and 97.1%, respectively. CONCLUSION: Normal total leukocyte and neutrophil counts are strongly associated with negative appendectomies. Non-operative measures and careful observation of total leukocyte and neutrophil counts are of paramount importance. Key words: Acute; appendicitis; leukocyte count; negative appendectomy; neutrophils; ROC curve.

INTRODUCTION Acute appendicitis (AA) remains the commonest surgical abdominal emergency.[1] Its incidence is 1.5-1.9 per 100.000 and is 1.4 times more common in men.[2] Life time risk of suffering from acute appendicitis is 7%[3] with peaks in the second and third decades of life.[4] In Pakistan, over 400.000 appendectomies are performed annually.[5] It is one of the most common surgical emergencies treated by resident surgeons. Acute appendicitis is a clinical diagnosis supported by various scoring methods, radiographic and laboratory (lab) tests. [6] Base line investigations like total leukocyte and neutrophil count are routinely carried out in every center due to the ease of availability and interpretation.[7] These are of special Address for correspondence: Muhammad Salman Rafiq, M.D. House No. 5, Street H, Danish Abad. 25000 Peshawar, Pakistan Tel: 0092-0346-9035574 E-mail: drsalmanrafiq@hotmail.com Qucik Response Code

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benefit in developing countries where modern health facilities may be out of reach. Use of such base line investigations for the diagnosis of common emergent conditions has a rewarding cost-benefit ratio. Total leukocyte count (TLC) and neutrophil count (NC) are among the commonly performed base-line investigations. The rate of negative appendectomy (NA); however, remains high varying between 15-30%.[8] A NA rate of 5-15% is acceptable, keeping in mind the adverse effects of non-operability in a true appendix (TA) and advantages of safety in a negative exploration.[9] Radiographic tools like computed tomography (CT) can reduce the rate of NA from 24% to 7.6%.[10] However, such valuable tools are not ubiquitously available. The use of simple diagnostic tools is, therefore, of great importance, especially if they are cheap, and easy to perform and interpret. Consequently, this study was carried out to analyze the role of TLCand NC in preventing and/or reducing acute appendicitis (AA).

Ulus Travma Acil Cerrahi Derg 2015;21(2):102-106 doi: 10.5505/tjtes.2015.29626

MATERIALS AND METHODS

This retrospective study was conducted in the Surgical Department of Khyber Teaching Hospital Peshawar after collecting the data of four hundred and eight patients from AuUlus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Rafiq et al. Total leukocyte and neutrophil count as preventive tools in reducing negative appendectomies

gust 2012 to May 2014. Approval of the research and ethical committees was taken. In all cases, written informed consent and uniform guidelines of management were followed with the standard operating technique of a right lower quadrant incision, saline wash and primary closure. All cases presented to us in the emergency with a diagnosis of acute appendicitis during the study period were included. Patients with interval, elective or incidental appendectomies were excluded. All cases with comorbidities such as Crohn’s disease, pelvic inflammatory disease, gastroenteritis, systemic infection, and pregnancy were also excluded. Pre-operative (pre-op) clinical and laboratory data was collected for all casesincluding demographic data (age, gender), TLC (x×109/ Liter), neutrophil count (x×109/Liter and %), neutrophil to lymphocyte ratio NLR, ALVARADO score,[11] and pre-operative (pre-op) assessment of signs of acute appendiceal inflammation. Cases were considered NA by post-op histopathological assessment. All investigations were obtained at the Pathology Department of Khyber Teaching Hospital, Peshawar. Elevated TLC was taken as count >11.5×109/Litre[6] and elevated Neutrophil count was taken as >75%11. Data analysis was carried out using SPSS 20 and MedCalc 12.5. Mean, percentage and standard deviation of the variables was calculated. Comparison of nominal data was done using Chi-Square and of interval data using t-test. Receiveroperating characteristic (ROC) curves were calculated for TLC and NC. Area under the curve (AUC) was obtained and appropriate cut-off points were identified for optimum sensitivity and specificity. In all cases, a p-value of <0.05 was considered statistically significant.

RESULTS Pre-operative assessment showed that two hundred and ninety-four (72.1%) of the total of 408 patients had signs consistent with acute appendicitis. This was further increased by 4.1% to 311 (76.2%) patients with acute appendicitis by histo-pathological findings of the specimens. Statistical analysis is shown in Table 1. Gender distribution (p=0.654) and mean age (p=0.240) were not statistically significant between the groups. Statistically significant differences between the groups were found with higher values each in the true appendicitis group for symptom duration (hours); 28.63±5.914 (p=0.023), admission temperature (°F); 99.906±0.8534 (p<0.001), TLC (x109/Liter); 13.090±1.2079 (p<0.001), neutrophil count (%); 69.41±2.994 (p<0.001), neutrophil count (x109/Liter); 9.106±1.1521 (p<0.001), neutrophil to lymphocyte ratio; 2.8851±0.5273 (p<0.001), and ALVARADO score; 7.43±0.771 (p<0.001), respectively. Two ROC-curves were obtained for TLC and NC after applying Logistic Regression to achieve greater probability and accurate distribution. Figure 1a represents ROC-curve for TLC (x109/Liter) and Figure 1b for neutrophil count (x109/ Liter). In both figures, the Youden associated criterion is represented by the white circle. AUC represents area under the curve. Table 2 shows the salient cut-off points for both ROCcurves with estimated specificity at fixed sensitivity and vice versa. Table 3 shows the diagnostic measures obtained for both curves. In Table 3, the salient measures for TLC include associated criterion; >11.9x109/L at 95% confidence interval, sensitivity; 87.14%, specificity; 91.75%, area under the curve; 0.960337, overall accuracy; 91.2%, and precision; 0.972719

Table 1. True and negative appendectomy comparison

True appendectomy

Negative appendectomy

n % Mean±SD n % Mean±SD

Status by per operative findings

294

72.1

114

27.9

Status by histopathology

311

76.2

23.8

149

47.9

50.5

162

52.1

49.5

Gender

Males

Females

0.654

Mean age (Years)

22.45±8.122

23.93±11.505

0.240

Symptom duration (Hours)

28.63±5.914

26.79±7.186

0.023

Admission temperature (°F)

99.906±0.8534

99.598±0.6561

<0.001

Total leukocyte count (x109/Liter) 13.090±1.2079 10.742±0.9259 <0.001 Neutrophil count (%)

69.41±2.994

62.70±1.916

<0.001

Neutrophil count (x109/Liter) 9.106±1.1521 6.748±0.7547 <0.001 Neutrophil to lymphocyte ratio

2.8851±0.5273

2.0147±0.1899

<0.001

ALVARADO score 7.43±0.771 6.01±0.653 <0.001 All findings in this table (after the per-op values) and the article are based on histo-pathological findings as the determinant of true or negative appendicitis status.

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Rafiq et al. Total leukocyte and neutrophil count as preventive tools in reducing negative appendectomies

Sensitivity

(b) 100

Sensitivity

(a) 100

50 40

10 0

Area under the curve = 0.090 p<0.001

40 50 60 100-Specificity

100

Legend Area under the curve = 0.987 p<0.001

40 50 60 100-Specificity

100

Figure 1. (a) ROC-curve analyasis of total leukocyte count. (b) ROC-curve analyasis of neutrophil count.

costs of resources.[15] However, it is satisfactory to mention that with modern tools and techniques, mortality associated with acute appendicitis has been brought down to <1%. [16] Acute appendicitis and appendectomy is associated with costs of time and money, risks and complications, pain and morbidity. The role of reducing negative appendectomies is, therefore, understandable. A helpful tool in this regard can be the use of the TLC and neutrophil counts.

at p<0.0001. The salient measures for NC include associated criterion; >7.735x109/L at 95% confidence interval, sensitivity; 98.71%, specificity; 91.75%, area under the curve; 0.987221, overall accuracy; 97.1%, and precision; 0.972719 at p<0.0001.

DISCUSSION The presentation of acute appendicitis has been extensively described. Diagnosis of the classical presentation is considered clinical.[12] The risk for emergency appendectomy in men and women is 12% and 23%, respectively.[13] The overall risk has been reduced due to modern antibiotics and surgical techniques.[14] Rates of complications are still higher for extremes of age, immune-compromisation, and co-morbid cases6. Complicated cases such as those with perforation, protracted course and morbidity are associated with higher

Estimated values for false positive and false negative cases for TLC were 8.722 and 45.896, respectively. Estimated values for false positive and false negative cases for NC were 8.722 and 4.06, respectively. Estimated false positive for both TLC and NC was the same, 8.722. As mentioned previously, the true and negative appendectomy status by pre-op assessment was 294 (72.1%) and 114 (27.9%), respectively. However, with histo-pathological reporting, the number of true appen-

Table 2. Summary table for various criterions of TLC and NC

Estimated specificity at fixed sensitivity Sensitivity (%)

Estimated sensitivity at fixed specificity

Variable

Criterion

Specificity (%)

Criterion

Specificity (%)

Sensitivity (%)

TLC count (x109/L)

>12.068 80.00

93.86 >11.694 80.00

91.63

>11.758 90.00

83.43 >11.871 90.00

87.68

>11.632 95.00

75.55 >12.107 95.00

77.93

>11.511 97.50

70.67 >12.219 97.50

66.90

Neutrophil Count (x109/L) >8.1799 80.00

100 >7.5679 80.00

99.36

>7.9743 90.00

92.06 >7.6758 90.00

99.04

>7.8099 95.00

91.75 >8.0409 95.00

87.96

>7.7741 97.50

91.75 >8.1091 97.50

82.77

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Rafiq et al. Total leukocyte and neutrophil count as preventive tools in reducing negative appendectomies

Table 3. TLC and neutrophil count diagnostic measures Associated criterion Sensitivity Specificity

TLC NC >11.9 (x109/L)

>7.735 (x109/L)

87.14% 98.71% 91.75% 91.75%

Estimated false negative

45.896947

4.06432

Estimated false positive

8.72207

Positive likelihood ratio

10.57

11.97

Negative likelihood ratio

0.14

0.014

95.0%

Area under the curve

0.960337

0.987221

Significance level - p

<0.0001

91.2%

97.1%

Confidence interval

Overall accuracy Precision

0.972719 0.972719

F1 score

0.9192765

0.9217731

TLC: Total leukocyte count; NC: Neutrophil count. F1 score; harmonic mean of precision and sensitivity.

dicitis cases increased to 311 (76.2%) i.e. an increase in the true appendectomy cases by 4.1%. Of the ninety-seven cases of negative appendectomy by histo-pathological assessment, 36 (37.1%) had faecolith obstruction of the lumen, 26 (26.8%) had parasitic infestation and obstruction, 17 (17.5%) had fibrotic strictures, 2 (2.1%) had growth in their wall, and in the remaining 16 (16.5%) cases, both pre-op and histo-pathological assessment failed to identify acute appendicitis as the cause. The statistical data obtained from these patients included TLC; 10.742±0.92 x109/L, NC; 6.748±0.75 x109/L, ALVARADO; 6.01±0.65 and NLR 2.014±0.18, respectively. In the current study, mean TLC and NC were found to be normal in patients with negative appendectomy which are both components of the ALVARADO score.[17] It was, therefore. not surprising to find statistically significant differences between the two groups regarding these three variables with p-values for all three; TLC, NC and ALVARADO <0.001. NLR or neutrophil to lymphocyte ratio for the TA group was 2.885±0.527 compared to 2.014±0.189 for the NA group, which was statistically significant with a p-value of <0.001. The calculated sensitivity and specificity for NLR was 82.64% and 100%, respectively. The sensitivity and specificity of TLC has been variably reported in the literature including Saaiq M. et al. 81.77% and 43.55%,[17] Anwar M. et al. 86.9% and 81.25%,[18] Kamran H. et al., 76.5% and 73.7%,[19] respectively. The sample sizes for these studies were: Saaiq M. et al. 233, Anwar M. et al. 100 and Kamran H. et al. 100. The sensitivity and specificity of TLC for this study Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

was 87.14% and 91.75%, respectively with a sample size of 408 patients at the Youden associated criterion of >11.9x109/L. As shown in Table 2, the ROC-curve analysis revealed that the highest sensitivity of 91.63% at the fixed specificity of 80% was obtained at the cut-off value of >11.694x109/L. The highest specificity of 93.86% at the fixed sensitivity of 80% was obtained at the cut-off value of >12.068x109/L. The sensitivity and specificity for NC was also analyzed. In the literature, the sensitivity and specificity for NC has been reported as; Anwar M. et al. 82% and 68.75%,[18] Bates M. F. et al., 91% and 95%,[6] respectively. Their sample sizes were 100 and 847, respectively. The sensitivity and specificity of NC for this study was 98.71% and 91.75%, respectively with a sample size of 408 patients at the Youden associated criterion of >7.735x109/L. As shown in Table 2, the ROCcurve analysis revealed that the highest sensitivity of 99.36% at the fixed specificity of 80% was obtained at the cut-off value of >7.5679x109/L. The highest specificity of 100% at the fixed sensitivity of 80% was obtained at the cut-off value of >8.1799x109/L. As mentioned previously, the sensitivity and specificity of NLR in our study was 82.64% and 100%, respectively compared to the sensitivity and specificity of NC which was 98.71% and 91.75%, respectively. NLR, therefore, seems to be a more specific indicator of acute appendicitis than NC; whereas, NC had greater sensitivity at 98.71%. The overall accuracy for TLC and NC as reported by Anwar M. et al. was 86% and 80%,[18] respectively. For this study, the overall accuracy for TLC and NC was 91.2% and 97.1%, respectively. The area under the Curve (AUC) calculated by Bates M. F. et al. was 0.86 and 0.87, respectively.[6] For this study, the AUC for TLC and NC was 0.96 and 0.987, respectively.

Conclusion With modern tools and techniques, the accuracy of diagnosis of acute appendicitis has greatly improved with resultant reduction in morbidity and mortality. In order to improve upon this, we need to further improve our diagnostic accuracy and reduce negative appendectomies. TLC and NC serve qualitatively on the ALVARADO score which notes their presence or absence. Qualitative use of the TLC and NC using appropriate cut-off points can not only improve the diagnostic accuracy but also reduce the rate of negative appendectomies, health care burden, and cost. The criterion values for our study were from a single institution, and further research must be carried out in this regard before these cut-off values can be recommended. All authors read and approved the final manuscript.

Ethical consideration In each case, written informed consent was taken and infor105

Rafiq et al. Total leukocyte and neutrophil count as preventive tools in reducing negative appendectomies

mation about the importance of this study was elaborated. The study was approved by the Research and ethical committee of Khyber Teaching Hospital, Peshawar. Conflict of interest: We wish to confirm that there are no known conflicts of interest associated with this publication & there has been no financial support for this work that could have influenced its outcome.

REFERENCES 1. Wei PL, Liu SP, Keller JJ, Lin HC. Volume-outcome relation for acute appendicitis: evidence from a nationwide population-based study. PLoS One 2012;7:e52539. 2. Chong CF, Adi MI, Thien A, Suyoi A, Mackie AJ, Tin AS, et al. Development of the RIPASA score: a new appendicitis scoring system for the diagnosis of acute appendicitis. Singapore Med J 2010;51:220-5. 3. Ohle R, O’Reilly F, O’Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Med 2011;9:139. 4. O’Connel PR. The vermiform appendix. In: Williams NS, Bulstrode CJK, O’Connel PR, editors. Bailey and Love’s Short Practice of Surgery. 25th ed. London: Arnold; 2008. p. 1204-16. 5. Khan KI, Mahmood S, Akmal M, Waqas A. Comparison of rate of surgical wound infection, length of hospital stay and patient convenience in complicated appendicitis between primary closure and delayed primary closure. J Pak Med Assoc 2012;62:596-8. 6. Bates MF, Khander A, Steigman SA, Tracy TF Jr, Luks FI. Use of white blood cell count and negative appendectomy rate. Pediatrics 2014;133:e39-44. 7. Mehraj A, Naqvi MA, Din HU, Waqas. Importance of clinical assessment in diagnosis of acute appendicitis and its role in decreasing negative appendicectomy rate. J Ayub Med Coll Abbottabad 2012;24:7-9. 8. Kamran H, Naveed D, Asad S, Hameed M, Khan U. Evaluation of modified Alvarado score for frequency of negative appendicectomies. J Ayub

Med Coll Abbottabad 2010;22:46-9. 9. Buchman TG, Zuidema GD. Reasons for delay of the diagnosis of acute appendicitis. Surg Gynecol Obstet 1984;158:260-6. 10. Ceydeli A, Lavotshkin S, Yu J, Wise L. When should we order a CT scan and when should we rely on the results to diagnose an acute appendicitis? Curr Surg 2006;63:464-8. 11. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557-64. 12. Cuschieri A. The small intestine and vermiform appendix. In: Cuschieri A, Grace P, Darzi A, editors. Clinical Surgery. 2nd ed. Blackwell Publishing Company; 2003. p. 386-406. 13. Paajanen H, Grönroos JM, Rautio T, Nordström P, Aarnio M, Rantanen T, et al. A prospective randomized controlled multicenter trial comparing antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis (APPAC trial). BMC Surg 2013;13:3. 14. Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials. BMJ 2012;344:e2156. 15. Kırkıl C, Karabulut K, Aygen E, Ilhan YS, Yur M, Binnetoğlu K, et al. Appendicitis scores may be useful in reducing the costs of treatment for right lower quadrant pain. Ulus Travma Acil Cerrahi Derg 2013;19:13-9. 16. Humes DJ, Simpson J. Clinical Presentation of Acute Appendicitis: Clinical Signs-Laboratory Findings-Clinical Scores, Alvarado Score and Derivate Scores. In: Keyzer C, Gevenois PA, eds. Imaging of acute appendicitis in adults and children. Springer Publishing Company 2012:13-21. 17. Saaiq M, Niaz-Ud-Din, Jalil A, Zubair M, Shah SA. Diagnostic accuracy of leukocytosis in prediction of acute appendicitis. J Coll Physicians Surg Pak 2014;24:67-9. 18. Anwar MW, Abid I. Validity of total leucocytes count and neutrophil count in diagnosing suspected acute appendicitis. Pak Armed Forces Med J Sept 2012;3:38-42. 19. Kamran H, Naveed D, Nazir A, Hameed M, Ahmed M, Khan U. Role of total leukocyte count in diagnosis of acute appendicitis. J Ayub Med Coll Abbottabad 2008;20:70-1.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Total lökosit ve nötrofil sayısı negatif apandektomilerin azaltılmasını sağlayan belirteçlerdir Dr. Muhammad Salman Rafiq, Dr. Mah Muneer Khan, Dr. Ataullah Khan, Dr. Bilal Ahmad Khyber Eğitim Hastanesi, Cerrahi Kliniği, Peşaver, Pakistan

AMAÇ: Negatif apandektomiler gereksiz hasta kabullerine neden olarak, sağlık hizmetlerine yük ve mali külfet getirmektedir. Bu çalışma, negatif apendektomilerin azaltılmasında total lökosit ve nötrofil sayılarını değerlendirmek üzere yürütüldü. GEREÇ VE YÖNTEM: Hastaneye kabul edilen ve apandektomi geçiren hastaların verileri incelendi. Değişik kestirim noktaları için total lökosit ve nötrofil sayılarının alıcı işletim karakteristik eğrisi (ROC) analizi hesaplandı. Optimal duyarlılık, özgüllük, genel doğruluk derecesi ve eğrisi altında kalan alan belirlendi. BULGULAR: Toplam 408 hastada cerrahi değerlendirmeye göre gerçek ve negatif apandisit oranları %72.1 (n=294) ve %27.9 (n=114) iken histopatolojik olarak bu oranlar sırasıyla %76.2 (n=311) ve %23.8 (n=97) idi. Total lökosit sayımının optimal kestirim değeri olan >11.9x109/L, %87.14 duyarlılık ve %91.75 özgüllüğe sahipti. Total nötrofil sayısının optimal kestirim değeri olan >7.735x109/L %98.71 duyarlılık ve %91.75 özgüllüğe sahipti. Total lökosit ve nötrofil sayıları için eğri sırasıyla 0.9603 ve 0.9872 olup, genel doğruluk oranları sırasıyla %91.2 ve 97.1 idi. TARTIŞMA: Normal total lökosit ve nötrofil sayıları negatif apandektomilerle kuvvetle ilişkilidir. Cerrahi dışı önlemler, toplam lökosit ve nötrofil sayıları dikkatli klinik takip oldukça önemlidir. Anahtar sözcükler: Akut; apandisit; lökosit sayısı; negatif apandektomi; nötrofiller; ROC eğrisi. Ulus Travma Acil Cerrahi Derg 2015;21(2):102-106

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doi: 10.5505/tjtes.2015.29626

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ORIG I N A L A R T IC L E

A comparative study of small intestinal perforation secondary to foreign body and other non-traumatic causes Qiang Chen, M.D.,1 Yuanquan Huang, M.D.,2 Yongyou Wu, M.D.,1 Kui Zhao, M.D.,1 Baosong Zhu, M.D.,1 Tengfei He, M.D.,1 Chungen Xing, M.D.1 1

Department of General Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China;

Department of Interventional Radiology, The First Peopleâ&#x20AC;&#x2122;s Hospital of Changzhou, Affiliated Third Hospital of Soochow University,

Changzhou, Jiangsu, China

ABSTRACT BACKGROUND: Little was known about gastrointestinal perforation secondary to foreign body in adults, which was only documented by several case series reports. The aim of this study was to characterize it with comparative methods. METHODS: A retrospective study was conducted on twenty patients with the diagnosis of gastrointestinal perforation secondary to foreign body between January 2003 and October 2013. The perforations were all located in the small intestine and compared to eighty-seven patients with non-traumatic small intestinal perforation. RESULTS: 35% of the patients in the foreign body group were over 65 years of age, which is much higher than the local elderly population ratio (p=0.002). In the foreign body group, more patients presented without diffuse abdominal physical signs (p=0.008) and preoperational CT scans had higher accuracy (p=0.027). Perforation repair was performed more often (p=0.024). Mean MPI was 19.9 and the morbidity rate was 35%, significantly lower than in the cases of other causes (p=0.001, 0.041). Mean duration of hospitalization was 11.5 days and was shorter compared to other causes (p=0.038). CONCLUSION: Clinical performance of small intestinal perforation secondary to foreign body is atypical, and preoperative diagnosis relies on CT scans. Primary perforation closure is safe and effective, and relatively better outcomes can be achieved. Key words: Foreign body; intestinal perforation.

INTRODUCTION Ingestion of foreign bodies is more common in children between 6 months and 6 years of age,[1,2] and most foreign bodies can pass the gastrointestinal tract without any complications.[3] However, it can also occur in adult patients and cause severe complications with high morbidity and mortality. [4,5] Although endoscopic intervention is the golden standard treatment for foreign body ingestion,[6] surgical operation is essential for patients with serious complications like gastrointestinal perforation.[7] Adult cases with gastrointestinal perfoAddress for correspondence: Chungen Xing, M.D. General Surgery Department, the Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road 215004 Suzhou - China Tel: 8613776100906 E-mail: bradychen@sohu.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

ration after foreign body ingestion have rarely been reported. To the best of our knowledge, there is no comparative study of gastrointestinal perforation yet. The aim of this study was to investigate the clinical characteristics and outcome of adult intestinal perforations after foreign body ingestion by comparing with intestinal perforation of other non-traumatic causes.

MATERIALS AND METHODS This retrospective study was conducted in two tertiary hospitals in China, whose study protocol was approved by the Ethical Committees of both hospitals. The medical records of adult patients, who were over 18 years of age at the time of enrollment and received surgical operation in these two hospitals between January 2003 and October 2013, were retrospectively searched in discharge diagnosis with International Classification of Diseases code 10: K27.101, K27.103, K27.503, K62.810, K63.101, K63.103 and K63.104. Afterwards, the corresponding operation documents were reviewed manually. A total of twenty patients met the diagnosis of gastrointestinal perforation secondary to foreign body, and all the perforation sites were located 107

Chen et al. A comparative study of small intestinal perforation secondary to foreign body and other non-traumatic causes

in the small intestine. Therefore, all small intestinal perforation cases of other non-traumatic causes were also included as the control group. Totally, eighty-seven patients were included into the control group. In this study, decision for surgical operation was based on clinical examination with the aid of plain radiographs or CT scans, which would be performed based on surgeons’ assessment and preference. All patients received emergency operations under general anesthesia, and surgical procedure was chosen by the surgeon according to intra-operative findings. All intestinal anastomoses were either hand-sewn or stapled. Prior to abdominal incision closure, peritoneal cavity washout was performed for all patients. After the operation, all patients received empiric antibiotics and fluid resuscitation treatment. Medical records of all patients, including demographic data, past history of systemic diseases and abdominal surgery operation, initial clinical presentations, accessory examination, therapeutic interventions, complications during hospitalization and outcomes, were reviewed and analyzed. Physical status was classified by American Society of Anesthesiologists (ASA).[8] The severity of abdominal sepsis and post-operative complications were graded with the Mannherm peritonitis index (MPI)[9] and the classification proposed by Clavien and group,[10,11] respectively.

All clinical data was analyzed with the Statistical Package for the Social Science version 20.0 (SPSS, Chicago, IL, USA). Student’s t test was used for continuous variables following normal distribution, non-parametric (Mann-Whitney U) test was used for continuous variables following abnormal distribution or ordinal categorical variables, χ2, Fisher exact test was used for non-ordinal categorical variables when appropriate, and Bivariate test was used to analyze the relationship between MPI and complications. Continuous data following normal and abnormal distribution were presented as mean (SD) and median (range), respectively. Categorical variables data were given as frequencies and percentages. All reported p values were two-sided, and only p values less than 0.05 were considered statistically significant.

RESULTS A total of one hundred and seven patients were diagnosed with small intestinal perforation and received surgical operation treatment in our study. Of these cases, twenty (18.7%) patients were diagnosed with intestinal perforation secondary to foreign body, and the remaining eighty-seven (81.3%) patients were diagnosed with intestinal perforation secondary to other causes, including hernia (n=30, 28.0%), adhesion (n=17, 15.9%), Crohn’s disease (n=8, 7.5%), diverticulitis

Table 1. Comparison of demographic and clinical characteristics

Foreign body group

Control group

Hospital

9 (45%)

37 (42.5%)

11 (55%)

50 (57.5%)

0.840

Gender

Male

Female

Age (years) Duration of symptoms (hours)

15 (75%)

62 (71.3%)

5 (25%)

25 (28.7%)

0.737

59.0±16.6

59.3±17.5

0.951

24.5 (5.0-188.0)

25.0 (2.0-280.0)

0.911

Number of comorbidity

11 (55%)

58 (66.7%)

6 (30%)

17 (19.5%)

3 (15%)

7 (8.0%)

4 (4.6%)

1 (1.1%)

0.297

7 (35%)

17 (19.5%)

0.147

History of abdominal surgical operation

ASA classification*

7 (35%)

31 (35.6%)

9 (45%)

23 (26.4%)

4 (20%)

26 (29.9%)

7 (8.0%)

0.351

ASA: American Society of Anesthesiologists.

108

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Chen et al. A comparative study of small intestinal perforation secondary to foreign body and other non-traumatic causes

(a)

(b)

Figure 1. The CT scans show the foreign bodies (a common jujube seed in figure (a) and a fish bone in figure (b)) (horizontal arrow) and small quantity of free peritoneal gas (vertical arrow).

(n=7, 6.5%), malignancy (n=6, 5.6%), tuberculosis (n=2, 1.9%), mesentery vein thrombus (n=1, 0.9%) and other unclear causes (n=16, 15.0%). In this study, 35% and 42.5% patients of the foreign body group and control group were over 65 years of age, respectively, which is much higher than the local elderly population ratio of 9.8% (p=0.002, 0.000, respectively). Predisposing factors for foreign body ingestion were wearing dentures: n=13 (65%); allotriophagy: n=1 (5%); and dysgnosia: n=1 (5%). Except for one case of allotriophagy, all patients hadn’t presented with foreign body ingestion history. All were unconscious of having ingested any foreign bodies, except for one case with allotriophagy and one case with dysgnosia. There was no statistically significant difference in demographic data, previous history, and physical status between the two groups (Table 1).

Patients of the foreign body group had higher probability of presenting with local abdominal pain with or without peritoneal irritation while diffuse abdominal pain with peritoneal irritation was more often in the cases of other non-traumatic causes. Pre-operative CT scan had higher accuracy in the foreign body group, which showed signs of pneumoperitoneum and foreign body in all seven cases (Figs. 1a, b), with the foreign body of one patient detected retrospectively after operation owing to the low density of the ingested common jujube seed. The differences between the two groups in blood pressure, body temperature, white blood cell count, leucocrit, or plain film results were not statistically significant, as shown in Table 2. All patients were diagnosed with small intestinal perforation intra-operatively. Foreign bodies found during operation were fish bones (n=11, 55%), bone flaps (n=4, 20%), com-

Table 2. Comparison of auxiliary examination

Foreign body group

Control group

Physical signs

None

4 (20%)

7 (8.0%)

Local

10 (50%)

26 (29.9%)

Diffuse

6 (30%)

54 (6.2%)

0.008

Blood pressure (BP)

Systolic BP (mmHg)

122.9±14.5

126.4±21.6

0.490

Diastolic BP (mmHg)

70.1±9.3

75.3±13.8

0.113

White blood cell count (10 /L)

13.0 (3.0-22.0)

12.3 (1.7-25.6)

0.342

Leucocrit (%)

88.1 (83.5-95.2)

86.3 (67.4-96.7)

0.171

Body temperature (oC)

37.2 (36.1-38.9)

36.9 (35.2-39.9)

0.169

Plain film

Positive

3 (15%)

19 (21.8%)

Negative

7 (35%)

28 (32.2%)

0.725

Positive

7 (35%)

13 (14.9%)

Negative

13 (14.9%)

Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

0.027

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Chen et al. A comparative study of small intestinal perforation secondary to foreign body and other non-traumatic causes

Table 3. Comparison of surgical treatments and outcomes Duration of surgical operation (min)

Foreign body group

Control group

120.0±67.4

132.6±65.1

0.445

Location of perforation

Jejunum

3 (15%)

24 (27.6%)

Ilium

17 (85%)

63 (72.4%)

0.275

19.9±6.6

26.2±8.4

0.001

Mannherm peritonitis index (MPI)

Surgical operation type

Repair

16 (80%)

36 (41.4%)

Resection

3 (15%)

37 (42.5%)

Right hemicolectomy

1 (5%)

10 (11.5%)

Stoma

4 (4.6%)

0.024

Classification of complications

Grade 1

1 (5%)

Grade 11

4 (20%)

24 (27.6%)

Grade 111

1 (5%)

4 (4.6%)

Grade 1V

1 (5%)

9 (10.3%)

Grade V

11 (12.6%)

0.042

11.5 (7.0-14.0)

14.0 (7.0-56.0)

0.038

Hospital stay of survivors (days)

mon jujube seeds (n=2, 10%), metal threads (n=2, 10%), and toothpick (n=1, 5%). Comparison of surgical treatments and outcomes in both groups during hospitalization is shown in Table 3. The duration of surgical operation in the foreign body group was shorter than in the control group, but it was not statistically different. Ileum was involved more often than jejunum in both groups. MPI was associated with prognosis and complication (p=0.00) and mean MPI was significantly lower in the foreign body group. During surgical operation, perforation repair was performed more often in the foreign body group while partial intestinal resection, stoma or right hemicolectomy were done more often in the control group. There was no death case in the foreign body group while the mortality rate was 12.6% in the control group, and the morbidity rate of the foreign body group and control group was 35% and 55.2%, respectively. Accordingly, the duration of hospitalization was shorter in the foreign body group than in the control group. In this study, no statistical significance could be found in any study items between the patient groups from two hospitals.

