Issuu on Google+

Cilt - Volume 19

Say› - Number 5

www.tjtes.org

Eylül - September 2013


Cilt - Volume 19

Sayı - Number 5

Eylül - September 2013

TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY

www.tjtes.org Index Medicus, Medline, EMBASE/Excerpta Medica, Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ ve TÜBİTAK-ULAKBİM Türk Tıp Dizini’nde yer almaktadır. Indexed in Index Medicus, Medline, EMBASE/Excerpta Medica and Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ, and the Turkish Medical Index of TÜB‹TAK-ULAKB‹M.

ISSN 1306 - 696x


TURKISH JOURNAL OF TRAUMA AND EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Editor (Editör) Recep Güloğlu Associate Editors (Yardımcı Editörler) Kaya Sarıbeyoğlu Hakan Yanar M. Mahir Özmen Former Editors (Geçmiş Dönem Editörleri) Ömer Türel Cemalettin Ertekin Korhan Taviloğlu

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

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

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

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

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

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


INTERNATIONAL EDITORIAL BOARD

ULUSLARARASI BİLİMSEL DANIŞMA KURULU

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

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

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

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

REDACTION (REDAKSİYON) Erman Aytaç

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 - 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

Abonelik: 2013 yılı abone bedeli (Ulusal Travma ve Acil Cerrahi Derneği’ne bağış olarak) 75.- YTL’dir. Hesap No: Türkiye İş Bankası, İstanbul Tıp Fakültesi Şubesi 1200 - 3141069 no’lu hesabına yatırılıp makbuz dernek adresine posta veya faks yolu ile iletilmelidir. Annual subscription rates: 75.- (USD) p-ISSN 1306-696x • e-ISSN 1307-7945 • 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 (Yayıncı): KARE Yayıncılık (KARE Publishing) • Design (Tasarım): Ali Cangül • Linguistic Editor (İngilizce Editörü): Corinne Can • Online Manuscript & Web Management (Online Dergi & Web): LookUs • Press (Baskı): Yıldırım Matbaacılık • Press date (Basım tarihi): September (Eylül) 2013 • This publication is printed on paper that meets the international standard ISO 9706: 1994 (Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur.)


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.


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.


TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 19

Number - Sayı 5 September - Eylül 2013

Contents - İçindekiler

Experimental Study - Deneysel Çalışma Deneysel Çalışma - Experimental Study 387-391 Effects of piperine in experimental intestinal ischemia reperfusion model in rats Sıçanlarda oluşturulan deneysel iskemi-reperfüzyon modelinde piperinin etkileri Akyıldız HY, Karabacak A, Akyüz M, Sözüer E, Akcan A 392-397 Serbest düşme hareketi yapan mermi çekirdeklerinin yaralama potansiyelleri The wounding potential of free-falling bullets Öğünç Gİ, Özer MT, Çoşkun K, Eryılmaz M, Uzar Aİ

Klinik Çalışma - Original Original Articles - KlinikArticles Çalışma 398-404 Acute pain management with intravenous 0.10 mg/kg vs. 0.15 mg/kg morphine sulfate in limb traumatized patients: a randomized double-blinded placebo-controlled trial Ekstremite yaralanması olan hastalarda intravenöz 0.10 mg/kg veya 0.15 mg/kg morfin sülfat ile akut ağrı tedavisi: Randomize çift kör plasebo kontrollü çalışma Farsi D, Movahedi M, Hafezimoghadam P, Abbasi S, Shahlaee A, Rahimi-Movaghar V 405-410 Management of penetrating injuries of the upper extremities Üst ekstremitelerin penetran yaralanmalarının tedavisi van Waes OJ, Navsaria PH, Verschuren RC, Vroon LC, Van Lieshout EM, Halm JA, Nicol AJ, Vermeulen J 411-416 Microsurgical reconstruction in pediatric patients: a series of 30 patients Çocuk hastalarda mikrocerrahi rekonstrüksiyon: 30 olguluk seri Akçal A, Karşıdağ S, Sucu DÖ, Turgut G, Uğurlu K 417-422 Epidemiologic and clinical characteristics and outcomes of scorpion sting in the southeastern region of Turkey Türkiye’nin Güneydoğu Anadolu Bölgesi’nde akrep sokmalarının epidemiyolojik, klinik özellikleri ve sonuçları Yılmaz F, Arslan ED, Demir A, Kalaci C, Durdu T, Yılmaz MS, Yel C, Akbulut S 423-428 Details of motorcycle accidents and their impact on healthcare costs Motorsiklet kazaları detayları ve sağlık maliyetleri üzerine etkileri Eroğlu SE, Toprak SN, Akoğlu E, Onur ÖE, Denizbaşı A, Özpolat Ç, Akoğlu H 429-433 The reflection of the Syrian civil war on the emergency department and assessment of hospital costs Suriye’deki çatışmaların acil servise yansıyan yönü ve hastane maliyetlerinin değerlendirilmesi Karakuş A, Yengil E, Akkücük S, Cevik C, Zeren C, Uruc V 434-440 The synergy between endoscopic assistance and extraoral approach in subcondylar fracture repair: a report of 13 cases Mandibular subkondil kırıkların onarımında endoskop yardımı ve ağız dışından yaklaşımın sinerjisi: 13 olgu deneyimi Eroğlu L, Aksakal İA, Keleş MK, Yağmur Ç, Aslan O, Şimşek T Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

vii


TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 19

Number - Sayı 5 September - Eylül 2013

Contents - İçindekiler 441-448 Three-year experience in the Emergency Department: the approach to patients with spinal trauma and their prognosis Acil serviste üç yıllık deneyim: Spinal travmalı hastalara acil servis yaklaşımı ve prognozları Akdemir HU, Aygün D, Katı C, Altuntaş M, Çokluk C 449-455 Retrospective analysis of 132 patients with orbital fracture Orbita kırığı saptanan 132 hastanın geriye dönük analizi Çağatay HH, Ekinci M, Pamukcu C, Oba ME, Özcan AA, Karşıdağ S 456-462 Femur boyun kırıklarına parsiyel protez uygulamasında anterior ve posterior kapsüler açılımın sonuçları Results of anterior and posterior capsular approaches in bipolar hemiarthroplasty patients with femoral neck fractures Zehir S, Şahin E, Sipahioğlu S, Azboy İ, Yar Ü 463-468 Türkiye’deki genel cerrahların penetran karın travmalarına yaklaşımı: Uygulama anketi General approach to penetrating abdominal traumas of Turkish general surgeons: survey of practice Karateke F, Özyazıcı S, Daş K, Menekşe E, Önel S, Özdoğan M, Özmen MM, Ağalar F, Ertekin C

Olgu CaseSunumu Reports- -Case OlguReports Sunumu 469-471 Emergency abdominal surgery in a patient anticoagulated with dabigatran Dabigatran ile antikoagüle edilen hastada acil karın cerrahisi DeMuro JP 472-474 Posttraumatic tricuspid valve injury and severe tricuspid valve regurgitation Travma sonrası gelişen triküspit kapak hasarı ve önemli triküspit kapak yetersizliği Gücük İpek E 475-479 A case report of multiple fractures with arterial vasospasm associated with ergotamine use Çoklu kırıklı bir olguda ergotamin kullanımına bağlı arteriyel vazospazm Küçükalp A, Durak K, Bilgen MS 480-484 Hepatic duct confluence injury in blunt abdominal trauma - a diagnostic dilemma Künt karın travmasında kompleks hepatik kanal yaralanması-tanısal ikilem Garge S, Narasimhan KL, Verma S, Sekhon V 485-487 Long-term follow-up results of a pediatric brachial plexus laceration Pediatrik brakiyal pleksus kesisinin uzun dönem takip sonuçları Öksüz S, Karagöz H, Külahçı Y, Ülkür E, Uslu A 488-490 Amyand fıtığında apendektomi yapılmalı mıdır? İki olgu sunumu Should appendectomy be performed in Amyand’s hernia?: two case reports Çığşar EB, Karadağ ÇA, Sever N, Dokucu Aİ

viii

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


EXPERIMENTAL STUDY

Effects of piperine in experimental intestinal ischemia reperfusion model in rats Hızır Yakup Akyıldız, M.D., Adem Karabacak, M.D., Muhammet Akyüz, M.D., Erdoğan Sözüer, M.D., Alper Akcan, M.D. Department of General Surgery, Erciyes University Faculty of Medicine, Kayseri

ABSTRACT BACKGROUND: Piperine is a spice principle, and its protective role against oxidative damage and lipid peroxidation has been reported. In this study, we aimed to investigate the effects of piperine in the prevention of ischemia-reperfusion injury to the small intestine. METHODS: Rats were allocated to three groups of 8 rats each. Rats in the sham group underwent laparotomy and observation only. Animals in the control and study groups underwent 45 minutes ischemia followed by 60 minutes reperfusion. In the study group, 10 mg/kg piperine was administered intraperitoneally just before the reperfusion procedure. Blood samples were obtained for measurement of lactate levels, and resection of the terminal ileum was performed to evaluate the histopathologic specimens and tissue malondialdehyde, superoxide dismutase, and glutathione activities. All results were expressed as mean±SD. Comparisons between groups were made by using the one way analysis of variance (ANOVA). RESULTS: Lactate and malondialdehyde levels were significantly higher in the control group than the study and sham groups (p<0.001). In the study group, superoxide dismutase, and glutathione activities were significantly higher than in the control group (p<0.001). The sham group had the highest activities. Histopathologic examination showed disruption of villous pattern and lamina propria in the control group. CONCLUSION: Intraperitoneal administration of 10 mg/kg piperine just before the reperfusion may reduce ischemia-reperfusion injury to the small intestine.

Key words: Ischemia; piperine; reperfusion; small intestine.

INTRODUCTION Intestinal ischemia-reperfusion is a common clinical event associated with both clinical and experimental distant organ injury. Arterial ischemia initiates alterations in tissues by blocking the oxygen supply, thus impeding aerobic energetic metabolism. During the ischemia process, there is an accumulation of metabolites, which, directly or through mediators, can cause cellular injury.[1,2] Depending on the time and

Address for correspondence: Hızır Yakup Akyıldız, M.D. Erciyes Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, 38039 Kayseri, Turkey Tel: +90 352 - 437 49 37 / 21608 E-mail: hyakyildiz@gmail.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):387-391 doi: 10.5505/tjtes.2013.48457 Copyright 2013 TJTES

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

intensity of the ischemia, when oxygen is reintroduced to the tissues, tissue injury can be further exacerbated (oxygen paradox).[3] Reperfusion leads to an aggravation of ischemic cell damage, especially reactive oxygen species (ROS) derived from activated Kupffer cells and neutrophils.[4] ROS and reactive metabolic intermediates generated from various oxidative factors are known to have an important role in cell damage and in the progression of ischemia-reperfusion injury (IRI).[5] Despite intensive researches that have aimed to investigate the pathogenesis and find a way to prevent or decrease the additional deleterious effect of IRI, the underlying mechanisms remain to be elucidated. There are many reports indicating that various spice principles form an important group as antioxidants. Piperine is a pungent alkaloid present in black and white pepper (Piper nigrum), long used as a spice and preservative.[6] Piperine has been shown to alter both the bioavailability[7] and biotransformation[8,9] of xenobiotics, and to alter lipid peroxidation and availability of glutathione in the liver[10] and intestine.[11] Piperine has also been demonstrated in in vitro experiments 387


Akyıldız et al. Effects of piperine in experimental intestinal ischemia reperfusion model in rats

to protect against oxidative damage by inhibiting or quenching free radicals and ROS and inhibiting lipid peroxidation.[12] We report here the results of an experimental study to evaluate whether intraperitoneal administration of piperine could be an effective strategy to reduce intestinal IRI.

the one way analysis of variance (ANOVA). Post-hoc comparisons of parameters were performed using the Tukey procedure. Statistical significance was set at p<0.05. All analyses were performed with the Statistical Package for Scientists (SIGMASTAT) Windows version 3.50.

MATERIALS AND METHODS

RESULTS

This study was performed at Erciyes University Experimental Research Center. Twenty-four male Wistar-Albino rats weighing 250 to 300 g were used for this study. Pre- and postoperatively, the animals were maintained under controlled conditions of temperature (21-24°C), humidity (40%60%), and light (12-hour light/dark cycle) and fed ad libitum on rat cubes and tap water. Our institutional ethical committee approved the experimental procedures of this study. The animals were divided randomly into three groups containing 8 rats each as follows: group 1 (sham), animals were sacrificed at the end of 105 minutes (min) observation after laparotomy; group 2 (control), operative procedure without further treatment; and group 3 (study), operative procedure with intraperitoneal piperine administration (10 mg/kg).[6] Intestinal ischemia was induced by microvascular clip occlusion of the superior mesenteric artery (SMA) for 45 min. Reperfusion was performed for 60 min after SMA clip removal.[13] In the study group, intraperitoneal piperine (Sigma, P49007, 10 mg/kg) was administered at the end of 45 min ischemia just before the removal of the microvascular clip.

Lactate levels were 1.29±0.07 mmol/L in the sham, 3.29±0.06 mmol/L in the control and 1.86±0.07 mmol/L in the piperine groups. The sham group had the lowest level while the control group had the highest, and the differences were statistically significant (p<0.001 for all) (Fig. 1a). Tissue MDA contents were 0.16±0.02 μM/mg in the sham, 0.38 ± 0.05 μM/mg in the control and 0.22±0.04 μM/mg in the piperine groups, and the content was significantly lower in the sham group. The control group had significantly higher content than the others (p<0.001) (Fig. 1b).

Operative Procedures

Histopathologic examination of the specimens showed well-preserved villi and intact intestinal mucosa in the sham group. Disruption of villous pattern, increased cellularity in the lamina propria, extension of the subepithelial space with the epithelial layer lifting up, and dilated capillaries were found mostly in the control group. Chiu scores were 0, 1 and 3, respectively, in the sham, study and control groups (p<0.001).

The rats were anesthetized using intraperitoneal ketamine hydrochloride (Ketalar; Parke Davis-EWL, İstanbul, Turkey; 20 mg/kg body weight) and xylazine (Rompun, Bayer, İstanbul, 10 mg/kg). After the abdomen was shaved and cleansed with povidone iodine solution, a 5-6-cm midline laparotomy was performed. All procedures were performed under sterile conditions by one surgeon who was blinded to the animal allocations. In groups 2 and 3, 1 ml heparinized blood for serum lactate analysis was obtained from the inferior vena cava after reperfusion, while in the sham group, it was obtained after the end of the observation period. For tissue analysis, a 3-cm ileal segment 10 cm proximal to the ileocecal valve was removed, and 2 cm was fixed in 10% neutral buffered formalin and embedded in paraffin for histopathological evaluation. Paraffin sections 5 µm in thickness were cut and stained with hematoxylin and eosin. Assessment of ileal injury was performed by light microscopy using a scoring system devised by Chiu et al. without knowledge of the study groups. The remaining 1 cm was conserved in an aluminum foil at -80°C for tissue malondialdehyde (MDA), superoxide dismutase (SOD) and glutathione peroxidase (GSH) activities.

Statistical Analysis All results were expressed as mean±SD. Comparisons of MDA, SOD and lactate between groups were made by using 388

Tissue SOD levels were 5.13±0.57 U/ml/g in the sham, 2.70±0.57 U/ml/g in the control and 3.77±0.48 U/ml/g in the piperine groups. The sham group had the significantly highest level while the control group had the significantly lowest level (p<0.001) (Fig. 1c). Tissue GSH levels were 89.06±11.78 nmol/ml/g in the sham, 32.89±6.55 nmol/ml/g in the control and 64.16±10.45 nmol/ml/g in the piperine groups. The level in the sham group was significantly higher than in the others. The control group had the significantly lowest level (p<0.001) (Fig. 1d).

DISCUSSION Ischemia and reperfusion of the small intestine provoke the rupture of the mucosal barrier, bacterial translocation and the activation of inflammatory responses,[1] as well as hydroelectrolytic and acid-alkaline equilibrium disturbances, which are manifested in distant organs.[14] With the return of blood perfusion, the influx of calcium into the intracellular medium increases, which leads to an expressive increase in phospholipase A2 activity. Arachidonic acid released by phospholipase A2 is metabolized during reperfusion by the enzyme cyclooxygenase, generating prostaglandins, thromboxane and prostacyclins, and by the enzyme lipoxygenase, which generates leukotrienes.[15] Another factor that induces intestinal injury after reperfusion is the generation of free radicals from oxygen molecules, derived from the electron transport chains of the mitochondria, xanthine-oxidase metabolism, endothelial cells, prostaglandins, and activated neutrophils.[4] Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


Aky覺ld覺z et al. Effects of piperine in experimental intestinal ischemia reperfusion model in rats (a)

(b)

Lactate #

4

0.4

*

*

2

0

0.2

Sham

Control

Piperine

(c)

0

Sham

(d) SOD

10

100

5

0

MDA #

Control

Piperine

GSH *

50

Sham

Control

Piperine

0

Sham

Control

Piperine

Figure 1. (a) The comparison of serum lactate levels. (b) The comparison of MDA levels. (c) The comparison of serum SOD levels. (d) The comparison of GSH levels. *: p<0.001 Sham group versus Control and Piperine groups; #: p<0.001 Control versus Piperine group.

Many studies in the literature have evaluated a lot of materials to prevent or decrease the effects of IRI. Many radical scavengers, interestingly naturally occurring antioxidants, have been found to be effective in inhibiting the induction of lipid peroxidation and ROS.[16-18] Studies have also indicated that various spice principles form an important group as antioxidants.[19-21] In this study, we investigated whether piperine might have a protective role in an experimental intestinal ischemia-reperfusion model in rats. Piperine has been demonstrated in in vitro experiments to protect against oxidative damage by inhibiting or quenching free radicals and ROS and inhibiting lipid peroxidation.[12,22] The aqueous extract of black pepper as well as piperine have been examined for their effect on human PMNL 5-lipoxygenase (5LO), the key enzyme involved in biosynthesis of leukotrienes. [23] The formation of the 5-LO product 5-HETE was significantly inhibited with 60 弮M piperine. Thus, piperine of black pepper might exert an antioxidant physiological role by modulating the 5-LO pathway. Using diabetes mellitus as a model of oxidative damage, Rauscher et al.[6] investigated whether intraperitoneal piperine treatment would protect against diabetes-induced oxidative stress. They demonstrated that treatment with piperine reversed the diabetic effects on glutathione concentration in the brain, on renal GSH and SOD activities, and on cardiac glutathione reductase activity and lipid peroxidation. Selvendiran recently investigated the impact of piperine on alterations of the mitochondrial antioxidant system and lipid peroxidation. Oral supplementation of piperine revealed a decrease in the extent of mitochondrial lipid peroxidation and concomitant increase in the activities of enzymatic antioxiUlus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

dants (SOD, catalase, GSH) and nonenzymatic antioxidants (reduced glutathione, vitamin E, vitamin C). They reported that piperine modulates lipid peroxidation and increases the antioxidant defense system.[24] Vijayakumar et al.[25] recently examined the effect of supplementation of black pepper or piperine on tissue lipid peroxidation and enzymic and non-enzymic antioxidants in rats fed a high-fat diet, and they observed that these spices can reduce high-fat diet-induced oxidative stress. They observed that simultaneous supplementation with black pepper or piperine lowered thiobarbituric acid reactive substances and conjugated dienes levels and maintained SOD, catalase, GSH, glutathione-S-transferase, and reduced glutathione levels near to those of control rats. In this study, the results were consistent with the previous reports. The statistically significant highest MDA and lactate levels and the statistically significant lowest GSH and SOD levels were in the control group. MDA and lactate levels of the piperine group were significantly lower than in the control group, and GSH and SOD levels were significantly higher. These results clearly show that intraperitoneal administration of piperine significantly decreases the effects of lipid peroxidation and protects against oxidative damage. The histopathologic examination revealed similar findings with intact intestinal wall in the sham group and well-preserved, mildly affected structures in the study group, but with disruption of villous pattern and lamina propria with dilated capillaries and increased cellularity in the control group. Although there are numerous reports 389


Akyıldız et al. Effects of piperine in experimental intestinal ischemia reperfusion model in rats

about the effectivity of spice species on peroxidation and oxidative stress, since IRI is a very complex process including many yet to be resolved steps in its pathogenesis, new studies are warranted for a further understanding of the biological effects of piperine regarding its inhibitory activities in IRI. In conclusion, in this experimental IRI model in rats, piperine treatment decreased IRI of the small intestine according to both morphological and biochemical criteria, even though its detailed mechanism of action remains unclear. Conflict of interest: None declared.

REFERENCES 1. Cerqueira NF, Hussni CA, Yoshida WB. Pathophysiology of mesenteric ischemia/reperfusion: a review. Acta Cir Bras 2005;20:336-43. 2. Granger DN, Höllwarth ME, Parks DA. Ischemia-reperfusion injury: role of oxygen-derived free radicals. Acta Physiol Scand Suppl 1986;548:47-63. 3. McCord JM. Oxygen-derived free radicals in postischemic tissue injury. N Engl J Med 1985;312:159-63. 4. Grace PA. Ischaemia-reperfusion injury. Br J Surg 1994;81:637-47. 5. Srinivasan K. Black pepper and its pungent principle-piperine: a review of diverse physiological effects. Crit Rev Food Sci Nutr 2007;47:73548. 6. Rauscher FM, Sanders RA, Watkins JB 3rd. Effects of piperine on antioxidant pathways in tissues from normal and streptozotocin-induced diabetic rats. J Biochem Mol Toxicol 2000;14:329-34. 7. Bano G, Raina RK, Zutshi U, Bedi KL, Johri RK, Sharma SC. Effect of piperine on bioavailability and pharmacokinetics of propranolol and theophylline in healthy volunteers. Eur J Clin Pharmacol 1991;41:6157. 8. Atal CK, Dubey RK, Singh J. Biochemical basis of enhanced drug bioavailability by piperine: evidence that piperine is a potent inhibitor of drug metabolism. J Pharmacol Exp Ther 1985;232:258-62. 9. Dalvi RR, Dalvi PS. Differences in the effects of piperine and piperonyl butoxide on hepatic drug-metabolizing enzyme system in rats. Drug Chem Toxicol 1991;14:219-29. 10. Dhuley JN, Raman PH, Mujumdar AM, Naik SR. Inhibition of lipid peroxidation by piperine during experimental inflammation in rats. Indian J Exp Biol 1993;31:443-5. 11. Khajuria A, Thusu N, Zutshi U, Bedi KL. Piperine modulation of

carcinogen induced oxidative stress in intestinal mucosa. Mol Cell Biochem 1998;189:113-8. 12. Mittal R, Gupta RL. In vitro antioxidant activity of piperine. Methods Find Exp Clin Pharmacol 2000;22:271-4. 13. Hei ZQ, Gan XL, Luo GJ, Li SR, Cai J. Pretreatment of cromolyn sodium prior to reperfusion attenuates early reperfusion injury after the small intestine ischemia in rats. World J Gastroenterol 2007;13:513946. 14. Turnage RH, Guice KS, Oldham KT. Endotoxemia and remote organ injury following intestinal reperfusion. J Surg Res 1994;56:571-8. 15. Cuzzocrea S, Rossi A, Serraino I, Di Paola R, Dugo L, Genovese T, et al. 5-lipoxygenase knockout mice exhibit a resistance to splanchnic artery occlusion shock. Shock 2003;20:230-6. 16. Kazez A, Demirbağ M, Ustündağ B, Ozercan IH, Sağlam M. The role of melatonin in prevention of intestinal ischemia-reperfusion injury in rats. J Pediatr Surg 2000;35:1444-8. 17. Augustin AJ, Goldstein RK, Milz J, Lutz J. Influence of anti-inflammatory drugs and free radical scavengers on intestinal ischemia induced oxidative tissue damage. Adv Exp Med Biol 1992;316:239-51. 18. Erdogan H, Fadillioglu E, Yagmurca M, Uçar M, Irmak MK. Protein oxidation and lipid peroxidation after renal ischemia-reperfusion injury: protective effects of erdosteine and N-acetylcysteine. Urol Res 2006;34:41-6. 19. Shen SQ, Zhang Y, Xiang JJ, Xiong CL. Protective effect of curcumin against liver warm ischemia/reperfusion injury in rat model is associated with regulation of heat shock protein and antioxidant enzymes. World J Gastroenterol 2007;13:1953-61. 20. Murugan P, Pari L. Antioxidant effect of tetrahydrocurcumin in streptozotocin-nicotinamide induced diabetic rats. Life Sci 2006;79:1720-8. 21. Jiang H, Deng CS, Zhang M, Xia J. Curcumin-attenuated trinitrobenzene sulphonic acid induces chronic colitis by inhibiting expression of cyclooxygenase-2. World J Gastroenterol 2006;12:3848-53. 22. Naidu KA, Thippeswamy NB. Inhibition of human low density lipoprotein oxidation by active principles from spices. Mol Cell Biochem 2002;229:19-23. 23. Prasad NS, Raghavendra R, Lokesh BR, Naidu KA. Spice phenolics inhibit human PMNL 5-lipoxygenase. Prostaglandins Leukot Essent Fatty Acids 2004;70:521-8. 24. Selvendiran K, Senthilnathan P, Magesh V, Sakthisekaran D. Modulatory effect of Piperine on mitochondrial antioxidant system in Benzo(a) pyrene-induced experimental lung carcinogenesis. Phytomedicine 2004;11:85-9. 25. Vijayakumar RS, Surya D, Nalini N. Antioxidant efficacy of black pepper (Piper nigrum L.) and piperine in rats with high fat diet induced oxidative stress. Redox Rep 2004;9:105-10.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Sıçanlarda oluşturulan deneysel iskemi-reperfüzyon modelinde piperinin etkileri Dr. Hızır Yakup Akyıldız, Dr. Adem Karabacak, Dr. Muhammet Akyüz, Dr. Erdoğan Sözüer, Dr. Alper Akcan Erciyes Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Kayseri

AMAÇ: Piperin oksidatif hasara ve lipit peroksidasyonuna karşı koruyucu etkisi bildirilmiş bir baharat türevidir. Çalışmamızda ince bağırsak iskemireperfüzyon hasarının önlenmesinde piperinin etkisini incelemeyi amaçladık. GEREÇ VE YÖNTEM: Sıçanlar her biri 8 sıçan içeren 3 gruba ayrıldı. Sham grubundaki sıçanlara sadece laparotomi ve gözlem uygulandı. Kontrol ve çalışma grubundaki hayvanlara 45 dakikalık iskemiyi takiben 60 dakikalık reperfüzyon uygulandı. Çalışma grubuna piperin, reperfüzyon işleminden hemen önce 10 mg/kg dozunda periton içi yolla verildi. Laktat seviyelerinin ölçümü için kan numuneleri alındı. Histopatolojik inceleme, doku malondialdehid, süperoksit dismutaz ve glütatyon aktivitesi ölçümleri için de terminal ileum rezeksiyonu gerçekleştirildi. Gruplar arası istatistiki karşılaştırma ANOVA testi ile yapıldı.