DISCUSSION As previous case series have reported, the groups with increased risk of ingesting foreign bodies include children and adolescents, the elderly, psychiatric patients, drug addicts, and alcoholics. Oral problems, wearing denture, improper mastication and poor vision are predisposing factors of foreign body ingestion.[12] The majority of our patients were the elderly, 110

and 35% of the patients in the foreign body group were over 65 years of age. Wearing dentures was the most common predisposing factor since the presence of dentures impaired the tactile sensitivity of the palate, resulting in unconscious ingesting of foreign bodies.[13] Previous abdominal operation history might increase the risk of gastrointestinal perforation after foreign body ingestion since 35% of the patients in the foreign body group had history of such surgical operation, and foreign body is easy to impact narrow, angled, pouching areas, and zones with adhesions or surgical anastomosis.[5] Most ingested foreign bodies can pass through the gastrointestinal tract successfully without any complications, with only about 1% of the foreign bodies perforating the intestinal wall. However, if the foreign body is a sharp object, the possibility mounts up to 35%.[14] In up to 93% of the cases, foreign bodies are component parts of ordinary diet.[15] In our group, all foreign bodies were sharp objects, and in seventeen cases (85%), they belonged to ordinary diet. Although perforation can take place all over the alimentary tract, the ileocaecal region is the most common area.[15] In our study, all patients had small intestinal perforation, and most of the perforation sites (17/20) were located in distal ileum within 2 m to the ileocaecal valve. The perforation process caused by progressive impaction of the foreign body is usually slow, allowing perforation site to be covered by fibrin and adjacent loops and prevents the leakage of extensive quantities of fluid or gas.[16] As a result, the occult symptoms varying from abdomen pain to local or Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Chen et al. A comparative study of small intestinal perforation secondary to foreign body and other non-traumatic causes

diffuse peritonitis, along with the lack of awareness of having ingested any foreign bodies, make preoperative diagnosis difficult.[13] Clinically common denominator is acute abdominal pain accompanied by severe inflammatory laboratory tests (severe elevation of the white blood cell count and C-reactive protein level).[17] In our study, there was no significant difference between the two groups on vital signs and laboratory tests. However, more patients in the foreign body group presented with slight symptoms and physical signs, and the group hadnâ&#x20AC;&#x2122;t presented with foreign body ingestion history, except for one case of allotriophagy. As a result, five cases were misdiagnosed as having acute appendicitis pre-operatively. Exposure was very difficult 3 of the cases because the perforation site was far away from the incision. Since the leakage of intestinal contents and gas is usually in small amounts and spontaneous closure of the defect and rapid resorption of any free gas can occur between the occurrence of the perforation and subsequent radiologic examination, pneumoperitoneum is seen in less than 50% of the patients in abdominal plain film.[18] Radiographs might only show the signs of small intestinal obstruction and could not identify the foreign body unless it is sufficiently radiopaque. Although chicken or fish bones may be sufficiently radiopaque to be found on abdominal plain film, large amount of soft tissue or fluid may obscure their minimal calcium contents, particularly in obese patients.[19] The sensitivity of plain film was low in both groups in our study. In the foreign body group, of the twelve cases who received plain film radiography examination, only four (33.3%) patients showed signs of pneumoperitoneum, and only the metallic foreign bodies could be found in one allotriophagy patient. CT scan can detect the calcified content of ingested foreign body, the presence of very small quantity of extra-luminal gas and associated complications, like abscess and obstruction. On the other hand, CT scan can eliminate other possible causes of acute abdominal conditions.[20] Thanks to the increasing availability of multidetector-row CT and spiral CT, high quality multiplanar reconstructions can be obtained with a very short delay, and foreign bodies are found without the restriction by their orientation.[17] More and more emergency patients with various non-traumatic acute abdominal conditions receive CT scans, which can characterize the aetiology of their abdominal pain and has the greatest impact on hospital admissions and surgical management.[21] In our group, preoperative CT scan was performed in seven patients, all of whom showed signs of pneumoperitoneum and foreign bodies in plain scans and associated reconstructions. Interestingly, preoperative CT scan had higher sensitivity in the foreign body group than in the control group, and the reason might be associated with the existence of foreign body that attracted the attention of the image readers. Therefore, we propose that plain scans and associated reconstructions, which are cost-effective and easy to obtain, are enough in such emergency situations. Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Preoperative diagnosis of intestinal perforation after foreign body ingestion relies on photography examination. Recent technical developments have led to the wide usage and elevated accuracy of CT scans. Nevertheless, definitive diagnosis is usually reached during exploratory laparotomy for most patients.[22] Surgical treatment is tailored to the individual patient. If conditions permit, laparoscopic repair can be attempted.[23] Surgical principles for intestinal perforation include early containment of the contamination, copious lavage, and partial resection for diseased segment removal and pathological examination.[24] In the foreign body group, more perforation closure operations were performed because of higher portion of small perforations and lower abdominal contamination. Another important reason was that the etiology of perforation could be confirmed during operation, and there was no need to perform partial intestinal resection for pathological examination. Although medical treatment has improved greatly since more than half a century, the mortality rate of small intestinal perforation is still as high as about 19.1%.[24] Postoperative mortality attributed to intestinal perforation after foreign body ingestion is 6.1-6.5%, and morbidity is 24.2-57.6%.[5,15] Some of the factors associated with poorer outcomes include worse peritoneal contamination and significant physiological derangement.[24] The morbidity of our foreign body group was comparable to other series at 35%. Though it was still considerable, most of the cases (71.4%) had mild complications. Apart from morbidity, there was no dead or anastomosis leakage cases in the foreign body group. MPI can predict the outcome of patients according to the severity of the peritonitis as the patients with higher MPI scores were associated with worse perioperative outcome.[24] In our study, MPI scores was associated with prognosis and complication. The control group had higher MPI scores, and accordingly, had higher mortality, morbidity rates and longer duration of hospitalization. The reason of this phenomenon might be that the greater diameter of perforation and pre-existing complications before perforation, like intestinal and infection, caused worse peritoneal contamination and more significant physiological derangement in the control group. Like perforation of other non-traumatic causes, small intestinal perforation secondary to foreign body was more common in the elderly population and involved ileum more often. It was difficult to diagnose pre-operatively without the history of foreign body ingestion, typical symptom or physical signs. Plain CT scan and associated reconstruction had high accuracy to make the diagnosis and locate the foreign bodies. It was proper and safe to repair by primary suture after foreign body removal. As compared with small intestinal perforation of other non-traumatic causes, the patients with small intestinal perforation after foreign body ingestion had relatively lower MPI scores, and consequently had lower mortality, morbidity, and shorter hospital stay after operation. Conflict of interest: None declared. 111

Chen et al. A comparative study of small intestinal perforation secondary to foreign body and other non-traumatic causes

REFERENCES 1. Cheng W, Tam PK. Foreign-body ingestion in children: experience with 1,265 cases. J Pediatr Surg 1999;34:1472-6. 2. Hachimi-Idrissi S, Corne L, Vandenplas Y. Management of ingested foreign bodies in childhood: our experience and review of the literature. Eur J Emerg Med 1998;5:319-23. 3. Nandi P, Ong GB. Foreign body in the oesophagus: review of 2394 cases. Br J Surg 1978;65:5-9. 4. Syrakos T, Zacharakis E, Antonitsis P, Zacharakis E, Spanos C, Georgantis G, et al. Surgical intervention for gastrointestinal foreign bodies in adults: a case series. Med Princ Pract 2008;17:276-9. 5. Rodríguez-Hermosa JI, Codina-Cazador A, Sirvent JM, Martín A, Gironès J, Garsot E. Surgically treated perforations of the gastrointestinal tract caused by ingested foreign bodies. Colorectal Dis 2008;10:701-7. 6. Mosca S, Manes G, Martino R, Amitrano L, Bottino V, Bove A, et al. Endoscopic management of foreign bodies in the upper gastrointestinal tract: report on a series of 414 adult patients. Endoscopy 2001;33:692-6. 7. Toyonaga T, Shinohara M, Miyatake E, Ouchida K, Shirota T, Ogawa T, et al. Penetration of the duodenum by an ingested needle with migration to the pancreas: report of a case. Surg Today 2001;31:68-71. 8. Keats AS. The ASA classification of physical status--a recapitulation. Anesthesiology 1978;49:233-6. 9. Billing A, Fröhlich D, Schildberg FW. Prediction of outcome using the Mannheim peritonitis index in 2003 patients. Peritonitis Study Group. Br J Surg 1994;81:209-13. 10. Clavien PA, Sanabria JR, Mentha G, Borst F, Buhler L, Roche B, et al. Recent results of elective open cholecystectomy in a North American and a European center. Comparison of complications and risk factors. Ann Surg 1992;216:618-26. 11. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-13. 12. Furukawa A, Sakoda M, Yamasaki M, Kono N, Tanaka T, Nitta N, et

al. Gastrointestinal tract perforation: CT diagnosis of presence, site, and cause. Abdom Imaging 2005;30:524-34. 13. Maleki M, Evans WE. Foreign-body perforation of the intestinal tract. Report of 12 cases and review of the literature. Arch Surg 1970;101:474-7. 14. Ohri SK, Hutton KA, Walsh R, Desa LA, Wood CB. Foreign body perforation of the ileum. Br J Clin Pract 1990;44:647-8. 15. Goh BK, Chow PK, Quah HM, Ong HS, Eu KW, Ooi LL, et al. Perforation of the gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg 2006;30:372-7. 16. Madrona AP, Fernandez-Hernandez JA, Carasco M, Carasco Pratas M, Riquelme J, Paritta Paricio P. Intestinal perforation by foreign bodies. Eur J Surg 2000;166:307-9. 17. 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;14:1918-25. 18. Ghahremani GG. Radiologic evaluation of suspected gastrointestinal perforations. Radiol Clin North Am 1993;31:1219-34. 19. Maglinte DDT, Taylor SD, Ng AC. Gastrointestinal perforation by chicken bones. Radiology 1979;130:597-9. 20. Coulier B. Diagnostic ultrasonography of perforating foreign bodies of the digestive tract. [Article in French] J Belge Radiol 1997;80:1-5. [Abstract] 21. Rosen MP, Siewert B, Sands DZ, Bromberg R, Edlow J, Raptopoulos V. Value of abdominal CT in the emergency department for patients with abdominal pain. Eur Radiol 2003;13:418-24. 22. Syrakos T, Zacharakis E, Antonitsis P, Zacharakis E, Spanos C, Georgantis G, et al. Surgical intervention for gastrointestinal foreign bodies in adults: a case series. Med Princ Pract 2008;17:276-9. 23. Wichmann MW, Huttl TP, Billing A, Jauch KW. Laparoscopic management of a small bowel perforation caused by a toothpick. Surg Endosc 2004;18:717-8. 24. Tan KK, Bang SL, Sim R. Surgery for small bowel perforation in an Asian population: predictors of morbidity and mortality. J Gastrointest Surg 2010;14:493-9.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Yabancı cisimle ince bağırsak perforasyonu ile diğer travma dışı nedenlerin karşılaştırmalı çalışması Dr. Qiang Chen,1 Dr. Yuanquan Huang,2 Dr. Yongyou Wu,1 Dr. Kui Zhao,1 Dr. Baosong Zhu,1 Dr. Tengfei He,1 Dr. Chungen Xing1 1 2

Soochow Üniversitesi, İkinci Bağlı Hastanesi, Genel Cerrahi Kliniği, Suzhou, Jiangsu, Çin; Soochow Üniversitesi, Üçüncü Bağlı Hastanesi, Changzhou İlk Halk Hastanesi, Girişimsel Radyoloji Bölümü, Changzhou, Jiangsu, Çin

AMAÇ: Yetişkinlerde yabancı cisme bağlı gastrointestinal perforasyon hakkında çok az bilgi sahibi olunduğu gibi, yalnızca birkaç olgu çalışmasında gastrointestinal perforasyon belgelenmiştir. Bu çalışmanın amacı bu olgularda karşılaştırmalı yöntemleri sunmaktır. GEREÇ VE YÖNTEM: Ocak 2003 ile Ekim 2013 tarihleri arasında yabancı cisimle gastrointestinal perforasyon tanısı konmuş 20 hastada geriye dönük bir çalışma yürütüldü. Bu hastaların hepsinde perforasyonlar ince bağırsak yerleşimliydi ve bu hastalar travma dışı nedenlere bağlı ince bağırsak perforasyonu olmuş 87 hasta ile karşılaştırıldı. BULGULAR: Yabancı cisim grubundaki hastaların %35’i, yerel popülasyona göre çok daha yaşlı olup 65 yaşın üstündeydi (p=0.002). Yabancı cisim grubunda daha fazla sayıda hastada yaygın abdominal fiziksel bulgu olmadığı gibi (p=0.008) ve ameliyat öncesi bilgisayarlı tomografi taramaları daha büyük bir doğruluk derecesine sahipti (p=0.027). Daha büyük bir sıklıkla perforasyon onarımı yapılmıştı (p=0.024). Ortalama MPI 19.9 ve morbidite oranı %35 olup diğer nedenlere bağlı olgulara göre anlamlı derecede daha düşük idi (p=0.001 ve 0.041). Diğer nedenlere bağlı perforasyonlara göre hastanede yatış süresi daha kısaydı (p=0.038). TARTIŞMA: Yabancı cisme bağlı ince bağırsak perforasyonun klinik sunumu atipik olup ameliyat öncesi tanı bilgisayarlı tomografi taramalara bağlıdır. Birincil perforasyonun kapanması güvenli ve etkili olup göreceli olarak daha iyi sonuçlar elde edilebilir. Anahtar sözcükler: Bağırsak perforasyonu; yabancı cisim. Ulus Travma Acil Cerrahi Derg 2015;21(2):107-112

112

doi: 10.5505/tjtes.2015.43896

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K Lİ N İ K Ç A LI ŞM A

Proksimal humerus kırıklarının tedavisinde lateral deltoid split girişim ile deltopektoral girişimin karşılaştırılması Dr. Mehmet Fatih Korkmaz,1 Dr. Mehmet Nuri Erdem,2 Dr. Mustafa Karakaplan,1 Dr. Gökay Görmeli,1 Dr. Engin Burak Selçuk,3 Dr. Zeynep Maraş,4 Dr. Turgay Karataş5 1

İnönü Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Malatya;

Kolan International Hospital, Ortopedi ve Travmatoloji Kliniği, İstanbul;

İnönü Üniversitesi Tıp Fakültesi, Aile Hekimliği Anabilim Dalı, Malatya;

İnönü Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Malatya;

Malatya Devlet Hastanesi, Genel Cerrahi Kliniği, Malatya

ÖZET AMAÇ: Proksimal humerus kırıkları sık görülen ve fonksiyonel kısıtlanmaya neden olan kırıklardandır. Bu geriye dönük çalışmanın amacı aynı fiksasyon metodu kullanılarak deltopektoral ile deltoid split girişimin karşılaştırılmasıdır. GEREÇ VE YÖNTEM: Eylül 2005 ile Temmuz 2011 arasında bu iki girişim kullanılarak cerrahi tedavi edilen 86 hasta çalışmaya alındı. Grup A deltoid split girişim, Grup B deltopektoral girişim kullanılan hastalardan oluşturuldu. Grup A 22 erkek, 34 kadın toplam 56 hastanın yaş ortalaması 62.5 yıl (26-90 yıl), Grup B 14 erkek, 16 kadın, toplam 30 hastanın yaş ortalaması 54.8 yıl (24-84 yıl) idi. Tüm hastalarda internal fiksasyon aracı olarak PHİLOS plak vida sistemi kullanıldı. Her iki grubun fonksiyonel sonuçları ve komplikasyonları karşılaştırıldı. BULGULAR: Lateral deltoid split girişim kullanılan olgularda baş ve tüberküler fragman redüksiyonunun daha iyi olduğu ve Constant omuz skorunun erken dönemde daha yüksek olduğu saptandı (sırasıyla, 66.8-57.4; p<0.01). Aksiller sinir gözlenip askıya alındığı için bu sinire ait komplikasyon saptanmadı. Altıncı aydaki Constant skorları arasında anlamlı farklılık saptanmadı (sırasıyla, 92.2-91.3; p>0.05). SONUÇ: Deltoid split girişim, özellikle AO/ASİF B ve C tipi kırıklarda proksimal humerusun 270 derece kontrolüne, tüberküler parçalardan ve döndürücü manşet tendonlarından geçirilen dikişlerle redüksiyon ve plağa tespitine olanak sağlamaktadır. Deltopektoral girişime göre hastanın iyileşme sürecinde Constant skorları anlamlı olarak farklıdır. Aksiller siniri eksplore ederek yapılan lateral deltoid split girişim, deltoid kas fonksiyonlarını ve aksiller siniri tehlikeye atmadan geniş ve çok yönlü kırık kontrolü sağlayan faydalı bir cerrahi girişim tekniğidir. Anahtar sözcükler: Humerus kırıkları-cerrahi; internal metodlar; kemik plakları; kemik vidaları; kırık fiksasyonu; omuz kırıkları-cerrahi.

GİRİŞ Proksimal humerus kırıkları sık görülen ve üst ekstremitede ciddi fonksiyonel kısıtlanmaya neden olan kırıklardır. Proksimal humerus kırıklarında en yaygın kullanılan cerrahi yaklaşım deltopektoral girişimdir. Plak ile internal fiksasyon sırasında Sorumlu yazar: Dr. Mehmet Fatih Korkmaz, İnönü Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, 44280 Malatya Tel: +90 422 - 341 06 60/5103 E-posta: fatih.korkmaz@inonu.edu. tr Ulus Travma Acil Cerrahi Derg 2015;21(2):113-118 doi: 10.5505/tjtes.2015.74150 Telif hakkı 2015 TJTES

Ulus Travma Acil Cerrahi Derg, Mart 2015, Cilt. 21, Sayı. 2

humerusun lateral yüzeyinin net olarak görülmesi gerekebilmektedir. Özellikle atletik hastalarda deltoid ve pektoralis majör kaslarının distal yapışma yerleri deltopektoral yaklaşım ile yapılacak cerrahi girişim esnasında proksimal humerus lateraline ulaşımı kısıtlamaktadır. Proksimal humerus kırıklarının tedavisinde kullanılan diğer cerrahi yaklaşım lateral deltoid split girişimdir.[1,2] Deltoid split yaklaşımla humerus başı, tüberculum majus, proksimal humeral şaftın lateral kısmı ve döndürücü manşet direkt görüntülenebilir. Bu yaklaşımın en önemli tehlikesi, aksiller sinirin seyri ve bu sinire ait varyasyonlardan kaynaklanmaktadır.[3] Bu çalışmanın amacı deltopektoral ve deltoid split yaklaşım kullanılarak cerrahi tedavisi yapılan proksimal humerus kırıklı olguların sonuçlarını incelemek ve iki farklı cerrahi yaklaşımın avantaj ve dezavantajlarını karşılaştırmaktır. 113

Korkmaz ve ark. Proksimal humerus kırıklarının tedavisinde lateral deltoid split girişim ile deltopektoral girişimin karşılaştırılması

GEREÇ VE YÖNTEM Eylül 2005 ile Temmuz 2011 arasında açık redüksiyon ve internal fiksasyon gerektiren proksimal humerusun 2-, 3-, 4- parçalı ve proksimal diafizel uzanımı olan kırıklar nedeni ile cerrahi yöntem ile tedavi edilen 134 hastadan, takip sonuçlarına ve bilgilerine ulaşılabilen 86 hasta çalışmaya dahil edildi. Deltoid split girişim kullanılarak tedavi edilen 56 hasta Grup A, deltopektoral girişim kullanılarak tedavi edilen 30 hasta Grup B olarak sınıflandırıldı. Grup A’yı oluşturan 22 erkek, 34 kadın hastanın cerrahi sırasındaki yaş ortalaması 62.5 (26-90) yıl ve 24’ü sağ omuzu içermekteydi. Grup B’yi oluşturan 14 erkek, 16 kadın hastanın yaş ortalaması 54.8 (24-84) yıl ve 15’i sağ omuzu içermekteydi. Tüm hastaların ameliyat sonrası altıncı haftada ve 3.- 6.- 12.- 24. ayda radyografi ile takipleri yapıldı. Takip süresi ortalama 48 (24-72) aydı. Kırık yapısını tam olarak değerlendirmek için tüm hastalarda standart anterior-posterior (AP), aksiller, lateral skapular görüntüleri içeren radyografik incelemeler ve seçilmiş olgularda bilgisayarlı tomografi (BT) kullanıldı. Tüm kırıklar tek bir cerrah tarafından (radyografiler üzerinden) AO sınıflamasına (Müler ve ark. 1990) göre sınıflandırıldı (Tablo 1). BT sadece seçilmiş olgularda kırık hattının artiküler yüzeye uzanımını ve parçalı kırıklardaki tuberkulum majusun deplasman miktarını değerlendirmek için kullanıldı. Deltoid kas üzerindeki duyu ve anterior deltoid kontraktiliteyi içeren aksiller sinir fonksiyonu ameliyat öncesi olarak kaydedildi. Tüm hastalarda cerahi tedavi PHILOS (The proximal humeral internal locked system plate: Synthes, Stratec Medical Ltd, Mezzovico, Switzerland) plağı uygulanarak yapıldı. Her iki yaklaşımın avantaj ve kısıtlamaları klinik uygulama ile gözden geçirildi. Tüm olgularda Constant omuz skoru kullanılarak fonksiyonel değerlendirilme yapıldı. Hastaların ameliyat sonrası ağrı kontrolü için iki-üç gün omuzkol askısı ile omuz immobilizasyonu sağlandı. Daha sonra ilgili omuz 90° abdüksiyon ve anteversiyona alınacak şeklinde pasif hareket başlatıldı. Uzatılmış kolun aktif penduler ve sirküler hareketine izin verildi. Ameliyat sonrası ikinci haftadan itibaren aktif hareket ve fizyoterapi yoğunlaştırıldı. Operasyonu takiben altıncı haftadan itibaren tüm sınırlamalar sonlandırıldı.

Tablo 1. Kırıkların AO-ASİF sınıflamasına göre sınıflandırılması AO-ASİF Deltoid split Deltopektoral sınıflaması yaklaşım yaklaşım 1.1 A.1 1.1 A.2 1.1 A.3 1.1 B.1 1.1 B.2 1.1 C.1 1.1 C.2 1.1 C.3 1.2 A.1 1.2 A.2 1.2 B.2

– %41 17 6 17 %43 7 4 %11 – 2 – %5 2 1

2 7 – 7 2 5 5 – 2 – –

%30 %30 %33 %7

olacak şekilde yerleştirildiğinde, akromion anterolateralinde işaret parmağı çizgisinden başlayıp deltoid kasın distal yapışma yerine doğru uzanan yaklaşık 10 cm’lik longitudinal insizyon yapıldı. Subkutan dokular kesilip ciltaltı doku deltoid fasya üzerinden disseke edildi. Elde edilen hareketli pencere kullanılarak cilt retraksiyonu ile deltoid lifler açığa çıkartıldı. Deltoid kası lifleri akromionun köşesinden yaklaşık 3 cm distale kadar ayrılıp subakromial bursaya ulaşıldı ve subakromial bursa kalıntıları eksize edildi. İşaret parmağı subdeltoid bursanın altında kalacak şekilde sokularak posteriorda kuadranguler aralıkta aksiller sinir palpe edildi, bu aşama bursanın altında duran sinirin kusursuz bir şekilde disseke edilip ortaya konması için çok önemli olup daha sonra deltoid lifler ayrıldı. Aksiller sinir ve sirkümfleks arter mersilen tape ile askıya alındı (Şekil 2a, b). Açık redükisyonu takiben plak humerus laterline yerleştirilerek kırık fiksasyonu yapıldı. Bu yaklaşım ile tedavisi yapılan sekiz olguda aksiller sinirin kırık fragmanları arasında, özelliklede baş ve cisim arasındaki bölgede sıkışmış olduğu saptandı ve bu yaklaşımın sağladığı görüntüleme avantajı sayesinde sinir serbestleştirildi (Şekil 2b). Humerus başı superolaterali direk görülebildiği için beş valgus

Cerrahi Teknik Genel anestezi uygulandıktan sonra hasta ameliyat masasında plaj sandalyesi pozisyonunda konumlandırıldı. Humerus, klavikula ve skapulanın cilt üzerindeki iz düşümleri işaretledi (Şekil 1). Floroskopi ile omuz AP görüntüsünün analizinden sonra hastanın başı uygun poziyonda sabitlendi ve silikon destekler ile korunmaya alındı. Larteral Deltoid Split Yaklaşım Cerrahın eli; orta parmak spina skapula, başparmak korokoid üzerinde ve işaret parmağı akromioklaviküler eklem üzerinde 114

Şekil 1. Kemiklerdeki cerrahi-anatomik noktalar; anteriorda korokoid, lateralde akromio-klaviküler eklemakromionun anterior tipi, ve posteriorda spina skapula.

Ulus Travma Acil Cerrahi Derg, Mart 2015, Cilt. 21, Sayı. 2

Korkmaz ve ark. Proksimal humerus kırıklarının tedavisinde lateral deltoid split girişim ile deltopektoral girişimin karşılaştırılması

(a)

(b)

(c)

Şekil 2. (a) Aksiller sinir ve sirkümfleks arter mersilen tape ile askıya alındı. (b) Aksiller sinirin baş ve cisim arasındaki bölgede sıkışmış olduğu görülmektedir. (c) Plağın tam laterale yerleştirilmesi.

impakte olguda elevasyon ve greftleme anatomiye uygun şekilde yapılabildi. Deltopektoral Yaklaşım Deltopektoral yaklaşım ile sefalik ven görüntülendi ve laterale retrakte edildi. Kırık bölgesini görünceye kadar minimal invaziv titiz yumuşak doku disseksiyonu yapıldı. Plak biseps tendonunun uzun başı ile plak arasında yeterli mesafe kalacak şekilde, bisipital oluğun 2-3 mm posterioru ve tuberkülüm majusun 5-10 mm distalinde anterolateral bölgeye yerleştirildi.

BULGULAR Ameliyat öncesi olarak, hastaların 85’inde deltoidin üç parçasınında normal motor fonksiyonu olduğu ve aksiller sinir sensoryal fonksiyonunun intakt olduğu kaydedildi. Bir hastada, daha önce başka bir merkezde geçirdiği cerrahi nedeniyle

(a)

aksiller sinir lezyonu kaydedildi. Ameliyat sonrası klinik muayenede, aksiller sinir ve deltoid fonksiyonu spesifik olarak değerlendirildi. Takip süresince direkt yaklaşıma bağlı veya kırık fiksasyonu sırasında oluşan aksiller sinir disfonksiyonuna ait bulgu saptanmadı. Hiçbir olguda yüzeyel veya derin enfeksiyon olmadı ve takip süresinde avasküler nekroz gözlenmedi. Deltoid kası akromion lateralinde iyileşti ve sonradan kemikten ayrılma veya kopma olmadı. Başlangıçta deltoid kasın gücünde değişik derecelerde azalma saptandı, ancak rehabilitasyon fazı sonrasında tüm hastalarda deltoid kas gücünün ameliyat öncesi durumuna tekrar kavuştuğu gözlendi. Tüm omuzlarda supraskapular sinir fonksiyoneldi ve rehabilitasyon sonrası tam kuvvette olduğu tespit edildi. Constant omuz skorunun erken dönemde (6. haftada) grup A’da grup B’den daha yüksek olduğu saptandı, sırasıyla %66.8

(b)

Şekil 3. PAO-ASİF sınıflamasına göre A 1.1.A 3 kırığın ameliyat (a) öncesi ve (b) sonrası grafileri.

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Korkmaz ve ark. Proksimal humerus kırıklarının tedavisinde lateral deltoid split girişim ile deltopektoral girişimin karşılaştırılması

Tablo 2. Constant omuz skoru 6. hafta 3. ay 6. ay

Grup A (Deltoid splitting)

Grup B (Deltopectoral)

%66.8 (%45-84) %86.0 (%72-92) %92.2 (%72-100)

%57.4 (%36-75) %84.8 (%68-92) %91.3 (%74-100)

(%45-84)-%57.4 (%36-75); p<0.01. Geç dönemdeki (6. ayda) Constant omuz skorları arasında anlamlı farklılık saptanmadı, sırasıyla %92.2 (%72-100)-%91.3 (%74-100); p>0.05 (Tablo 2).