390

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


Akyıldız et al. Effects of piperine in experimental intestinal ischemia reperfusion model in rats

BULGULAR: Kontrol grubunda laktat ve malondialdehid seviyeleri çalışma ve sham gruplarına göre anlamlı olarak yüksekti (p<0.001). Çalışma grubunda, süperoksit dismütaz ve glutatyon aktiviteleri kontrol grubundan anlamlı olarak yüksekti (p<0.001). Sham grubu her iki parametrede de en fazla aktiviteye sahipti. Histopatolojik incelemede kontrol grubunda villöz yapının ve lamina propria bütünlüğünün bozulduğu görüldü. TARTIŞMA: Reperfüzyondan hemen önce periton içi verilen 10 mg/kg piperin ince bağırsaklarda iskemi-reperfüzyon hasarını azaltabilir. Anahtar sözcükler: İskemi, piperin, reperfüzyon, ince bağırsak. Ulus Travma Acil Cerr Derg 2013;19(5):387-391

doi: 10.5505/tjtes.2013.48457

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

391


DE NE Y SEL ÇA LI Ş M A

Serbest düşme hareketi yapan mermi çekirdeklerinin yaralama potansiyelleri Dr. Gökhan İbrahim Öğünç1, Dr. Mustafa Tahir Özer2, Dr. Kağan Çoşkun2, Dr. Mehmet Eryılmaz3, Dr. Ali İhsan Uzar4 1

Emniyet Genel Müdürlüğü, Kriminal Polis Laboratuvarı Dairesi Başkanlığı, Ankara

2

Gülhane Askeri Tıp Akademisi, Genel Cerrahi Anabilim Dalı, Ankara

3

Gülhane Askeri Tıp Akademisi, Acil Tıp Anabilim Dalı, Ankara

4

Nurol Araştırma ve Geliştirme, Ankara

ÖZET AMAÇ: Bu çalışmada dik ve dike yakın atış sonrası serbest düşme hareketi gerçekleştiren mermi çekirdeğinin hedef üzerinde hayati yaralanmalara neden olabilme potansiyelinin ortaya konulması hedeflendi. GEREÇ VE YÖNTEM: Çalışmada 9x19 mm ve 7,65x17 mm çapındaki mermilerin namlu çıkış hızları ölçüldü ve bu hızlar EBV4® Dış Balistik Yazılımı kullanılarak yatayla 65 derece ila 90 derece arasında beşer derecelik aralıklardaki atışlarla simüle edildi. Mermilerin serbest düşme hareketleri ve düşüş hızları incelendi. Elde edilen sonuçlar, dokuların eşik hız değerleriyle karşılaştırıldı. Ayrıca adli ve basın kayıtları incelenerek Türkiye’de oluşan bu tip yaralanmaların analizi yapıldı ve literatür eşliğinde değerlendirildi. BULGULAR: Havaya 65 ila 90 derece arasında beşer derecelik aralıklarla yapılan atışlar neticesinde serbest düşme hareketi yapan mermi çekirdeklerinin ortalama isabet hızı ve kinetik enerji değerlerinin 9x19 mm çapında mermi için 92,25 m/sn ve 34,05 J olduğu; 7,65x17 mm çapında mermi için 79,66 m/sn ve 14,91 J olduğu saptandı. Yapılan arşiv taramasında 2000-2012 yılları arasında Türkiye’de 65 adet bu tip yaralanma tespit edildi ve bunların 27 tanesinin ölümle sonuçlandığı anlaşıldı. SONUÇ: Elde edilen bulgular havaya yapılan atıştan sonra serbest düşen 9x19 mm ile 7,65x17 mm çapındaki mermilerin isabet anı hızlarının cilt ve yassı kemik için eşik hız ve kritik hız sınırlarını aştığı ve kinetik enerji değerlerinin ciddi yaralanma oluşturabileceğini göstermektedir. İlk müdahale anındaki muayene bulguları ateşli silah yaralanmasına benzer özellik göstermese de bunların ASY olabileceği ihtimali unutulmadan değerlendirilmeleri ve tedavileri yapılırken adli boyutu göz önüne alarak delilleri koruyacak şekilde davranılmasına dikkat edilmelidir. Anahtar sözcükler: Serbest düşen mermi çekirdeği, ateşli silah yaralanmaları, yara balistiği.

GİRİŞ Kamuoyunda “yorgun mermi” olarak tanımlanan ve Dünya Sağlık Örgütü’nün 2010 tarihli Uluslararası Hastalıklar Sınıflandırma Listesinde (ICD) W32 (Kaza Sonucu Ateşli Silah Yaralanması)[1] koduyla ve 1992 tarihli ICD listesinde İstem Dışı Ateşli Silah Yaralanması (W32)[2] koduyla tanımlanan, serbest düşme hareketi yapan mermi çekirdeklerine bağlı yaralanma Sorumlu yazar: Dr. Gökhan İbrahim Öğünç, Emniyet Genel Müdürlüğü, Ankara Kriminal Polis Laboratuvarı Müdürlüğü 06830 Ankara Tel: +90 312 - 462 95 11 E-posta: gokhan.ogunc@egm.gov.tr Kare kod Quick Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):392-397 doi: 10.5505/tjtes.2013.22309 Telif hakkı 2013 TJTES

392

riski, özellikle meskun mahallerde yapılan düğün ve kutlama merasimlerinde ateşli silahların kullanımıyla daha da artmaktadır. Bu tür yaralanmalar seyrek görüldüğü için yaralanmaya ilk müdahale yapacak sağlık personelinin yaralanma şeklini tanıması ve gerekli müdahaleyi zamanında ve gerektiği ciddiyetle yapmasında bazen gecikmeler olabilmektedir. Bu nedenle deneysel bir çalışma ile yorgun mermilerin isabet anındaki hız ve enerjilerinin belirlenmesi; bu değerlerin dokuların delme eşik hızları ile karşılaştırılması ve geriyö dönük olarak da ilgili kayıt ve arşivin taranması ile yorgun mermi yaralanmalarının incelenmesi ve literatür eşliğinde tartışılması amaçlanmıştır.

GEREÇ VE YÖNTEM Çalışma kapsamında 9x19 mm çapında fişek (mermi çekirdeği ağırlığı 8 gram; ortalama namlu ağzı hızı 365±10 m/sn) atan CZ marka 75B model ve 7,65x17 mm çapında fişek (mermi çekirdeği ağırlığı 4,7 gram; namlu ağzı hızı ortalama 310±10 m/sn) atan Browning marka 1922 model yarı otomatik tabanUlus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5


Öğünç ve ark. Serbest düşme hareketi yapan mermi çekirdekleri

70 60

21

Mortalite Bölge

50 40 30 20 2 10 0

2 Baş

Boyun

Sırt

1

1

0

0

0

Toraks

Karın

Kalça

Ü. Ekstr.

A. Ekstr.

Şekil 1. 2001-2011 yılları arasında serbest düşme hareki sonucunda meydana gelen yaralanmalarının anatomik bölge dağılımı ve mortalite durumu.[6]

calar kullanıldı. Silahların namlu ağzı hızlarının tespiti için test atışları, Oehler M35 İlk Hız Tespit cihazı kullanılarak Emniyet Genel Müdürlüğü Kriminal Polis Laboratuvarları Dairesi Başkanlığı açık hava test poligonunda yapıldı. Pratikte atmosferik ve coğrafi değişkenler, serbest düşme hareketi gerçekleştiren mermi çekirdeğinin isabet hızında ±5 m/ sn değişikliğe neden olabilmektedir.[10] Atmosfer şartlarının kontrol edilememesi, mermi çekirdeği isabet noktasının ve isabet anındaki hızının tespit edilememesi; pratikte havaya dik veya dike yakın bir açıyla yapılan atışlar neticesinde yere düşen mermi çekirdeğinin etkilerinin gözlenmesini imkansız kılmaktadır. Bu nedenle çalışma kapsamında 65 derece ila 90 derece arasında beşer derecelik her bir açıda havaya yapılan atışlar, EBV4® Dış Balistik Yazılımı kullanılarak simüle edildi. Simülasyon atışlarında 65-90 derece arasında kalan atış açıları, serbest düşmenin gerçekleşebilmesi için sınır değerler olmalarından dolayı tercih edildi. Simülasyonda atmosferik ve coğrafi değişkenlerin kontrol altında tutulabilmesi için atmosfer şartlar ISO (Basınç: 1013,25hPa; Sıcaklık: 15; Nisbi Nem: %0; Rüzgar: 0 km/s) standardında ve coğrafi özellik olarak da deniz seviyesi kabul edildi. Yapılan dış balistik simülasyonu neticesinde elde edilen isabet hızları ile dokuların eşik hızları ve kritik hız sınırı karşılaştırıldı,

serbest düşme hareketi yapan bir mermi çekirdeğinin yaralama potansiyeli incelendi. Diğer taraftan basın ve adli arşivlerden 2000-2012 yılları arasında oluşan bu tip yaralanmalar bulunup yaralanmaya ilişkin veriler çıkarıldı ve deneysel çalışmada çıkarılan sonuçlarla yeniden yorumlandı.

BULGULAR Arşiv taramaları neticesinde Türkiye’de 2000-2012 yılları arasında mermi çekirdeğinin serbest düşmesine bağlı 65 ateşli silah yaralanmasının gerçekleştiği tespit edildi. Bu yaralanmalarının 39’u (%60) baş, 4’ü (%6) boyun, 3’ü (%5) omuz ve üst ekstremite, 9’u (%14) sırt, 2’si (%3) toraks, 2’si (%3) karın, 2’si (%3) kalça ve 4’ü (%6) alt ekstremite bölgesinde meydana gelmiştir.[6] Baş yaralanmalarının 21’inin (%54), boyun yaralanmalarının 2’sinin (%50), sırt yaralanmalarının 2’sinin (%33), toraks yaralanmalarının 2’sininin (%50), karın yaralanmalarının 2’sinin (%50) ölümle sonuçlandığı tespit edilmiş ve diğer yaralanma bölgelerinde ölüm meydana gelmemiştir (Şekil 1). 9x19 mm ve 7,65x17 mm çapındaki silah ve mermi çekirdeklerinin EBV4® yazılımı kullanılarak 65 ila 90 derece arasında beşer derecelik her bir açıda havaya yapılan atışlara ilişkin simülasyon sonuçları Tablo 1 ve 2’de verilmiştir.

Tablo 1. 9x19 mm çap ve tipindeki mermi çekirdeğinin 65-90 derece arasında beşer derecelik her bir açıda havaya yapılan atışlara ilişkin simülasyon sonuçları Atış açısı (º) 65 70 75 80 85 90

Maksimum yükseklik (m)

Serbest düşme isabet hızı (m/sn)

1.057 1.120 1.171 1.209 1.232 1.240

Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5

91,00 92,00 92,20 92,60 92,80 92,90

Serbest düşme isabet kinetik enerjisi (J) 33,10 33,80 34,00 34,30 34,46 34,53

Serbest düşme isabet açısı (º) -83,00 -84,00 -85,00 -87,00 -88,00 -89,00

393


Öğünç ve ark. Serbest düşme hareketi yapan mermi çekirdekleri

Tablo 2. 7,65x17 mm çap ve tipindeki mermi çekirdeğinin 65-90 derece arasında beşer derecelik her bir açıda havaya yapılan atışlara ilişkin simülasyon sonuçları Atış açısı (º)

65 70 75 80 85 90

Maksimum yükseklik (m)

Serbest düşme isabet hızı (m/sn)

Serbest düşme isabet kinetik enerjisi (J)

Serbest düşme isabet açısı (º)

826 874 914 943 961 967

78,70 79,30 79,70 80,00 80,10 80,20

14,56 14,78 14,93 15,04 15,08 15,12

-83,66 -84,99 -86,23 -87,45 -88,70 -89,00

TARTIŞMA Türkiye’de yorgun mermi ile oluşan yaralanmalar zaman zaman görülmekte ve bu durum can kaybına neden olabilmektedir. Türkiye’de suç istatistiklerine “Meskun Mahalde Ateş Etme” olarak giren kutlama için havaya ateş etme neticesinde, merminin serbest düşmesi sonucu meydana gelen yaralanmalara ilişkin istatistiki veri bulunmamaktadır. Ayrıca bu tip yaralanmalar ile hedef gözetmeksizin yapılan atış neticesi yaralanmalar (serseri mermi isabeti) çoğu zaman aynı kategoride değerlendirilmekte; serbest düşme sonucu meydana gelen yaralanmalar özel olarak istatistiklerde ifade edilmemektedir. Bu nedenle tıbbi ve adli istatistiklerde bu yönde bir ayrım bulunmamaktadır. Bununla beraber, basın arşivlerinde yapılan tarama neticesinde; Türkiye’de 2000-2012 yılları arasında mermi çekirdeğinin serbest düşmesine bağlı 65 ateşli silah yaralanması gerçekleştiği tespit edilebilmiştir.[6] Mermi çekirdeğinin havada dengeli olarak hareket edebilmesi (Statik Denge [SD]) ve sivri ucunun önde gitmesi için kendi ekseni etrafında dönmesinin sağlanması gerekir. Jiroskopik denge formülü namludaki yiv-setin mermi çekirdeğine kazandırdığı dönme hızının “w”, merminin doğrusal hızına “v” oranıdır. İyi bir jiroskopik denge için bu oranın 1’e yakın ancak 1’den büyük bir değer olması gerekmektedir[8,9] ve “SD= w / v >1” formülüyle gösterilir.[10] Mermi çekirdeği namluyu terk ettiği anda, sahip olduğu doğrusal hızı, açısal hızına oranla daha fazladır. Bu durum “SD” değerinin 1’den küçük olmasına ve mermi çekirdeğinin dengesiz olmasına sebep olur. Namludan uzaklaştıkça daha fazla hava direnci ve yerçekimi etkisiyle mermi çekirdeğinin, doğrusal hızı “v” sürekli olarak azalacak ve “SD” değeri artarak 1’i geçerek jiroskopik dengeye ulaşacaktır.[8,9] Mermi çekirdeği irtifa kazandıkça doğrusal hızı azalırken dönme hızı büyük ölçüde korunur ve bu durum “SD” değerini, 1’in çok üstüne çıkartarak jiroskopik dengenin yeniden kaybedilmesine neden olur. Zirve noktasına ulaştığında doğrusal hızı tamamen tükenmiş, ancak açısal hızı büyük ölçüde korunmuş olan mermi “aşırı denge” konumuna gelir ve takla atarak yerçekimi etkisiyle serbest düşme hareketine başlar.[11] 394

Serbest düşme sırasında yerçekimi ivmesi mermi çekirdeğinin aşağı doğru hız kazanmasına neden olurken; aksi yönde hava direnci “Limit Hızı” veya “Paraşüt Etkisi” olarak tanımlanan ve mermi çekirdeğinin serbest düşme sırasındaki aşağıya doğru ivmelenmesini yavaşlatan etkiyi oluşturur.[11] Serbest düşme sonucunda aşağı doğru kazanılan doğrusal hız sayesinde mermi çekirdeği tekrardan jiroskopik dengeye ulaşmaya başlayacaktır. Ancak, doğrusal hızın “Limit Hız” etkisiyle sınırlanması; serbest düşme sırasında kazanılan jiroskopik denge değerinin düşük olmasına ve mermi çekirdeğinin hedefe hafif yalpa yaparak isabet etmesine ve bu da hedef üzerinde eliptik bir giriş deliği oluşmasına neden olabilmektedir.[12] Mermi çekirdeğinin isabet ettiği dokuları delebilmesi için dokunun elastikiyet sınırını aşması gerekir. Dokuların bu elastikiyet sınırı “Eşik Hız Değeri” olarak tanımlanmaktadır. Dokuların eşik hız değeri, isabet eden mermi çekirdeğinin çapı ve ağırlığına bağlı olarak değişmektedir.[13] Bir mermi çekirdeğinin cilt ve kemik dokularını delerek hayati organlara ulaşabilmesi için sahip olması gereken minimum hız değeri, geçtiği dokuların eşik hız değerlerinin toplamıdır ki bu “Kritik Hız Değeri” olarak tanımlanmaktadır.[13] Diğer bir ifadeyle mermi çekirdeğinin hayati organlara ulaşabilmesi için isabet hızının, geçtiği dokuların eşik hız değerlerinin toplamı olan Kritik Hız Değerinden daha yüksek olması gerekir. Literatürde, çalışmada kullanılan 9x19 mm çaplı mermilerin cilt için eşik hız değeri 60 m/sn, yassı kemik için 60 m/sn, yuvarlak kemik için 90 m/sn ve 7,65x17 mm çaplı merminin eşik hız değerleri ise; cilt için 75 m/sn, yassı kemik için 62 m/sn, yuvarlak kemik için 100 m/sn. olarak verilmektedir.[13] Bu durumda 9x19 mm çap ve tipindeki mermi çekirdekleri için Kritik Hız Değeri; 60–150 m/sn; 7,65x17mm çap ve tipindeki mermi çekirdekleri için ise 75–175 m/sn arasındadır. Çocuklar için söz konusu kritik hız değerleri 15–20 m/sn daha düşüktür. 9x19 mm çapındaki mermi çekirdeğinin poligonda yapılan atışlarda ölçülen namlu çıkışı hızlarının EBV4® Dış Balistik Yazılımında kullanılmasıyla elde edilen serbest düşme hızı dikkate Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5


Öğünç ve ark. Serbest düşme hareketi yapan mermi çekirdekleri

alındığında; bu merminin 65–90 derece arası atışlara ilişkin serbest düşme hareketinde ortalama 92,25 m/sn isabet hızı ve 34,05J isabet enerjisiyle cilt dokusunu delebileceği, cilt dokusunun arkasında yer alan yassı kemikte ciddi tahribata neden olabileceği hatta delebileceği; yuvarlak kemiğe isabet etmesi durumunda ise kemik dokusunu delemeyeceği sonucuna varılmıştır. Yine 7,65x17 mm çapındaki mermi çekirdeği için yapılan aynı tip hesaplamada ortalama 79,66 m/sn hız ve 14,91 J enerjiyle cilt dokusunu delebileceği, cilt dokusunun arkasında yer alan yassı kemikte ciddi tahribata neden olabileceği; yuvarlak kemiğe isabet etmesi durumunda ise kemik dokusunda yaralanma yapamayacağı değerlendirilmiştir. Türkiye verileri incelendiğinde serbest düşme ile oluşan yaralanmaların çoğunlukla kafa bölgesinde (%60), daha sonra boyun (%6) ve omuz (%9) bölgeleri ile sırtın üst kısmı (%14) gibi bölgelerde oluştuğu görülmektedir. Bu durumun yaralanan kişilerin gün içinde genellikle dik durumda bulunması ve serbest düşen merminin yeryüzüne dik veya dike yakın bir açıyla düşmesiyle ilişkili olduğu düşünülmüştür. Özellikle kafa ve boyun bölgelerinde meydana gelecek yaralanmalar ölümcül sonuçlara neden olabilir ki yaralanmalar incelendiğinde kafa yaralanmalarında ölüm oranı %54, boyunda ise %50 olarak bulunmuştur. Ayrıca bu bölge yaralanmalarında gerçekleşen ölüm sayısı, bu tip yaralanmalarla oluşan toplam sayının %86’sını oluşturmaktadır. 1991 yılında 1. Körfez Savaşı sonrasında Kuveyt’in Irak işgalinden kurtarılmasına ilişkin kutlamalar sırasında havaya yapılan atış neticesinde 20 kişi hayatını kaybetmiştir.[3] Latin Amerika ülkelerinde yılbaşı kutlamaları sırasında havaya ateş edilmesi yaygın bir kutlama şeklidir ve kayıtlardan Porto-Riko’da yılbaşı kutlamalarında her yıl ortalama 25 kişinin serbest düşen mermi çekirdeğiyle yaralandığı ve bunlardan 2’sinin hayatını kaybettiği anlaşılmaktadır.[4] 1985–1992 yılları arasında Los Angeles’ta 118 kişi “yorgun mermi”den ötürü yaralanmış, bu yaralılardan 38’i hayatını kaybetmiştir.[5] Literatürde serbest düşmeden kaynaklanan ateşli silah yaralanmalarının en detaylı analizi Porto Riko’da 2004 yılbaşı kutlamalarına ilişkindir. 2004 yılbaşı kutlamalarında Porto Riko’da serbest düşmeye bağlı olarak meydana gelen yaralanmaların anatomik dağılımı, Türkiye’de meydana gelen yaralanmaların oranı ile paralellik göstermektedir. Porto Riko’da meydana gelen yaralanmaların %36’sı baş ve boyun bölgesinde, %27’si omuz ve sırt bölgelerinde, %11’i üst ve alt ekstrimite bölgelerinde, %11’i toraks bölgesindedir.[15] Kafa bölgesine isabet eden mermi çekirdekleri kranyumu da delerek beyin dokusuna kadar ulaşabilmekte, beyin dokusunda direkt tahribat oluşabildiği gibi kafa içi kanamalarla da erken ölümlere sebebiyet vermektedir. Yine geç dönem takiplerde enfeksiyon ve sepsise bağlı ölümlerde gözlenmiştir. Mermi çekirdeğinin kranyuma yaptığı darbe ile kopan kemik fragmanları da beyin dokusu içinde ayrıca hasar oluşturabilir.[16-18] Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5

Doğrudan atış neticesinde kafatasında gözlenen parçalanma, serbest düşme hareketi yapan mermi çekirdeğinin isabetinde gözlenmez. Serbest düşen mermi çekirdeğinin kinetik enerji miktarının düşük olması, kemik dokusuna aktarılan enerji miktarının da az olmasına neden olacağından kranyumda düzensiz ancak parçalı olmayan bir giriş deliği meydana gelebilir. Ayrıca bu tip yaralanmalarda mermi çıkış yarası oluşumu çok nadirdir.[19,20] Namlu çıkış hızının yaklaşık 1/3’ü ile kafa bölgesine isabet eden serbest düşme halindeki mermi çekirdeğinin frontal ve oksipital kemiklere oranla daha kırılgan olan burun, zigomatik kemik, maksilla ve temporal kemiklere isabet etmesi halinde parçalı giriş yarası meydana gelebilir ve kemik ardı dokularda daha ciddi tahribat oluşabilir. Anatomik yapıdan ötürü bir diğer tehlikeli bölge boyun ve ensedir. Büyük kan damarlarının bulunduğu boyun ve ense bölgesinde meydana gelecek ateşli silah yaralanması, kısa zamanda yoğun kan kaybının yaşanmasına neden olabildiği için hızlı ölümlere neden olabilir. Omur kemiklerinin yapısal özelliklerinden ötürü serbest düşme hareketi yapan mermi çekirdeğinin omur kemiklerini delip geçmesi yaygın bir durum değildir. Ayrıca boyun kaslarının elastik yapısı mermi çekirdeğinin kinetik enerjisini sönümleyerek serbest düşen bir mermi çekirdeğinin medülla spinalise zarar verme ihtimalini azaltır. Ancak, omuru delebilen veya kırabilen mermi çekirdeği, medulla spinalise bası oluşturup bunla ilgili semptomlar yaratabilir. Yine trakea ve özefagus yaralanmaları gibi ciddi yaralanmalar oluşabilir. Özellikle küçük çocuklarda trakeyayı delip asfiksi oluşturan yaralanmalar bildirilmiştir. Boyun bölgesi çapının az olması sebebiyle, bu bölgeye isabet eden bir merminin giriş ve çıkış yarası oluşturması mümkündür. Serbest düşme hareketi yapan mermi çekirdeğinin isabet hızının düşük olması, boyundaki büyük damarlara isabet ettikten sonra içine girip içinde kalmasına ve damar yolunu takip ederek emboli oluşmasına da neden olabilir.[21-24] Emboli gelişimi özellikle küçük çaplı mermi çekirdeklerinde veya saçma tanelerinde daha yaygın olarak görülebilir. Serbest düşme hareketi yapan mermi çekirdeğinin uçuş yörüngesi düşünüldüğünde yere dik ve dike yakın açıyla geldiğinden ayakta duran veya oturan bir kişide toraks ve karın yaralanması oluşturma oranı düşüktür (%6). Türkiye’deki yaralanmalar incelendiğinde özellikle yaz aylarında geceleri çatı veya terasta yatma kültürünün olduğu Adana ve İzmir illerinde bu tip yaralanmalara daha çok rastlanmaktadır. Toraks ve karın bölgesinde meydana gelen mermi çekirdeğinin serbest düşmesi kaynaklı yaralanmalarda hayati tehlike, kalp ve büyük damar yaralanması ile akciğer yaralanmaları ve emboli gelişimi kaynaklı olabilmektedir.[3,25] Mermi çekirdeğinin serbest düşmesi sonucu oluşan yaralanmalar, tıbbi, adli ve sosyal yönleri itibariyle diğer ateşli silah yaralanma olaylarından daha farklıdır. Bu tip yaralanmalarda 395


Öğünç ve ark. Serbest düşme hareketi yapan mermi çekirdekleri

çoğunlukla yaralı ve yakınında bulunan kişiler silah sesi duymazlar, kişinin kendinden geçmesini veya düşmesini başka sebeplere bağlarlar. Bu durum, merminin serbest düşmesi sonucunda oluşan yaralanmaların tıbbi açıdan farkını yaratan başlıca etmendir. Yaralanma bölgesi hastanın altında kalır ve çok fazla kan çıkmazsa yaralıya ilk müdahale ateşli silah yaralanmasından ziyade kalp krizi, tansiyon, sıcak çarpması veya baygınlık gibi rahatsızlıklara yöneliktir. Özellikle yaralının bilincinin kapalı olduğu durumlarda ilk yardım ekipleri ile acil servis personeli yaralıdan herhangi bir bilgi alamaz ve yaralının yakınlarının yönlendirmeleri ışığında tıbbi müdahalede bulunulur. Bu durum çok kıymetli olan zamanın etkin kullanılamamasına neden olmaktadır. Yaralının acil servise ulaşmasının hemen akabinde tüm vücut muayenesinin yapılması, herhangi bir yaralanmanın olup olmadığının kontrol edilmesi, radyolojik incelemeye tabi tutulması yorgun mermi yaralanmalarının erken tanısında önemlidir. Ateşli silah yaralanmalarında tetiği çeken kişinin ve atış yerinin tespit edilmesi amacıyla yürütülen “Atışın Yapılandırılması” çalışmaları, adli soruşturmalarda çok önemli bulguların elde edilmesini sağlamaktadır. Serbest düşme sonucu meydana gelen ateşli silah yaralanmalarında yaralı ve yakınındaki kişiler ateşli silah yarasının oluştuğunu fark etmediklerinden, atış yön ve açısının tespiti için çok önemli olan yaralının vurulduğu andaki pozisyonu hakkında bir bilgiyi çoğunlukla veremezler. Ayrıca, bu tür olguların ateşli silah yaralanması kaynaklı olduğu, olaydan saatler sonra tespit edildiğinden olay yeri incelemeleri ve atışın yapılandırılması çalışmaları gecikmeden ötürü gerektiği gibi yapılamamaktadır. Hedef gözeterek yapılan atışlarda, tetiği çeken kişi atışın sosyal ve adli sorumluluğunu hisseder. Ancak havaya doğru yapılan atışlarda kişi, merminin yere düşeceğinin ve masum birinin yaralanabileceğinin idrakine varamamaktadır. Bu nedenle serbest düşme sonucu oluşan ateşli silah yaralanmalarıyla mücadele etmenin en önemli bileşenini “Eğitim” oluşturmaktadır. İlk olarak silah sahiplerinin eğitilmesi, silahın tehlike ve sorumlulukları hakkında bilinçlendirilmeleri gerekir. İkinci sırada, sağlık personelinin bu tip yaralanmalara karşı eğitilmeleri, nedeni bilinmeyen yaralanmalarla karşılaşıldığında yorgun mermi olabileceğinin akılda tutulması, müdahale kayıtlarının ve ilk müdahalenin delillerin kararmasına engel olacak şekilde yapılmasının sağlanmasına dikkat edilmelidir. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

be lethal at terminal velocity? Cardiac injury caused by a celebratory bullet. Ann Thorac Surg 2007;83:283-4. 4. Centers for Disease Control and Prevention (CDC). New Year’s Eve injuries caused by celebratory gunfire--Puerto Rico, 2003. MMWR Morb Mortal Wkly Rep 2004;53:1174-5. 5. Maugh TH. Bullets fired at sky cited in 38 deaths: study: hospital lists holiday data over seven years. Police question it. Los Angles Times; 30 June 1992. 6. Turkish National Police. Press Archives. Ankara; 2012. 7. Hürriyet, “Umut maganda kurbanı oldu” http://hurarsiv.hurriyet.com. tr/goster/ShowNew.aspx?id=2132167028.08.2012. 8. McCoy RL. Modern exterior ballistics. The launch and flight dynamics of symmetric projectiles. 1st ed. Atglen: Schiffer Publication; 1999. p. 2303. 9. Carlucci DE, Jacobson SS. Ballistics theory and design of guns and ammunition. 1st ed. New York: CRC Press; 2008. p. 286. 10. Ruprecht N. Exterior ballistics. Version 4, User Manuel. Wiesbaden: Digital Copy; 1999. p. 12. 11. Öğünç Gİ. Balistik. In: Karakuş O, editor. Kriminalistik. 1st ed. Ankara: Adalet Yayınevi; 2010. p. 88. 12. Rinker R. Understanding firearm ballistics. Basic to advance ballistics simplified, illustrated & explained. 6th ed. Indiana: Mulberry House Publishing; 2005. p. 88 13. Sellier KG, Kneubuehl BP. Wound ballistic and the scientific background. 1st ed. Amsterdam: Elsevier; 1994. p. 217-22. 14. Turkish National Police, Department of Criminal Police Laboratories (KPL), 2001 – 2011 years Ankara KPL ballistics examination statistics. Ankara; 2012. 15. Rodriguez I, Mirabal CB, Echanove JA, Rodriguez C, Rullan J, et.al. Centers for Disease Control and Prevention (CDC). New Year’s Eve injuries caused by celebratory gunfire--Puerto Rico, 2003. MMWR Morb Mortal Wkly Rep 2004;53:1174-5. 16. Uzar AI, Dakak M, Oner K, Ateşalp AS, Yiğit T, Ozer T, et al. Comparison of soft tissue and bone injuries caused by handgun or rifle bullets: an experimental study. Acta Orthop Traumatol Turc 2003;37:261-7. 17. Fackler ML, Surinchak JS, Malinowski JA, Bowen RE. Bullet fragmentation: a major cause of tissue disruption. J Trauma 1984;24:35-9. 18. Uzar Aİ, Kayahan C, Güleç B, Özer MT, Kozak O, Alpaslan F. Yara Balistiği-II. Ateşli silah yaralanmalarında mermideki şekil bozuklukları ve parçalanma etkileri. Ulus Travma Acil Cerr Derg 1998:4;235-9. 19. Malcom JD. Terminal ballistics: a text and atlas of gunshot wounds. New York: CRC Taylor &Francis; 2006. p. 103. 20. Di Maio VJM. Gunshot wounds. Practical aspects of firearms, ballistics, and forensic techniques. 2nd ed. Florida: CRC Press; 1999. p. 147. 21. Demirkilic U, Yilmaz AT, Tatar H, Ozturk OY. Bullet embolism to the pulmonary artery. Interact Cardiovasc Thorac Surg 2004;3:356-8. 22. Cysne E, Souza EG, Freitas E, Machado E, Giameroni R, Alves LP, et al. Bullet embolism into the cardiovascular system. Tex Heart Inst J 1982;9:75-80.