TARTIŞMA Kompleks humeral kırıklarda, tedavi sonrası fizyolojik eklem hareket aralığı elde edebilmek için anatomik redüksiyon ve stabil fiksasyonun önemi konusunda birçok yazar hemfikirdir. Humerus başının vasküler beslenmesi nedeni ile kırık dışında, kırığın redüksiyonu ve implantları yerleştirmek için yapılacak yumuşak doku disseksiyonu nedeni ile de avasküler nekroz riski artmaktadır.[4] Proksimal humerus üç parçalı kırıklarının %12 ile %34’ünde[5,6] ve dört parçalı kırıkların ise %41-59’unda[7,8] açık redüksiyon ve internal fiksasyon (ARİF) sonrası malunion, nonunion ve osteonekroz bildirilmiştir. Yaşlı hastalarda osteoporotik kemik (genellikle ince ve rüptüre döndürücü manşet ile birliktedir) hastaları öngörülemeyen klinik sonuçlara yatkın hale getirmektedir. Kilitli periartiküler plakların temel avantajları iyi konturlu düşük profilli olmaları, farklı multidireksiyonel vidalar ile anguler stabiliteyi sağlayacak kilitlenen vida teknolojisine sahip olmalarıdır. Bu plakların özellikle zayıf kemikte olmak üzere, proksimal humerus kırıklarının daha güvenli tespitini sağladıkları konusunda genel bir kanı vardır.[9-11] Stabil bir fiksasyon sağlamak için sabit açılı vidalar ve plaklar ile biyolojik tespit uygularken minimal invaziv teknikleri uygulama konusunda bir eğilim vardır.[12,13] Bu prensipler sayesinde, kırık fragmanlarının tamamen açığa çıkarılması ve anatomik redüksiyonu gerekmemektedir. Proksimal humerusa deltopektoral yaklaşımda yumuşak doku disseksiyonunun genişliği biyolojik fiksasyon tespit prensiplerini uygularken zorluk yaratmaktadır. Deltoid split yaklaşım ise bu prensiplere göre uygulanabilir ve şekillendirilebilir. Bu nedenle, ideal insizyon seçimi tartışmalıdır. Bazı yazarlar standart deltopektoral yaklaşımı tercih ederken[14-17] diğerleri ise, bu yaklaşımın humerus başının vaskülarizasyonunda önemli bir role sahip olan anterior sirkumfleks arterin yaralanmasına neden olabileceği gerekçesiyle deltoid split yaklaşımı tavsiye etmektedir.[11,18] Proksimal humerusun 270 derece kontrolüne, kırığın tipine ve yer değiştirmesine göre gerektiğinde tip C kırıklarda artiküler redüksiyonu kolaylaştırmak için döndürücü manşet longitüdinal olarak açılır. Tüberküler fragmanlardan ve döndürücü 116

manşet tendonlarından geçirilen 5 numara Ethibond dikişlerle redüksiyon ve kemik fragmanlarının plağa tespitine olanak sağlanır. Bu yaklaşımla plağın tam laterale yerleştirilmesi mümkün olur (Şekil 2c). Medial parçalanması olan hastalarda başın inferioruna gönderilecek vidaların daha güvenli yerleştirilmesi sağlanır. Ek olarak varus kollapsını önleyecek şekilde vidaların inferiordan süperiora doğru humerus başında güvenli bir şekilde yerleştirilebilmesini sağlar (Şekil 3). Herhangi bir deltoid splitting yaklaşımda aksiller sinir yaralanması anterior deltoid liflerinde güç kaybı ile sonuçlanır. Burkhead ve ark., 102 balmumunda duran eşleştirilmiş omuz piyesini disseke etmiş ve anterolateral akromiondan aksiller sinire olan mesafenin ortalama 57 mm (aralığı: 41-71 mm) olduğunu belirtmiştir.[19] Vathana ve ark. 77 örnekte, aksiller sinirin akromiondan 63 mm uzakta olduğunu göstermiştir.[20] Gardner ve ark., deltoidin anterior ve orta başları arasındaki fibroz bant seviyesinde aksiller sinirin başka dalının geçmediğini ve bu sayede deltoidin küçük dalları riske sokmadan anterior dal tanımlanması ile split edilebileceğini belirtmiştir. Anterior dal bulunduktan sonra, proksimal humerusa ulaşmak üzere deltoidi split edebilecek güvenli bir plan bulunmuştur. Sinir bufirkasyonundan anterior ve posteriordaki ilk dallara yapılan ölçümler, bu dalların deltoid anterior fibroz bandının 4 mm posterior ve 5 mm anteriorundan çıktığını göstermiştir. Sinirin yaklaşık 20 derecelik superior oblik açısı ve fibröz bandı geçtiği yerdeki kalınlığı, siniri tanımlarken cerraha ne bekleyebileceği konusunda genel bir fikir vermektedir.[21] Mackenzie sinirin yaralanma potansiyelinden kaçınmak için akromionun lateral köşesinden 6 cm’den daha fazla distalde olmayacak ve sonrada durdurucu sütür ile deltoid splitting tariflemiştir.[22] Flatow ve Bigliani sinir lokalizasyonu için tug testini tariflemişlerdir.[23] Yumuşak dokunun cerrahi disseksiyonu ve kırık fragmanlarının manipulasyonuna bağlı vasküler yaralanma avasküler nekroz riskini artırır[8,24,25] ki bu da ARİF sonrası %37 oranına kadar görülebilmektedir.[26,27] Posterior humeral sirkumfleks arter kuadrilateral boşluktan aksiller sinir ile beraber geçer ve humerus başının dolaşımına çok az katkıda bulunur,[28] ancak bu iki yapı da deltoid splitting yaklaşımında hemen görülür ve korunur. Anterior sirkumfleks humeral arter, pektoralis majorun alt sınırının 1 cm distalinde aksiller arterden çıkar ve subskapularis tendonunun alt sınırı boyunca laterale gider. [28] Deltopektoral yaklaşım kullanıldığında, bu pozisyonu onu riske sokar.[29] Glenohumeral ekleme deltoid splitting cerrahi yaklaşımın avantajları supraspinatus, infraspinatus, teres minora kolay ulaşılabilmesidir. Orta ve inferior subskapularis, orta ve inferior glenohumeral ligamentler ve glenoidin görülmesi sınırlıdır. Bu yaklaşım akromioklaviküler eklemde ve akromionda parsiyel akrominektomiye izin verir. Biz inanıyoruz ki, bu yaklaşımın posterosuperiora deplase olmuş tuberkulum majus fragmanına ve baş fragmanına ulaşmada daha fazla kolaylık sağlamaktadır. Tüberkulumların deplasman veya nonunionu daha sık ameliyat sonrası komplikasyonlardan biri olması nedeniyle Ulus Travma Acil Cerrahi Derg, Mart 2015, Cilt. 21, Sayı. 2

Korkmaz ve ark. Proksimal humerus kırıklarının tedavisinde lateral deltoid split girişim ile deltopektoral girişimin karşılaştırılması

sağlam bir tuberkulum onarımı önemlidir. Sütürler, her iki tüberkulum ve plak içindeki delikleri içine alacak şekilde horizontal ve tuberkulumlar ve humeral şaftı içine alacak şekilde de vertikal olmalıdır. Herhangi bir döndürücü manşet yırtığı tamir edilmelidir. Çalışmamızda plak tespiti için bu yaklaşımın kullanıldığı 56 olgunun hiçbirinde cerrahi yaklaşıma atfedilebilecek aksiller nöropraksi ile karşılaşılmadı. Çalışmamızın önemli çıkarımlarından birisi, aksiller sinir korunur veya disseke edilmezse, sonradan ameliyat sonrası aksiller sinir disfonksiyonu saptanmamasıdır. Deltoid split girişim, özellikle AO/ASİF B ve C tipi kırıklarda proksimal humerusun 270 derece kontrolüne, tüberküler fragmanlardan ve döndürücü manşet tendonlarından geçirilen dikişlerle redüksiyona ve plağa tespitine olanak sağlamaktadır. Deltoid split girişim, Constant skorlarına uygun olarak rehabilitasyonun erken peryodlarında daha fazla fonksiyon sağlar. Aksiller siniri eksplore ederek yapılan lateral deltoid split girişim, deltoid kas fonksiyonlarını ve aksiller siniri tehlikeye atmadan geniş ve çok yönlü kontrol sağlayan faydalı bir cerrahi girişim tekniğidir ve erken ameliyat sonrası sonuçları anlamlı bir şekilde iyidir. Deltoid splitting yaklaşımın güvenilirliğini belirlemek için uzun vadeli sonuçlar gereklidir. Ancak bizim ilk sonuçlarımız aksiller sinirin ve proksimal humerusun ortaya konmasında faydalı bir teknik olduğunu göstermektedir.

merus fractures. Clin Orthop Relat Res 2006;442:100-8. 11. Korkmaz MF, Aksu N, Göğüş A, Debre M, Kara AN, Işiklar ZU. The results of internal fixation of proximal humeral fractures with the PHILOS locking plate. Acta Orthop Traumatol Turc 2008;42:97-105. 12. Lill H, Hepp P, Korner J, Kassi JP, Verheyden AP, Josten C, et al. Proximal humeral fractures: how stiff should an implant be? A comparative mechanical study with new implants in human specimens. Arch Orthop Trauma Surg 2003;123:74-81. 13. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br 2002;84:1093-110. 14. Papadopoulos P, Karataglis D, Stavridis SI, Petsatodis G, Christodoulou A. Mid-term results of internal fixation of proximal humeral fractures with the Philos plate. Injury 2009;40:1292-6. 15. Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures [corrected]. J Bone Joint Surg Am 2008;90:233-40. 16. Egol KA, Ong CC, Walsh M, Jazrawi LM, Tejwani NC, Zuckerman JD. Early complications in proximal humerus fractures (OTA Types 11) treated with locked plates. J Orthop Trauma 2008;22:159-64. 17. Moonot P, Ashwood N, Hamlet M. Early results for treatment of threeand four-part fractures of the proximal humerus using the PHILOS plate system. J Bone Joint Surg Br 2007;89:1206-9. 18. Parmaksizoğlu AS, Sökücü S, Ozkaya U, Kabukçuoğlu Y, Gül M. Locking plate fixation of three- and four-part proximal humeral fractures. Acta Orthop Traumatol Turc 2010;44:97-104.

Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

19. Burkhead WZ Jr, Scheinberg RR, Box G. Surgical anatomy of the axillary nerve. J Shoulder Elbow Surg 1992;1:31-6.

KAYNAKLAR

20. Vathana P, Chiarapattanakom P, Ratanalaka R, Vorasatit P. The relationship of the axillary nerve and the acromion. J Med Assoc Thai 1998;81:953-7.

1. Geiger EV, Maier M, Kelm A, Wutzler S, Seebach C, Marzi I. Functional outcome and complications following PHILOS plate fixation in proximal humeral fractures. Acta Orthop Traumatol Turc 2010;44:1-6. 2. Park MC, Murthi AM, Roth NS, Blaine TA, Levine WN, Bigliani LU. Two-part and three-part fractures of the proximal humerus treated with suture fixation. J Orthop Trauma 2003;17:319-25. 3. Robinson CM, Page RS. Severely impacted valgus proximal humeral fractures. Results of operative treatment. J Bone Joint Surg Am 2003;85A:1647-55. 4. Szyszkowitz R, Seggl W, Schleifer P, Cundy PJ. Proximal humeral fractures. Management techniques and expected results. Clin Orthop Relat Res 1993;292:13-25. 5. Flatow EL, Cuomo F, Maday MG, Miller SR, McIIveen SJ, Bigliani LU. Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. J Bone Joint Surg Am 1991;73:1213-8. 6. Hawkins RJ, Bell RH, Gurr K. The three-part fracture of the proximal part of the humerus. Operative treatment. J Bone Joint Surg Am 1986;68:1410-4. 7. Neer CS 2nd. Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970;52:1090-103. 8. Stableforth PG. Four-part fractures of the neck of the humerus. J Bone Joint Surg Br 1984;66:104-8. 9. Cantu RV, Koval KJ. The use of locking plates in fracture care. J Am Acad Orthop Surg 2006;14:183-90. 10. Helmy N, Hintermann B. New trends in the treatment of proximal hu-

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21. Gardner MJ, Griffith MH, Dines JS, Briggs SM, Weiland AJ, Lorich DG. The extended anterolateral acromial approach allows minimally invasive access to the proximal humerus. Clin Orthop Relat Res 2005;434:123-9. 22. Mackenzie D. The anterior-superior approach to the shoulder. Orthop Trauma 1993;2:71-7. 23. Flatow EL, Bigliani LU. Tips of the trade. Locating and protecting the axillary nerve in shoulder surgery: the tug test. Orthop Rev 1992;21:503-5. 24. Speck M, Lang FJ, Regazzoni P. Proximal humeral multiple fragment fractures--failures after T-plate osteosynthesis. [Article in German] Swiss Surg 1996;2:51-6. [Abstract] 25. Traxler H, Surd R, Laminger KA, Windisch A, Sora MC, Firbas W. The treatment of subcapital humerus fracture with dynamic helix wire and the risk of concommitant lesion of the axillary nerve. Clin Anat 2001;14:41823. 26. Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am 2002;84-A:1919-25. 27. Rees J, Hicks J, Ribbans W. Assessment and management of threeand four-part proximal humeral fractures. Clin Orthop Relat Res 1998;353:18-29. 28. Gerber C, Schneeberger AG, Vinh TS. The arterial vascularization of the humeral head. An anatomical study. J Bone Joint Surg Am 1990;72:148694. 29. Duval MJ, Parker AW, Drez D Jr, Hinton MA. The anterior humeral circumflex vessels and the axillary nerve. An anatomic study. Orthop Rev 1993;22:1023-6.

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Korkmaz ve ark. Proksimal humerus kırıklarının tedavisinde lateral deltoid split girişim ile deltopektoral girişimin karşılaştırılması

ORIGINAL ARTICLE - ABSTRACT OLGU SUNUMU

Comparison of lateral deltoid splitting and deltopectoral approaches in the treatment of proximal humerus fractures Mehmet Fatih Korkmaz, M.D.,1 Mehmet Nuri Erdem, M.D.,2 Mustafa Karakaplan, M.D.,1 Gökay Görmeli, M.D.,1 Engin Burak Selçuk, M.D.,3 Zeynep Maraş, M.D.,4 Turgay Karataş, M.D.,5 Department of Orthopaedics and Traumatology, Inonu University Faculty of Medicine, Malatya; Department of Orthopaedics and Traumatology, Kolan International Hospital, Istanbul; 3 Department of Family Physcian, Inonu University Faculty of Medicine, Malatya; 4 Department of Radiology, Inonu University Faculty of Medicine, Malatya; 5 Department of General Surgery, Malatya State Hospital Ministry of Health, Malatya 1 2

BACKGROUND: Fractures of the proximal humerus that limit function are quite common. The objective of this retrospective study was to compare deltoid splitting and deltopectoral approaches by using the same fixation method. METHODS: Eighty-six patients who underwent surgical treatment between September 2005 and July 2011 were included into the study group. Deltoid splitting approach was used by exploring the axillary nerve on Group A patients as described by Codman, and deltopectoral approach was used on Group B patients. Group A consisted of a total of fifty-six patients of whom twenty-two were male and thirty-four were female patients, with a mean age of 62.5 years (range, 26 to 90 years). Group B consisted of a total of thirty patients of whom fourteen were male and sixteen were female patients, with a mean age of 54.8 years (range, 24 to 84 years). PHILOS plate system was utilized as an internal fixation tool in all patients. Functional results and complications of the two groups were compared using Constant scores. RESULTS: It was observed that humeral head and tubercular fragment reduction were better with lateral deltoid splitting approach, and Constant shoulder scores were higher in the early stages (66.8-57.4 consecutively; p0.05). DISCUSSION: Deltoid splitting approach, especially with AO/ASIF B and C type fractures, enables reduction and plate fixing under 270 degree control of the proximal humerus without forceful retraction and soft tissue damage, providing easy access to posterior tubercular fragment. Compared to deltopectoral approach, patients treated with deltoid splitting approach achieved higher Constant scores at an earlier stage. Lateral deltoid splitting approach, by exploring the axillary nerve, is a useful surgical technique which provides an expansive and multi-dimensional control without risking the deltoid muscle function and the axillary nerve. Key words: Bone plates; bone screws; fracture fixation; internal methods; humeral fractures-surgery; shoulder fractures-surgery. Ulus Travma Acil Cerrahi Derg 2015;21(2):113-118

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doi: 10.5505/tjtes.2015.74150

Ulus Travma Acil Cerrahi Derg, Mart 2015, Cilt. 21, Sayı. 2

ORIG I N A L A R T IC L E

Which modality is the best choice in distal radius fractures treated with two different Kirschner wire fixation and immobilization techniques? Cüneyd Günay, M.D.,1 Özdamar Fuad Öken, M.D.,2 Osman Yüksel Yavuz, M.D.,3 Sinem Hürsen Günay, M.D.,4 Hakan Atalar, M.D.5 1

Department of Orthopaedic Surgery and Traumatology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir;

Department of Orthopaedics and Traumatology, Ankara Numune Training and Research Hospital, Ankara;

Department of Orthopaedic Surgery and Traumatology, Turgut Ozal University Faculty of Medicine, Ankara;

Department of Anesthesiology and Reanimation, Eskisehir State Hospital, Eskisehir;

Department of Orthopaedic Surgery and Traumatology, Gazi University Faculty of Medicine, Ankara

ABSTRACT BACKGROUND: The aim of the study was to investigate whether the number and position of Kirschner (K)-wires, and the manner and duration of immobilization influence radiologic and functional outcomes of distal radius fractures treated with percutaneous K-wire fixation. METHODS: Ninety-two patients were included into the study with a mean follow-up period of 19.84±5.22 months (range, 13-34 months). In Group I, forty-five patients were treated with 3 K-wires and supported with a volar semi-circular cast for the first 3 weeks followed by a removable splint for a further 3 weeks. In Group II, forty-seven patients were treated with 2 K-wires and supported with a below-elbow circular cast for 6 weeks postoperatively. RESULTS: No significant difference in grip strength and DASH scores was found between the two groups. In clinical examination, significantly better functional results were determined in patients supported with a removable volar splint. At 6 weeks postoperatively, volar tilt, radial inclination, and radial length were significantly better in Group I compared to Group II (all p values). CONCLUSION: Tripod technique with 3 K-wires is a safe and reliable procedure to achieve stability and good radiological results. The use of a removable splint also improves the functional outcomes in the treatment of both intra- and extra-articular distal radius fractures. Key words: Distal radius fracture; functional outcome; Kirschner wires; percutaneous pinning; radiological outcome; treatment.

INTRODUCTION Fractures of the distal radius are the most common of all orthopedic injuries accounting for nearly 20% of all fractures presenting in the Emergency Department.[1] First treatment principles involve obtaining an anatomic reduction and then

Address for correspondence: Cüneyd Günay, M.D. Eskişehir Osmangazi Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, 26480 Eskişehir, Turkey Tel: +90 222 - 239 29 79 E-mail: cungunay@hotmail.com Qucik Response Code

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maintaining that reduction with appropriate methods of immobilization. In addition, immobilization for a short period and achieving good functional results are the main goals of management.[2] Various techniques defined for the fixation of unstable distal radius fractures include open reduction and internal fixation, percutaneous pinning and plaster casting, external fixation, and combinations of all these.[3] However, the optimal management method has not yet been established.[2,4] Despite the development of different fixation devices for distal radius fractures, Kirschner (K) -wire fixation still plays an important role in the treatment of both stable and unstable fractures of the distal radius. K-wire fixation meets the criteria of biological osteosynthesis as a less invasive procedure that prevents soft-tissue damage.[5] Additionally, fixation of K-wires allows a shorter operation time, ease of hardware removal, excellent cosmetic outcomes, and early motion after removal. 119

Günay et al. Two different treatment technique in distal radius fractures

However, uncertainty remains about the indications for percutaneous pinning, the best technique to employ, and the extent and duration of immobilization.[2] There are few studies in the literature comparing radiologic and functional outcomes of various K-wire techniques. The present study aimed to compare radiologic and functional outcomes of two different K-wire fixation methods and immobilization techniques of extra- and intra-articular fractures of the distal radius.

II, 2 K-wires were used. The manner of postoperative immobilization, and the number of K-wires used depended on the preferences of the surgeons (author 1-CG, author 2-OFO). The mode of trauma in all patients was a simple fall onto the outstretched hand. All fractures were extra-articular (23-A type) or intra-articular (23-C type) as classified by the AO classification. The demographic data of the patients is presented in Table 1.

MATERIALS AND METHODS

In both groups, the patients were scheduled for operative treatment within 48 hours of injury. All operations were performed under general anesthesia with a prophylactic 1 g dose of intravenous antibiotics. With the patient in supine position on a radiolucent arm table, closed reduction was performed under fluoroscopic control in both groups by maintaining traction and counter-traction and correcting the components of the deformity. Two or three smooth K-wires, 1.8-2.0 mm in diameter, were inserted through small stab incisions. In Group I, the first K-wire was inserted through the styloid process of the radius and the other through the dorso-ulnar border of the distal fragment with both wires engaging the opposite cortex. The third one was placed through the distal dorsal of the radius to the volar opposite cortex (Figs. 1a-c). In Group II, the first and second K-wires were inserted as in Group I (Figs. 2a-c)

The institutional review board approved the chart review for this study, and informed consent was obtained from all patients. Between January 2011 and January 2013, a total of two hundred and four patients were treated for a displaced distal radius fracture in our department. Of these, one hundred and twelve patients were treated with K-wire fixation. The inclusion criteria were acute presentation within 24 hours of the injury and dorsally angulated unstable closed fractures of the distal radius in skeletally mature patients suitable for treatment with percutaneous K-wire fixation. Twenty patients excluded from the study included two that had previously sustained a distal radius fracture, six that had a high energy trauma, four that had bilateral fractures, three that died, and five that went to another hospital for further treatment. Exclusion criteria were open fractures, previously sustained distal radius fracture, high energy trauma, bilateral fractures, and loss to follow-up. Thus, the study was completed with ninetytwo of the one hundred and twelve treated patients. These patients, who underwent full assessment, were allocated to one of the two main groups depending on the number of Kwires used for fixation. In Group I, 3 K-wires and in Group

The wires were protected with gauze. In both groups, the wires were bent outside the skin to avoid migration, and were cut to facilitate removal at six weeks postoperatively in the out-patient clinic. In both groups, active finger, elbow and shoulder mobilization exercises were started within the limits of comfort the day after surgery. A below-the-elbow

Table 1. Desciption of patients data

Group I (3 K-wire)

Group II (2 K-wire)

Total

9 (20%)

10 (21.3%)

19 (20.7%)

Sex

Male

Female

Age

36 (80%)

37 (78.7%)

73 (79.3%)

62.22±12.47 (range:41-87)

65.43±12.02 (range:41-89)

63.86±12.28 (range:41-89)

35 (77.8%)

39 (83%)

74 (80.4%)

Side

Right

Left

Operation delay (day) Follow-up mean (month)

10 (22.2%)

8 (17%)

18 (19.6%)

1.36±0.48 (range:1-2)

1.23±0.42 (range:1-2)

1.29±0.45 (range:1-2)

21.40±5.89 (range:13-34)

18.34±4.01 (range:13-31)

19.84±5.22 (range:13-34)

Fracture type/AO

23-A2

12 (26.7%)

13 (27.7%)

25 (27.2%)

23-A3

13 (28.9%)

12 (25.5%)

25 (27.2%)

23-C1

7 (15.6%)

11 (23.4%)

18 (19.6%)

23-C2

8 (17.8%)

6 (12.8%)

14 (15.2%)

23-C3

5 (11.1%)

5 (10.6%)

10 (10.9%)

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G端nay et al. Two different treatment technique in distal radius fractures

(a)

(b)

(c)

Figure 1. (a) Antero-posterior and lateral radiographs of a distal radius fracture in a 62-year-old male. (b) Tripod technique with 3- K wires immediately postoperative. The fracture is supported via a semi-circular volar cast in the same patient. (c) X-rays at six weeks show the healed fracture without loss of reduction. A satisfactory outcome was achieved.

(a)

(b)

(c)

Figure 2. (a) Antero-posterior and lateral radiographs of a distal radius fracture in a 73-year-old female. (b) Fixation with 2- K wires immediately postoperative. The fracture is supported via a below-the-elbow circular cast in the same patient. (c) Antero-posterior and lateral radiographs of the same patient at six weeks postoperatively.

semi-circular cast (in neutral position) was used for three weeks after the surgery, and then, a removable volar splint allowing mobilization several times a day was applied for a further three weeks. In Group II, a well- molded below-theelbow circular cast (in neutral position) was applied. Physiotherapy after cast/splint removal was carried out routinely in both groups. Moreover, excessively tiring activity was forbidden for one month after the removal of the K-wires. Patients in the circular cast group (Group II) were discharged the day after surgery with confirmed good distal circulation of the fingers. Follow-up of the patients was performed at 2, 4 and 6 weeks and at 3, 6 and 12 months after the procedure. Radiographic and functional outcomes of all patients were assessed by one blinded physician who was not involved in the initial surgical treatment. The active range of motion (ROM) of the wrist including flexion, extension, pronation, supination, radial deviation, and ulnar deviation was measured using a standardized goniometer at six weeks and at one year postoperatively. Grip strength was measured using a Jamar dynamometer (Jamar, Preston, USA). The average Disabilities of the Arm, Shoulder, and Hand (DASH) scores[6] and Grip strength were assessed in both groups at the 1-year follow-up. The radiographic study including volar tilt, radial length, and Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

radial inclination was based on antero-posterior and lateral wrist radiographs taken on postoperative day one and at six weeks after K-wire removal, which was interpreted as the final result. The measurements were performed on the first postoperative day and at pin removal to assess any loss of reduction. Statistical analyses were performed using SPSS (Version 13.0; SPSS Inc, Chicago, IL). Radiographic results (for independent variables) were analyzed between the two groups using the independent t-test. Functional parameters (for dependent variables) were analyzed using the paired sample t-test. Power analyses were also calculated using PS program by William D. Dupont and Walton D. Plummer (version 3.0.43). Statistical significance was set at p<0.05.

RESULTS Both groups were similar in terms of age, gender, follow-up, fracture type distribution, injury mechanism, injury-surgery interval, fracture patterns, and injured side. There was no significant difference in the demographics of each group (p>0.05) (Table 1). Surgical procedure was performed after the first day of the injury in sixty-five (71%) patients. Operation was delayed in twenty-seven (29%) patients for anesthetic reasons. There were no problems in reduction and fixation 121

Günay et al. Two different treatment technique in distal radius fractures

Table 2. Radiographic outcomes between two groups

Group I

Group II

Mean±SD

Radial inclination (°)

Immediate after surgery

22.78±1.71

21.72±1.80

<0.01

At 6 weeks postoperatively

21.18±1.69

20.17±1.98

<0.01

Loss of radial inclination

1.60±0.91

1.55±0.95

>0.05

Radial length (mm)

Immediate after surgery

13.33±1.33

13.21±1.53

>0.05

At 6 weeks postoperatively

11.93±1.62

10.89±1.68

<0.01

Loss of radial length

1.40±0.98

2.32±1.18

<0.001

Volar tilt (°)

Immediate after surgery

12.29±1.25

11.32±1.38

<0.001

At 6 weeks postoperatively

13.04±1.31

12.66±1.44

<0.01

Loss of volar tilt

0.76±0.90

1.34±1.10

<0.01

in any patients, and there was no need to change the technique in any case. No loss of reduction was observed during the treatment period. By 6 weeks, progression of fracture healing was demonstrated by clinical and radiologic examination. No patient had any tendon rupture, vessel injury, radial sensory branch injury, median nerve compression or Sudeck’s atrophy. One superficial pin track infection healed within one week with local pin care without administering antibiotics in Group I. All patients could be followed-up. The alignment at the time of reduction was anatomical in both groups. Radiographic measurements of both groups in the early postoperative period and at six weeks postoperatively are presented in Table 2. The mean radial length, immediately after surgery, was the same in both groups with no statistically significant difference. Mean radial inclination and mean volar tilt immediately after surgery were higher in Group I than in Group II (22.78°±1.71°/ 21.72°±1.80°, 12.29°±1.25°/ 11.32°±1.38°, respectively). These were statistically significant (p<0.01, p<0.001; power>0.70, power>0.80, respectively). At six weeks postoperatively, volar tilt, radial inclination, and radial length were significantly better in Group I compared to Group II. At six weeks, radial length was less in Group II than in Group I (p<0.01, power>0.80). The mean loss in radial length at six weeks was higher and statistically significant in Group II compared to Group I (p<0.001, power>0.80). Radial inclination was higher in Group I than in Group II (p<0.01, power>0.70) at six weeks postoperatively. There were no differences in loss of radial inclination between the two groups. Immediately after surgery, the mean volar tilt in Group I was higher than in Group II (p<0.001, power>0.80). At six weeks, the mean volar tilt was increased in Group II (p<0.01). There was a statistically significant difference in loss of volar tilt in Group II (p<0.01, power>0.70). 122

Mean active ROM at six weeks postoperatively and at the final follow-up, and mean increases between the two time intervals for both groups are shown in Table 3. Clinical examination of ROM in the injured wrist at six weeks after surgery showed significantly better flexion, extension, ulnar deviation, supination, and pronation (all p values <0.001, power>0.80) in Group I than in Group II. Only radial deviation was statistically insignificant (p=0.17). ROM parameters, except for radial deviation at the final follow-up, were better in Group I compared to Group II (all p values <0.001, power>0.80). However, there was no difference in radial deviation between the two groups (p=0.23). Mean increase in ulnar deviation at the final follow-up was higher in Group I (p<0.05, power>0.70), but mean increases for other parameters between the two groups were not statistically significant (p>0.05). In clinical examination, significantly better functional results were determined in patients treated with 3 K-wires. DASH scores and Grip strength measurements were minimally higher in Group I at the 1-year follow-up, but there was no statistically significant difference (Table 3).

DISCUSSION Distal radius fractures are common clinical problems which are generally treated conservatively. If this is not possible, then surgical fixation is required.[7] Percutaneous pinning with K-wires was first recommended by Green as a simple and inexpensive procedure to provide additional stability. [8] Treatment with a plaster cast and percutaneous wires is considered common practice and can achieve a good functional outcome for specific and properly assessed fractures.[9] Many pinning variations have been described in the literature. [10,11,12,13] However, cross-pin fixation is advocated the most effective method for excellent stability of all major fragments. Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Günay et al. Two different treatment technique in distal radius fractures

Table 3. Results of clinical examination, DASH score and Grip strength’s of both groups

Group I

Group II

Mean±SD

Flexion (º)

At 6 weeks postoperative

70.44±4.16

65.09±5.37

<0.001

At 1 year

74.29±3.96

69.64±6.22

<0.001

Mean increase

3.84±2.44

4.55±3.17

=0.23

Extension (º)

At 6 weeks postoperative

65.49±3.74

60.64±4.91

<0.001

At 1 year

68.60±3.84

63.40±5.53

<0.001

Mean increase

3.11±2.47

2.76±2.93

=0.54

Radial deviation (º)

At 6 weeks postoperative

16±2.39

15.21±2.98

=0.17

At 1 year

17.96±2.31

17.32±2.75

=0.23

Mean increase

1.95±1.27

2.10±1.73

=0.63

Ulnar deviation (º)

At 6 weeks postoperative

22.04±2.96

19.28±3.11

<0.001

At 1 year

23.62±3.22

19.91±4.01

<0.001

Mean increase

1.57±1.58

0.63±1.91

<0.05

Supination (º)

At 6 weeks postoperative

73.22±2.65

69.91±3.31

<0.001

At 1 year

77.22±2.91

73.68±3.96

<0.001

Mean increase

4±2.45

3.76±2.82

=0.67

Pronation (º)

At 6 weeks postoperative

73.24±2.77

69.72±3.58

<0.001

At 1 year

76.71±3.19

72.32±4.39

<0.001

Mean increase

3.46±2.78

2.59±3.36

=0.18

20.45±3.55

20.38±3.48

=0.93

DASH score/At 1 year follow-up

(range:14.00-28.50) (range:10.80-26.90)

Grip Strength(kg/cm2)/At 1 year follow-up

9.00±1.45 (range:6-12)

[14] There is scarce evidence as to the most appropriate number and placement of K-wires and supporting techniques.