KAYNAKLAR

23. Greaves N. Gunshot bullet embolus with pellet migration from the left brachiocephalic vein to the right ventricle: a case report. Scand J Trauma Resusc Emerg Med 2010;18:36.

1. World Health Organisation. International Classification of Diseases (ICD). Geneva: Digital Copy; 2010.

24. Demetriades D, Salim A, Brown C, Martin M, Rhee P. Neck injuries. Curr Probl Surg 2007;44:13-85.

2. World Health Organization. International Statistical Classification of Diseases And Related Health Problem, Tenth Revision. Geneva: Digital Copy; 1992.

25. Bowley DM, Degiannis E, Westaby S. Thoracic injury. In: Mahoney PF, Ryan J, Brooks AJ, Schwab CW, editors. Ballistic trauma: a practical guide. 2nd ed. Philadelphia: Springer-Verlag London Limited; 2005. p. 241-70.

3. Incorvaia AN, Poulos DM, Jones RN, Tschirhart JM. Can a falling bullet

396

Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5


Öğünç ve ark. Serbest düşme hareketi yapan mermi çekirdekleri

EXPERIMENTAL STUDY - ABSTRACT OLGU SUNUMU

The wounding potential of free-falling bullets Gökhan İbrahim Öğünç, M.D.,1 Mustafa Tahir Özer, M.D.,2 Kağan Çoşkun, M.D.,2 Mehmet Eryılmaz, M.D.,3 Ali İhsan Uzar, M.D.4 General Directorate of Security, Department of Criminal Police Laboratories, Ankara Department of General Surgery, Gulhane Military Medical Academy, Ankara 3 Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara 4 Nurol Research and Developing, Ankara 1 2

BACKGROUND: It was aimed in this study to clarify the wounding potential of free-falling bullets fired at 90° or close to right angles. MEHTOHDS: In this study, 9x19 mm and 7.65x17 mm bullets, which are commonly used among civilians, were used. The muzzle velocities of these ammunitions were measured. According to the muzzle velocity data, the free-falling motion and strike velocity of the 9x19 mm and 7.65x17 mm bullets were simulated using the EBV4® External Ballistics Software at angles of 65°-90° with firings at 5° intervals. The simulation results were compared with critical velocity of tissues. In addition, the judicial records and press reports on this type of wound were examined and evaluated in light of the literature. RESULTS: The strike velocity and kinetic energy of free-falling bullets, which were fired into the air at 5° intervals between 65°-90°, were measured. The average strike velocity and kinetic energy of 9x19 mm bullets were 92.25 m/sec and 34.05 J and of 7.65x17 mm bullets were 79.66 m/ sec and 14.91 J, respectively. As a result of the archives examination, 65 such wounds were detected between 2000 and 2012, and 27 of them resulted in death. DISCUSSION: According to these results, the strike velocity of free-falling 9x19 mm and 7.65x17 mm bullets, which were fired into the air, exceeds the threshold and critical velocity limits of skin and flat bones, and the kinetic energy of the bullets is able to cause significant wounding. Even though the symptoms and features of these types of wounds may not be similar to those of ordinary gunshot wounds in the first medical examination, the first responders should be aware of the possibility of gunshot wounds, and they should take into account the criminal investigation phase during the treatment process; the necessary precautions should be taken in order to preserve the evidence. Key words: Free-falling bullet, gunshot wounds, wound ballistics. Ulus Travma Acil Cerr Derg 2013;19(5):392-397

doi: 10.5505/tjtes.2013.22309

Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5

397


ORIGINAL ARTICLE

Acute pain management with intravenous 0.10 mg/kg vs. 0.15 mg/kg morphine sulfate in limb traumatized patients: a randomized double-blinded placebo-controlled trial Davood Farsi, M.D.,1 Mitra Movahedi, M.D.,2 Peyman Hafezimoghadam, M.D.,3 Saeed Abbasi, M.D.,3 Abtin Shahlaee, M.D.,4,5 Vafa Rahimi-Movaghar, M.D.4 1

Hazrat-e-rasool Akram Medical Complex, Tehran University of Medical Sciences, Tehran, Iran

2

Shahid Mohammadi Hospital, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

3

Department of Emergency Medicine, Tehran University of Medical Sciences, Tehran, Iran

4

Sina Trauma and Surgery Research Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran

5

Studentsâ&#x20AC;&#x2122; Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran

ABSTRACT BACKGROUND: We aimed to compare pain relief and safety of two doses of morphine in adult emergency department (ED) patients with acute limb trauma pain. METHODS: A total of 200 adult ED patients over 20 years of age requiring opioid analgesia were randomly allocated to two groups. Following a first dose of intravenous morphine sulfate at 0.10 mg/kg, a randomized double-blind placebo-controlled trial of intravenous morphine sulfate at 0.05 mg/kg versus the same amount of placebo was performed. Measurement of visual analogue scale pain intensity and assessment of adverse effects were performed at baseline (before morphine at 0.10 mg/kg), 30 minutes from baseline (just before study drug administration), and at 60 minutes from baseline (30 minutes after study drug). RESULTS: No significant difference was found between groups at 30 minutes from baseline. There was significant reduction in final pain after 1 hour in the 0.15 mg/kg compared to 0.10 mg/kg group (p<0.05). In addition, there was a significant improvement in the mean score of pain in the same group (p<0.05). The percent of pain reduction in the intervention and control group relative to the basic measures was 52.70% and 35.82%, respectively. Adverse effects were present in both groups; however, there was no statistically significant difference between groups. CONCLUSION: Using two doses of morphine instead of one is a safe and effective method for pain reduction in isolated limb trauma. We recommend performing a second injection of 0.05 mg/kg morphine 30 minutes after the initial standard dose of 0.10 mg/ kg to decrease pain in these patients.

Key words: Acute pain, emergency medicine, randomized controlled trial.

INTRODUCTION Up to 70% of all patients presenting to emergency departments (EDs) experience varying degrees of pain, and if the insult is trauma, management could be challenging because Address for correspondence: Vafa Rahimi-Movaghar, M.D. Sina Hospital, Hassan-abad Square, Imam Khomeini Ave, Tehran University of Medical Sciences, 11365 Tehran, Iran Tel: +98 915 342 2682 E-mail: v_rahimi@tums.ac.ir Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):398-404 doi: 10.5505/tjtes.2013.86383 Copyright 2013 TJTES

398

different systems could be involved.[1] After a primary survey including vital survey of the respiratory and cardiovascular systems, pain management is a key step in the ED.[2] Opioids are a mainstay of moderate to severe pain management in acute events such as trauma and chronic pain due to malignancies.[3,4] The prototype of opioids in the ED is morphine. It is the most frequent drug for acute pain control because it has few side effects and provides acceptable analgesia with different dosage protocols.[5] Various doses for morphine administration have been recommended. Nevertheless, previous studies have reported inadequate pain control in the ED.[6-9] A study conducted by Bijur et al.[10] suggested that the common 0.10 mg/kg starting dose of morphine may be too low to adequately control acute severe pain. Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


Farsi et al. Acute pain management in limb traumatized patients

The aim of this study was to define a minimum effective dose of morphine for obtaining maximum analgesia in limb trauma. We compared the pain relief and safety of two doses of morphine in adult ED patients with acute limb trauma pain.

MATERIALS AND METHODS Study Design Following the first intravenous morphine sulfate at 0.10 mg/ kg, a prospective randomized double-blind placebo-controlled trial of intravenous morphine sulfate at 0.05 mg/kg versus the same amount of distilled water as a placebo was performed in adult ED patients over 20 years of age with acute limb trauma pain requiring opioid analgesia.

Setting The study was conducted in the ED of an academic large trauma center from 20 March 2009 to 19 March 2011. Data collection was performed by four emergency medicine residents available 24 hours per day, 7 days per week. They were trained and blinded to the study protocol. They assessed the pain score at baseline and 30 and 60 minutes afterwards.

Selection of Participants Patients over 20 years of age presenting to the ED with pain following acute limb trauma of less than three daysâ&#x20AC;&#x2122; duration, and considered by the ED attending professors to require opioid analgesia, were suitable for inclusion. Exclusion criteria were: requirement of rescue analgesia, death of patients in

less than one hour, referral of patients to the operating room in less than one hour, multiple trauma patients for whom the ED attending professor ordered naloxone or more opioids, unwillingness to provide informed consent or to receive a second dose of analgesic, serious life-threatening complications such as respiratory depression after the first dose injection, previous adverse reaction to morphine, cognition problems, or disoriented patients who were unable to cooperate. Emergency medicine residents ordered the morphine injection for those patients whose triage assessment indicated pain and for whom opioid analgesia was deemed to be warranted by the ED attending physician. Written informed consent was obtained from all participants. The study protocol was approved by the ethical committee of Tehran University of Medical Sciences.

Interventions Patients were randomly allocated to two pain management groups that were assigned to receive morphine sulfate at either 0.10 mg/kg or 0.15 mg/kg (Fig. 1). After initial assessment of baseline pain, all participants received an initial dose of morphine sulfate at 0.10 mg/kg. Reassessment of pain was performed at 30 minutes from baseline, followed immediately by intravenous administration of morphine at 0.05 mg/ kg or placebo during two minutes. Patients received either a second dose of morphine sulfate at 0.05 mg/kg or the same amount of purified water solution as placebo in the form of clear, colorless fluid. Final pain assessment was performed at 60 minutes from baseline (equal to 30 minutes after the sec-

Assessment for eligibility

Exclusion criteria: Requirement of rescue analgesia Death within 1 hour of arrival Admission to operating room within 1 hour of arrival Patients requiring naloxone administration or higher doses of morphine in judgment of ED attending Refused study entry Serious or life-threatening adverse effects such as hypotension, respiratory depression, or loss of consciousness Lack of patient cooperation due to decreased level of consciousness

Randomization (n=200)

0.15 mg/kg group (n=100) Allocated to an initial dose of morphine 0.10 mg/kg plus a second dose of morphine 0.05 mg/kg

0.10 mg/kg group (n=100) Allocated to an initial dose of morphine 0.10 mg/kg plus a dose of placebo

Figure 1. Enrollment, randomization, and treatment protocols.

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

399


Farsi et al. Acute pain management in limb traumatized patients

ond injection). The patient and ED resident both remained blinded to the group assignments during the entire study.

syringe injection; the executive manager was aware of the presence of water versus morphine.

All medications were administered by an ED nurse who was blinded to the study. Safety was monitored by continuous pulse oximetry, monitoring of respiratory rate and pulse rate, and blood pressure monitoring every 10 minutes. Oxygen was to be administered for an oxygen saturation of less than 95%. Normal saline solution was administered for a systolic blood pressure less than 100 mmHg, and naloxone was considered for a pulse oximeter reading less than 95% after oxygen administration, a pulse rate less than 60 beats/min, or a systolic blood pressure less than 100 mgHg after administration of a saline solution bolus.

Visual analogue scale (VAS) of pain for all patients was documented three times: at the entrance time, at 30 minutes after injecting a dose of 0.10 mg/kg morphine, and at 30 minutes after the second injection, which was 0.05 mg/kg morphine in the intervention (two-dose) group and water as placebo in the control (one-dose) group. Morphine side effects, including vomiting, hypotension, tachycardia, respiratory depression, decreased consciousness, and urinary retention, were documented after each injection in both the one-dose and two-dose groups.

Methods of Measurement Patients were asked by one of the four trained emergency medicine residents to rate their pain intensity on 10-point visual analogue scale (VAS), ranging from 0, equivalent to “no pain”, to 10, equivalent to “worst possible pain.” The VAS pain score is the most commonly used tool to assess pain, is sensitive to small changes, and provides a continuous variable suitable for statistical analysis.[11] It has been widely accepted due to its ease and brevity of administration, minimal intrusiveness, and conceptual simplicity.[12] The VAS pain intensity measurement was administered at baseline (before morphine at 0.10 mg/kg), 30 minutes from baseline (just before study drug administration), and at 60 minutes from baseline (30 minutes after the study drug). Based on the pharmacokinetics of morphine, 30 minutes following morphine injection was chosen as a practical time within which adequate analgesia is achieved in patients with severe pain without missing an analgesic effect.[13] Morphine side effects including vomiting, hypotension, tachycardia, respiratory depression, decreased level of consciousness (Glasgow Coma Scale (GCS) score), and urinary retention were documented after each injection in both groups. Hypotension was defined as a drop of systolic pressure below 90 mmHg after morphine administration. Tachycardia was defined as a heart rate above 100/min, and respiratory depression was defined as a respiratory rate below 10/min associated with an oxygen saturation of rate less than 90%. For all of the mentioned adverse effects, underlying conditions such as hemorrhage or head trauma were ruled out.

Data Entry Data were entered into a Statistical Package for the Social Sciences (SPSS) version 16.0 (SPSS, Inc., Chicago, IL) database. Patients with acute isolated limb trauma, who referred to the referral university hospital in Tehran, the capital of Iran, were included in the study. Two hundred patients over 20 years of age were divided into two equal groups to receive one or two doses of morphine as a controlled clinical trial. Randomization was performed based on simple block randomization. Both patients and physicians were double-blinded to the onedose and two-dose groups, and there was a code over each 400

Primary Data Analysis Descriptive statistics are reported as frequency and percent for categorical data and as mean and SD for continuous data. Means were compared using a t test for normally distributed data or the nonparametric Mann-Whitney U or Wilcoxon signed-ranks tests for data not fitting the assumptions of parametric testing. The data were tested for normality using the Kolmogorov-Smirnov normality test. Covariate analysis was used to assess the effect of possible confounding variables such as age, sex, and initial pain score. A sample size of 100 was calculated a priori for each treatment group to detect differences with 90% power with an a level of 0.05. Statistical analysis was conducted using the SPSS 16.0 software (SPSS, Inc., Chicago, IL).

Outcome Measures The primary outcome measure, the between-group difference in mean before-after change in pain score at 30 and 60 minutes among patients randomized to receive either morphine at 0.05 mg/kg or placebo, was calculated as follows: The change in VAS from 30 to 60 minutes was calculated for each subject. The mean change in VAS was calculated for each treatment group. The difference between the mean changes in VAS for the two groups was calculated with 95% CI. A minimum clinically significant change in patient pain severity was defined a priori as a change of 40% on the VAS. Secondary outcome measures included adverse events, which were defined a priori as respiratory depression, hypotension, tachycardia, vomiting, decreased consciousness, and urinary retention.

RESULTS Two hundred patients were enrolled in our study. Random allocation resulted in 100 patients assigned to the 0.10 mg/kg morphine group and 100 assigned to the 0.15 (0.10 + 0.05) mg/kg group. All patients received the initial morphine dose of 0.10 mg/kg, and all the patients allocated to the 0.15 mg/kg group received the second bolus of the study drug. Baseline characteristics of the study groups are described in Table 1; Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


Farsi et al. Acute pain management in limb traumatized patients

Table 1. Baseline characteristics of the study group Characteristics

0.10 mg/kg group (n=100)

0.15 mg/kg group (n=100)

32.8 (30.4-35.2)

33.1 (30.3-35.9)

Mean age, y (range)

Sex, n (%)

Male

82 (82)

76 (76)

Female

18 (18)

24 (24)

these characteristics were balanced among the two treatment protocols. The VAS scores at the three time points at which pain was assessed and between the two doses of morphine are demonstrated in Table 2. No significant difference was found between the two groups at 30 minutes, indicating the same effect of the 0.10 mg/kg initial bolus administered to both groups. Statistical analysis of pain score revealed a significant reduction in final pain after 1 hour in the 0.15 mg/kg compared to the 0.10 mg/kg group (p<0.05). In other words, injection of half a dose of the first injection (0.05 mg) morphine compared with the water 30 minutes after the initial standard dose of 0.10 mg/kg morphine significantly decreased pain in patients with acute limb trauma. In addition, there was a significant improvement in the mean pain score in the same group (p<0.05). The percent of pain reduction in the intervention and control groups relative to the basic measures was 52.70% and 35.82%, respectively. Adverse effects were present in both groups; however, there was no significant difference between the two groups (Table 3). None of the patients in either group received naloxone for reversal of opioid effects. Hypotension occurred in 12 patients, half of which were males. Eighteen patients had one episode of vomiting, 12 of which occurred in males. Nine patients had a fall in consciousness level indicated by a GCS score of 14/15, and 7 of these cases were males. We had 22 incidences of tachycardia, 14 of which occurred in males. We observed no cases of respiratory depression or urinary retention. None of our study population required intubation.

DISCUSSION This study was conducted to compare the safety and analgesic efficacy of two morphine sulfate dosages (0.10 mg/kg versus 0.15 mg/kg) in adult patients with acute limb trauma. We were able to demonstrate a significant (p<0.05) decrease in pain scores in patients receiving 0.15 mg/kg, 30 minutes after administering the extra 0.05 mg/kg dose. Additionally, comparing the VAS scores at 30 and 60 minutes after baseline in each group showed significant pain reduction in the intervention group (p<0.05) and no significant difference in the control group. There have been few studies on the ideal dosage of opioids for management of acute pain. One such study determining the best intravenous morphine titration protocol by comparing two methods showed that receiving 0.10 mg/kg morphine then 0.05 mg/kg every 5 minutes intravenously is associated with more pain relief than receiving half the amount for each dose.[14] Another study quantifying the analgesic effect of a 0.10 mg/kg dose of intravenous morphine to ED patients presenting in acute, severe pain suggested that this dosage may be inadequate for pain management.[10] The method of morphine administration is also of question. In some studies, a loading dose is administered followed by intravenous morphine titration every 5 minutes.[10,14,15] Other studies suggest starting treatment with a titration regimen in order to monitor and minimize adverse effects.[15,16] Morphine and fentanyl are among the most widely used and studied analgesics for trauma patients in the ED. A randomized double-blinded study comparing morphine and fentanyl

Table 2. Mean pain score (using visual analogue scale) by group at baseline, 30 minutes, and 60 minutes Visual Analogue Scale

0.10 mg/kg group (n=100)

0.15 mg/kg group (n=100)

Mean±SD (range)

Mean±SD (range)

p

Baseline score before first morphine dose

8.04±2.238 (7.6-8.48) 7.95±2.194 (7.53-8.37) >0.05

Score at 30 min (30 min after first morphine dose)

5.2±2.558 (4.69-5.71)

Score at 60 min (30 min after study drug)

5.16±2.74 (4.62-5.7) 3.76±3.198 (3.13-3.39) *<0.05

5.69 ± 2.529 (5.19-6.19) >0.05

SD: Standard deviation; *Considered statistically significant.

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

401


Farsi et al. Acute pain management in limb traumatized patients

Table 3. Comparison of adverse effects in two groups of one- versus two-dose morphine injection for acute pain of limb trauma 60 minutes after baseline (30 minutes after placebo vs. 0.05 mg/kg morphine administration) Adverse effect

0.10 mg/kg 0.15 mg/kg group (n=100) group (n=100)

Hypotension No

96

92

Yes

4

8

No

92

86

Yes

8

14

No

92

90

Yes

8

10

No

96

95

Yes

4

5

No

100

100

Yes

0

0

No

100

100

Yes

0

0

Tachycardia

Vomiting

Decreased level of consciousness

Respiratory depression

Urinary retention

in a prehospital setting demonstrated the two drugs were comparable in treating severe, acute pain in a prehospital setting during the first 30 minutes in spontaneous breathing patients.[17] The minimum clinically significant difference in pain reduction has been determined for pain scaling methods through extensive studies.[18-21] Accordingly, various meaningful percentages or cut-off points for pain reduction scores have been defined ranging from 33%[22] to 50%.[23] In a study aimed to categorize declines in pain intensity and percent pain reduction, a 20% reduction in pain score corresponded to ‘minimal’ improvement, a 35% reduction to ‘much’ improvement, and a 45% reduction corresponded to ‘very much’ improvement.[24] Overall, it can be assumed that a decrease of 40% is an acceptable pain reduction threshold. According to our study, the mean reduction in pain score was 52.7%, which is well above the threshold. The reduction in the control group was 35.82%. It can therefore be concluded that a single 0.10 mg/kg dose of morphine is minimally effective for pain management in patients with acute limb trauma as previously concluded,[10] whereas administering a cumulative 0.15 mg/kg morphine dose by adding a second dose of 0.05 mg/kg 30 minutes after the initial dose significantly increases the analgesic efficacy. 402

In this study, we also attempted to compare the safety and side effects of the two treatment protocols. Administration of 0.15 mg/kg of morphine was not associated with a statistically or clinically significant increase in adverse effects. We found that a 50% increase in analgesia lead to increased pain relief, without increasing the risk of potential adverse events. Our results support the superior analgesic effect of 0.15 mg/ kg morphine over the commonly used 0.10 mg/kg dose. It can be concluded that the maximum potential effect of morphine is exceeded at doses above 0.10 mg/kg, with higher doses providing additional effect, as observed in our study. Our findings are consistent with those of previous studies assessing the relationship between analgesia and the amount of morphine administered.[25] It was concluded by Aubrun et al.[25] that the VAS score does not markedly change until the morphine dose approaches that dose ultimately needed to obtain pain relief, and abruptly decreases afterwards. According to this hypothesis, acute pain reduction in response to increased administration of opioids may follow a stepwise pattern in which an analgesic threshold must be reached before patients can perceive clinically meaningful additional relief. Patients in severe pain may need to receive a “threshold” amount of morphine before it is possible for them to recognize and report that a minimal clinically important improvement in pain severity has occurred. The finding that a dose of 0.15 mg/kg of morphine provided superior pain relief to a dose of 0.10 mg/kg is consistent with this hypothesis, indicating that 0.15 mg/kg is the analgesic threshold for a further clinically significant decrease in VAS for a substantial number of patients. On the other hand, there is a similar study that is in discrepancy with our concluded optimal dose. In a randomized controlled trial, the effectiveness of 0.15 mg/kg intravenous morphine was also compared with that of 0.1 mg/kg in adult ED patients with acute pain.[26] The 0.15 mg/kg group achieved a statistically superior analgesic response at 60 minutes, with a mean between-group difference of 0.8 on the Numerical Rating Scale (NRS). However, this difference did not reach the 1.3-point threshold for being clinically superior. The authors suggested that a possible next step would be to study even higher doses of morphine. There are several potential explanations for the discrepancies. First of all, the study population in the mentioned study consisted of 280 patients 21-65 years of age, presenting to the ED with pain of less than or equal to seven days’ duration with heterogeneous causes. As indicated in the study, it is possible that different conditions involve different pain production and perception pathways and that not all are equally responsive to morphine. We narrowed our study cases to a more homogeneous population consisting of 200 patients with acute limb trauma pain of less than three days’ duration. Another influential factor is the different pain measurement scales used in our studies. We used VAS instead of the verbally administered numeric rating scale (VNRS) previously administered. A recent comparison of VAS and VNRS in the assessment of acute pain Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


Farsi et al. Acute pain management in limb traumatized patients

in the ED showed a strong correlation between VAS and VNRS (rs=0.93). However, there was not perfect agreement between the two scales. VAS and VNRS were therefore not interchangeable in assessing an individual patientâ&#x20AC;&#x2122;s pain over time in the ED setting, with VNRS having practical advantages over VAS in this setting.[27] Nevertheless, the 50% reduction in pain score considered as a threshold was achieved with our study protocol. The possible impact of cultural influences on pain perception and expression may also have contributed to our different results. There was general agreement with previous studies[14,26] in terms of safety and adverse effects of our study dosage. In randomized evaluations of pain management, we must, for ethical reasons, assure that adequate rescue analgesia is available to all patients, regardless of whether they receive the investigative drug. For this reason, we excluded from the study patients who required additional doses of analgesics or rescue analgesia. Use of rescue therapy has been reported to affect visual analogue scores, side effects and discharge times, lead to underestimation of symptom duration and severity, and increase the number of dropouts. There is no general agreement as to the ideal method of assessing pain scores in this context. The population of our study was limited to adult patients over 20 years of age with limb trauma. As such, our results cannot be extrapolated to the pediatric or elderly population or to patients presenting with other causes of pain. In conclusion, according to our study, using two doses of morphine instead of one is a safe and effective method for pain reduction in isolated limb trauma. Therefore, it is recommended to perform a second injection of 0.05 mg/kg morphine 30 minutes after the initial standard dose of 0.10 mg/kg to decrease pain in patients with acute limb trauma.

Acknowledgement This paper was the thesis of Dr. Mitra Movahedi, under guidance of the first author, to achieve a specialist degree in Emergency Medicine. Conflict of interest: None declared.

REFERENCES 1. Cordell WH, Keene KK, Giles BK, Jones JB, Jones JH, Brizendine EJ. The high prevalence of pain in emergency medical care. Am J Emerg Med 2002;20:165-9. 2. Ducharme J. Acute pain and pain control: state of the art. Ann Emerg Med 2000;35:592-603. 3. Carr DB, Goudas LC. Acute pain. Lancet 1999;353:2051-8. 4. Ripamonti C, De Conno F, Blumhuber H, Ventafridda V. Morphine for relief of cancer pain. Lancet 1996;347:1262-3. 5. Patanwala AE, Keim SM, Erstad BL. Intravenous opioids for severe acute pain in the emergency department. Ann Pharmacother 2010;44:1800-9.

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

6. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med 1989;7:620-3. 7. Beel TL, Mitchiner JC, Frederiksen SM, McCormick J. Patient preferences regarding pain medication in the ED. Am J Emerg Med 2000;18:37680. 8. Todd KH, Ducharme J, Choiniere M, Crandall CS, Fosnocht DE, Homel P, et al. Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI) multicenter study. J Pain 2007;8:460-6. 9. Rupp T, Delaney KA. Inadequate analgesia in emergency medicine. Ann Emerg Med 2004;43:494-503. 10. Bijur PE, Kenny MK, Gallagher EJ. Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients. Ann Emerg Med 2005;46:362-7. 11. Evans E, Turley N, Robinson N, Clancy M. Randomised controlled trial of patient controlled analgesia compared with nurse delivered analgesia in an emergency department. Emerg Med J 2005;22:25-9. 12. Simonnet G, Rivat C. Opioid-induced hyperalgesia: abnormal or normal pain? Neuroreport 2003;14(1):1-7. 13. AHFS drug information. August 6, 2012]; Available from: http://www. online.statref.com/Document/document.aspx?DocID=1&StartDoc=1 &EndDoc=1266&FxID=1&offset=7&sessionID=71C263NJIHVOII XH. 14. Bounes V, Charpentier S, Houze-Cerfon CH, Bellard C, DucassĂŠ JL. Is there an ideal morphine dose for prehospital treatment of severe acute pain? A randomized, double-blind comparison of 2 doses. Am J Emerg Med 2008;26:148-54. 15. Aubrun F, Valade N, Riou B. Intravenous morphine titration. [Article in French] Ann Fr Anesth Reanim 2004;23:973-85. [Abstract] 16. Lvovschi V, Aubrun F, Bonnet P, Bouchara A, Bendahou M, Humbert B, et al. Intravenous morphine titration to treat severe pain in the ED. Am J Emerg Med 2008;26:676-82. 17. Galinski M, Dolveck F, Borron SW, Tual L, Van Laer V, Lardeur JY, et al. A randomized, double-blind study comparing morphine with fentanyl in prehospital analgesia. Am J Emerg Med 2005;23:114-9. 18. Todd KH, Funk KG, Funk JP, Bonacci R. Clinical significance of reported changes in pain severity. Ann Emerg Med 1996;27:485-9. 19. Gallagher EJ, Liebman M, Bijur PE. Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Ann Emerg Med 2001;38:633-8. 20. Bijur PE, Latimer CT, Gallagher EJ. Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department. Acad Emerg Med 2003;10:390-2. 21. Kendrick DB, Strout TD. The minimum clinically significant difference in patient-assigned numeric scores for pain. Am J Emerg Med 2005;23:828-32. 22. Farrar JT, Portenoy RK, Berlin JA, Kinman JL, Strom BL. Defining the clinically important difference in pain outcome measures. Pain 2000;88:287-94. 23. Forouzanfar T, Weber WE, Kemler M, van Kleef M. What is a meaningful pain reduction in patients with complex regional pain syndrome type 1? Clin J Pain 2003;19:281-5. 24. Cepeda MS, Africano JM, Polo R, Alcala R, Carr DB. What decline in pain intensity is meaningful to patients with acute pain? Pain 2003;105:151-7. 25. Aubrun F, Langeron O, Quesnel C, Coriat P, Riou B. Relationships between measurement of pain using visual analog score and morphine requirements during postoperative intravenous morphine titration. Anesthesiology 2003;98:1415-21. 26. Birnbaum A, Esses D, Bijur PE, Holden L, Gallagher EJ. Randomized double-blind placebo-controlled trial of two intravenous morphine dos-

403


Farsi et al. Acute pain management in limb traumatized patients ages (0.10 mg/kg and 0.15 mg/kg) in emergency department patients with moderate to severe acute pain. Ann Emerg Med 2007;49:445-53, 453.e1-2.