In radius fracture management, a satisfactory functional outcome is unlikely unless a good anatomical result is achieved. [15] Most authors estimate loss of radial length as the most important radiologic parameter influencing the functional outcome, and it seems that any technique maintaining the radial length may attain better functional results.[3,13,16,17] However, loss of radial length in terms of effects on functional outcome has been reported in various forms in the literature.[18,19,20,21] In the current study, it was supposed that significant cortical and cancellous comminution in the distal radius on the dorsal and on the radial side may lead to late collapse due to resorption of the crushed bone. Therefore, an additional Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

8.60±2.05

=0.29

(range:5.10-12.50)

dorsal third K-wire was used to reduce the risk of collapse and regain better radiologic results. The use of the third Kwire reduced loss of radial length by about 1mm in Group I compared to Group II. Therefore, the better functional results in Group I patients can be considered to be due to not only early movement but also to the lower reduction loss of radial length. Many studies have shown that the number or position of K-wires does not influence radial inclination.[19,22,23,24] In the present study, although radial inclination was better in Group I, there were no statistically significant differences between the groups in loss of radial inclination at follow-up. However, loss of volar tilt was higher in Group II. These results conform with those in the literature where the reduction loss 123

GĂźnay et al. Two different treatment technique in distal radius fractures

in volar tilt is one of the most important factors of worse functional outcomes.[21,22,25,26,27] The possibility of early functional treatment depends on the intraoperative influence of stability, complexity of the fracture pattern, quality of the bone, and age of the patient.[1] However, since K-wire fixation is not rigid, the patients often have to be immobilized in a plaster cast, generally for at least 4 to 6 weeks postoperatively. In the literature, the period of immobilization and the time of K-wire removal have been reported as median six weeks.[24,28] In two trials testing the duration of immobilization after surgery, no statistically significant difference was found in functional and radiological results.[29,30] The method of limb immobilization following pinning is considered controversial among authors studying this topic.[2,31,32] To the best of our knowledge, there has been no previous report in the English literature of an immobilization method as described here for Group I patients of this study. In the current study, all operations were performed with a prophylactic 1 g dose of intravenous antibiotics. In contrast to this, some authors do not advocate the use of prophylactic antibiotics in the management of the distal radius fractures treated with K-wire fixation. However, they have showed 2% infection rate in their study.[33] In the present study, Grip strength was minimally higher in Group I compared to Group II, but this was not statistically significant as previously reported in other studies.[22,24,25] A meta-analysis study has demonstrated that external fixation may lead to greater recovery of grip strength, especially compared to fixation with locking volar plates.[34] Since our treatment protocol resembles a kind of external fixation with K-wires and supporting devices, grip strength measurements may have showed higher scores in both groups. Although DASH scores in Group I were minimally higher, there was no statistically significant difference between the two groups. Szyluk et al. have reported that DASH scores were good in their study group treated with K-wires and supported with a plaster cast.[35] Many studies have demonstrated various ROM outcomes according to the supporting devices used and the duration.[24,25,28,36] Milliez et al.[30] have not recommended early functional treatment as a general concept. In contrast, Das et al.[26] have reported that prolonged immobilization of the wrist for more than 3 weeks increases stiffness. Based on the results of the current study, if postoperative fracture fixation stability allows, then the use of a removable splint and encouragement of early wrist movement may improve functional outcome. A wire diameter of 2.0 mm did not result in any significantly enhanced stability in a test model of unstable distal radius fractures when compared to a wire with a diameter of 1.6 mm, with the K-wire being directed parallel and diagonal manner. Hence, the authors described the differences in ri124

gidity according to pin size, and advocated that at least 1.6 mm diameter K-wires were needed for stable cross-pin fixation.[14] In both groups, similar cross-pin fixation (with 1.8-2.0 mm K-wire) was applied. Biomechanical study could not be carried out for this case series because our study patients had both intra-articular and extra-articular fractures of the distal radius. In a biomechanical study, it is easy to obtain an extraarticular fracture model. In contrast, it is too difficult to obtain a standardized intra-articular fracture model for the distal radius fractures. Tsai et al., have showed that greater bone strength, higher wire stiffness, and longer wire contact length provide a more stable wire-bone construct, thus facilitating fracture reduction and bone union. In terms of entry point and insertion angle, surgical planning for the contact length has been more important than bony quality for stabilizing the whole wire-bone construct.[37] From a biomechanical point of view for this study, in Group I patients (fixation with 3 Kwires), the extent of the wire-bone contact plays a significant role in stability and reduction of a distal radius fracture. In order to prevent median nerve compression and finger stiffness in Group II patients, we avoided placing the wrist in too much flexion. This may have been the reason that no Sudeckâ&#x20AC;&#x2122;s atrophy was encountered during the follow-up period. Previous studies have reported that K-wire fixation is a valid option only in A2 and C1 fractures,[21] or in A2, A3, and certain C type fractures.[5] K-wire fixation in elderly patients has been reported by some authors as not efficient[23,24] while others have found no loss in reduction.[38] In the present study, the results from at least one year follow-up seem capable of restoring judicious joint function, including in older patients. Two K-wire fixation and long immobilization with a circular rigid cast could not reduce loss of reduction in all three radiologic parameters. However, fixation with 3 K-wires and the application of a semi-circular cast for three weeks postoperatively was more rigid, thus preventing loss of reduction. In addition, in Group I, using a removable splint after three weeks postoperatively allowed a much greater range of movement of the wrist and better functional results were obtained at the early and final follow-up. The limitations of this study include that it was retrospective in design and there was no measurement of inter-observer errors in radiographic interpretation or functional evaluation. We acknowledge that obtaining standardized antero-posterior and lateral radiographs of the wrist with the forearm in an exact neutral position is difficult in clinical practice. Any forearm rotation may influence the accuracy of our radiological parameters. However, these errors in measurement would probably still be present in a prospectively designed study group. Furthermore, we only evaluated the loss of reduction between the first postoperative day and six weeks postoperatively. The injured wrists were not examined for any degenerative changes at the latest follow-up. This study demonstrated that the use of an additional dorUlus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Günay et al. Two different treatment technique in distal radius fractures

sal K-wire was marginally superior in radiologic results. The third K-wire acts as an additional support and maintains three points of fixation on each side of the fracture, which generally acts as a ‘tripod chair’. It has also been shown that applying a semi-circular volar cast in neutral position followed by a removable splint allows for earlier rehabilitation without jeopardizing the fracture alignment. There is still a need for further investigation of the management methods of these fractures with large prospective randomized clinical trials, particularly to clarify the best use of K-wire stabilization and supporting techniques. Conflict of interest: None declared.

REFERENCES 1. Simic PM, Weiland AJ. Fractures of the distal aspect of the radius: changes in treatment over the past two decades. Instr Course Lect 2003;52:185-95. 2. Handoll HH, Vaghela MV, Madhok R. Percutaneous pinning for treating distal radial fractures in adults. Cochrane Database Syst Rev 2007;18: CD006080. 3. Liporace FA, Adams MR, Capo JT, Koval KJ. Distal radius fractures. J Orthop Trauma 2009;23:739-48. 4. Lichtman DM, Bindra RR, Boyer MI, Putnam MD, Ring D, Slutsky DJ, et al. Treatment of distal radius fractures. J Am Acad Orthop Surg 2010;18:180-9. 5. Fritz T, Wersching D, Klavora R, Krieglstein C, Friedl W. Combined Kirschner wire fixation in the treatment of Colles fracture. A prospective, controlled trial. Arch Orthop Trauma Surg 1999;119:171-8. 6. Beaton DE, Wright JG, Katz JN; Upper Extremity Collaborative Group. Development of the QuickDASH: comparison of three item-reduction approaches. J Bone Joint Surg Am 2005;87:1038-46. 7. Fernandez DL. Closed manipulation and casting of distal radius fractures. Hand Clin 2005;21:307-16. 8. Green DP. Pins and plaster treatment of comminuted fractures of the distal end of the radius. J Bone Joint Surg Am 1975;57:304-10. 9. Matschke S, Marent-Huber M, Audigé L, Wentzensen A; LCP Study Group. The surgical treatment of unstable distal radius fractures by angle stable implants: a multicenter prospective study. J Orthop Trauma 2011;25:312-7. 10. DePALMA AF. Comminuted fractures of the distal end of the radius treated by ulnar pinning. J Bone Joint Surg Am 1952;24:651-62. 11. Rayhack JM, Langworthy JN, Belsole RJ. Transulnar percutaneous pinning of displaced distal radial fractures: a preliminary report. J Orthop Trauma 1989;3:107-14. 12. Ruschel PH, Albertoni WM. Treatment of unstable extra-articular distal radius fractures by modified intrafocal Kapandji method. Tech Hand Up Extrem Surg 2005;9:7-16. 13. Stein AH Jr, Katz SF. Stabilization of comminuted fractures of the distal inch of the radius: percutaneous pinning. Clin Orthop Relat Res 1975;108:174-81. 14. Naidu SH, Capo JT, Moulton M, Ciccone W 2nd, Radin A. Percutaneous pinning of distal radius fractures: a biomechanical study. J Hand Surg Am 1997;22:252-7. 15. Walton NP, Brammar TJ, Hutchinson J, Raj D, Coleman NP. Treatment of unstable distal radial fractures by intrafocal, intramedullary K-wires. Injury 2001;32:383-9. 16. Hollevoet N, Verdonk R. The functional importance of malunion in distal radius fractures. Acta Orthop Belg 2003;69:239-45. 17. Short WH, Palmer AK, Werner FW, Murphy DJ. A biomechanical study

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of distal radial fractures. J Hand Surg Am 1987;12:529-34. 18. Kelly AJ, Warwick D, Crichlow TP, Bannister GC. Is manipulation of moderately displaced Colles’ fracture worthwhile? A prospective randomized trial. Injury 1997;28:283-7. 19. Kurup HV, Mandalia V, Shaju A, Beaumont A. Bicortical K-wires for distal radius fracture fixation: how many? Acta Orthop Belg 2007;73:2630. 20. Leung F, Ozkan M, Chow SP. Conservative treatment of intra-articular fractures of the distal radius--factors affecting functional outcome. Hand Surg 2000;5:145-53. 21. van Aaken J, Beaulieu JY, Della Santa D, Kibbel O, Fusetti C. High rate of complications associated with extrafocal kirschner wire pinning for distal radius fractures. Chir Main 2008;27:160-6. 22. Karnezis IA, Panagiotopoulos E, Tyllianakis M, Megas P, Lambiris E. Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius. Injury 2005;36:1435-9. 23. Kennedy C, Kennedy MT, Niall D, Devitt A. Radiological outcomes of distal radius extra-articular fragility fractures treated with extra-focal kirschner wires. Injury 2010;41:639-42. 24. Lenoble E, Dumontier C, Goutallier D, Apoil A. Fracture of the distal radius. A prospective comparison between trans-styloid and Kapandji fixations. J Bone Joint Surg Br 1995;77:562-7. 25. Azzopardi T, Ehrendorfer S, Coulton T, Abela M. Unstable extra-articular fractures of the distal radius: a prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning. J Bone Joint Surg Br 2005;87:837-40. 26. Das AK, Sundaram N, Prasad TG, Thanhavelu SK. Percutaneous pinning for non-comminuted extra-articular fractures of distal radius. Indian J Orthop 2011;45:422-6. 27. Rodríguez-Merchán EC. Plaster cast versus percutaneous pin fixation for comminuted fractures of the distal radius in patients between 46 and 65 years of age. J Orthop Trauma 1997;11:212-7. 28. Strohm PC, Müller CA, Boll T, Pfister U. Two procedures for Kirschner wire osteosynthesis of distal radial fractures. A randomized trial. J Bone Joint Surg Am 2004;86-A:2621-8. 29. Allain J, le Guilloux P, Le Mouël S, Goutallier D. Trans-styloid fixation of fractures of the distal radius. A prospective randomized comparison between 6- and 1-week postoperative immobilization in 60 fractures. Acta Orthop Scand 1999;70:119-23. 30. Milliez PY, Dallaserra M, Defives T, el Ayoubi L, Thomine JM. Effect of early mobilization following Kapandji’s method of intrafocal wiring in fractures of the distal end of the radius. Results of a prospective study of 60 cases. [Article in French] Int Orthop 1992;16:39-43. [Abstract] 31. Lozano-Calderón SA, Doornberg J, Ring D. Fractures of the dorsal articular margin of the distal part of the radius with dorsal radiocarpal subluxation. J Bone Joint Surg Am 2006;88:1486-93. 32. Roumen RM, Hesp WL, Bruggink ED. Unstable Colles’ fractures in elderly patients. A randomised trial of external fixation for redisplacement. J Bone Joint Surg Br 1991;73:307-11. 33. Subramanian P, Kantharuban S, Shilston S, Pearce OJ. Complications of Kirschner-wire fixation in distal radius fractures. Tech Hand Up Extrem Surg 2012;16:120-3. 34 Wei DH, Poolman RW, Bhandari M, Wolfe VM, Rosenwasser MP. External fixation versus internal fixation for unstable distal radius fractures: a systematic review and meta-analysis of comparative clinical trials. J Orthop Trauma 2012;26:386-94. 35. Szyluk K, Jasiński A, Koczy B, Widuchowski W, Widuchowski J. Results of operative treatment of unstable distal radius fractures using percutaneous K wire fixation. Ortop Traumatol Rehabil 2007;9:511-9. 36. Stoffelen DV, Broos PL. Closed reduction versus Kapandji-pinning for extra-articular distal radial fractures. J Hand Surg Br 1999;24:89-91. 37. Tsai WC, Lin SC, Hsiao CC, Lu TW, Chao CK, Liu HC. Biomechanical

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study of clinical and radiological outcomes of dorsally angulated, unstable distal radius fractures in elderly patients: intrafocal pinning versus volar locking plating. J Hand Surg Am 2007;32:1385-92.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Hangi yöntem iki farklı Kirschner teli ile tespit ve immobilizasyon teknikleri ile tedavi edilen distal radius kırıklarında en iyi seçimdir? Dr. Cüneyd Günay,1 Dr. Özdamar Fuad Öken,2 Dr. Osman Yüksel Yavuz,3 Dr. Sinem Hürsen Günay,4 Dr. Hakan Atalar5 Esikişehir Osmangazi Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Eskişehir; Ankara Numune Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmataloji Kliniği, Ankara; 3 Turgut Özal Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Ankara; 4 Eskişehir Devlet Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, Eskişehir; 5 Gazi Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Ankara 1 2

AMAÇ: Bu çalışmanın amacı, Kirschner (K) tellerinin sayısı ve pozisyonunun ve immobilizasyon şekli ve süresinin, kapalı olarak K-teli fiksasyonu ile tedavi edilen distal radius kırıklarının radyolojik ve fonksiyonel sonuçları üzerine etkisini araştırmaktır. GEREÇ VE YÖNTEM: Doksan iki hasta ortalama 19.84±5.22 ay (aralık: 13-34 ay) takip ile çalışmaya alındı. Grup I’deki 45 hastaya üç adet K-teli ile tespit sağlandı ve ilk üç hafta volar yarım alçı ile, sonraki üç hafta da ise çıkarılabilir splintle desteklendi. Grup II’deki, 47 hasta ise iki adet K-teli ile tespit edildi ve ameliyat sonrası altı hafta dirsek altı sirküler alçıyla desteklendi. BULGULAR: Her iki grup arasında kavrama gücü ve DASH skorları arasında önemli bir değişiklik yoktu. Klinik muayenede, daha iyi fonksiyonel sonuçlar, çıkarılabilir volar splint ile desteklenen hastalarda saptandı. Ameliyat sonrası altıncı haftada, volar tilt, radial inklinasyon ve radial yükseklik Grup I’deki hastalarda Grup II’dekilerden daha iyi idi (tüm p değerleri <0.05). TARTIŞMA: Tripod tekniğiyle üç K-teli uygulaması stabilite ve iyi radyolojik sonuçlar elde etmek için güvenli ve geçerli bir yöntemdir. Çıkarılabilir splint kullanımı, eklem içi ve eklem dışı distal radius kırıklarının tedavisinde fonksiyonel sonuçları geliştirmektedir. Anahtar sözcükler: Distal radius kırığı; fonksiyonel sonuç; Kischner teli; perkütan pinleme; radyolojik sonuç; tedavi. Ulus Travma Acil Cerrahi Derg 2015;21(2):119-126

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doi: 10.5505/tjtes.2015.55938

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ORIG I N A L A R T IC L E

Evaluation of autopsy reports in terms of preventability of traumatic deaths Yusuf Emrah Eyi, M.D.,1 Mehmet Toygar, M.D.,2 Kenan Karbeyaz, M.D.,3 Ümit Kaldırım, M.D.,1 Salim Kemal Tuncer, M.D.,1 Murat Durusu, M.D.1 1

Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara;

Department of Forensic Medicine, Gulhane Military Medical Academy, Ankara;

Council of Forensic Medicine, Eskisehir

ABSTRACT BACKGROUND: The analysis of autopsy reports plays an important role in the evaluation of trauma care quality. The objective of this study was to determine the rate of preventable deaths and medical errors in regard to the autopsy reports as an indicator of trauma care quality in traumatic deaths. METHODS: A retrospective review of traumatic autopsy reports kept between 2011 and 2012 in Eskişehir, Turkey was conducted. Demographic data of the cases, injury type, injury mechanism, injury location, ISS values, and cause and place of death were recorded. Deaths were judged in three groups including preventable deaths, potentially preventable deaths and non-preventable deaths. In the definiton of preventability, the criteria of American College of Surgeons Committee on Trauma were used. A commission composed of two forensic medicine specialists and one emergency medicine specialist reviewed preventability and defined medical errors. RESULTS: A total of five hundred and ninety-two autopsy reports were examined in the study period. Trauma was defined as the cause in 65.2% (n=386) of the cases. 81.9% (n=316) of the cases were observed to have suffered blunt injury and 18.1% (n=70) penetrating injury. Death occurred at the scene of trauma in 56.7% (n=219) of the cases, in the pre-hospital period in 11.7% (n=45), and in hospital in 31.6% (n=122). In preventability analysis, it was decided that 4.1% (n=16) of the cases had the properties of being preventable, 14.5% (n=56) potentially preventable and 81.3% (n=314) non-preventable. Suboptimal care was determined in 65.3% (n=47) of the total cases, delayed intervention in 58.3% (n=42), error in the medical method decision in 8.3% (n=6), delayed or wrong diagnosis in 1.4% (n=1), and inappropriate or incorrect medical application in 1.4% (n=1). CONCLUSION: High rates of preventable deaths in the pre-hospital period, in cases of penetrating injuries, and particularly in cases of chest trauma were evaluated as noteworthy findings. Integrated working of pre-hospital emergency healthcare services with trauma centres would enable the development of trauma care and reduce the rates of preventable deaths. Key words: Autopsy; medical error; preventable death; trauma.

INTRODUCTION Death associated with trauma is a leading cause of death in children and the young population. Morbidity and mortality rates associated with trauma have shown significant improvement in the last three-four decades due to developments in Address for correspondence: Yusuf Emrah Eyi, M.D. GATA Acil Tıp Anabilim Dalı, Etlik, 06010 Ankara, Turkey Tel: +90 312 - 304 30 31 E-mail: dremraheyi@yahoo.com Qucik Response Code

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medical science and privatised trauma care systems which have resulted in increased quality of trauma care.[1,2] Studies directed towards decreasing trauma-related deaths and increasing the quality of trauma care have concentrated on the causes of preventable deaths. The concept of preventable death was first defined in the 1970s and stated to be cases which could survive after the application of current standard trauma care to the injuries. [3] That the rates of preventable death are related to the quality of trauma care is accepted as one of the indications. Blind clinical studies and autopsy studies have been stated as two basic methods in the determination of preventable death rates.[4] In studies directed towards the determination of trauma-related preventable deaths and increasing the quality of trauma care, autopsy studies have been reported to be effective and reliable.[5] 127

Eyi et al. Evaluation of autopsy reports in terms of preventability of traumatic deaths

This study aimed to investigate trauma care quality as an indicator of preventable death rates according to autopsy reports.

MATERIALS AND METHODS A retrospective review was conducted regarding the hospital records, autopsy reports and inquest files of Eskişehir Forensic Medicine Department of cases that had undergone autopsy due to trauma-related deaths between January 1, 2011 and December 31, 2012. Cases whose cause of death was uncertain accroding to the autopsy and whose death was related to other causes than trauma were excluded from the study. Demographic data, injury type, injury mechanism, injury site, Injury Severity Score (ISS) values, cause and place of death were evaluated for all cases. Injuries were classified as blunt or penetrating. According to the site of injury, cases were classified as head, neck, chest, abdomen, pelvis, and extremities. Systems, airway, respiratory, circulation, neurological and other reasons were classified. Place of death was classified as site of the trauma event, pre-hospital and in hospital. Deaths were judged in three groups including preventable, potentially preventable and non-preventable. In the determination of preventability, the criteria of American College of Surgeons Committee on Trauma were used[6] (Table 1). A commission composed of two forensic medicine specialists and one emer-

gency medicine specialist reviewed preventability. Data was evaluated using SPSS 16.0 software program and expressed as number, percentage, mean, and standard deviation values.

RESULTS A total of five hundred and ninety-two autopsy reports were examined in the study period. Trauma was defined as the cause of death in 65.2% (n=386) of the cases. Cause of death was determined in all cases of death due to trauma. Three hundred and eighty-six cases comprised two hundred and ninety-two male (75.6%) and ninety-four female cases (24.4%) (M:F, 3:1). Mean age was determind 35.8±16.4 years (min 10 months, max 85 years). One hundred and twenty-five cases (32.4%) were in the 20-29 age group, and thirty-nine cases (10.1%) were aged 18 years and below (Table 2). 81.9% (n=316) of the cases were observed to have suffered blunt injury and 18.1% (n=70) penetrating injury (Fig. 1). When causes of injury were evaluated, these were determined as traffic accidents in one hundred and thirty-three cases (34.5%), stabbing in sixty-five cases (16.8%), fall from height in sixty cases (15.5%), and firearms injury in fifty-three cases (13.7%) (Fig. 2). Excluding ninety-seven cases (25.1%) injured by drowning, stabbing and burning, the remaining two hundred and eightynine cases were evaluated as injuries in one anatomic area in two hundred and twenty-two cases (76.82%) and in more than one anatomic area in sixty-seven cases (23.18%). Isolated injuries were found as isolated head wound in one hun-

Table 1. Preventability criteria Preventable Non-life-threatening injury The injured patient is generally stable or becomes stable with treatment There are doubts about the treatment or medical management ISS¹ <20 Potentially preventable Very serious injury but survival is possible with optimal medical care The injured patient is generally unstable and there is minimal response to treatment Medical care conforms with ATLS²/PHTLS³ but there are doubts about errors which may cause death directly or indirectly ISS: 20-50 Non-preventable Despite optimal medical care, the injury is not compatible with survival The physiological status in the first evaluation is not critical for the medical decision Trauma management conforms with ATLS ve PHTLS ISS >50 The injured patient has major comorbidities which could cause death 1: Injury severity score; 2: Advanced Trauma Life Support; 3: Prehospital Trauma Life Support.

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Table 2. Case distribution by age and gender

0-9

10-19

20-29

30-39

40-49

50-59

60-69

70-79

80-85

Total

n %* n %* n %* n %* n %* n %* n %* n %* n %* n %**

Male 7 2.4 37 12.7 75 25.7 39 13.4 64 21.9 43 14.7 19 6.5 2 0.7 6 2.1 292 75.6 Female 3 3.2 4 4.3 50 53.2 18 19.1 4 4.3 4 4.3 6 6.4 5 5.3 â&#x20AC;&#x201C; â&#x20AC;&#x201C; 94 24.4 Total 10 2.6 41 10.6 125 32.4 57 14.8 68 17.6 47 12.2 25 6.5 7 1.8 6 1.6 386 100 *

Percentage of lines are used; **Percentage of columns are used.

dred and thirty-eight cases (47.8%), isolated neck injury in eleven (3.8%), isolated chest injury in fifty-four (18.7%), isolated abdominal injury in eight (2.8%), and isolated extremity injury in eleven (3.8%) (Fig. 3). 350

Preventable Potential preventable

300

Non-preventable

When cause of death was examined according to systems, single system impairment was determined in two hundred and thirty-two cases (60.1%), two systems in one hundred and eight (28%), and multiple systems in forty-six (11.9%). Neurological problems were determined in one hundred and forty-five cases (37.6%), isolated respiratory problems in sixty-four (16.6%), and isolated circulation problems in 6%. (Table 3). Death occurred at the scene of the trauma in two hundred and nineteen cases (56.7%), in pre-hospital period in fortyfive (11.7%), and in hospital in one hundred and twentytwo (31.6%). Time of death was determined as immediate or within minutes in two hundred and twenty-eight cases (59.1%), within the first two hours in ninety-nine (25.6%), and at a later time in fifty-nine (15.3%) (Figure 4).

250

200 150 100 50

Preventability

Blunt

Type of Injury

In preventability analysis, it was decided that 4.1% (n=16) of the cases had the properties of being preventable, 14.5% (n=56) of being potentially preventable and 81.3% (n=314) of being non-preventable.

Penetratign

Figure 1. Type of injury.

Preventable

Preventable Potential preventable

100

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D ro w

an g H

lle fa ll/

ry ju in

ob je

p Sh ar

re a Fi

fic Tr af

Figure 2. Cause of injury.

Non-preventable

ea d N ec k Th or Ab ax do Ex me tre n m H iti ea es d + H N ea ec d k Th + or Th ax or + ax Ab do m en O th er

0 rn

in ju ry

Cause of Injury

Potential preventable

125

Non-preventable

de nt

125

Part of Injury

Figure 3. Part of injury.

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Eyi et al. Evaluation of autopsy reports in terms of preventability of traumatic deaths

Table 3. Distribution of cause of death according to affected systems

(23.2%), in the pre-hospital period in four (7.1%) and in the hospital in thirty-nine (69.7%).

Single system

Two systems

Multiple systems

Medical Errors

–

A+B 66

B+C+D 40

B+C 39

B+C+D 6

D+E 3

D 145 E – Total 232 108

Mean ISS scores of the cases determined as preventable, potentially preventable and non-preventable were calculated as 15.8±4.2, 33.6±9.3 and 55.1±13.7, respectively.

When medical errors were evaluated in seventy-two preventable and potentially preventable deaths, a single error was determined in forty-seven cases (65.3%) and two errors in twenty-five cases (34.7%). Evaluation was performed on a total of ninety-seven errors which were detected from seventytwo cases in our study. Suboptimal care was determined in forty-seven (65.3%) of the total cases, delayed intervention in forty-two (58.3%), error in the medical method decision in six (8.3%), delayed or wrong diagnosis in one (1.4%), and inappropriate or incorrect medical application in one (1.4%) (Figure 5).

250

Preventable

Causes of Preventable Deaths

150

The mechanism of trauma was traffic accident in nine cases (56.2%), blunt trauma in four (25%), firearms in two (12.5%) and sharp penetrative tool in one (6.2%).

100

Isolated respiratory problems were determined in eleven cases (68.8%), isolated circulation problems in one case (6.2%), isolated neurological problems in one case (6.2%), and respiratory and circulation problems in three cases (18.8%).

Death occurred at the scene of the trauma in thirteen cases 130

s dg U em ns er en u ro t m ita r ed ble ic o al r pr wr ac on S tic g de ubo e la pt y im in a tre l c at are m + en t

os i ic

di ag n

C lin

al is

se d

tim M

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tre at

ca re

en t

el ay

Isolated respiratory problems were determined in twentyseven cases (48.2%), isolated circulation problems in nine cases (16.1%), isolated neurological problems in eleven cases (19.6%), two systems were affected in three cases (5.4%) and multiple systems in five cases (8.8%).

Preventable Potential preventable

The mechanism of trauma was traffic accident in sixteen cases (28.6%), firearms in thirteen (23.2%), blunt trauma in eleven (19.6%), fall from height in eleven (19.6%), and sharp penetrative tool in five (8.8%).

Hospital

Figure 4. Distribution of cases according to preventability and place of death.

Causes of Potentially Preventable Deaths Fifty-six cases evaluated as potentially preventable deaths comprised male and female cases at a ratio of 1.7:1, with a mean age of 36.1±14.5 years. The injuries were blunt in thirty-eight cases (67.9%) and penetrating in eighteen (32.1%).

Prehospital Place of Death

Scene

Death occurred at the scene of the trauma in four cases (25%), in the pre-hospital period in seven (43.8%), and in the hospital in five (31.2%).

Non-preventable

200

Sixteen cases evaluated as preventable deaths comprised 10 male and 6 female cases (M:F, 1.7:1) with a mean age of 30.4±9.3 years. The injuries were blunt in thirteen cases (81.3%) and penetrating in three (17.8%).

Potential preventable

Proble Error

Figure 5. Probable error.

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Eyi et al. Evaluation of autopsy reports in terms of preventability of traumatic deaths

DISCUSSION Trauma is a leading cause of mortality particularly affecting the young population. Therefore, evaluation of preventability in traumatic deaths is critically important for improving the quality of trauma care and reducing medical errors. Studies in the literature analyzing traumatic deaths can generally be categorised as studies which have only used data of the cases that reached the hospital and those which included pre-hospital data. The studies which include pre-hospital data are more general but are evaluated as including more sound epidemiological data. Although the analyses of cases reaching the hospital lack a portion of traumatic deaths, they seem to have reached clearer results with more detailed and appropriate data collected. In a 2008 study of traumatic deaths by Durusu et al.,[7] limitation was reported to be lack of prehospital data due to inadequate records and documentation. When the demographic characteristics of traumatic death cases are examined in the literature, different data is seen to have reported the mean age between 35 and 55 years. In developed countries, the elderly population has been reported to be affected by traumatic death, but generally, studies have reported a greater distribution in the 3rd decade and of male gender. Mean age in our study was 35.8Âą16.4. The average value is compatible with the studies conducted at national level, but not with the foreign studies where the average value is lower. Causes of injury: Four most common causes of injury were traffic accidents, firearms injuries, falls from height and sharp penetrative tools, and these were seen in this order at similar ratios in preventable and non-preventable deaths. These findings were compatiple with the studies in the literature. In a study by Ohene et al.[8] evaluating adolescent traumatic deaths, findings have been different with the most common cause being drowning (37%) then traffic accidents (33%). This difference can be considered to be due to the age group or regional differences. In a study by Sharma et al.,[9] in which diagnostic errors have been evaluated in cases reaching the hospital, head trauma has been reported to be the most common at a rate of 56%. In the current study, head trauma was again in first place at a rate of 50%. It was also reported first place at a rate of 38% in the study by Durusu et al.[7] However, it is noticeable that the rates of preventability in these cases were extremely low compared to other anatomic areas. Distribution according to place and time of death: In a retrospective study by Sanddal et al.[10] investigating the causes of preventable death in cases which reached the hospital, deaths have been reported to have occurred in the first 24 hours in 84% of cases and after 24 hours in the remaining 16%. De Knegt et al.[11] have also reviewed time of death in cases which reached the hospital and reported time of death to be in the first hour in 11.5% and in the first 24 hours in 47% of the cases. Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

In these two studies, rates of death in the first hour and in the early period are lower than the findings of the current study, which is thought to be due to the exclusion of cases where death was recorded at the site of trauma or in prehospital period. In a study by Evans et al.[12] of one hundred and seventy-five cases including pre-hospital deaths, the rate of pre-hospital deaths has been reported at approximately 65%, which is compatible with the findings of the current study.In a 2003 study in South Africa by Meel et al.[13] evaluating traumatic deaths, pre-hospital deaths were reported at 74%. The higher rates of these studies than those of the current study are thought to be related with the inadequacy of the pre-hospital emergency services. The study by Durusu et al.[7] reported that deaths occurred at the site of the incident in 52.46% of the cases, in the prehospital period in 6.92%, and in hospital in 40.61%. Although these findings are similar to those of the current study, the rates at the site of the incident and in the pre-hospital period are seen to be lower and deaths in hospital are proportionally higher. This difference is thought to be due to regional differences and a higher proportion of cases of burns, drowning and stabbings than in the current study. Preventability: When preventability rates of traumatic deaths are examined, various rates between 2% and 20% have been reported. In a review of twenty-four studies by Settervall et al.,[14] mean preventability rate has been reported as 10.7%. In a study by Kleber et al.[15] of two hundred and sixty-four traumatic deaths, the reported rates have been 5.3% preventable, 9.9% potentially preventable, and 84.8% non-preventable. Saltzherr et al.[16] have evaluated forty-four cases of traumatic death in a Level 1 trauma centre and stated that one case was preventable and five cases were potentially preventable. Hogan et al.[17] have randomly selected two hundred and fifty cases of traumatic death from hospital records and the preventability rate was found to be 5.2%. In the examination of previous studies, inclusion of pre-hospital deaths, older studies and studies conducted in a region without a trauma centre were observed to be factors raising preventability rates. In an autopsy study by Wilson et al.[18] in which a series of five hundred traumatic deaths have been analysed, the preventability rate is reported 14%. This rate is relatively high due to not using the category of potentially preventable. In 2008, Durusu et al.[7] evaluated seven hundred forty-seven traumatic deaths and reported a preventable death rate at 4.15%, potentially preventable death at 16.2% and non-preventable at 79.65%. Although four years have passed since that study, similar rates are seen at national level. When the connection of preventability rates with other variables is examined, pre-hospital preventable deaths are seen to be proportionally high, and there is an excessive rate of 131

Eyi et al. Evaluation of autopsy reports in terms of preventability of traumatic deaths

potentially preventable deaths in the hospital. Although there is a great number of deaths at the site of the trauma, the majority are non-preventable. In addition, despite head trauma being the leading cause of deaths associated with trauma, the majority have the properties of non-preventable deaths, and the proportionally high rates of chest trauma, particularly as preventable and potentially preventable deaths, are evaluated as significant.

deaths comparing ISS on admission to trauma center with the ISS during autopsy. Although clinical evaluation has revealed preventability rate of death as 12%, post autopsy evaluation has revealed a rate of 3%. In our study, evaluation was made only upon autopsy; Ince et al. has reported minimally lower preventability rates when compared with our rates. The difference is considered to be due to determining the upper limit of ISS as 20 in terms of preventability in our study.

Medical Errors: Single error per case in forty-seven cases and double error per case in twenty-five cases, totally 97 errors, were detected from preventable and potentially preventable deaths in the group of patients who had a total of seventytwo cases. Suboptimal care in 65.3% of the patients (n=47) and interference delay in 58.3% (n=42) of the patients were the most frequently detected medical errors. The least common errors were delayed or incorrect diagnosis in 1.4% (n=1) of the patients and inappropriate or incorrect medical malpractice in 1.4% (n=1) of the patients. When the literature was reviewed for medical errors related to traumatc deaths, it was seen that medical errors were categorised in different ways. In a study by Ivatury et al.[19] evaluating seven hundred and sixty-four cases of traumatic deaths, medical errors have been reported at a rate of 9.9%. Zafarghandi et al.[20] have evaluated one hundred and sixty-five traumatic deaths in Tehran and classified the cases as with and without central nervous system involvement, and medical errors have been categorised as diagnostic errors and teatment errors. A total of sixty-four medical errors have been determined as fifteen diagnostic errors in fifteen cases and forty-nine treatment errors in twenty-five cases. Vast majority of the errors were in injuries not related to the central nervous system and were treatment errors. As diagnostic errors were relatively fewer, this can be accepted as conforming the findings of the current study.

Limitations

In a study by Teixeira et al.[21] evaluating two thousand and eighty-nine traumatic deaths that reached hospital, medical errors have been categorised as delay in treatment, clinical judgement error, missed diagnosis, technical error, and other errors. Delay in treatment and clinical judgement error have been reported as the most frequently made errors. As suboptimal care has not been categorised, the findings of that study conform those of the current study. In a 2008 study by Durusu et al.[7] evaluating seven hundred and forty-seven traumatic deaths, medical errors were reported as delay in treatment at 49.34% and suboptimal care at 41.5%.Although the order is similar, these findings are seen to be at a higher rate than those of the current study. This result is thought to be possibly due to regional differences or differences related to evaluation. ISS Scores: Ince et al.[22] have declared that patient deaths are considered to be preventable with an ISS score<or=14 in their study including one hundred and sixty posttraumatic 132

In the current study, all data and preventability decisions were conducted on autopsy reports and additional patient files. As there was a low number of cases in some sub-groups like isolated abdominal injury, the power of preventability rates of those groups was evaluated as having decreased. In the analysis of medical errors, objective criteria were not used and evaluation was made by a specialist physician and recorded. Records of deaths at the site of trauma and in the pre-hospital period were seen to be more limited, and thus, preventability and medical error decisions were made on the basis of fewer data. ISS of patients during admission to emergency service could not be calculated while ISS was calculated according to the autopsy data of the study. ISS acquired from autopsy might be different from those which were obtained from first evaluation during admission to the emergency service. Ince et al.[22] reported that ISS scores obtained from autopsy might be different from the ISS obtained from clinical evaluation in their study based on trauma scoring systems conducted in 2006.

Conclusion When the findings of the current study were evaluated together with those of the literature, preventability rates were seen to be lower in regions where there were efficiently working trauma centres. It was noticeable that the rates of preventable death were found to be higher in the pre-hospital period, in cases of penetrating injury, and particularly in cases of chest trauma. The integration of pre-hospital emergency healthcare services with trauma centres would enable trauma care to be developed and reduce the rates of preventable deaths. Conflict of interest: None declared.

REFERENCES 1. Guenther S, Waydhas C, Ose C, Nast-Kolb D; Multiple Trauma Task Force, German Trauma Society. Quality of multiple trauma care in 33 German and Swiss trauma centers during a 5-year period: regular versus on-call service. J Trauma 2003;54:973-8. 2. Mock C, Nguyen S, Quansah R, Arreola-Risa C, Viradia R, Joshipura M. Evaluation of Trauma Care capabilities in four countries using the WHO-IATSIC Guidelines for Essential Trauma Care. World J Surg 2006;30:946-56. 3. Rutstein DD, Berenberg W, Chalmers TC, Child CG 3rd, Fishman AP,

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Eyi et al. Evaluation of autopsy reports in terms of preventability of traumatic deaths Perrin EB. Measuring the quality of medical care. A clinical method. N Engl J Med 1976;294:582-8. 4. Shackford SR, Hollingsworth-Fridlund P, McArdle M, Eastman AB. Assuring quality in a trauma system--the Medical Audit Committee: composition, cost, and results. J Trauma 1987;27:866-75. 5. Esposito TJ, Sanddal T, Sanddal N, Whitney J. Dead men tell no tales: analysis of the use of autopsy reports in trauma system performance improvement activities. J Trauma Acute Care Surg 2012;73:587-91. 6. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons; 2006. 7. Durusu M, Eryilmaz M, Toygar M, Baysal E. [Analysis of preventable deaths according to postmortem reports in traumatic deaths]. Ulus Travma Acil Cerrahi Derg 2010;16:357-62. 8. Ohene SA, Tettey Y, Kumoji R. Injury-related mortality among adolescents: findings from a teaching hospital’s post mortem data. BMC Res Notes 2010;3:124. 9. Sharma BR, Gupta M, Harish D, Singh VP. Missed diagnoses in trauma patients vis-à-vis significance of autopsy. Injury 2005;36:976-83. 10. Sanddal TL, Esposito TJ, Whitney JR, Hartford D, Taillac PP, Mann NC, et al. Analysis of preventable trauma deaths and opportunities for trauma care improvement in utah. J Trauma 2011;70:970-7. 11. de Knegt C, Meylaerts SA, Leenen LP. Applicability of the trimodal distribution of trauma deaths in a Level I trauma centre in the Netherlands with a population of mainly blunt trauma. Injury 2008;39:993-1000. 12. Evans JA, van Wessem KJ, McDougall D, Lee KA, Lyons T, Balogh ZJ. Epidemiology of traumatic deaths: comprehensive population-based assessment. World J Surg 2010;34:158-63.

13. Meel BL. Pre-hospital and hospital traumatic deaths in the former homeland of Transkei, South Africa. J Clin Forensic Med 2004;11:6-11. 14. Settervall CH, Domingues Cde A, Sousa RM, Nogueira Lde S. Preventable trauma deaths. Rev Saude Publica 2012;46:367-75. 15. Kleber C, Giesecke MT, Tsokos M, Haas NP, Buschmann CT. Traumarelated preventable deaths in Berlin 2010: need to change prehospital management strategies and trauma management education. World J Surg 2013;37:1154-61. 16. Saltzherr TP, Wendt KW, Nieboer P, Nijsten MW, Valk JP, Luitse JS, et al. Preventability of trauma deaths in a Dutch Level-1 trauma centre. Injury 2011;42:870-3. 17. Hogan H, Healey F, Neale G, Thomson R, Vincent C, Black N. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual Saf 2012;21:737-45. 18. Wilson JL, Herbella FA, Takassi GF, Moreno DG, Tineli AC. Fatal trauma injuries in a Brazilian big metropolis: a study of autopsies. Rev Col Bras Cir 2011;38:122-6. 19. Ivatury RR, Guilford K, Malhotra AK, Duane T, Aboutanos M, Martin N. Patient safety in trauma: maximal impact management errors at a level I trauma center. J Trauma 2008;64:265-72. 20. Zafarghandi MR, Modaghegh MH, Roudsari BS. Preventable trauma death in Tehran: an estimate of trauma care quality in teaching hospitals. J Trauma 2003;55:459-65. 21. Teixeira PG, Inaba K, Hadjizacharia P, Brown C, Salim A, Rhee P, et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma 2007;63:1338-47. 22. Ince H, Ince N, Taviloğlu K, Güloğlu R. A different approach to trauma scoring. Ulus Travma Acil Cerrahi Derg 2006;12:195-200.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Travmatik ölümlerde otopsi raporlarının önlenebilirlik açısından değerlendirilmesi Dr. Yusuf Emrah Eyi,1 Dr. Mehmet Toygar,2 Dr. Kenan Karbeyaz,3 Dr. Ümit Kaldırım,1 Dr. Salim Kemal Tuncer,1 Dr. Murat Durusu1 Gülhane Askeri Tıp Akademisi, Acil Tıp Anabilim Dalı, Ankara; Gülhane Askeri Tıp Akademisi, Adli Tıp Anabilim Dalı, Ankara; 3 Adli Tıp Kurumu, Eskişehir 1 2

AMAÇ: Bu çalışmada travmatik ölümlerde, travma bakım kalitesinin bir göstergesi olarak önlenebilir ölüm oranlarının ve medikal hataların otopsi raporlarına göre araştırılması amaçlandı. GEREÇ VE YÖNTEM: Eskişehir/Türkiye’de 2011 ve 2012 yıllarına ait travmatik otopsi raporları geriye dönük olarak incelendi. Olguların demografik verileri, yaralanma tipi, yaralanma nedeni, yaralanma bölgesi, ISS değerleri, ölüm nedeni ve ölüm yeri kaydedildi. Bütün ölümler önlenebilir, potansiyel önlenebilir ve önlenemez ölümler olmak üzere üç gruba ayrıldı. BULGULAR: Çalışma döneminde 386 travmatik otopsi raporu incelendi. Olguların %81.9’unun (n=316) künt, %18.1’inin (n=70) ise penetran yaralanmaya maruz kaldığı gözlendi. Yine olguların %56.7’sinin (n=219) olay yerinde, %11.7’sinin hastane öncesinde (n=45), %31.6’sının (n=122) hastanede öldüğü belirlenmiştir. Önlenebilirlik analizinde olguların %4.1’inin önlenebilir (n=16), %14.5’inin (n=56) potansiyel önlenebilir ve %81.3’ünün (n=314) önlenemez nitelikte olduğuna karar verildi. Toplamda olguların %65.3’ünde (n=47) suboptimal bakım, %58.3’ünde (n=42) müdahalenin gecikmesi hataları gözlendi. TARTIŞMA: Önlenebilir ölüm oranlarının hastane öncesi periyotta, penetran yaralanmalarda ve özellikle göğüs travmalarında yüksek bulunmasının dikkat çekici bulgular olduğu değerlendirilmektedir. Anahtar sözcükler: Medikal hata; otopsi; önlenebilir ölüm; travma. Ulus Travma Acil Cerrahi Derg 2015;21(2):127-133

doi: 10.5505/tjtes.2015.94658

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ORIG I N A L A R T IC L E

Epidemiology of animal-related injuries in a high-income developing country Hani O. Eid, M.D.,1 Ashraf F. Hefny, M.D.,2 Fikri M. Abu-Zidan, M.D.1,3 1

Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates;

Department of Surgery, Al Rahba Hospital, Abu Dhabi, United Arab Emirates;

Department of Surgery, Al-Ain Hospital, Al-Ain, United Arab Emirates

ABSTRACT BACKGROUND: The objective of this study was to investigate the incidence, mechanisms, types, anatomical distribution, and outcome of animal related-injuries in Al-Ain, the United Arab Emirates in order to improve preventive measures. METHODS: The study included all patients admitted to Al-Ain Hospital with animal-related injuries for more than 24 hours or the patients who died in the Emergency Department between March 2003 and March 2007. RESULTS: There were eighty-nine (2.3%) patients, of whom 99% were males. The median age of the patients was 30 (range, 5-89) years. Camel-related injuries were the most common (84.3%) injuries followed by cow-related injuries (6.7%). 88.7% of the injuries occurred at work. Animal kick was the most common mechanism of injury (32.6%) followed by falls (30.3%). Upper extremity was the most commonly injured region. The median Injury Severity Score (ISS) was 4 (range, 1-13) and the median hospital stay was 6 (range, 1-53) days. CONCLUSION: The majority of animal-related injuries were caused by camels. Experience in handling the animals, a good knowledge of animal behavior along with using safety devices and prevention education can reduce the toll of animal-related injuries. Key words: Animals; epidemiology; hospitalization; injury; mechanism.

INTRODUCTION Animal-related injuries are associated with considerable morbidity and mortality worldwide. These injuries vary by region depending on the type, size, and behavior of animals living in that geographical region, and on the profession, tradition, and sport activities of the inhabitants.[1-4] These injuries can be due to direct contact with animals like horses, camels, cattle, and dogs, or indirect contact caused by the collision of motor vehicles with large animals like kangaroos, moose, camels, and deer.[5] The United Arab Emirates (UAE) is a high-income developing Address for correspondence: Fikri M Abu-Zidan, M.D. Pobox 17666 Al-Ain, United Arab Emirates Tel: 009713 7137579 E-mail: fabuzidan@uaeu.ac.ae Qucik Response Code

134

country with a fast growing economy related to oil exports. Professions like farming and herding are rarely practiced by the UAE citizens, and since workers in these areas are usually immigrants, the necessity to hiring immigrants with relevant experiences arises.[6,7] The endemic animals inhabiting the UAE are camels and cattle. Camels, which are traditional animals of the UAE, are used in racing and in banquets in social events. Cattle are mainly raised for dairy products industry or as a source of fresh meat. Street dogs are very scarce in the UAE because they are well-controlled by local authorities. Camel-related injuries have been previously well-studied.[8-10] Nevertheless, the general magnitude of animal-related injuries in the UAE has not been previously studied. Therefore, this study was conducted to study the incidence, mechanisms, types, anatomical distribution, and outcome of animal related-injuries in Al-Ain, the UAE so as to give recommendations on preventive priorities.

MATERIALS AND METHODS This study was performed in Al-Ain, which is the largest city Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Eid et al. Epidemiology of animal-related injuries in a high-income developing country

located in the east of Abu Dhabi Emirate of the UAE, with a population of 463.000 inhabitants during the study period. [7] Trauma patients in need of admission were managed in two major hospitals of Al-Ain (Al-Ain and Tawam Hospitals). About eighty percent of the patients were treated in Al-Ain Hospital and this study included all patients admitted to AlAin Hospital with animal-related injuries for more than 24 hours or those who died after arrival to the hospital between March 2003 and March 2007. The data was prospectively collected from Al-Ain Hospital Trauma Registry.[11,12] The Local Ethics Committee of Al-Ain Health District Area had approved data collection of the Trauma Registry. Studied variables included patient demography, mechanism of injury, distribution and severity of injury, the length of hospital stay, and outcome. Injury Severity Score (ISS), as a global marker of injury severity, was calculated manually using the Abbreviated Injury Scale (AIS) 1998 handbook.[13] The population data was retrieved from the general census of the UAE for the year 2005.[7] The data was analyzed with the PASW Statistics 18, SPSS Inc, USA.

RESULTS There were three thousand eight hundred and sixty patients included in the Trauma Registry of Al- Ain Hospital. Out of these, eighty-nine (2.3%) patients had animal-related injuries. The estimated annually hospitalized patients in Al-Ain with animal-related injury was 6/100 000. Eighty-eight (98.9%) were male patients. The median age of the patients was 30 (range, 5-89) years. Patients from the Indian subcontinent were the most commonly injured patients (80.7 %) (Table 1). Camel-related injuries were the most common (84.3%) followed by cow related-injuries (6.7%) (Table 2). In forty-five patients whose professions were known, there were thirty-one (63.3%) camel caregivers, eleven (22.4%) farm workers, and five (10.2%) camel jockeys. In sixty-two patients with known place of trauma, forty-six (74.2%) of the injuries occurred

Table 1. Nationality of the patients with animal-related injuries, Al-Ain, the United Arab Emirates 2003-2007 Nationality

Pakistani

52.3

Bangladeshi

19.3

Indian

9.1

UAE

6.8

Sudanese

3.4

Others

9.1

Total

100

One patient had missing data.

in farms and nine (14.5%) at camel race sites. Animal kick was the most common mechanism of injury followed by falls while riding (Table 2). All horse-related injuries were due to fall from a horse. Upper extremity was the most commonly injured body region followed by the lower limbs (Table 3). The median ISS was 4 (range, 1-13) and the median Glasgow Coma Scale (GCS) was 15 (range, 8-15). Three patients (3.4%) were admitted to the Intensive Care Unit (ICU) with a median ICU stay of one day (range, 1-11). Median hospital stay was 6 (range, 1-53) days. There was no mortality.

DISCUSSION There is a need for information about the incidence and magnitude of animal-related injuries in the UAE so as to develop injury prevention strategies against it. This study showed that 6 out of 100.000 people is the estimated number of patients annually hospitalized for animal-related injuries in our city. Although the number of admitted patients in the current study was small, it constituted 2.3% of all admitted trauma patients. Their mean hospital stay was six days, occupying

Table 2. Animal-related injuries: different animals and their mechanisms of injury, Al-Ain, the United Arab Emirates 2003-2007

Kick

Fall

Bite

Blow

Crushed

Stepped on

Others

Total

n %

n % n % n % n %

n %

Camel

28 37.3

22 29.3

17 22.7

2 2.7

75 84.3

Cow

1 16.7 – – 1 16.7 1 16.7 – – – – 3 50 6 6.7

Horse

– –

4 100

– –

4 4.5

Fox

– –

1 100

– –

1 1.1

Snake

– –

1 100

– –

1 1.1

Donkey

– –

1 100

– –

1 1.1

1 1.3

2 2.7

3 4

Sheep

– –

– – – – – – 1 100 1 1.1

Total

29 32.6

27 30.3

20 22.5

3 3.4

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1 1.1

2 2.2

7 7.9

89 100

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Table 3. Animal-related injuries by anatomical region, Al-Ain, the United Arab Emirates 2003-2007. (Number of patients=89) Region

Head and face

22.5

Neck

1.1

Chest

20.2

Abdomen

12.4

Pelvis

2.2

Spine

5.6

Upper limb

28.1

Lower limb

24.7

Patients may have more than one injured region; therefore, total percentage adds up to more than 100%.

about two hospital beds each day. On the other hand, this study did not show the overall number of animal-related injuries in our city because those who died before arrival to the hospital and those who did not seek medical advice at all were not included. Furthermore, mild injuries were treated in the Emergency Department and patients were discharged home. Other authors have found that animal-related injuries constitute 0.2%-8.3% of all trauma admissions.[14-17] A previous study from our city has found that animal-related injuries constitute 7% of all occupational injuries.[6] Majority of our patients were middle-aged males. Males are injured more by animals than females, which is a predominance also reported by others.[3,14-19] Other studies from Turkey, Tanzania, Saudi Arabia, and Poland have demonstrated that most patients with animal-related injuries are middle-aged.[14,15,17,20] Almost 80% of the patients with animal-related injuries in our study were from the Indian subcontinent, reflecting their high percentage in the UAE population.[7] A previous study on occupational injuries in Al-Ain has found that 96% of the hospitalized patients with work-related injuries are immigrants, 98% are males, and 69% are middle aged.[6] Most animal-related injuries in our study were considered work-related injuries since they occurred in farms and racing fields. Large animal-related injuries are usually blunt.[15,16,21] The leading mechanism of injury among our patients was animal kick followed by fall while riding, and animal-bites. Camels were responsible for 84% of admissions due to animal-related injuries, which could be attributed to their presence in the Arabian Peninsula, their size and behavior, and being linked with the UAE tradition and activities. Camel racing has a social and economic importance. Furthermore, about three quarters of patient profession was related to camels. A study from Saudi Arabia has found that camels are the most common cause of animal-related injuries necessitating hospitalization.[20] A nine136

year prospective study on camel-related injuries in Al-Ain has presented that camel kick is the most common mechanism of injury followed by falls and bites.[9] Others have put forward that animal kicks are responsible for 16-58% of animal-related injuries.[2,3,14,18-20,22] Similar to others, our study suggested that the most common injured body regions were the upper and lower extremities. [2,9,15,16,18,19] Head and face, and chest were the second most common injured body regions. Norwood et al. have stated that upper extremity injuries caused by large animals are predictors of head and torso injuries.[3] Shahan et al. have found that injury patterns are affected by patient age. Very young patients who are short and injured by animal-kick are associated more with head injuries.[23] In a study by Nawaz et al., 56% of the children having camel-related injuries have suffered head injuries.[10] Prevention and control of animal-related injuries hold different approaches. The victim can be protected against the force of impact. To illustrate, highways between major cities in the UAE have been fenced by properly designed metallic barriers to prevent the collision of motor vehicles with large animals. This measure has been effective in reducing this type of collision in the UAE in a dramatic way.[5] Similarly, using a muzzle to cover the animal mouth can prevent bite injuries.[8,9] Protective equipments are effective in reducing the severity of the injury. Using helmets and face guard reduce the severity of head injury among equestrians.[2,22,24] Those who are riding large animals should use helmets and other protective gears.[23] Legislation plays a role in preventing and reducing injuries. Banning children from participating camel racing in the UAE in 2005 and complete replacement of them by robots have completely prevented injuries related to child camel jockeys. [25] Legislation to mandate using of protective equipment when handling or riding large animals will reduce animal-related injuries.[10,23] Education and training are other important preventive measures to reduce the burden of trauma. Understanding animal behavior, training workers on dealing with animals, teaching safe falling techniques to animal riders, and increasing awareness through educational campaigns are recommended to prevent animal-related injuries.[2,9,10,19,24,26]

Limitations of the Study We studied only hospitalized patients in one of the two main hospitals in our city. Many patients with dog and rat bites were treated in our Emergency Department without being admitted to the hospital, which highlights the need for a future prospective study on animal-related injuries in the Emergency Department to better understand the magnitude of animal-related injuries in our setting. Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Eid et al. Epidemiology of animal-related injuries in a high-income developing country

Furthermore, the period of our study was between 2003 and 2007. Our Trauma Registry was the only registry in the UAE at that time and it was supported by a research fund from our university. The registry including the data of the injuries that occurred after 2007 could not be reached mainly due to lack of financial support.[11] Animal-related injuries constitute 2.3% of the hospitalized trauma patients in our setting. The majority of animal-related injuries in Al-Ain were caused by camels. Experience in handling the animals, a good knowledge of animal behavior along with using safety devices and education can reduce the toll of animal-related injuries and their consequences.

Acknowledgement This study was supported by Individual University Grant (#01-07-8-11/03), Faculty of Medicine Research Grants (NP/03/11,2003; and NP/04/28, 2004) and an Interdisciplinary Grant (#02-07-8-1/4). Conflict of interest: None declared.

REFERENCES 1. Abu-Zidan FM, Parmar KA, Rao S. Kangaroo-related motor vehicle collisions. J Trauma 2002;53:360-3. 2. Abu-Zidan FM, Rao S. Factors affecting the severity of horse-related injuries. Injury 2003;34:897-900. 3. Norwood S, McAuley C, Vallina VL, Fernandez LG, McLarty JW, Goodfried G. Mechanisms and patterns of injuries related to large animals. J Trauma 2000;48:740-4. 4. Rudloff U, Gonzalez V, Fernandez E, Holguin E, Rubio G, Lomelin J, et al. Chirurgica Taurina: a 10-year experience of bullfight injuries. J Trauma 2006;61:970-4. 5. Bashir MO, Abu-Zidan FM. Motor vehicle collisions with large animals. Saudi Med J 2006;27:1116-20. 6. Barss P, Addley K, Grivna M, Stanculescu C, Abu-Zidan F. Occupational injury in the United Arab Emirates: epidemiology and prevention. Occup Med (Lond) 2009;59:493-8. 7. United Arab Emirates Census. Population Preliminary results 2005 by age and nationality. Adapted from: Preliminary Results of the General Census for Population, Housing and Establishments, United Arab Emirates 2005. Availablefrom:http://www.zu.ac.ae/library/html/UAEInfo/ documents/CensusResults2005.pdf (accessed 27.05.10.). 8. Abu-Zidan FM, Eid HO, Hefny AF, Bashir MO, Branicki F. Camel bite injuries in United Arab Emirates: a 6 year prospective study. Injury

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2012;43:1617-20. 9. Abu-Zidan FM, Hefny AF, Eid HO, Bashir MO, Branicki FJ. Camel-related injuries: prospective study of 212 patients. World J Surg 2012;36:2384-9. 10. Nawaz A, Matta H, Hamchou M, Jacobsz A, Al Salem AH. Camel-related injuries in the pediatric age group. J Pediatr Surg 2005;40:1248-51. 11. Shaban S, Ashour M, Bashir M, El-Ashaal Y, Branicki F, Abu-Zidan FM. The long term effects of early analysis of a trauma registry. World J Emerg Surg 2009;4:42. 12. Shaban S, Eid HO, Barka E, Abu-Zidan FM. Towards a national trauma registry for the United Arab Emirates. BMC Res Notes 2010;3:187. 13. Association of the Advancement of Automotive Medicine. Abbreviated Injury Scale. Association for the Advancement of Automotive Medicine, Barrington, IL, 1998. 14. Emet M, Beyhun NE, Kosan Z, Aslan S, Uzkeser M, Cakir ZG. Animalrelated injuries: epidemiological and meteorological features. Ann Agric Environ Med 2009;16:87-92. 15. Gilyoma JM, Mabula JB, Chalya PL. Animal-related injuries in a resource-limited setting: experiences from a Tertiary health institution in northwestern Tanzania. World J Emerg Surg 2013;8:7. 16. Moini M, Peyvandi AA, Rasouli MR, Khajei A, Kakavand M, Eghbal P, et al. Pattern of animal-related injuries in Iran. Acta Med Iran 2011;49:1638. 17. Nogalski A, Jankiewicz L, Cwik G, Karski J, Matuszewski Ł. Animal related injuries treated at the Department of Trauma and Emergency Medicine, Medical University of Lublin. Ann Agric Environ Med 2007;14:57-61. 18. Murphy CG, McGuire CM, O’Malley N, Harrington P. Cow-related trauma: a 10-year review of injuries admitted to a single institution. Injury 2010;41:548-50. 19. Watts M, Meisel EM. Cattle associated trauma--a one year prospective study of all injuries. Injury 2011;42:1084-7. 20. Janjua KJ, van den Berg AA. Animal injuries presenting to Riyadh Armed Forces Hospital: a survey. Trop Doct 1994;24:84. 21. Bury D, Langlois N, Byard RW. Animal-related fatalities--part I: characteristic autopsy findings and variable causes of death associated with blunt and sharp trauma. J Forensic Sci 2012;57:370-4. 22. Eckert V, Lockemann U, Püschel K, Meenen NM, Hessler C. Equestrian injuries caused by horse kicks: first results of a prospective multicenter study. Clin J Sport Med 2011;21:353-5. 23. Shahan CP, Emmett K, Zarzaur BL. Large animal-related injury requiring hospital admission: injury pattern disparities. Injury 2012;43:1898902. 24. Chitnavis JP, Gibbons CL, Hirigoyen M, Lloyd Parry J, Simpson AH. Accidents with horses: what has changed in 20 years? Injury 1996;27:103-5. 25. Abu-Zidan FM, Hefny AF, Branicki F. Prevention of child camel jockey injuries: a success story from the United Arab Emirates. Clin J Sport Med 2012;22:467-71. 26. Hendricks KJ, Adekoya N. Non-fatal animal related injuries to youth occurring on farms in the United States, 1998. Inj Prev 2001;7:307-11.