27. Mohan H, Ryan J, Whelan B, Wakai A. The end of the line? The Visual Analogue Scale and Verbal Numerical Rating Scale as pain assessment tools in the emergency department. Emerg Med J 2010;27:372-5.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Ekstremite yaralanması olan hastalarda intravenöz 0.10 mg/kg veya 0.15 mg/kg morfin sülfat ile akut ağrı tedavisi: Randomize çift kör plasebo kontrollü çalışma Dr. Davood Farsi,1 Dr. Mitra Movahedi,2 Dr. Peyman Hafezimoghadam,3 Dr. Saeed Abbasi,3 Dr. Abtin Shahlaee,4,5 Dr. Vafa Rahimi-Movaghar4 Tahran Üniversitesi Tıp Bilimleri, Hazrat-e-rasool Akram Sağlık Kompleksi, Tahran, İran Hormozgan Üniversitesi Tıp Bilimleri, Shahid Mohammadi Hastanesi, Bandar Abbas, Iran 3 Tahran Üniversitesi Tıp Bilimleri, Acil Tıp Bölümü, Tahran, İran 4 Tahran Üniversitesi Tıp Bilimleri, Sina Hastanesi, Sina Travma ve Cerrahi Araştırma Merkezi, Tahran, İran 5 Tahran Üniversitesi Tıp Bilimleri, Bilimsel Araştırma Merkezi Öğrencisi, Tahran, İran 1 2

AMAÇ: Akut ekstremite yaralanması olan hastalarda erişkin acil serviste yapılan iki ayrı morfin dozunun ağrı giderimi ve güvenliliğini karşılaştırmak. GEREÇ VE YÖNTEM: Opiyoit analjesisine gerek duyan 200 acil servis hastası randomize olarak iki gruba ayrıldı. Bu randomize çift-kör, plasebo kontrollü çalışmada intravenöz yolla 0.10 mg/kg dozda morfin ve daha sonra hastaların bir bölümüne 0.05 mg/kg IV dozda morfin veya aynı miktarda plasebo verildi. Başlangıçta (0.10 mg/kg morfin vermeden önce), 30 (çalışma ilacı verilmeden hemen önce) ve 60 dakika sonra Görsel Analog Ölçekle ağrının şiddet derecesi ve yan etkiler değerlendirildi. BULGULAR: Başlangıca göre 30. dakikada önemli bir farklılık saptanmadı. Morfinin 0.15 mg/kg dozda yapıldığı grupta diğer gruba (0.10 mg/kg doz grubu) göre bir saat sonra ağrı anlamlı derecede azalmıştı (p<0.05). Bu grubun ağrı skorunda önemli bir iyileşme vardı (p<0.05). Girişim ve kontrol grubunda ağrı sırasıyla %52.70 ve %35.82 oranında azalmıştı. Her iki grupta gözlemlenen yan etkiler açısından istatistiksel açıdan anlamlı bir fark yoktu. TARTIŞMA: İki morfin dozu yerine tek doz morfin uygulaması ekstremite yaralanmalarında ağrı giderimi açısından güvenli ve etkili bir yöntemdir. Bu hastalarda ağrıyı azaltmak için ilk standart 0.10 mg/kg dozdan 30 dakika sonra 0.05 mg/kg dozda morfin verilmesini önermekteyiz. Anahtar sözcükler: Akut ağrı, acil tıp, randomize kontrollü çalışma. Ulus Travma Acil Cerr Derg 2013;19(5):398-404

404

doi: 10.5505/tjtes.2013.86383

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


ORIGIN A L A R T IC L E

Management of penetrating injuries of the upper extremities Oscar JF Van Waes, M.D.,1 Pradeep H Navsaria, M.D.,2 Renske CM Verschuren,1 Laurens C Vroon,1 Esther MM Van Lieshout, MSc. Ph.D.,1 Jens A Halm, M.D. Ph.D.,1 Andrew J Nicol, M.D. Ph.D.,2 Jefrey Vermeulen, M.D., MSc., Ph.D.3 1

Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands

2

Trauma Unit, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa

3

Trauma Surgery, Admiraal De Ruyter Hospital, Goes, The Netherlands

ABSTRACT BACKGROUND: Routine surgical exploration after penetrating upper extremity trauma (PUET) to exclude arterial injury leads to a large number of negative explorations and iatrogenic injuries. Selective non-operative management (SNOM) is gaining in favor for patients with PUET. The present study was undertaken to assess the validity of SNOM in PUET and to present a practical management algorithm. METHODS: All consecutive patients presenting to a tertiary referral center following PUET were included in this prospective observational cohort study. Patients were managed along Advanced Trauma Life Support (ATLSŠ) guidelines, and based on clinical manifestations, either underwent emergency surgery or were treated conservatively with or without additional diagnostic investigations. Computed tomography angiography (CTA) was indicated by a preset protocol based on the physical examination. RESULTS: During the four-month study period, 161 patients with PUET were admitted. Sixteen (9.9%) patients underwent emergency surgery, revealing 14 vascular injuries. Another 8 (5.0%) patients underwent vascular exploration following CTA. The remaining patients (n=137) were managed non-operatively for vascular matters. Eighteen (11.2%) patients required semi-elective surgical intervention for fractures or nerve injuries. During the follow- up, no missed vascular injuries were detected. CONCLUSION: Neither routine exploration nor routine CTA is indicated after PUET. Stable patients should undergo additional investigation based on clinical findings only. SNOM is a feasible and safe strategy after PUET.

Key words: Emergency surgery, penetrating trauma, upper extremity, vascular injury.

INTRODUCTION Penetrating injuries to the extremities account for about 50% of penetrating traumas, but overall they are still very uncommon in West European countries.[1,2] The low incidence makes it difficult for trauma surgeons to gain experience in its management. Moreover, patients with penetrating injury

Address for correspondence: Jefrey Vermeulen, M.D. â&#x20AC;&#x2DC;s Gravenpolderseweg 114 4462RA, Goes, The Netherlands Tel: +31(0)621440809 E-mail: j.vermeulen.1@erasmusmc.nl Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):405-410 doi: 10.5505/tjtes.2013.08684 Copyright 2013 TJTES

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

usually present unexpectedly to the emergency department. This could lead to an inappropriate preparation for assessment, especially when the hospital is not an allocated trauma center for such trauma with a protocol treatment strategy. Penetrating upper extremity trauma (PUET) is considered a difficult injury to manage because vascular and nerve injuries are serious and may significantly impair the patient outcome. [2,3] In the past, routine emergent exploration was common practice for the deeper penetrating trauma, resulting in a large number of unnecessary extremity explorations and iatrogenic injuries.[1,4] Although rapid detection, localization and specification of a vascular injury in these patients are essential for the effective management of PUET, it is ill-advised to perform diagnostic computed tomography angiography (CTA) or conventional angiography in every patient.[5-7] Over 90% of CTAs in these patients will be negative, representing a large cost as a screening tool.[7] 405


Van Waes et al. Selective non-operative management is safe

Based on the experience from high-volume hospitals in developing countries, selective screening based on physical examination is gaining in favor. The accuracy of the physical examination to detect vascular injury is very high in patients after penetrating trauma.[6,8-10] Hard signs of a vascular injury (Table 1) mandate emergent surgical exploration, or, when the patient is hemodynamically stable, endovascular treatment could be considered.[7,11] Diagnostic CTA is indicated in hemodynamically stable patients with clinical signs of vascular injury (Table 1). Similar to the case with penetrating trauma in other body regions, a selective non-operative management (SNOM) protocol should be used in PUET.[2,8,9] Without signs of vascular impairment in PUET, a conservative observational strategy is likely.[8] The present study was undertaken to assess SNOM in PUET in a tertiary referral trauma center (Groote Schuur Hospital, Cape Town), to which over 800 patients with penetrating trauma of the extremities present each year. Based on the results, a management algorithm is proposed and adjusted towards health care in western countries.

MATERIALS AND METHODS To create a database, details of all consecutive patients presenting with PUET to the Trauma Center at Groote Schuur Hospital in Cape Town, South Africa, from 6 June 2011 to 2 October 2011 (4 months) were prospectively collected using standardized data forms. Inclusion criteria were patients with PUET and age over 18 years. The range of injury that was included was from below the axilla up to the wrist of the upper extremity. Patients who died within 24 hours (hrs) due to other injuries were excluded from the study. Amongst others, age, gender, mechanism of injury, type of injury (vascular, orthopedic, nerve), clinical manifestations and vitals, indications for additional investigations, treatment strategy, and outcome of all patients were collected and analyzed. All patients were initially resuscitated along Advanced Trauma Life Support (ATLS) guidelines. Hemodynamically stable patients and patients who stabilized after immediate simple resuscitation were first evaluated with a thorough history and clinical examination. Wounds were described by different anatomic zones of the arm (upper or lower arm, elbow or cubital fossa, anterior-posterior, medial-lateral). Special investigations were requested when indicated by a preset protocol based on history and clinical manifestations. A routine X-ray was performed in case of gunshot injuries. Indications for CTA were symptoms suggesting vascular injury (hard and soft signs) as found by clinical examination of the upper extremities (Table 1) in the presence of a viable limb. If any severe injury was found by additional investigations and surgical care was needed, patients were immediately transferred to the operating room for surgical intervention. 406

Table 1. Signs of arterial injury Hard signs Active hemorrhage Absent distal pulses or ischemia Expanding or pulsatile hematoma Bruit or thrill Soft signs Subjective reduced or unequal pulses Large non-pulsatile hematoma Orthopedic injuries carrying a high index of suspicion of vascular injury Neural injury History of bleeding

Hemodynamically stable patients with a negative history and clinical examination suggestive of vascular injury were admitted to the trauma surgical ward for observation and were discharged after 24 hours. All patients were informed about alarm symptoms of vascular injury; if these occurred, patients were advised to return to the hospital immediately. Hemodynamically unstable patients and those with ischemia were immediately transferred to the operating room. In actively bleeding patients, hemorrhage control was attempted by using Foley catheter balloon tamponade (FCBT).[12] If hemorrhage control was not established, surgical exploration of the injured arm followed immediately. If hemorrhage was controlled by FCBT, CTA was performed to detect major arterial injury and, if positive, patients could still be transferred to the operating room or were treated by endovascular options. Without any serious arterial injury, the patient was observed for 24-48 hrs, after which the Foley catheter was removed in the operating room. In case of re-bleeding, surgical intervention was performed.

RESULTS A total of 162 patients with PUET presented during the four-month study period. One patient died of accompanying abdominal bleeding within 24 hrs after admission and was excluded from the study. Some patients had multiple wounds to the upper extremities, with a total of 179 wounds in 161 patients (Table 2). Stab wounds (SW) or deeper penetrating glass wounds were found in 128 (79.5%) patients (145 arms) and gunshot wounds (GSW) in the remaining 33 (20.5%) patients (34 arms). Sixteen (9.9%) patients underwent emergency exploration because of active bleeding or hemodynamic instability not improving during initial resuscitation or due to other reasons mentioned in Table 3. In all but two patients, an arterial injury was detected during exploration that required repair. A total of 24 (14.9%) patients underwent CTA (Table 3) for a Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


Van Waes et al. Selective non-operative management is safe

Table 2. Demographics of 161 patients with penetrating upper extremity injury

Table 3. Indications and results of emergent surgical exploration or additional vascular investigations

Sex ratio (Male/Female) Number of upper extremities injured Median age, years (range) Penetrating upper extremity injury Deep glass injury Stab wound Gunshot wound Zone of extremity injury Right arm Upper Elbow, cubital fossa Lower Upper and lower Left arm Upper Elbow, cubital fossa Lower Upper and lower Bilateral injury Suspected extremity injury Vascular Emergent exploration¹ Computed tomography angiography¹ Fracture X-ray² Nerve Physical examination² Accompanying penetrating injury Neck Neck and chest Chest Abdomen Chest and abdomen Thigh

Indication for emergency exploration

140/21 179 27 (16-71) 13 132 34

30 6 25 4 53 4 40 11 6

16 (14) 24 (11) 19 (10) 35 (11) 14 4 19 12 6 6

1: Values in parentheses are numbers of positive findings; 2: Values in parentheses are numbers of surgical interventions because of injury.

suspected vascular injury. In 2 patients, CTA was performed without relevant indication and neither showed any vascular injury. A total of 3 patients were initially treated with FCBT because of active bleeding. In 1 patient, hemostasis could not be achieved, and the patient was subsequently emergently surgically treated. The other 2, in whom hemostasis was achieved, were observed and underwent diagnostic CTA within 24 hrs. Only 1 of these patients showed an arterial injury, which was repaired during semi-elective exploratory surgery. The Foley catheter of the patient, who did not need to undergo surgery, was removed in the operating room 2 days after the patient’s presentation, and no re-bleeding occurred. Overall, 16 (9.9%) patients underwent emergency exploration of the upper extremity, including two negative exploUlus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

Active hemorrhage or shock Absent pulses Foley catheter balloon tamponade failure Hematoma accompanied with neural injury Indication for computed tomography angiography Absent or diminished pulses Large hematoma Foley catheter balloon tamponade Bruit Injury at cubital fossa Fracture and neural injury Not specified

n 4 (4) 3 (3) 1 (1) 8 (6) n 12 (6) 3 (2) 2 (1) 1 (1) 3 (1) 1 (0) 2 (0)

Values in parentheses are numbers of positive findings of arterial injury.

rations. Eventually, another 8 (5.0%) patients underwent elective surgery for a vascular injury (Table 4); no patients were treated with radiological intervention. One hundred and thirty-seven (85.1%) patients underwent non-operative management with observation only. Following observation, none of the patients subsequently needed surgical intervention to treat (late-onset) vascular complications. Some of the later-mentioned patients did undergo surgical treatment by orthopedics (n=10) or plastic or neurosurgeons (n=8). In 3 patients, the plastic surgeon joined the trauma surgeon during emergent exploration to repair a nerve injury primarily. The median hospital stay was 4 days (range, 1-30 days). Longer hospital stay was related to associated injuries as listed in Table 2. One patient died of abdominal sepsis after penetrating chest and abdominal injury. Upper extremity-related complications were surgical site infection in 8 of the patients that underwent surgery. Loss of function or other nerve impairment was found in only 5 patients, besides the 11 patients that underwent surgical repair of damaged nerves. Long-term functional outcome of these 11 patients was not known at the end of this study. Fractures of the upper extremity after penetrating injury were almost exclusively found after GSW. In 1 patient, an ulnar shaft fracture was found in a patient with SW in combination with blunt assault.