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KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Yüksek gelirli gelişmekte olan ülkelerde hayvanların neden olduğu yaralanmaların epidemiyolojisi Dr. Hani O. Eid,1 Dr. Ashraf F. Hefny,2 Dr. Fikri M. Abu-Zidan1,3 Birleşik Arap Emirlikleri Üniversitesi, Tıp ve Sağlık Bilimleri Fakültesi, Cerrahi Kliniği, Al-Ain, Birleşik Arap Emirlikleri;; Al Rahba Hastanesi, Abu Dhabi, Birleşik Arap Emirlikleri; 3 Al-Ain Hastanesi, Cerrahi Kliniği, Al-Ain, Birleşik Arap Emirlikleri 1 2

AMAÇ: Koruyucu önlemleri iyileştirme amacıyla Birleşik Arap Emirliklerinde Al-Ain ilinde hayvanların neden olduğu yaralanmaların insidansı, mekanizmaları, tipleri, anatomik dağılımı ve sonucunu incelendi. GEREÇ VE YÖNTEM: Mart 2003 ile Mart 2007 yılları arasında hayvanlar tarafından yaralandıktan 24 saatten uzun bir süre sonra Al-Ain Hastanesine getirilen ve acil serviste ölen hastaların hepsi incelendi. BULGULAR: Seksen dokuz (%2.3) hastanın %99’u erkek hastalardan ibaretti. Hastaların ortanca (aralığı) yaşı 30 (5-89 yaş) yaşındaydı. En sık develerin (%84.3), daha sonra ineklerin (%6.7) neden olduğu yaralanmalar görülmekteydi. Yaralanmaların %88.7’si işteyken oluşmuştu. En sık görülen yaralanma hayvan çiftesi (%32.6) ve düşmeler (%30.3) sonucu oluşmuştu. En sık üst ekstremite yaralanmıştı. Ortanca (aralık) ISS, 4 (1-13) ve hastanede yatış süresi 6 (1-53 gün) idi. TARTIŞMA: En çok develerin neden olduğu yaralanmalar görülmüştür. Hayvanlarla uğraşıda deneyim, hayvan davranışlarını iyi bilme, güvenli cihazların kullanılması ve yaralanmalardan koruyucu eğitim, hayvanların neden olduğu yaralanmaların oranını azaltabilmektedir. Anahtar sözcükler: Epidemiyoloji; hayvanlar; hospitalizasyon; mekanizma; yaralanma. Ulus Travma Acil Cerrahi Derg 2015;21(2):134-138

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doi: 10.5505/tjtes.2015.76508

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ORIG I N A L A R T IC L E

Total oxidant status, total antioxidant status, and paraoxonase activity in acute appendicitis Hande Köksal, M.D.,1 Sevil Kurban, M.D.,2 Osman Doğru, M.D.1 1

Department of General Surgery, Konya Training and Research Hospital, Konya;

Department of Biochemistry, Necmettin Erbakan University Meram Faculty of Medicine, Konya

ABSTRACT BACKGROUND: The aim of this study was to investigate the levels of oxidative stress including total oxidant status, total antioxidant status, and paraoxonase activity in patients with a diagnosis of acute appendicitis. METHODS: Seventy-three patients who underwent surgery with a preoperative diagnosis of acute appendicitis (Group I) were included into the study. The control group (Group II) consisted of thirty otherwise healthy subjects. After histopathologic examination, the patients were categorized as follows: 1) Acute focal appendicitis, 2) Acute advanced appendicitis including acute suppurative, phlegmonous and gangrenous appendicitis, 3) Acute perforated appendicitis, 4) Sub-acute appendicitis, and 5) Negative exploration. Blood samples for paraoxonase activities, and total oxidant and antioxidant status levels were obtained preoperatively. RESULTS: Total oxidant and antioxidant status of the patients in the acute appendicitis group were higher than those of the control group. When paraoxonase activities of Group I was compared with Group II, no significant difference was determined. Both total oxidant and antioxidant status levels of acute perforated appendicitis were higher than those of both acute focal appendicitis and acute advanced appendicitis. CONCLUSION: The increase in the oxidative status (total oxidant and antioxidant status) was related with the progression of inflammation to the perforation in acute appendicitis. Key words: Acute appendicitis; paraoxonase activity; total antioxidant status; total oxidant status.

INTRODUCTION Acute appendicitis (AA), a common and urgent surgical illness, is a condition characterized by the inflammation of the appendix. It is thought to result from obstruction of the appendiceal lumen, typically by lymphoid hyperplasia, but occasionally by a fecalith, foreign body, or even worms. The obstruction leads to distention, inflammation, bacterial overgrowth, and finally ischemia. If untreated, necrosis and perforation occur. If the perforation is restricted by the omentum, an appendiceal abscess develops.[1]

Address for correspondence: Hande Köksal, M.D. Konya Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Konya, Turkey Tel: +90 332 - 235 45 00 E-mail: drhandeniz@yahoo.com Qucik Response Code

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Paraoxonase (PON1) is associated with high-density lipoprotein particles and is known to have an antioxidant function. In humans, the PON gene family has three members, PON1, PON2, and PON3. PON1 has three known enzymatic molecules, including PON, arylesterase (ARE) and dyazoxonase. Human serum PON1 and ARE are both esterase enzymes that have lipophilic antioxidant characteristics. These enzymes play a role in decreasing oxidative stress. PON1, in particular, is an important endogenous free radical scavenging system in the human body.[2-5] Studies of oxidative stress in AA have been reported until today.[6-9] The aim of this study was to investigate the levels of oxidative stress including total oxidant status, total antioxidant status, and paraoxonase activity in patients with a diagnosis of AA.

MATERIALS AND METHODS Seventy-three patients who underwent surgery with a preoperative diagnosis of acute appendicitis (Group I) were included into the study. The control group (Group II) consisted 139

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of thirty otherwise healthy subjects. The presence of any of the following conditions was used as an exclusion criteria in this study: diabetes mellitus, neoplastic disease, inflammatory disease (such as infections and autoimmune disorders), hypercholesterolemia, hypertriglyceridemia, use of an antihypertensive medication, lipid-lowering drug use, antioxidant substance use, known secondary hypertension, chronic renal failure, cerebrovascular disease, ischemic heart disease, congestive heart failure, gastrointestinal disease or liver disease. The demographic features, complete blood count and final pathologic diagnosis of the patients were recorded. Leukocyte counts greater than 10x109/L was defined as leukocytosis. Neutrophil rate greater than 74% was defined as neutrophilia. After histopathologic examination, the patients were categorized as follows: 1) Acute focal appendicitis (AFA), 2) Acute advanced appendicitis (AAA) including acute suppurative, phlegmonous and gangrenous appendicitis, 3) Acute perforated appendicitis (APA), 4) Sub-acute appendicitis (SA) and 5) Negative exploration. Blood samples were obtained preoperatively. Serum samples were centrifuged for 15 min at 3000 rpm, transferred to Eppendorf tubes and stored at −80ºC, and were used to measure TAS and TOS levels, and paraoxonase activity. Paraoxonase activity was measured by using paraoxon and phenylacetate as substrates. The basal activity of paraoxonase was measured. The rate of paraoxon hydrolysis (diethyl-p-nitrophenylphosphate) was measured monitoring an increase in absorbance at 412 nm at 37ºC on an autoanalyser (Beckman Coulter, Fullerton, CA, U.S.A.). The amount of generated pnitrophenyl was calculated from the molar absorptivity coefficient at a pH of 8.5, which was 18290 M-1cm-1.[10] Paraoxonase activity was expressed as U/L of serum. TAS levels of the sera were determined using an automated measurement method based on bleaching of the characteristic color of a more s 2,2’-azino-bis [3-ethylbenz-thiazoline6-sulfonic acid (ABTS)] radical cation caused by antioxidants. [11] The results were expressed in mmol Trolox equivalents/L. TOS levels of the sera were determined using a novel automated measurement method.[12] Oxidants present in the

sample oxidized the ferrous ion-o-dianisidine complexes into ferric ions. The oxidation reaction was enhanced by glycerol molecules that were abundantly present in the reaction medium. The ferric ions formed a colored complex with xylenol orange in an acidic medium. Therefore, color intensity, measured spectrophotometrically, was related to the total number of oxidant molecules present in the sample. The assay was calibrated with hydrogen peroxide and the results were expressed in terms of micromolar hydrogen peroxide equivalent per liter (μmol H2O2 equiv./L). The study protocol was approved by the Ethics Committee of Selcuk University, Faculty of Medicine (number 2010/13), and was conducted according to the Declaration of Helsinki, Good Clinical Practice Guidelines. The participants were informed about the nature of the study and informed consents were obtained. Statistical analysis was performed using SPSS software for Windows, release 13.0. Results were expressed as mean ± standard deviation (SD). Statistical analysis was performed using the Mann-Whitney U test, and statistical significance was assumed at a level of p<0.05.

RESULTS Seventy-three patients who underwent surgery with a diagnosis of acute appendicitis and thirty healthy subjects were included into the study. In Group I, the median age of the patients was 24 years (range, 16-60 years), and thirty-seven of the patients were male and thirty-six patients were female. In Group II, the median age was 25 years (range, 16-48 years), and seventeen of the patients were female and thirteen were male. Mean and SD values of TOS and TAS levels, and PON1 activities are presented in Table 1. TOS and TAS levels of the patients were higher than the ones of the control groups (p=0.0001 and p=0.004, respectively). When PON1 activities of Group I were compared with Group II, no significant difference was determined. TOS, and TAS levels, and PON1 activities of the patients were analyzed according to leukocyte counts, neutrophil rates, duration of symptoms, and pathologic subgroups (Table 2).

Table 1. Total oxidant status, total antioxidant status levels, and paraoxonase activity of the patients and control groups TOS (μmol H2O2 equiv./L) TAS (mmol Trolox equivalents/L) PON1(U/L)

Group 1*

Group 2

44.45±29.55

22.34±7.04

0.0001

2,49±0,56

2,21±0,32

0.004

51.96±39.15 55.97±36.91 0.63

*The patients with negative exploration were excluded because definitive pathologic diagnosis was not appendicitis.

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Table 2. TOS and TAS levels and PON1 activities according to the subgroups of the patients

TOS

TAS

PON1

*Leukocyte counts

Normal (n=12)

58.49±49.06

2.6±0.92

48.92±46.46

Leukocytosis (n=56)

39.59±21.63

2.4±0.44

54.04±36.72

p value

*Neutrophil rate

≤74% (n=24)

50.63±39.82

2.52±0.72

55.72±37.93

>74% (n=44)

38.72±19.91

2.43±0.42

51.68±38.8

p value

*Duration of the symptoms

≤24 hours (n=18)

52.51±43.34

2.6±0.78

57.3±38.21

24-48 hours (n=23)

35.71±17.84

2.37±0.46

54.69±44.95

>48 hours (n=27)

42.68±21.16

2.45±0.42

49.07±30.95

p value

39.65±20.27

2.45±0.43

51.03±41.03

Patologic subgroups

AFA (n=38)

AAA (n=19)

38.76±20.6

2.35±0.43

57.1±39.17

APA (n=5)

102.52±54.96

3.35±1.13

39.27±24.51

SA (n=6)

27.21±12.86

2.18±0.13

65.04±28.1

Negative exploration (n=5)

28.06±3.25

2.43±0.52

81.45±6.01

p value

†

‡

††

: The patients with negative exploration were excluded because definitive pathologic diagnosis was not appendicitis. : AFA vs APA, p=0.007; AAA vs APA, p=0.009; SA vs APA, p=0.028; Negative exploration vs AFA, ASA and APA (p=0.003, p=0.039 and p=0.016, respectively). ‡ : AFA vs APA, p=0.049; AAA vs APA, p=0.025. †† : Negative exploration vs AFA, ASA and APA (p=0.0001, p=0.017 and p=0.016, respectively). *

†

DISCUSSION Acute appendicitis, a condition caused by the inflammation of appendix, is a common and urgent surgical illness with many manifestations, generous overlaps with other clinical syndromes, and significant morbidity increasing with diagnostic delay. No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal inflammation in all cases. In pathophysiology of AA, obstruction of the appendiceal lumen by thick mucus, feces, a foreign object, or sometimes even a tumor is the primary cause of appendicitis. An anatomic blind pouch or obstruction of the appendiceal lumen leads to distension of the appendix due to accumulated intraluminal fluid. Ineffective lymphatic and venous drainage allow bacterial invasion of the appendiceal wall and, in advanced cases, perforation and spillage of pus into the peritoneal cavity can be seen.[1,13] On pathology, the following stages of AA can be distinguished: 1) simple appendicitis where the inflamed appendix is still viable; 2) gangrenous appendicitis is characterized by focal and diffuse necrosis; and 3) perforated appendicitis is characterUlus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

ized by necrosis and destruction of the appendix.[14,15] Oxidative stress is essentially an imbalance between the production of free radicals and the ability of the body to counteract or detoxify their harmful effects through neutralization by antioxidants. It leads to many pathophysiological conditions including neurodegenerative diseases, cancers, heart and blood vessel disorders, and inflammatory diseases. The immune system uses lethal effects of oxidants by making production of oxidizing species a central part of its mechanism of killing pathogens, with activated phagocytes producing both reactive oxygen species and reactive nitrogen species, including superoxide, nitric oxide, and their particularly reactive product, peroxynitrite. Although the use of these highly reactive compounds in the cytotoxic response of phagocytes causes damage to host tissues, the nonspecificity of these oxidants is also an advantage since they will damage almost every part of target cell. This prevents the pathogen escaping from immune response by mutation of a single molecular target.[2-5]

Several studies on oxidative stress in AA have been reported up to now.[6-9] In a study by Koltuksuz et al.,[6] plasma superoxide dismutase activity and malondialdehyde level in AA have been studied. In this study, both superoxide dismutase and malondialdehyde have been significantly higher in both acute suppurative and perforated appendicitis than both control and AFA. They have speculated that oxygen free radicals may play an important role in the extent of AA. In another study by Ozdogan et al.,[7] the levels of TAS and malondialdehyde levels in patients with acute phlegmonous appendicitis, advanced appendicitis or negative exploration have been investigated. In patients with AAA (acute gangrenous or perforated appendicitis), TAS level has been significantly lower than the other groups, and they have concluded that TAS might be a predictor for the progression of inflammation to the perforation in AA. Total antioxidant capacity in children with AA has been investigated, and total antioxidant capacity level in AA has been significantly higher than non-appendicitis and healthy groups in another study by Kaya et al.[8] The possible role of nitric oxide and whether there is a relation between oxidative stress and nitric oxide in AA has been investigated in another study.[9] It has been found that serum nitric oxide 141

Köksal et al. Total oxidant status, total antioxidant status, and paraoxonase activity in acute appendicitis

levels and oxidative stress elevate in AA independently from the extent of pathology, and the authors have concluded that increased nitric oxide could play a role in the increased oxidative stress levels in AA. PON1 has many enzymatic activities and is known to have an antioxidant function. These enzymes play a role in decreasing the oxidative stress. PON1 in particular is an important endogenous free radical scavenging system in the human body. Decreased PON1 activity has been observed in patients with different diseases, including coronary artery disease, hypercholesterolemia, type 2 diabetes or iron-deficiency anemia.[2-5] In our study, the levels of oxidative stress including total oxidant status, total antioxidant status, and paraoxonase activity in patients with AA were investigated. TOS and TAS levels of the patients were higher than the ones of the control group. However, no significant difference in PON1 activities was determined between the patients and healthy subjects, and this status could not be explained. Both TOS and TAS levels of APA were higher than both AFA and AAA. PON1 activities of the patients with negative exploration were higher than AFA, ASA and APA. In our study, our data showed that the increase in TOS and TAS levels, and decrease in PON1 activities were due to the progression of inflammation to the perforation in acute appendicitis. The increase in both TOS and TAS levels and decrease in PON1 activities can be explained by the progression of the inflammation and increased response of the organism to this oxidative stress. The increase of oxidative status (both TOS and TAS) was related with the progression of inflammation to the perforation in acute appendicitis. Conflict of interest: None declared.

REFERENCES 1. Hardin DM Jr. Acute appendicitis: review and update. Am Fam Physician 1999;60:2027-34. 2. Bodolay E, Seres I, Szodoray P, Csípo I, Jakab Z, Vegh J, et al. Evaluation of paraoxonase activity in patients with mixed connective tissue disease. J Rheumatol 2008;35:237-43. 3. Furlong CE. Genetic variability in the cytochrome P450-paraoxonase 1 (PON1) pathway for detoxication of organophosphorus compounds. J Biochem Mol Toxicol 2007;21:197-205. 4. Chait A, Han CY, Oram JF, Heinecke JW. Thematic review series: The immune system and atherogenesis. Lipoprotein-associated inflammatory proteins: markers or mediators of cardiovascular disease? J Lipid Res 2005;46(3):389-403. 5. Erdem FH, Karatay S, Yildirim K, Kiziltunc A. Evaluation of serum paraoxonase and arylesterase activities in ankylosing spondylitis patients. Clinics (Sao Paulo) 2010;65:175-9. 6. Koltuksuz U, Uz E, Ozen S, Aydinç M, Karaman A, Akyol O. Plasma superoxide dismutase activity and malondialdehyde level correlate with the extent of acute appendicitis. Pediatr Surg Int 2000;16:559-61. 7. Ozdogan M, Devay AO, Gurer A, Ersoy E, Devay SD, Kulacoglu H, et al. Plasma total anti-oxidant capacity correlates inversely with the extent of acute appendicitis: a case control study. World J Emerg Surg 2006;1:6. 8. Kaya M, Boleken ME, Kanmaz T, Erel O, Yucesan S. Total antioxidant capacity in children with acute appendicitis. Eur J Pediatr Surg 2006;16:34-8. 9. Yilmaz FM, Yilmaz G, Erol MF, Köklü S, Yücel D. Nitric oxide, lipid peroxidation and total thiol levels in acute appendicitis. J Clin Lab Anal 2010;24:63-6. 10. Eckerson HW, Wyte CM, La Du BN. The human serum paraoxonase/ arylesterase polymorphism. Am J Hum Genet 1983;35:1126-38. 11. Erel O. A novel automated direct measurement method for total antioxidant capacity using a new generation, more stable ABTS radical cation. Clin Biochem 2004;37:277-85. 12. Erel O. A new automated colorimetric method for measuring total oxidant status. Clin Biochem 2005;38:1103-11. 13. Graffeo CS, Counselman FL. Appendicitis. Emerg Med Clin North Am 1996;14:653-71. 14. Carr NJ. The pathology of acute appendicitis. Ann Diagn Pathol 2000;4:46-58. 15. Butler C. Surgical pathology of acute appendicitis. Hum Pathol 1981;12:870-8.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Akut apandisitte toplam oksitadif durum, toplam antioksidan durum ve paraoksonaz enzim aktivitesi Dr. Hande Köksal,1 Dr. Sevil Kurban,2 Dr. Osman Doğru1 1 2

Konya Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Konya; Necmettin Erbakan Üniversitesi Meram Tıp Fakültesi, Biyokimya Anabilim Dalı, Konya

AMAÇ: Bu çalışmanın amacı, akut apandisit tanısı alan hastalarda toplam okstadif durum, toplam antioksidan durum değerleri ile paraoksonaz enzim aktivitesinin araştırılmasıdır. GEREÇ VE YÖNTEM: Ameliyat öncesi akut apandisit tanısıyla ameliyata alınan 73 hasta (Grup I) ile kontrol grubu olarak (Grup II) sağlıklı 30 kişi çalışmaya alındı. Patolojik inceleme sonucunda hastalar: 1) Akut fokal apandisit, 2) Akut ilerlemiş apandisit (süpüratif, flegmenöz ve gangrenöz apandisit), 3) Akut perfore apandisit, 4) Subakut apandisit ve 5) Negatif eksplorasyon olarak sınıflandırıldı. Paraoksonaz enzim aktivitesi, toplam okstadif durum, toplam antioksidan durum değerleri için kan örnekleri ameliyat öncesinde alındı. BULGULAR: Hastaların toplam oksidatif ve antioksidatif durum düzeyleri kontrol grubuna göre yüksekti. Paraoksonaz enzim aktivitesi karşılaştırıldığında grup I ile II arasında herhangi bir anlamlı fark saptanmadı. Akut perfore apandisitli hastaların toplam oksidatif ve antioksidatif durum düzeyleri hem akut fokal apandisitli hem de akut ilerlemiş apandisitli hastalardan daha yüksek bulundu. TARTIŞMA: Toplam oksidatif ve antioksidatif durum düzeylerinin akut apandisitli hastalarda enflamasyonun ilerlemesi ile artmaktadır. Anahtar sözcükler: Akut apandisit; paraoksonaz enzim aktivitesi; toplam antioksidan durum; toplam oksitadif durum. Ulus Travma Acil Cerrahi Derg 2015;21(2):139-142

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S H OR T R EP O R T

Disaster medical assistance in super typhoon Haiyan: Collaboration with the local medical team that resulted in great synergy Hoon Kim, M.D.,1 Moo Eob Ahn, M.D.,2 Kang Hyun Lee, M.D.,3 Yeong Cheol Kim, M.D.,4 Eun Seok Hong, M.D.5 1

Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea;

Department of Emergency Medicine, College of Medicine, Hallym University, Chuncheon, Korea;

Department of Emergency Medicine, Wonju College of Medicine, Yonse University, Wonju, Korea;

Department of Trauma Surgery, National Medical Center, Seoul, Korea;

Department of Emergency Medicine, Ulsan University, Ulsan, Korea

ABSTRACT BACKGROUND: On 8 November 2013, Typhoon Haiyan made landfalls over the center of the Philippines and devastated the region. Soon aftermath of the disaster, many foreign medical teams (FMTs) headed toward the site, and the Korean team was one of them. METHODS: This study described the experiences of the team during the initial phase of response, focusing on collaborative efforts with the local medical team. RESULTS: The Korean team was capable of providing primary care, and the Filipino team provided incomplete secondary care which was insufficient for covering the patient load. Not only did the Korean team provide electricity for hospital operation and various materials, but also supplemented medical personnel, who covered the emergency and outpatient departments. Collaborative efforts filled in each other’s gap, and resulted in great synergy. CONCLUSION: Disaster medical relief mission of FMTs should be cooperated with a coordination mechanism. Collaboration with the local resources can be a great opportunity for both parties, and should not be overlooked in any disaster situations. Key words: Collaboration; disaster; typhoon.

INTRODUCTION Category 5 tropical cyclone Yolanda, known as Super Typhoon Haiyan, devastated the Philippines on November 8, 2013. As of January 29, 2014, the death toll had reached 6201 with 1785 missing according to the Philippines National Disaster Risk Reduction and Management Council (NDRRMC). The report of the agency revealed that 28.626 were injured. The typhoon affected fifty-seven cities and more than three Address for correspondence: Moo Eob Ahn, M.D. 77, Sakju-ro, Chuncheon-si, Gangwon-do 200-704, Republic of Korea 200704 Chuncheon, South Korea Tel: +82 - 10-9719-7119 E-mail: mooeob@gmail.com Qucik Response Code

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million households. Nearly one million families lost their houses while four million people were displaced.[1] Most hospitals and health facilities in the typhoon-hit areas were seriously damaged, and in Tacloban, only one public hospital remained functional following Haiyan.[2] Soon after the tragedy, international aid mechanism was operational, but suffered many difficulties due to logistical problems. The geography of the Philippines produced several similarly affected regions that could not be reached easily. Not every island was covered by aid agencies in a timely fashion due to tackled logistics. World Health Organization (WHO) set up a coordination center for medical aid agencies in Tacloban and Cebu. Korean Disaster Relief Team (KDRT) was one of the foreign medical teams (FMT) that provided medical service in Tacloban. KDRT was deployed on November 15, and started to provide medical service as of November 16 in St. Paul’s hospital, Tacloban City. St. Paul’s hospital was also severely damaged and partially operated by the Filipino medical team 143

Kim et al. Disaster medical assistance in super typhoon Haiyan

deployed from Davao. They treated about two hundred outpatients per day, provided minor surgical services while running thirty patient beds at the time of KDRT’s arrival. Four terms of KDRT provided seamless medical services for six weeks thereafter, in cooperation with the Filipino healthcare workers.

Table 1. Human recourses of KDRT and Filipino team Occupation

Specialty

KDRT Philippines Total

Doctor

Emergency medicine 1 1 2

This article highlighted initial cooperation efforts from both sides and its effect in hospital function which was greatly enhanced with cooperation.

General surgery 1 8 9

Surgical oncology

Orthopedics

MATERIALS AND METHODS

Anesthesiology 1 3 4

Internal medicine 1 1 2

The capacity of KDRT and the Philippines medical team was classified using WHO guidelines and described accordingly.[3] Each team’s role in the hospital was described and hospital functions were measured using Inter-Agency Standing Committee (IASC) health service availability checklist form, and the status of before and after collaboration was compared. [4] Operational information including daily reports from both sides were collected to access patient statistics.

Pediatrics 1 1

OB-Gynecologist 1 1

General physician

Sub total

Supporting

Nurses

Healthcare

Nursing aide

RESULTS Composition and Capacity of Both Teams KDRT consisted of five medical doctors (two emergency physicians, one general surgeon, one orthopedic surgeon, one pediatrician, and one internal medicine specialist), seven nurses, one pharmacist, one radiology technician, three emergency medical technicians, and three medical administrators. KDRT was type 1 FMT which could provide outpatient emergency care according to the WHO classification. KDRT lacked the capacity to provide maternal-child health care service and inpatient care, which was categorized as primary service in IASC checklist. KDRT brought various equipment for hospital operations which far exceeded type 1 FMT’s capacity. Eight gasoline generators, two blood analyzers, X-ray machine, ultrasonography, and six patient monitors were included. Essential medicines and consumables covering more than 10.000 patients were also included. The Filipino medical team was composed of twenty-one doctors, sixteen nurses, and twenty-eight logisticians. The Filipino team provided inconsistent primary and secondary health care services, but soon was overwhelmed by large patient load. Shortage of electricity and equipment like ultrasonography for prenatal care hampered their activities again. After collaboration, stable provision of most primary and secondary health care services was enabled 24 h per day. Some tertiary health care services like advanced trauma care were also ensured. Total capacity was upgraded to type 2 FMT, which could provide stable inpatient acute care, general and obstetric surgery for trauma and other conditions (Table 1, Fig. 1).

Performance of Both Teams and the Collaboration Team The Filipino team started to work on November 14, which 144

1 5 6

Workers

EMT

3 3

Pharmacist

1 1

Radiologic technician 1 1 2

Sub total

12 16 28

Supporting staff

Administrator 2 2 4

Engineer

Logistician 25 25

Sub total

Total

20 65 85

1 2 3 28

was the post-event 6th day. They provided primary care and limited inpatient care for the victims and handled about two hundred outpatients and ten inpatients per day. KDRT started to work on November 16, and collaboration became stable the next day. KDRT was mainly in charge of the outpatient and emergency departments, and the Filipino team started to focus on inpatient care and surgical procedures. Daily number of outpatients increased more than twofold after one week of collaboration, and the number of inpatients was also doubled (Fig. 2, Table 2). Necessary surgeries were performed without compromising outpatient department capacity (Table 3). 24 h operations, including the emergency department, was enabled due to enough electricity provided by the Korean gasoline generators.

DISCUSSION Sudden onset disaster (SOD) in developing countries usually generate large number of sick and injured that overwhelms the local capacity to respond, mandating international assistance. [5] The Philippines suffer damages from typhoons annually, and established National Disaster Risk Reduction&Management Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Kim et al. Disaster medical assistance in super typhoon Haiyan

DAY 10 17th, November

Type 3 (Inpatient referral care)

DAY 7 14th, November

Type 2 (Inpatient surgical emergency care) Type 1 (Outpatient emergency care) : Filipino medical team

: KDRT

: Collaboration team

Figure 1. Capacity of KDRT and Filipino team, and collaboration team.

Council (NDRRMC) in 2009, which is a working group of various government, non-government, civil and private sector organizations of the Government of the Philippines to tackle the detrimental effects of natural disasters. Although relatively well prepared to disaster among developing countries, the intensity of Super Typhoon Haiyan was beyond the responding capacity of the Philippines. Most hospitals and health care facilities in the affected regions were not working properly due to structural damage and loss of human resources. Situation was worse in the Eastern Samar area, compared to Tacloban in which many FMTs were in operation.[2]

port network was hampered during the initial period aftermath of the disaster. After the initial assessment, Korean government decided to deploy consecutive small medical teams rather than bulky field hospital unit. KDRT was the one of the FMTs in Tacloban. As of November 15, KDRT started to participate in health cluster meeting held daily in Tacloban. KDRT was assigned to St. Paulâ&#x20AC;&#x2122;s hospital to help the Filipino medical team which took over the hospital with markedly reduced function in terms of shortage of medicines, consumables, equipment, and especially electricity. At the time of arrival, the Filipino team strived to accommodate flow of victims, and especially the outpatient and emergency departments needed more resources for proper operation. KDRT took

Affected regions were scattered in several islands and trans-

100

600 507

500

80 392

417

402

361

259

232 33

173

100

34 161

304

50 40 30

177 94

12 0

213 35

185

161

286

261

241

70 60

293

300

408

402

400

200

20 10

14. Nov. 15. Nov. 16. Nov. 17. Nov. 18. Nov. 19. Nov. 20. Nov. 21. Nov. 22. Nov. Total

Out-Total Kor.-Refer

Kor.-Out

Phil.-Adm

Phil.-Out

Inpatients

Figure 2. Patient load during KDRT-Philippine cooperation. Phil.-Adm: Philippine admission; Kor.-Refer: KDRT referral; Phil.-Out: Philippine outpatient; Kor.-Out: KDRT outpatient; Out-Total: Total outpatient.

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Philippine team; †Korean team; ‡Outpatient; §Admission; //Referral to higher facility.

173 255 261 361 402 408 392 417 507 3176

161 13 241 18 232 21 8

Global humanitarian societies have been responding more vigorously in recent disasters. The Southern Asia tsunami in 2004 and the Haiti earthquake in 2010 are good examples. Nowadays, aid is coming from all over the world as soon as the disaster hits. International organizations with experience in SOD have responded rapidly, and provided essential emergency medical care in coordinated fashion.[6] Well-intentioned, but ill prepared medical teams have also responded and caused detrimental consequences to the victims.[7] Poor cooperation with the local authorities and inadequate medical services, not acceptable in the local context, have been the reasons.[8] Disaster tourists headed to the site without any proper set of knowledge and attitude have been criticized recently.[9] Many unprepared foreign medical teams have operated freely and unmonitored. Lack of coordination has led to duplication of aid in certain regions and gaps in others. Call for accountability and well-organized coordination efforts was announced, and global efforts to tackle the problem were started in the mid 2000’s.[10] Cluster approach is one of them and has been endorsed since 2005. WHO is supposed to lead the health cluster and coordinate FMTs on site.

Total

- 185 15 161 - 177 12 213 5 94 21 293 12 93 13 286 10 98 15 304 10 90 15 402 10

over the whole outpatient department, aided the emergency department, and eight gasoline generators provided enough electricity for the entire hospital so that it could operate 24 hours continuously. The Filipino team was able to focus on inpatient division, and the opening of one more operation theater allowed for surgical procedures. As a result, hospital functions were nearly normalized to pre-disaster status that served virtually all patients visited.

Subtotal

Others 3 7 6 18 27 61

Orthopedic 4 4 1 1 2 2 6 6 2 2 6 6 2 2 2 2 4 2 14 70

2 1 4 4 3 4 5 3 6 3 6 3 2 8 3 2 9 3 3 10 4 5 13 106 OBGY

30 1 60 1 66 4 5 71 0 83 71 0 87 27 3 103 35 0 100 47 0 117 37 4 159 1111 Medical

Pediatric 28 3 80 8 78 5 2 39 3 34 53 2 59 28 5 80 25 5 85 18 7 86 38 4 115 890

97 4 96 4 83 6 1 64 3 44 45 5 58 30 5 95 28 4 86 28 3 73 7 0 74 943 Surgical

O‡ A§ O A O A O R// O A O R O A O R O A O R O A O R O A O R O A O R

Phil* Phil Phil KOR† Phil KOR Phil KOR Phil KOR Phil KOR Phil KOR Phil KOR

Day 3 (16 Nov) Day 1 Day 2 (14 Nov) (15 Nov)

Table 2. Statistic of patient visits by presumptive categorization

Day 4 (17 Nov)

Day 5 (18 Nov)

Day 6 (19 Nov)

Day 7 (20 Nov)

Day 8 (21 Nov)

Day 9 (22 Nov)

Total

Kim et al. Disaster medical assistance in super typhoon Haiyan

The Korean government has been running a certification course for medical disaster relief team workers since 2009. More than one thousand health care workers have received their accreditation after completing the 3-day training course, and have been eligible for becoming a KDRT member. Among them, around a hundred have also proceeded to a 5-day advanced course, where they have been prepared to work in an austere environment with limited resources. KDRT also possesses deployable 30-bed field hospital with surgical capacity. Geography of the affected area, in this case, posed unique logistical problems, and the Korean government decided to deploy consecutive small group of medical teams rather than well-prepared field hospital. The capacity of KDRT was limited to be able to provide only outpatient emergency services, and we were arranged by WHO to cooperate with the local medical team in the local hospital. The Filipino medical team, which took over St. Paul’s hospital two days prior to KDRT’s arrival, suffered from shortage of pharmaceutics and human resources. The hospital function was restricted again, only to provide partial coverage due to shortage of electricity. KDRT replenished the shortages and assumed full charge of the outpatient and emergency departments. Soon, the hospital function was normalized, and the Filipino medical team could concentrate Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Kim et al. Disaster medical assistance in super typhoon Haiyan

Table 3. Type of surgical procedures performed in St. Paul Hospital Suture

Day 1 (14 Nov)

Day 2 Day 3 (15 Nov) (16 Nov)

Day 4 (17 Nov)

Day 5 (18 Nov)

Day 6 (19 Nov)

Day 7 (20 Nov)

Day 8 (21 Nov)

Day 9 (22 Nov)

Total

8 5 12 7 6 6 8 6 5 63

Debridement 3 2 3 6 5 4 2 2 4 31 Amputation 3 1 0 0 1 0 0 0 0 5 Cesarean section 2 3 3 1 2 0 2 0 1 14 Laparotomy 0 2 0 0 3 2 0 0 1 8 Ungiectomy 0 0 0 1 0 0 0 0 0 1 Closed reduction 0 0 0 0 1 0 1 0 0 2 External fixation 0 0 0 2 1 2 1 1 0 7 Open reduction &Internal fixation 0 0 0 0 3 2 2 0 0 7 Disarticulation 1 0 0 0 0 0 1 0 0 2 Tracheostomy 0 0 0 0 0 1 0 0 0 1 Herniotomy 0 0 0 0 0 1 0 0 0 1 Total

17 13 18 17 22 18 17 9 11 142

on more sophisticated services such as inpatient care and surgeries. Collaboration of the two teams with limited capacity supplemented each other, and the result was greater than the sum of their capacity. The limitation of our study was that it only reflected a short period of whole relief work. This situation could be further changed as collaboration continued. However, we tried to focus on the initial disaster response phase when the chaotic situation often overwhelmed, and optimal usage of scarce resource was important. Efficacy of independent short term medical missions in disasters has been argued elsewhere.[11-13] In Haiti, many limbs were amputated by the FMTs without any future plan for prosthetics and rehabilitation. After the initial massive relief mission, FMTs left and disabled survivors who were forced to produce another huge need for aftercare.[14] Many aid agencies still urge to manage their “own” medical supplies and their “own” patients, without engaging in the coordination mechanism. It can lead to wastes, duplication of services, and inefficiency.[15] FMTs that participate in disaster relief mission should clarify their capacity and limit, and should eagerly engage in formal coordinating mechanisms. Though collaborative operation with the local resources may not look better than separate one, harmonious efforts will produce more benefit to the victims.

Conclusion Disaster medical relief mission of FMTs should be cooperated Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

with a coordination mechanism. Collaboration with the local resources can be a great opportunity for both parties, and should not be overlooked in any disaster situations.

Acknowledgement The study was not sponsored.

Ethics Aapproval The study was approved by the Institutional Review committee of College of Medicine, Hallym University. Conflict of interest: None declared.

REFERENCES 1. “SitRep No. 104 Effects of Typhoon “Yolanda” (Haiyan)”. National Disaster Risk Reduction and Management Council 2014. 2. Chiu YT. Typhoon Haiyan: Philippines faces long road to recovery. Lancet 2013;382:1691-2. 3. World Health Organization. Classification and minimum standards for foreign medical teams in sudden onset disasters. Geneva: WHO; 2013. 4. Inter-Agency Standing Committee. Initial rapid assessment(IRA): Field assessment form; 2009. from:http://www.who.int/hac/network/global_ health_cluster/ira_form_v2_7_eng.pdf. 5. Emergency care in natural disasters. Views of an international seminar. WHO Chron 1980;34:96-100. 6. Devi S. Helping earthquake-hit Haiti. Lancet 2010;375:267-8. 7. Anderson MB. Do no harm: how aid can support peace – or war. London: Lynne Rienner Publishers; 1999. 8. Habibzadeh F, Yadollahie M, Kucheki M. International aid in disaster zones: help or headache? Lancet 2008;372:374. 9. Van Hoving DJ, Wallis LA, Docrat F, De Vries S. Haiti disaster tourism-

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Kim et al. Disaster medical assistance in super typhoon Haiyan -a medical shame. Prehosp Disaster Med 2010;25:201-2. 10. Humanitarian Accountability Partnership International. The Humanitarian Accountability Report 2006. Geneva: HAPInternational;2006. Available from: http://www.hapinternational.org. 11. Bajkiewicz C. Evaluating short-term missions: how can we improve? J Christ Nurs 2009;26:110-4. 12. Ver Beek K. The impact of short-term missions: a case study of home construction after hurricane Mitch. www.calvin.edu/sociology; 2005.

13. Graves M. The benefits of short-term volunteer health work in developing nations as reported by health professionals: a content analysis (master’s thesis). www.calvin.edu/academic/sociology, 1997. 14. Jobe K. Disaster relief in post-earthquake Haiti: unintended consequences of humanitarian volunteerism. Travel Med Infect Dis 2011;9:1-5. 15. Benjamin E, Bassily-Marcus AM, Babu E, Silver L, Martin ML. Principles and practice of disaster relief: lessons from Haiti. Mt Sinai J Med 2011;78:306-18.

KISA RAPOR - ÖZET OLGU SUNUMU

Süper Haiyan tayfunu felaketinde tıbbi yardım: Yerel sağlık ekipleriyle işbirliği büyük bir sinerji içinde gerçekleşmiştir Dr. Hoon Kim,1 Dr. Moo Eob Ahn,2 Dr. Kang Hyun Lee,3 Dr. Yeong Cheol Kim,4 Dr. Eun Seok Hong5 Inje Üniversitesi Ilsan Paik Hastanesi, Acil Tıp Kliniği, Goyang, Kore; Hallym Üniversitesi, Tıp Fakültesi, Acil Tıp Anabilim Dalı, Chuncheon, Kore; Yonse Üniversitesi, Wonju Tıp Fakültesi, Acil Tıp Anabilim Dalı, Wonju, Kore; 4 Ulusal Tıp Merkezi, Travma Cerrahisi Kliniği, Seoul, Kore; 5 Ulsan Üniversitesi, Acil Tıp Bölümü, Ulsan, Kore 1 2 3

AMAÇ: Sekiz Kasım 2013 tarihinde Haiyan tayfunu Filipinler’in merkezinde toprak kaymalarına neden olmuş ve bölgeyi yerle bir etmiştir. Bu felaketten hemen sonra birçok yabancı sağlık ekibi bölgeye hareket etmiştir. Kore ekibi de onlardan biriydi. GEREÇ VE YÖNTEM: Bu çalışma ilk yardım döneminde yerel sağlık ekibiyle işbirliği çabalarına odaklanarak ilk etapta ekibin deneyimlerini anlatmaktadır. BULGULAR: Kore ekibi birincil bakımı sağlayabilmiş, Filipin ekibi hasta yükünü kapsamak için yetersiz ikincil bakım hizmeti sağlamıştır. Kore ekibi hastanenin çalışması için elektrik ve değişik malzemeler sağlamakla kalmamış, acil ve poliklinikler için tıbbi personel katkısında bulunmuştur. Ortak işbirlikçi çabalarla birbirlerinin açığını doldurmuş, sonuçta büyuk bir sinerji oluşmuştur. TARTIŞMA: Yabancı sağlık ekibinin afetlerde tıbbi yardım misyonu bir koordinasyon mekanizması içinde işbirliği için çalışmalıdır. Yerel kaynaklarla işbirliği her iki taraf için büyük bir fırsat olabilir ve herhangi bir afet durumunda gözden kaçırılmamalıdır. Anahtar sözcükler: Afet; işbirliği; tayfun. Ulus Travma Acil Cerr Derg 2015;21(2):143-148

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CAS E R EP O RT

Intrathoracic dislocation of the humeral head accompanied by polytrauma: How to treat it? Jinming Chen, M.D.,1 Jin Yan, M.D.,2 Shenhua Wang, M.D.,1 Huiming Zhong, M.D.,1 Haibo Zhou, M.D.1 1

Department of Emergency Medicine, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China;

Department of Emergency Medicine, Zhejiang Hospital, Hangzhou, China

ABSTRACT High-energy trauma to the shoulder is associated with multiple injuries and is often difficult to evaluate. One of these complex traumas is the displacement of the humeral head into the thoracic cavity. This study aimed to report a patient who presented after falling three floors. Initially, the patient underwent chest drainage and thoracoscopy to remove the displaced humeral head and, subsequently, underwent delayed artificial humeral head replacement. Hemodynamic stability, systematic evaluation, removal of the humeral head, and individual shoulder reconstruction are recommended for these patients. Key words: High-energy trauma; humeral head; intrathoracic dislocation.

INTRODUCTION Fracture-dislocation of the humeral head with displacement into the chest is an extremely rare injury. It is associated with high-energy trauma to an abducted and externally rotated shoulder, and there are no uniform guidelines for its treatment. There are few cases reported in the literature involving dramatically different treatments. This study reported a case of a 51-year-old woman who suffered an intrathoracic fracture-dislocation of the proximal humerus after falling three floors.. The humeral head fragment was retrieved through a thoracoscopic approach and, subsequently, the patient was treated with artificial humeral head replacement.

CASE REPORT A 51-year-old woman presented after falling three floors. She reported severe pain in her left chest, shoulder and hip, and

Address for correspondence: Jinming Chen, M.D. Haibo Zhou, M.D., Department of Emergency Medicine, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China Tel: +86 571-8778 3777 E-mail: zhouhaibohz@163.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

complained of severe respiratory discomfort. Her Glasgow Coma Scale score was 15. She was haemodynamically unstable with a heart rate of 110 beats/min, a respiratory rate of 18 breaths/min, and a blood pressure of 76/48 mmHg. There was extensive subcutaneous emphysema on the left neck and chest, and the posterior aspects of her left ribs were tender to palpation. Her trachea was deviated to the right, and respiratory sounds were diminished on the left side. Additionally, her left shoulder and upper hemithorax were swollen. Vascular examination and sensation of the left upper limb were fully intact. Radiography and computed tomography of the chest, pelvis, left shoulder, and left elbow revealed multiple fractures of the left ribs, contusion of the bilateral lungs, fracture-dislocation of the proximal humerus, intrathoracic displacement of the humeral head (Fig. 1a, b), massive left hemopneumothorax, comminuted fracture-dislocation of the elbow, and multiple fractures of the pelvis. A thoracic drainage tube was inserted for the drainage of the left hemopneumothorax, and the patient was transfused with six units of packed red cells. Subsequently, the patient was transferred to the intensive care unit of our hospital despite being clinically and haemodynamically stable. On day three after admission, the displaced humeral head was found lying loosely in the apex of the aortic arch and retrieved from the chest cavity through thoracoscopy by a chest surgeon. Secondary survey failed to reveal the esophagus, aorta, or adjacent vital structure injuries. 149

Chen et al. Intrathoracic dislocation of the humeral head accompanied by polytrauma

(a)

(b)

Figure 1. (a) Radiography of the chest showing a proximal humerus fracture and displacement of the humeral head into the left lung field (arrow). (b) Coronal computerized tomography demonstrating the intrathoracic position of the humeral head fragment (arrow), as well as the hemopneumothorax.

Due to a concern about avascular necrosis of the humeral head, the patient did not undergo open reduction and internal fixation for this particular injury. Artificial humeral head replacement and internal fixation of the elbow were performed by an orthopedic surgeon three weeks after presentation. The postoperative course of the patient was uneventful, and the patient maintained full sensory function of the involved upper limb. In one-year follow-up, the patient demonstrated 105 degrees of forward flexion, internal rotation up to the L1 level, and external rotation of 35 degrees.

DISCUSSION Displacement of the humeral head into the thoracic cavity is a very rare injury. The cause of injury is often high-level falls or traffic accidents.[1,2] In addition to reports of dislocation of the humeral head into the ipsilateral hemithorax, there are two case reports of displacement into the contralateral hemithorax, and one case report of displacement into the retroperitoneal space.[3-5] Regarding the mechanism of dislocation, it is postulated that a sudden high-energy force was tremendous enough to both fracture the humerus and drive the dislocated humerus head to pierce the chest wall, mediastinum, and diaphragm. In addition, it might be associated with multiple rib fractures as well. There are no uniform guidelines for the treatment of this injury, and each case must be appropriately managed according to its specific features. Abellan et al.[6] presented a case of a 70-year-old woman who underwent hemiarthroplasty of the right shoulder; however, the humeral head fragment could not be removed. At the 27-month follow-up, the patient had limited mobility of her right shoulder due to axillary nerve palsy, but no pain or intrathoracic complications. Thus, the removal of the humeral head may not be necessary. Kaar et al.[7] also reported a case in which the humeral head fragment 150

was not removed from the intrathoracic space. However, some authors recommend that the humeral head should always be removed.[8,9] We suggest that the humeral head fragment should be removed. Later removal of the humeral head at six weeks was associated with extensive adhesions, and it was found to be embedded in the lung parenchyma.[10] High-energy trauma to the shoulder can lead to complex fractures and dislocations that challenge even the most experienced orthopedic surgeonâ&#x20AC;&#x2122;s reconstructive capabilities.[11] Anderson et al.[12] reported the case of a 27-year-old man following a motorcycle crash. The humeral head fragment was retrieved from the chest cavity through an extended deltopectoral approach, and then, an open reduction and internal fixation were performed. The patient achieved clinical and radiographic union of his fracture with no evidence of loss of reduction or avascular necrosis in one-year follow-up. Reattachment of the humeral head to the shaft utilizing a plate was also reported in three other patients.[13-15] Two of the patients subsequently developed avascular necrosis of the humeral head.[13,14] The remaining patient showed no evidence of avascular necrosis at the 18-month follow-up.[15] Shoulder hemiarthroplasty is the treatment of choice for shoulder fracture.[6,2,8,9] Maroney et al.[11] first presented a case of a 67-year-old woman after a fall down one flight of stairs. After emergent extrication of the intrathoracic humeral head and proximal medial shaft, the patient underwent delayed shoulder reconstruction with a reverse total shoulder arthroplasty and allograft augmentation. The reverse total shoulder arthroplasty is a viable option to treat complicated proximal humerus trauma in appropriately selected patients. Conservative management is associated with a poor outcome although it might be considered in the elderly and high-risk patients.[2] Fracture-dislocation of the humeral head with displacement into the thoracic cavity is an extremely serious injury. Patients who are hemodynamically unstable often require immediate operative intervention when the injury involves vital structures. Stable patients are systematically evaluated to reconfirm whether or not important structures are injured. Ideally, the humeral head should be removed via a minimally invasive method as soon as possible. Following the removal, the subsequent technique for shoulder reconstruction will depend on individual patient specifics. Conflict of interest: None declared.

REFERENCES 1. Patel MR, Pardee ML, Singerman RC. Intrathoracic dislocation of the head of the humerus. J Bone Joint Surg Am 1963;45:1712-4. 2. Salhiyyah K, Potter D, Sarkar PK. Fracture-dislocation of humeral head with intrathoracic displacement. Asian Cardiovasc Thorac Ann 2012;20:196-8. 3. Eberson CP, Ng T, Green A. Contralateral intrathoracic displacement of the humeral head. A case report. J Bone Joint Surg Am 2000;82:105-8.

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Chen et al. Intrathoracic dislocation of the humeral head accompanied by polytrauma 4. Abbott GF, Gaissert H, Faberman RS. Contralateral intrathoracic migration of humeral head fracture dislocation. AJR Am J Roentgenol 1999;172:1403-4. 5. Wirth MA, Jensen KL, Agarwal A, Curtis RJ, Rockwood CA Jr. Fracture-dislocation of the proximal part of the humerus with retroperitoneal displacement of the humeral head: A case report. J Bone Joint Surg Am 1997;79:763-6. 6. Abellan JF, Melendreras E, Gimenez DJ, Carrillo FJ, Ruano L, Rivkin J. Intrathoracic fracture-dislocation of the humeral head: A case report. J Orthop Surg (Hong Kong) 2010;18:254-7. 7. Kaar TK, Rice JJ, Mullan GB. Fracture-dislocation of the shoulder with intrathoracic displacement of the humeral head. Injury 1995;26:638-9. 8. Harman BD, Miller NG, Probe RA. Intrathoracic humeral head fracture-dislocation. J Orthop Trauma 2004;18:112-5. 9. Kocer B, Gulbahar G, Aktekin CN, Gunal N, Birinci B, Dural K, et al. Intrathoracic humeral head fracture-dislocation: Is removal of the humeral head necessary? Ann Thorac Surg 2007;84:1371-2.

10. Griffin NC, Temes RT, Gill IS, Rice TW. Intrathoracic displacement of a fractured humeral head. Ann Thorac Surg 2007;84:1400. 11. Maroney SS, Devinney DS. Intrathoracic fracture-dislocation of the proximal humerus treated with reverse total shoulder arthroplasty. Orthopedics 2009;32:924. 12. Anderson M, Rose P, Jacofsky DJ, Torchia ME, Dahm DL.Intrathoracic fracture- dislocation of the proximal humerus: A case report and report of a new surgical technique. J Trauma 2007;63:920-3. 13. Hardcastle PH, Fisher TR. Intrathoracic displacement of the humeral head with fracture of the surgical neck. Injury 1981;12:313–5. 14. Wirth MA, Jensen KL, Agarwal A, Curtis RJ, Rockwood CA Jr. Fracture-dislocation of the proximal part of the humerus with retroperitoneal displacement of the humeral head: A case report. J Bone Joint Surg Am 1997;79:763-6. 15. Argekar HG , Dharap S, Kale A, Ghag G. Intrathoracic dislocation of humeral head: A case report. J Maharashtra Orthopaedic Association 2012;7:18-21.

OLGU SUNUMU - ÖZET

Politravmanın eşlik ettiği humerus başının intratorasik dislokasyonu: Nasıl tedavi edilir? Dr. Jinming Chen,1 Dr. Jin Yan,2 Dr. Shenhua Wang,1 Dr. Huiming Zhong,1 Dr. Haibo Zhou1 1 2

Zhejiang Üniversitesi Tıp Fakültesi, İkinci Bağlı Hastanesi, Acil Tıp Kliniği, Hangzhou, Çin; Zhejiang Hastanesi, Acil Tıp Kliniği, Hangzhou, Çin

Omuzun yüksek enerjili travmaları çoklu yaralanmalarla ilişkili olduğundan değerlendirmesi sıklıkla zordur. Bu kompleks travmalardan biri de humerus başının toraks boşluğu içine deplasmanıdır. Üçüncü kattan düştükten sonra başvuran bir hastayı tanımlamaktayız. İlk önce deplase olmuş humerus başını çıkartmak için kadın hastaya toraks drenajı ve torakoskopi yapılmış, daha sonra hastaya geç dönemde yapay humerus başı replasmanı uygulanmıştır. Bu hastalar için hemodinamik stabilite, sistematik değerlendirme, humerus başının çıkartılması ve bireye uygun omuz rekonstrüksiyonu önerilmektedir. Anahtar sözcükler: Humerus başı; intratorasik dislokasyon; yüksek enerjili travma. Ulus Travma Acil Cerrahi Derg 2015;21(2):149-151

doi: 10.5505/tjtes.2015.72566

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Severe thoracic impalement injury: Survival in a case with delayed surgical definitive care Sorinel Lunca, M.D., Corneliu Morosanu, M.D., Ovidiu Alexa, M.D., Mihaela Pertea, M.D. Department of Surgery, University of Medicine and Pharmacology “Gr. T. Popa” Iasi, Emergency Hospital “Sf. Ioan”, Iasi, Romania

ABSTRACT Impalement injuries are rare and among the most spectacular and dramatic traumatic lesions. The survival of a patient with a thoracic impalement injury is an extremely rare event. The objective of this study was to present the case of a 24-year-old male patient with a severe thoracic impalement injury successfully treated despite his late arrival in our hospital. A log in 12 cm diameter penetrated his right thorax producing injuries of the right main bronchus, right pulmonary lobe, right subclavian artery as well as extensive parietal lesions. Definitive surgical repair of these lesions was performed more than seven hours after trauma. The management principles contributing to the successful outcome that we would like to emphasize are: rapid transportation and reaction of the trauma team, minimal manipulation of the impaling object, removal of the log as one piece under direct vision in the operating room, ventilatory support, extensive debridement, and lavage associated with appropriate antibiotherapy. Key words: Foreign body; impalement injury; thoracic injury; thoracotomy.

INTRODUCTION Impalement injury is an uncommon form of trauma encountered rarely in a surgeon’s career. These injuries are spectacular and dramatic, and due to the multiple lesions they may associate, they represent a challenge even for an experienced surgeon. The literature presents only few survival cases, the vast majority being unfortunately fatal.[1-8] One important issue for patient survival is rapid transportation of the victim to the appropriate hospital. A rapid and prompt reaction of the trauma team and adherence to a structured management protocol are also essential. In this report, we presented the case of a young male with severe thoracic impalement injury successfully treated despite his late arrival. Management principles were also discussed.

CASE REPORT A 24-year-old male patient was involved in a car accident. He Address for correspondence: Sorinel Lunca, M.D. Regional Institute of Oncology, No.2-4 General Berthelot Street Iasi - Romania Tel: 0040744437305 E-mail: sdlunca@yahoo.com Qucik Response Code

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was on the backseat of the car when the vehicle was engaged in collision with a cart full of very long logs. One log penetrated the windshield of the car, and the patient sustained an impalement injury of the right thorax. The ambulance arrived in about 15 minutes. The log, measuring about 12 centimeters in diameter and 7 meters in length, was cut with a chain saw in the proximity of the thoracic wall and the patient was transported to a regional hospital, 40 km away, where he arrived 2 hours after trauma. During transportation, the patient was hemodynamically stable, with a respiratory rate of 29 breaths per minute and fully aware. This small hospital was not able to deal with such a complicated case and immediately the patient was transported to the county hospital, 20 km away. He became dyspnoeic and a nonselective orotracheal intubation had to be performed. A central venous catheter was also inserted. At this moment, the surgeon decided that the county hospital did not have the experience and the facilities to treat such a case, and sent the patient to the university hospital, 140 km away. During transportation, cardiac arrest occurred which was successfully managed. He arrived in our hospital more than 7 hours after the accident. Upon arrival, the patient was intubated and hemodynamically stable (blood pressure, 70/40 mmHg; heart rate, 90 beats per minute; and urine output of 1 litre for a 3-hour period). Physical examination revealed a right thoracic impalement wound with foreign body retention (log), edema and cyanosis of the right arm and the right hemi-face (Fig. 1). Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Lunca et al. Severe thoracic impalement injury

(a)

(b)

Figure 1. Right thoracic impalement injury: anterior, posterior and lateral aspect.

The patient was immediately transported in the operating room. A generous right lateral thoracotomy was performed in the 4th intercostal, joining the entry and exit places of the impaled log. The log was carefully extracted as one piece (Fig. 2). The extraction raised difficulties due to the numerous small wood branches present on the surface of the log. No massive hemorrhage was noted. An inventory of intrathoracic lesions revealed an incomplete right main bronchus rupture, extensive pulmonary dilaceration and partial (adventitial) rupture of the right subclavian artery (Fig. 3). The opening in the right main bronchus was immediately occluded, allowing the arterial oxygen saturation to rise from 50% to 95%, followed by suture of the bronchus. An atypical partial superior right pulmonary lobe resection was performed in order to address the pulmonary dilacerations and to achieve correct hemostasis and aerostasis. Right brachiocephalic and right subclavian veins appeared compressed but without dilacerations of the vessels. The small adventitial arterial subclavian lesion was sutured. Multiple multifocal rib fractures (rib 1 to 8) and a fracture of the internal third of the right clavicle were also present. All devitalized tissue, foreign bodies (large and numerous fragments of leather and textile material) and bone fragments were removed. The log entry and exit sites were extensively irrigated. The thoracic wall was then reconstructed using autologous structures and two drains were positioned in the pleural cavity (Fig. 4a). Postoperatively, the patient maintained intubated and mechanically ventilated. Cardiac arrest occurred five hours postoperatively, with successful resuscitation. For the next five days, the patient maintained intubated with internal pneumatic stabilization of the thoracic wall. On the 6th postoperaUlus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Figure 2. (a) Extensive thoracotomy joining the entrance and exit sites, the impaling object is fully exposed and extracted as one piece; (b) the log, 12 cm in diameter, with a large fragment of patients leather jacket.

tive day, the patient was extubated, and followed next day by oral feeding and ambulation. During hospitalization, the patient developed bronchopneumonia which responded well to broad spectrum antibiotics. Entry and exit orifices became infected and required a series of local excisions, dressing and secondary suture. We also noted osteitis associated with the open fractures of the 3rd, 4th and 5th ribs that required partial resections. The patient was discharged on the 40th postoperative day. Two months after the operation, the patient presented limitation of abduction and rotation of the right upper

Figure 3. Intraoperative aspect - 1.5 cm in diameter dilacerations is present in the right main bronchus (black arrow).

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(b)

Figure 4. (a) Final aspect of the operation (b) and patient 2 months post-operatively.

limb and thoracic scoliosis but without impact on his quality of daily life (Fig. 4b).

DISCUSSION Impalement injuries are fortunately rare nowadays, and few surgeons have the â&#x20AC;&#x153;privilegeâ&#x20AC;? to treat such an injury. Impalement injuries usually occur in motor vehicle and labor accidents.[1,2,5-8] Eachempati et al. have divided impalement injuries into two types:[6] type I injuries result from impalement of the body with an immobile object as it happens in collisions with protruding objects or in case of falls; type II injuries involve a mobile object intentionally manipulated that is lodged in a stationary body and are frequently encountered in children, in the pelvic, anorectal and vaginal regions as a result of sexual perversion or rape.[9] Virtually, any region of the body may be subject to an impalement injury.[6,9-11] Impalement injuries of the thoracic cavity are uncommon, but dramatic when they occur.[12] Thoracic impalement accidents on the right side are more frequently encountered because on the left side the presence of the heart makes survival exceptional, with few survivals cases reported in the literature.[1,4,5,7,8,13-15] If the patient survives, this is because the foreign object missed vital internal structures, especially the great vessels or heart.[4,15] This was also the case of our patient in whom vital structures were spared by the injury. Critical decisions and actions during prehospital and operative stages are essential in improving survival rate. Unfortunately, impalement injuries are frequently fatal, few patients arriving alive at the hospital. Therefore, transportation of the patient must be as expeditious as possible. However, first aid on-site must be extremely qualified and rapid. On-site, paramedics and physicians must regard patient situation as a major trauma and adhere to the trauma protocol recommended by the American Association for the Surgery of Trauma.[16] 154

Special attention must be paid to the injured region, and by all means the impalement object must not be mobilized or removed.[1,3-16] All authors recognize the tamponade effect of the impaling object. Any dislodgement of the impaling object in the field may result in cataclysmic hemorrhage impossible to control. Kelly et al. have reported the case of a 15-yearold boy impaled upon a gate through the anterior abdominal region, who was lifted off the gate by a friend.[17] When the ambulance arrived, he was profoundly shocked due to abdominal life-threatening hemorrhage. The patient should be mobilized, shifted and examined as gently as possible, avoiding any mobilization of the impaled object. Reduction of the impaling object to a manageable size is recommended so that the patient can be transported easier but without the risk of losing the tamponade effect.[18,19] A level I trauma or teaching hospital is probably the best solution for these patients. Unfortunately for our patient, he initially reached two regional hospitals without medical experience and facilities to treat such injuries, including lack of a thoracic and vascular surgeon, lack of a blood bank, and absence of cardiopulmonary bypass. This was the reason why the patient arrived to our hospital more than 7 hours after the accident. This delay, which resulted in the alteration of the general status of the patient, caused the patient to require intubation and ventilation, put the patient in cardiac arrest during transportation, and led to hypotension at arrival. This is probably one of the weaknesses of our medical system. In our hospital, the case was operated by a general surgeon qualified in trauma emergencies, thoracic and vascular surgery. These types of injuries remain a general surgical problem, because the general surgeon is the person on the spot. Moreover, we consider that every general surgeon should be qualified and able to deal with such complex cases. We consider that in the very moment the patient arrives at the hospital, he should be immediately transported in the operating room. Preoperative imaging is rarely possible, esUlus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Lunca et al. Severe thoracic impalement injury

pecially in thoracic involvement. Chui et al.[13] have reported a 24-year-old man surviving impalement injury of the left thorax with a steel rod, in whom the precise nature and extent of the injury were determined by computer tomography and aortography. In the case described above, there were no attempts for complex exploration due to his severe condition on arrival. The position of the patient on the surgery table may be difficult, especially when a posterior impaling object is present. For thoracic impalement, a decubitus lateralis position is the rule, but this position may prove difficult for the anesthetist for selective intubation of the selected lung. Our patient arrived already intubated, but not selectively, and no attempt was made to switch to a selective intubation due to its position on the table. As a principle, the incision must join the entrance and exit sites. The surgeon may use conventional or unconventional incisions, the aim being to gain the best possible access in order to remove the object and to control any possible hemorrhage. One or more incisions may be used to remove the impaling object. In a thoracoabdominal impalement case, Thomson et al.[1] have performed a left thoracoabdominal incision followed by a right anterolateral thoracotomy. The impaling object must be removed as one piece and under direct vision. A vascular control should be achieved whenever possible. In the thoracic cavity, vascular control is often not possible in advance so the surgeon must be prepared to perform rapid hemostasis after the impaling object is removed. When a major vascular lesion is suspected, cardiopulmonary bypass should be considered.[20,21] Shimokawa et al.[20] have reported the successful removal of a thoracic impaling bolt 7 mm in diameter involving the right ventricle and the esophagus under cardiopulmonary bypass. Generally, impaling objects are wooden materials (logs, planks, branches) or metal bars and are less than 5 cm in diameter. Objects of greater dimension impaled in the thorax produce major visceral destructions, but also important parietal lesions. In the situation we described, the log was 12 cm in diameter and produced major damages to the chest wall. Reconstruction of the thoracic wall is sometimes very challenging when a large amount of thoracic wall is lost. Internal pneumatic stabilization should be considered in patients with loss of parietal tissue, flail chest, and extensive thoracotomy. Pathogen contamination of the region must be regarded as a very serious problem. Wooden fragments, soil particles, clothes, and bone fragments are usually present in the wound. Extensive debridement and lavage is mandatory. Postoperative care should control infection at any level. Patients are at risk for bronchopneumonia, soft tissue infection, and osteitis as was the case of our patient. Broad spectrum antibiotics should be administrated.[7,14] Impalement injuries must be regarded as major trauma, and Advanced Trauma Life Support principle should be applied. Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

The impaling object must not be removed in the field. The rapid transport of the patient to a qualified hospital is critical, and emergency operation is mandatory. The impaling object must be removed under direct vision and as one piece, thus, an incision joining the entry and exit sites is advisable. Hemorrhage represents a major risk after removing the object so all means should be employed in order to achieve hemostasis, and cardiopulmonary bypass should be considered. Extensive debridement and lavage are mandatory and broad spectrum antibiotics are advisable. Reconstruction of the thoracic wall may prove difficult, and internal pneumatic stabilization may be considered to stabilize parietal lesions. Conflict of interest: None declared.

REFERENCES 1 Thomson BN, Knight SR. Bilateral thoracoabdominal impalement: avoiding pitfalls in the management of impalement injuries. J Trauma 2000;49:1135-7. 2. Missliwetz J. Fatal impalement injuries after falls at construction sites. Am J Forensic Med Pathol 1995;16:81-3. 3. Horowitz MD, Dove DB, Eismont FJ, Green BA. Impalement injuries. J Trauma 1985;25:914-6. 4. Robicsek F, Daugherty HK, Stansfield AV. Massive chest trauma due to impalement. J Thorac Cardiovasc Surg 1984;87:634-6. 5. Darbari A, Tandon S, Singh AK. Thoracic impalement injuries. IJTCVS 2005;21:229-31. 6. Eachempati SR, Barie PS, Reed RL 2nd. Survival after transabdominal impalement from a construction injury: a review of the management of impalement injuries. J Trauma 1999;47:864-6. 7. Hyde MR, Schmidt CA, Jacobson JG, Vyhmeister EE, Laughlin LL. Impalement injuries to the thorax as a result of motor vehicle accidents. Ann Thorac Surg 1987;43:189-90. 8. Shikata H, Tsuchishima S, Sakamoto S, Nagayoshi Y, Shono S, Nishizawa H, et al. Recovery of an impalement and transfixion chest injury by a reinforced steel bar. Ann Thorac Cardiovasc Surg 2001;7:304-6. 9. Orr CJ, Clark MA, Hawley DA, Pless JE, Tate LR, Fardal PM. Fatal anorectal injuries: a series of four cases. J Forensic Sci 1995;40:219-21. 10. Rose EH. Massive foreign body impalement of the shoulder and chest wall. Ann Plast Surg 1990;24:451-4. 11. Carragher AM, Sulaiman SK, Panesar KJ. Scroto-abdominal impalement injury in a skateboard rider. J Emerg Med 1990;8:419-21. 12. Vaslef SN, Dragelin JB, Takla MW, Saliba EJ Jr. Multiple impalement with survival. Am J Emerg Med 1997;15:70-2. 13. Chui WH, Cheung DL, Chiu SW, Lee WT, He GW. A non-fatal impalement injury of the thorax. J R Coll Surg Edinb 1998;43:419-21. 14. Romero LH, Nagamia HF, Lefemine AA, Foster ED, Wysocki JP, Berger RL. Massive impalement wound of the chest. A case report. J Thorac Cardiovasc Surg 1978;75:832-5. 15. Oâ&#x20AC;&#x2122;Leary ST, Waterworth P, Fountain SW. Multiple impalement injury-a remarkable survival. Injury 1996;27:589-90. 16. 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. 17. Kelly IP, Attwood SE, Quilan W, Fox MJ. The management of impalement injury. Injury 1995;26:191-3. 18. Ketterhagen JP, Wassermann DH. Impalement injuries: the preferred approach. J Trauma 1983;23:258-9. 19. Shagoury C, Fazio J. Case review. A 23-year-old man with an unusual impalement injury. J Emerg Nurs 1990;16:379-81.

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21. Endara SA, Xabregas AA, Butler CS, Zonta MJ, Avramovic J. Major mediastinal injury from crossbow bolt. Ann Thorac Surg 2001;72:2106-7.

OLGU SUNUMU - ÖZET

Ağır toraks penetran yaralanması: Kesin cerrahi tedavisi gecikmiş olguda sağkalım Dr. Sorinel Lunca, Dr. Corneliu Morosanu, Dr. Ovidiu Alexa, Dr. Mihaela Pertea Grigore T. Popa Üniversitesi Tıp ve Eczacılık Fakültesi, Sf. Ioan Acil Hastanesi, Romanya Romanya

Kazık şeklindeki cisimlerin batmalarına bağlı penetran yaralanmalar seyrek görülen, en dikkat çekici ve dramatik travmatik lezyonlardan biridir. Toraksın penetran yaralanması sonucu hastanın sağkalması son derece nadir görülen bir olaydır. Yirmi dört yaşında, göğüs kafesine kazık batması sonucu ağır derecede yaralanmış, hastanemize geç dönemde başvurmasına rağmen başarıyla tedavi edilmiş bir olguyu sunmaktayız. On iki santimetre çapında bir kütük göğüs kafesinin sağ tarafına saplanmış, sağ ana bronş, sağ akciğer lobu, sağ subklavyen arteri yaralamış, yaygın pariyetal lezyonlara neden olmuştu. Bu lezyonların kesin cerrahi onarımı travmadan yedi saat sonra yapılmıştı. Vurgulamak isteyeceğimiz, başarılı sonuçlara katkıda bulunan tedavi ilkeleri arasında travma ekibinin hızla olay yerine ulaşımı ve olaya müdahalesi, batan cismin minimal manipülasyonu, ameliyathanede doğrudan görüş altında batan cismin tek parça halinde çıkartılması, solunum desteği, yaygın debridman ve lavajla birlikte uygun antibiyoterapi yer almaktadır. Anahtar sözcükler: Penetran yaralanmalar; torakotomi; toraks yaralanması; yabancı cisim. Ulus Travma Acil Cerrahi Derg 2015;21(2):152-156

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CAS E R EP O RT

Bouveret syndrome: A fatal diagnostic dilemma of gastric outlet obstruction Fazıl Sağlam, M.D., Emre Sivrikoz, M.D., Ali Alemdar, M.D., Sedat Kamalı, M.D., Ufuk Arslan, M.D., Hakan Güven, M.D. Department of General Surgery, Okmeydani Training and Research Hospital, Istanbul

ABSTRACT The patient presented in this study was a 54-year-old woman complaining of nausea and vomiting, onset preceding four days, with no significant past medical history and an unremarkable surgical history. The patient was afebrile and hypertensive. Physical examination revealed a non-tender abdomen, and initial laboratory evaluation revealed elevated blood glucose level, ketonuria, leukocytosis, elevated C-reactive protein, gamma glutamyl transferase, lactate dehydrogenase, and total bilirubin. The patient was admitted to the internal medicine ward due to new onset of diabetes mellitus. Due to persistent nausea and vomiting, gastroscopy revealed a healed duodenal ulcer, and abdominal ultrasonography revealed cholelithiasis. The medical condition of the patient deteriorated further in the internal medicine ward, with impending hypotension, tachycardia, leukocytosis, and acute renal failure, and she was admitted to the intensive care unit due to septic shock. A computerized tomography was obtained, which revealed an impacted gallstone in the distal duodenum.The patient was taken to the operating room.The gallstone was encountered in proximal jejunum immediately distal to the ligament of Treitz. A longitudinal enterotomy was made, and the stone was extracted. Her drains were cleared on postoperative day 5, and gastrointestinal function returned to normal. Unfortunately, the patient developed an overwhelming sepsis due to bacteremia and fungemia, and died on post-operative day 19. Key words: Bouveret syndrome; diabetes; gastric outlet obstruction.

INTRODUCTION

CASE REPORT

Bouveret syndrome was first described by Leon Bouveret in 1896.[1] The pathophysiology consists of a gallstone passing through a cholecystoduodenal fistula into the duodenal lumen, causing a gastric outlet obstruction. Prominent symptoms include abdominal pain, nausea and vomiting. Endoscopic findings suggestive of this syndrome include a dilated stomach containing digested food and a hard non-fleshy mass at the obstruction.[2] Rigler’s triad was described to characterize Bouveret syndrome: pneumobilia, obstruction, ectopic gallstones.[3]

The patient presented in this study was a 54-year-old woman with no significant past medical history and an unremarkable surgical history, complaining about nausea and vomiting, onset preceding 4 days. The patient was afebrile, and hypertensive (190/100 mmHg), and her physical examination revealed a non-tender abdomen. Her initial laboratory evaluation revealed elevated blood glucose level (379 mg/dl), ketonuria, leukocytosis (14.230 / mm), elevated C-reactive protein (50.2 mg/L), gamma glutamyl transferase (83 U/L), lactate dehydrogenase (831 U/L), and total bilirubin (1.68 mg/dl). She was admitted from the emergency department to the internal medicine ward due to the diagnosis of new onset diabetes mellitus.

Address for correspondence: Fazıl Sağlam, M.D. Okmeydanı Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Kaptan Paşa Mahallesi, Şişli, 34384 İstanbul, Turkey Tel: +90 212 - 221 77 77 E-mail: fzlsaglam@yahoo.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2

Upon admission, intravenous insulin infusion was started and her blood glucose was regulated to upper-normal limits. The patient underwent routine evaluation for new onset of diabetes mellitus including echocardiography (left ventricular hypertrophy), ophthalmoscopy (unremarkable for retinopathy), and electromyography (unremarkable for polyneuropathy). Due to persistent nausea and vomiting, a gastroscopy was 157

Saglam et al. Bouveret syndrome

with a proximal gastrointestinal obstruction. After stabilizing her vitals in the ICU, the patient was taken to the operating room. Following a median laparotomy, the ligament of Treitz was exposed and the gallstone was encountered in proximal jejunum immediately distal to the ligament of Treitz (Fig. 2a). A longitudinal enterotomy was made and the stone was extracted (Fig. 2b). Enterotomy was closed transversely. The patient was taken back to the ICU. Her drains were cleared on postoperative day 5, and gastrointestinal function returned to normal. Unfortunately, she developed an overwhelming sepsis due to bacteremia and fungemia, and died on post-operative day 19.

DISCUSSION Figure 1. CT scan showing impacted gallstone.

undertaken, and a healed duodenal ulcer was encountered. An abdominal ultrasonography revealed cholelithiasis, and an elective cholecystectomy was planned. However, her medical condition deteriorated further in the internal medicine ward, with impending hypotension (80/40 mmHg), tachycardia (140/min), leukocytosis (19.000/mm), and her creatinine level increased to 3.62 mg/dl (initially normal). She was admitted to the intensive care unit (ICU) due to septic shock, and intravenous dopamine infusion was started. Upon admission to the ICU, a computerized tomography (CT) was obtained, which revealed an impacted gallstone in the distal duodenum (Fig. 1). General surgery was consulted for the first time, and decision for an operative intervention was made due to her unstable medical condition associated

(a)

Gallstone ileus is encountered in 0.3-0.4% of all cholelithiasis cases, with a preponderance of advanced age. Terminal ileum is the most affected (50-90%) site for impaction, which results in a mechanical small bowel obstruction.[4] Less commonly, a proximal obstruction at jejunum and ileum may occur (20-40%), which essentially presents as a gastric outlet obstruction. Obstructive jaundice may accompany the clinical picture depending on the level of obstruction close to the ampulla of Vater. Given the lack of substantial expertise on such a rare disease, there is controversy regarding the management of gallbladder at the time of surgery. Surgery should be carried out in a goal directed fashion, where the mainstay of treatment is relief of the offending obstruction.[5] Cholecystectomy with or without fistula repair should carefully be weighed against a medically deprived patient requiring a rapid alleviation of obstruction rather than an expeditious surgery. The present

(b)

Figure 2. (a) Exposure of impacted gallstone. (b) Enterotomy and gallstone extraction.

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Saglam et al. Bouveret syndrome

not arrest the development of overwhelming sepsis which led to the patient’s demise. Bouveret Syndrome is a rare entity, which should be kept in mind when evaluating a gastric outlet obstruction associated with chronic cholelithiasis, especially when gastro-duodenoscopy reveals normal findings.

case emphasized the need for correct diagnosis in a timely fashion. Since the patient, cohort harboring this syndrome, rapidly reached the extremis due to excessive electrolyte imbalance and possible obstructive jaundice, the diagnosis depended upon meticulous suspicion. It should also be noted that the surgical procedure is not skill demanding, but early intervention is the only hope for cure. In addition, there is evidence in the literature documenting spontaneous closure of fistulae following endoscopic gallstone retrieval.[6]

REFERENCES

As reported in this unfortunate case, surgery was delayed due to diagnostic confusion, and an irreversible cascade not amenable to surgical intervention developed. Nausea and vomiting comprised the cardinal presenting symptoms of the patient, and a gastro-duodenoscopy was performed revealing a healed duodenal ulcer during her work-up in the internal medicine ward. The third and fourth portions of the duodenum were not routinely visualized during gastro-duodenoscopy. Since the lesion/stone was not within the reach, an endoscopic treatment was not deemed feasible during the surgical consultation. Moreover, the overall medical condition of the patient was unstable, which was a clear indication for urgent laparotomy. The patient survived the operation, yet surgery could

1. Bouveret L. Stenose du pylore adherent a la vesicule [French]. Revue Medicale (Paris) 1896;16:1000-11. 2. Cappell MS, Davis M. Characterization of Bouveret’s syndrome: a comprehensive review of 128 cases. Am J Gastroenterol 2006;101:2139-46. 3. Brennan GB, Rosenberg RD, Arora S. Bouveret syndrome. Radiographics 2004;24:1171-75. 4. Mavroeidis VK, Matthioudakis DI, Economou NK, Karanikas ID. Bouveret syndrome-the rarest variant of gallstone ileus: a case report and literature review. Case Rep Surg 2013;2013:839370. 5. Lowe AS, Stephenson S, Kay CL, May J. Duodenal obstruction by gallstones (Bouveret’s syndrome): a review of the literature. Endoscopy 2005;37:82-7. 6. Englert ZP, Love K, Marilley MD, Bower CE. Bouveret syndrome: gallstone ileus of the duodenum. Surg Laparosc Endosc Percutan Tech 2012;22:e301-3.

Conflict of interest: None declared.

OLGU SUNUMU - ÖZET

Bouveret sendromu: Mide çıkış yolu obstrüksiyonunda ölümcül bir tanısal ikilem Dr. Fazıl Sağlam, Dr. Emre Sivrikoz, Dr. Ali Alemdar, Dr. Sedat Kamalı, Dr. Ufuk Arslan, Dr. Hakan Güven Okmeydanı Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

Bilinen ek hastalığı ve geçirilmiş ameliyat öyküsü olmayan 54 yaşında kadın hasta dört gündür devam eden bulantı ve kusma yakınmasıyla acil servise başvurdu. Fizik muayenede karında hassasiyet saptanmadı. Başvurusunda yapılan laboratuvar incelemelerinde yüksek kan şekeri, ketonüri, lökositoz, yüksek C-reaktif protein, gama-glutamil-transferaz, laktat dehidrogenaz ve total bilirubin saptandı. Hasta yeni başlangıç diabetes mellitus tanısıyla dahiliye servisine yatırıldı ve rutin incelemelerine başlandı. Devam eden bulantı ve kusma nedeniyle yapılan gastroskopide iyileşmiş duodenal ülser saptandı. Karın ultrasonografisinde kolelityazis saptandı. Dahiliye servisinde incelemeleri devam etmekteyken hastanın tıbbi durumu giderek kötüleşti. Hipotansiyon, taşikardi, lökositoz ve akut böbrek yetersizliği gelişen hasta septik şok tanısıyla yoğun bakım ünitesine alınarak intravenöz dopamin infüzyonu başlandı. Çekilen bilgisayarlı tomografide distal duodenumda sıkışmış görünümde bir safra taşı saptandı. YBU’da vital bulguları stabilize edilen hasta ameliyata alındı. Laparotomiyi takiben Treitz ligamanı distalinde proksimal jejunumda safra taşı görüldü. Longitudinal enterotomi ile taş çıkarıldı. Hasta tekrar YBU’ya alındı. Ameliyat sonrası beşinci günde drenleri alınan hastanın gastrointestinal fonksiyonları normale döndü. Takiplerinde bakteriyemi ve fungemiye sekonder sepsis gelişen hasta ameliyat sonrası 19. günde kaybedildi. Anahtar sözcükler: Bouveret sendromu; diyabet; mide çıkış yolu obstrüksiyonu. Ulus Travma Acil Cerrahi Derg 2015;21(2):157-159

doi: 10.5505/tjtes.2015.62558

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Nadir bir ince bağırsak tıkanıklık nedeni: Spontan strangüle transomental fıtık Dr. Birol Ağca, Dr. Aziz Bora Karip, Dr. Yalın İşcan, Dr. Yetkin Özcabı, Dr. Mehmet Mahir Fersahoğlu, Dr. Kemal Memişoğlu Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

ÖZET İnce bağırsak tıkanıklığına neden olabilen internal fıtıklar nadir görülür. Öyküsünde travma ya da cerrahi bir operasyon olmadan da görülebilen transomental fıtıklar daha da nadirdir. Seksen beş yaşında ameliyat ya da travma öyküsü bulunmayan erkek hasta şiddetli karın ağrısı ve kusma nedeniyle acil polikliniğimize başvurdu. Yapılan fiziksel incelemelerde ileus tanısı konularak ameliyata alınan olguda transomental fıtığa bağlı strangülasyona uğramış ileum ansları tespit edildi. Rezeksiyon-anastomoz uygulandı ve omental defekt parsiyel omentektomi ile bozuldu. Transomental fıtıklar çok nadir görülseler de hikayesinde ameliyat ve travma saptanmayan olgularda mekanik bağırsak tıkanıklığı ayırıcı tanısında düşünülmelidir. Anahtar sözcükler: İnce bağırsak tıkanıklığı; internal fıtık; transomental fıtık.

GİRİŞ İnternal fıtıklara bağlı ince bağırsak tıkanıklıklarının insidansı %0.2-0.9 olarak bildirilmektedir.[1] Karın içerisinde, değişik anatomik bölgelerde oluşabilen internal fıtıklar sıklıkla; paraduodenal (%53), periçekal (%13), foramen Winslow (%8), transmezenterik (%2) ve transomental (%1) alanlarda görülmektedir.[2] Omental hernilerde çok nadir de olsa hastalarda ameliyat veya travma hikayesi yoktur. Omental defektlerin oluşumunda travma, enflamasyon ve yaşa bağlı gelişen atrofiler sorumlu tutulmaktadır.[3] Bu çalışmada hikayesinde ameliyat ve travma hikayesi olmayan, ince bağırsak tıkanıklığı ve nekrozuyla seyreden bir internal omental herni olgusu sunulmuştur.

OLGU SUNUMU Şiddetli karın ağrısı, bulantı ve kusma şikâyetleri ile acil polikliniğimize başvuran 85 yaşındaki erkek hastanın son iki gündür İletişim adresi: Dr. Birol Ağca, Barbaros Mahallesi Uphill Court Sit. A8, D14, Ataşehir, İstanbul Tel: +90 216 - 578 30 00 E-mail: birolagca@yahoo.com Qucik Response Code

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gaz-gaita çıkışı yoktu. Hasta fekaloid karakterde kusmaktaydı. Özgeçmişinde; kalp yetersizliği, hipertansiyon, diabetes mellitus ve kronik obstrüktif akciğer hastalığı (KOAH) olan hasta KOAH nedeniyle bir hafta önce göğüs hastalıkları yoğun bakım ünitesinde yatırılmış ve ev yardımlı mekanik ventilasyon desteğiyle taburcu edilmişti. Yapılan fizik muayenede karında yaygın hassasiyet ve sol üst kadranda ele gelen kitle tespit edildi. Laboratuvar incelemelerinde; lökosit 24.000/mm3, hemoglobin 10.4 gr/dl, hemotokrit %31.7, BUN 53 mg/dl, kreatinin 1.65 mg/dl, glukoz 167 mg/dl olarak saptandı. Ayakta direkt batın grafisinde (ADBG) ince bağırsak tipi hava-sıvı seviyeleri saptanan hastanın, intravenöz kontrastlı batın tomografisinde (BT) ise sol üst kadranda mezenteri ile birbiri üzerine dönmüş ince bağırsak segmentleri ve karında yaygın serbest sıvı olduğu izlendi (Şekil 1a-c). Bu bulgularla olgu, akut mekanik bağırsak tıkanıklığı ön tanısı ile ameliyata alındı. Göbek üstü ve kısmi göbek altı orta hat kesiyle batına girildi. Yapılan incelemede batın içerisinde yaygın defibrine kana ve proksimal ince bağırsaklarda dilatasyona ek olarak, ileo-çekal kapağa 10 cm mesafede 50 cm ileum ansının mezenteri ile birlikte sol alt kadranda omental bir pencereden girip torsiyone olduğu ve bu segmentde nekroz oluştuğu tespit edildi (Şekil 2a, b). Makroskopik perforasyon alanı saptanmayan sıkışmış bağırsak ansları omental açıklıktan redükte edildi. Nekroze bağırsak segmenti rezeke edildi ve ileum uçlarına, iki adet 45 mm’lik kesici kapatıcı zımba (Covidien LLC, Mansfield, MA, USA) yardımı ile yan-yana anastomoz yapıldı. Tüm periton içi alanların bol serum fizyolojikle yıkanmasını takiben, batın katları anatomik planda kapatıldı. Ameliyat sonrası dönemde solunum ve kalp sorunları nedeniyle iki gün cerrahi yoğun bakım ünitesinde takip edilen hasta dokuzuncu gün taburcu edildi. Ulus Travma Acil Cerrahi Derg, Mart 2015, Cilt. 21, Sayı. 2

Ağca ve ark. Spontan strangüle transomental fıtık

(a)

(b)

(c)

Şekil 1. (a) Ayakta direkt karın grafisinde ince bağırsak tipi hava sıvı seviyeleri görülmekte. (b, c) Bilgisayarlı tomografide distal ileal anslardan başlayarak ince bağırsak anslarında dilatasyon ve karında sıvı.

TARTIŞMA Mekanik bağırsak tıkanıklığı tanısıyla ameliyata alınan olgularda, altta yatan sebep %0.2-0.9 internal fıtıklar olmaktadır.[1] Bunların da %1’i omental defektlere bağlı gelişir. Transomental fıtıklar omentum majus veya minustan kaynaklanabilir.[4] Bu tip fıtıklar çocukluk yaşlarında daha çok büyük omentum ve gastrokolik ligamandaki doğumsal defektlerden gelişir.[5] Klinik bulguların karakterini, fıtıklaşan bağırsak segmenti ve defektin çapı belirlemektedir. Yetişkinlerde internal fıtıklar daha çok gastrik bypass ve Rouxen-Y anastomozlardan kaynaklanan mezenterik açıklıklara bağlı bildirilmiştir.[6] Daha nadir olarak peritoneal enflamasyon ve travma suçlanmaktadır.[2] Öyküsünde travma veya enflamasyon bulgusu olmayan hastalarda, senil atrofiye bağlı gelişen omental pencereler sorumlu tutulmaktadır.[3]

(a)

Olgumuzun öyküsünde karın cerrahisi ve travma olmaması senil atrofik omental açıklığı desteklemektedir. İnternal fıtıklarda hastanın klinik bulguları çok değişken olmakla beraber tıkanıklığın süre ve derecesi ana belirleyicilerdir. Hastamızda şiddetli ağrı ve palpasyonla ele gelen kitle, sıkışmış iskemik bir bağırsak ansını akla getirmiştir. Olgumuzda omentum majustaki pencereden girmiş olan ileum ansında, defektin darlığına ve giren ince bağırsak segmentinin uzunluğuna bağlı nekroz meydana gelmişti; erken müdahale kararıyla perforasyon oluşmadan rezeksiyon yapılmış ve temiz karında güvenli bir şekilde ince bağırsak anastomozu uygulanmıştır. Kaybedilen zamanla perforasyon kaçınılmaz olan bu tip hastalarda ameliyat öncesi dönemde yakın takip ve hızlı değerlendirme çok önemlidir.[3] Transomental fıtıkların kliniğinde, kronik sindirim sistemi şika-

(b)

Şekil 2. (a) Omental açıklıktan girip nekroze olmuş ileum segmenti, (b) omentum majusta defekt alanı görülmekte.

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yetleri olabilir. Aralıklı ve ciddi tıkanıklıkla karakterize sindirim sistemi şikayetleri olan, hikayelerinde ameliyat ya da travma öyküsü olmayan yaşlı olgularda omental fıtıklar ayırıcı tanıda düşünülmelidir. Bu tip olgulara ameliyat öncesi tanı koymak zordur.[7-9] Ameliyat öncesi yapılan görüntülemelerde hava-sıvı seviyelerinin varlığı, ince bağırsak anslarında genişleme ve karın içi serbest mayi varlığı ileusu destekleyen bulgulardır. Olgumuzun yapılan ayakta direkt karın grafisinde çok sayıda ince bağırsak tipi hava sıvı seviyeleri ve kontrastlı batın tomografisinde genişlemiş jejunum ve ileum segmentleri saptanmıştı. BT’de ilaveten torsiyone bağırsak segmentleri için klasik ‘Girdap Görüntüsü’ yani mezenteri ile beraber fıtıklaşmış ince bağırsak segmentleri saptandı. Bu tip hastalarda BT eşlik eden kitlesel ve iltihabi durumları da ortaya koymamıza yardım etmektedir.[3] İnternal fıtıklarda ameliyat yaklaşımı iştirak eden organ veya organların dolaşım durumuna göre belirlenir. Olgumuzda fıtıklaşan ileum segmentinde yaklaşık 40 cm’lik alanda nekroz gelişmişti. Bu segment rezeke edildi ve yan yana kesici kapatıcı zımba yardımıyla anastomoz yapıldı. Omental pencere tekrar fıtıklaşmaya neden olmaması için kısmi omentum rezeksiyonu yapılarak bozuldu. Sonuç olarak, transomental fıtıklar çok nadir görülseler de öyküsünde ameliyat ve travma saptanmayan olgularda mekanik bağırsak tıkanıklığı ayırıcı tanısında düşünülmelidir. Erken dönemde şüphelenilen ve cerrahi müdahalesi yapılan olgularda sadece redüksiyon yeterli olabilmekte, rezeksiyon gerekse bile güvenli anastomoz yapılabilmektedir. Fakat genelde tanı

ve tedavi geç dönemde olmakta, perforasyon ve peritonite ikincil morbidite ve mortalite artabilmektedir. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

KAYNAKLAR 1. Özkan OV, Zararsız İ, Yetim İ, Semerci E. Nadir bir ince bağırsak tıkanıklık nedeni olarak transomental herni: olgu sunumu. Tıp Araştırmaları Dergisi 2009:7:157-60. 2. Martin LC, Merkle EM, Thompson WM. Review of internal hernias: radiographic and clinical findings. AJR Am J Roentgenol 2006;186:70317. 3. Camera L, De Gennaro A, Longobardi M, Masone S, Calabrese E, Del Vecchio W, et al. A spontaneous strangulated transomental hernia: Prospective and retrospective multi-detector computed tomography findings. World J Radiol 2014;6:26-30. 4. Duarte GG1, Fontes B, Poggetti RS, Loreto MR, Motta P, Birolini D. Strangulated internal hernia through the lesser omentum with intestinal necrosis- a case report. Sao Paulo med J 2002;120:84-6. 5. Villalona GA, Diefenbach KA, Touloukian RJ. Congenital and acquired mesocolic hernias presenting with small bowel obstruction in childhood and adolescence. J Pediatr Surg 2010;45:438-42. 6. Renvall S, Niinikoski J. Internal hernias after gastric operations. Eur J Surg 1991;157:575-7. 7. Selçuk D, Kantarci F, Oğüt G, Korman U. Radiological evaluation of internal abdominal hernias. Turk J Gastroenterol 2005;16:57-64. 8. Kohli A, Choudhury HS, Rajput D. Internal hernia : A case report. Indian J Radiol Imaging 2006;16:563-6. 9. Tekin A, Şahin M, Küçükkartallar T, Kaynak A. Nadir bir ileus nedeni: Paraduodenal herni. Genel Tıp Derg 2007;17:111-4.

CASE REPORT - ABSTRACT

A rare cause of small intestinal obstruction: Spontaneous strangulated trans-omental hernia Birol Ağca, M.D., Aziz Bora Karip, M.D., Yalın İşcan, M.D., Yetkin Özcabı, M.D., Mehmet Mahir Fersahoğlu, M.D., Kemal Memişoğlu, M.D. Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul

Internal herniation is a very rare condition which can cause small bowel obstruction. Trans-omental hernias are an infrequent form of internal herniation and can be seen without a history of trauma and previous abdominal surgery. An 85-year-old male patient without a history of abdominal surgery or trauma was admitted to the emergency service with severe abdominal pain and vomiting. Physical examination and laboratory tests revealed a diagnosis of ileus. During laparotomy, a trans-omental hernia causing strangulation of the ileum was detected. Resection-anastomosis was performed and the omental defect was disrupted by partial omentectomy. Although trans-omental hernia is a very rare condition, it should be considered in the differential diagnosis of patients without mechanic intestinal obstruction. Key words: Internal hernia; small intestinal obstruction; trans-omental hernia. Ulus Travma Acil Cerrahi Derg 2015;21(2):160-162

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