DISCUSSION In the Netherlands, as in the rest of West Europe, the incidence of penetrating injury is rather low. In Dutch trauma centers, there is definitely much less experience with the management of PUET than, for example, in the United States or South Africa. Due to this low incidence, it is not possible for a trauma surgeon to gain experience with the manage407


Van Waes et al. Selective non-operative management is safe

Table 4. Summary of arterial injuries and their management Site of injury

Treatment

During emergency exploration Brachial artery Venous interposition graft with fasciotomy (5) Primary repair (3) Primary repair with fasciotomy (3) Radial artery Ligation (2) Ligation with fasciotomy After computed tomography angiography Axillary artery Occlusion Primary repair False aneurysm Primary repair Brachial artery Occlusion Venous interposition graft (2) AV fistula with basilica vein Venous interposition graft Active bleeding Primary repair (2) False aneurysm Primary repair False aneurysm Conservative Posterior circumflex humeral artery Active bleeding Conservative Ulnar artery False aneurysm Conservative Values in parentheses are number of patients, if more than one.

ment and treatment of this kind of trauma. Protocol management of PUET is lacking, causing obscurity, disagreement in diagnostic and treatment options, and an insufficient or incomplete management of this trauma patient. The lack of protocol assessment of patients suffering PUET increases the risk of mistakes and hampers good outcome.

vascular injuries. An advantage of using angiography, however, is the possibility of interventional procedures, if indicated, during the same session. Nevertheless, for diagnostic evalua-

In trauma centers that do treat a high number of patients with penetrating trauma, SNOM is becoming more and more accepted.[6,8] SNOM is based on clinical examination and additional investigations. Together, they have shown to be a reliable indicator of clinically significant injury, with a sensitivity of 99% and a negative predictive value of 99% in patients with PUET.[5,13] The present study was done in a high-volume, tertiary referral trauma center for penetrating injuries, which manages about 800 patients with penetrating extremity injury each year. The management protocol for assessing and treating patients with PUET is based essentially on hemodynamic status, together with a thorough physical examination. Initial management of GSW and SW is similar, except that X-ray to rule out a fracture of the upper extremity is standard care in GSW patients. Adjuvant CTA is only indicated based on hard and subtle signs of vascular injury found during clinical assessment in hemodynamically stable patients. At present, in most trauma centers, CTA has replaced angiography as the preferred diagnostic tool in assessment of 408

Figure 1. Computed tomography angiography of a patient without peripheral pulses on physical examination, showing an occlusion of the brachial artery, which was subsequently surgically reconstructed with venous interposition grafting.

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


Van Waes et al. Selective non-operative management is safe

tion of PUET, CTA has several advantages over conventional angiography.[14,15] It is relatively fast, minimally invasive, has fewer potential complications, and is available in most trauma centers in western countries. Moreover, no support of additional physician staff is required, unlike with conventional angiography, and structures other than vascular structures can be visualized on CTA (Figure 1). Most important, it is a reliable and accurate investigation with a sensitivity and specificity of over 90% and 100%, respectively, a positive predictive value of almost 100%, and a negative predictive value of 98%.[16,17] Therefore, CTA is more and more becoming the diagnostic tool of choice during the initial evaluation of stable patients with vascular injury and thus very useful in patients with PUET. In this study, the SNOM protocol for penetrating extremity injury was correctly executed with good persistence. Violation of the hospital protocol was noted in a total of 10 patients. Two patients with no signs of vascular injury underwent CTA. As neither showed vascular lesions, they were successfully treated conservatively. On the other hand, eight patients with hematoma accompanied by nerve injury underwent immediate surgical exploration. As they were hemodynamically stable, they should have undergone protocol CTA. Two of those patients showed no vascular injury during exploration, and surgery could have been withheld if CTA had been performed. The use of FCBT has been shown to be beneficial in penetrating injury of the neck and extremities.[12,18] This procedure allows for rapid hemorrhage control and stabilization of patients, giving the opportunity to visualize any vascular injury on CTA. Especially venous injuries are compliant to FCBT, and in those patients, FCBT is often the definitive treatment.[12] If hemostasis cannot be achieved by FCBT, emergency exploration is indicated. Alternatively, temporary hemorrhage control can be achieved by using a tourniquet or hemostatic dressings before surgery or FCBT. After FCBT, diagnostic CTA should be performed; CTA is useless with a tourniquet in place. In this study, FCBT was used in three patients, of whom one failed, and the patient subsequently underwent emergent exploration with brachial artery repair. Vascular observational management after PUET was applied in 85% of patients without or after CTA assessment. During the follow-up, none of the patients who was conservatively treated and observed presented with a missed vascular injury. This indicates that initial conservative management (or SNOM) of patients with PUET is feasible and safe. The total surgical treatment rate was 26% (24 vascular injuries, 10 fractures, 8 exclusive nerve injuries), indicating that PUET should be considered a serious injury that requires intensive and thorough assessment of the arm.[19] The prevalence of vascular injury after PUET that requires intervenUlus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

Penetrating Upper Extremity Injury

ATLS

Active bleeding? Yes No

Foley balloon tamponade

Shock? GSW

No

X-ray

Foley catheter, Active bleeding, Large hematoma, Thrill, Bruit, Pulse deficit, Fracture, Neural injury Yes Yes

Exploration

CTA

Endovascular treatment

No

Observation

Figure 2. Algorithm for initial management of patients with penetrating upper extremity injury. ATLS: Advanced Trauma Life Support; GSW: Gunshot wounds; CTA: Computed tomography angiography.

tion is 15%. Frequently, PUET is associated with penetrating injuries (this study, in 38% of cases) that possibly need to be managed first or that distract the physicianâ&#x20AC;&#x2122;s attention away from the injuries of the upper extremity. Eventually missed or even delayed assessment of PUET may significantly impair patient outcome. This is best prevented by protocol-driven management strategies. In penetrating trauma, the different protocols could be combined. In summary, clinical examination has a high negative predictive value for the absence of any injury, and can therefore dictate CTA to prove or exclude clinically significant vascular injuries in PUET. The low failure rate in this study further validates the SNOM protocol for initial management of PUET. Following the results of this study, we present a simple and practical algorithm for the initial management of PUET in western countries (Figure 2). Vascular assessment after GSW should not be different from that of SW, although one must realize that the severity of injury usually is more extensive due to high energy, and an X-ray is performed to exclude a fracture. Conflict of interest: None declared. 409


Van Waes et al. Selective non-operative management is safe

REFERENCES

Upper extremity arterial injuries: factors influencing treatment outcome. Injury 2009;40:815-9.

1. Doody O, Given MF, Lyon SM. Extremities-indications and techniques for treatment of extremity vascular injuries. Injury 2008;39:1295-303.

11. Stone WM, Fowl RJ, Money SR. Upper extremity trauma: current trends in management. J Cardiovasc Surg (Torino) 2007;48:551-5.

2. Manthey DE, Nicks BA. Penetrating trauma to the extremity. J Emerg Med 2008;34:187-93.

12. Navsaria P, Thoma M, Nicol A. Foley catheter balloon tamponade for life-threatening hemorrhage in penetrating neck trauma. World J Surg 2006;30:1265-8.

3. Zellweger R, Hess F, Nicol A, Omoshoro-Jones J, Kahn D, Navsaria P. An analysis of 124 surgically managed brachial artery injuries. Am J Surg 2004;188:240-5. 4. Geuder JW, Hobson RW 2nd, Padberg FT Jr, Lynch TG, Lee BC, Jamil Z. The role of contrast arteriography in suspected arterial injuries of the extremities. Am Surg 1985;51:89-93. 5. Inaba K, Branco BC, Reddy S, Park JJ, Green D, Plurad D, et al. Prospective evaluation of multidetector computed tomography for extremity vascular trauma. J Trauma 2011;70:808-15. 6. Frykberg ER, Dennis JW, Bishop K, Laneve L, Alexander RH. The reliability of physical examination in the evaluation of penetrating extremity trauma for vascular injury: results at one year. J Trauma 1991;31:502-11. 7. Keen JD, Dunne PM, Keen RR, Langer BG. Proximity arteriography: cost-effectiveness in asymptomatic penetrating extremity trauma. J Vasc Interv Radiol 2001;12:813-21. 8. Dennis JW, Frykberg ER, Veldenz HC, Huffman S, Menawat SS. Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-year follow-up. J Trauma 1998;44:243-52. 9. Van Waes OJ, Cheriex KC, Navsaria PH, van Riet PA, Nicol AJ, Vermeulen J. Management of penetrating neck injuries. Br J Surg 2012;99:14954. 10. Dragas M, Davidovic L, Kostic D, Markovic M, Pejkic S, Ille T, et al.

13. Peng PD, Spain DA, Tataria M, Hellinger JC, Rubin GD, Brundage SI. CT angiography effectively evaluates extremity vascular trauma. Am Surg 2008;74:103-7. 14. Wallin D, Yaghoubian A, Rosing D, Walot I, Chauvapun J, de Virgilio C. Computed tomographic angiography as the primary diagnostic modality in penetrating lower extremity vascular injuries: a level I trauma experience. Ann Vasc Surg 2011;25:620-3. 15. Patterson BO, Holt PJ, Cleanthis M, Tai N, Carrell T, Loosemore TM; London Vascular Injuries Working Group. Imaging vascular trauma. Br J Surg 2012;99:494-505. 16. Miller-Thomas MM, West OC, Cohen AM. Diagnosing traumatic arterial injury in the extremities with CT angiography: pearls and pitfalls. Radiographics 2005;25:133-42. 17. Seamon MJ, Smoger D, Torres DM, Pathak AS, Gaughan JP, Santora TA, et al. A prospective validation of a current practice: the detection of extremity vascular injury with CT angiography. J Trauma 2009;67:238-44. 18. Ball CG, Wyrzykowski AD, Nicholas JM, Rozycki GS, Feliciano DV. A decade’s experience with balloon catheter tamponade for the emergency control of hemorrhage. J Trauma 2011;70:330-3. 19. Brown KR, Jean-Claude J, Seabrook GR, Towne JB, Cambria RA. Determinates of functional disability after complex upper extremity trauma. Ann Vasc Surg 2001;15:43-8.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Üst ekstremitelerin penetran yaralanmalarının tedavisi Dr. Oscar JF Van Waes,1 Dr. Pradeep H Navsaria,2 Renske CM Verschuren,1 Laurens C Vroon,1 Dr. Esther MM Van Lieshout,1 Dr. Jens A Halm,1 Dr. Andrew J Nicol,2 Dr. Jefrey Vermeulen1,3 Erasmus Üniversitesi Tıp Merkezi, Travma Cerrahisi Bölümü, Roterdam, Hollanda Cape Town Üniversitesi, Groote Schuur Hastanesi, Travma Bölümü, Cape Town, Güney Afrika 3 Admiraal De Ruyter Hastanesi, Travma Cerrahisi, Goes, Hollanda 1 2

AMAÇ: Arter yaralanmasını dışlayan üst ekstremite penetran yaralanmasının rutin cerrahi eksplorasyonu çok sayıda olumsuz sonuçlu açınımlara ve iyatrojenik yaralanmalara yol açmaktadır. Bu hastalarda seçici cerrahi dışı tedavi giderek daha fazla oranda benimsenmektedir. Bu çalışma bu cerrahi dışı tedavinin geçerliliğini değerlendirme ve pratik bir algoritma sunma amacıyla gerçekleştirilmiştir. GEREÇ VE YÖNTEM: Penetran üst ekstremite yaralanmaları ardından üçüncü basamak sevk merkezine gelen tüm ardışık hastalar bu ileriye dönük gözlemsel kohort çalışmasına alındı. Hastalar ATLS© kılavuzları ve klinik belirtilerine göre yönetildi, ya acil cerrahiye alındı veya ek tanısal araştırmalar yapılmadan veya gerekirse yapılarak konservatif tedavi uygulandı. Fiziksel incelemeye göre daha önce hazırlanan bir protokole uyarak bilgisayarlı tomografik anjiyografi (BTA) gerekli oldu. BULGULAR: Dört aylık çalışma döneminde penetran üst ekstremite yaralanması olan 161 hasta çalışmaya alındı. On dördünde damar yaralanmaları olan 16 (%9.9) hastaya acil cerrahi girişim yapıldı. Ayrıca 8 (%5) hastaya BTA sonrası vasküler eksplorasyon uygulandı. Geri kalan hastaların (n=137) vasküler sorunları cerrahi dışı yöntemlerle tedavi edildi. Kırıkları veya sinir yaralanmaları nedeniyle 18 (%11.2) yarı-seçici cerrahi girişim gerekti. İzlem döneminde herhangi bir damar yaralanmasının atlanmadığı belirlendi. TARTIŞMA: Üst ekstremitelerin penetran yaralanmalarından sonra rutin eksplorasyon veya BTA’ya gerek yoktur. Durumu stabil hastalar yalnızca klinik bulgularına göre ek araştırmalardan geçmelidir. Seçici cerahi dışı tedavi bu yaralanmalardan sonra uygun ve güvenli bir tedavi stratejisidir. Key words: Acil cerrahi, penetran yaralanma, üst ekstremite, damar yaralanması. Ulus Travma Acil Cerr Derg 2013;19(5):405-410

410

doi: 10.5505/tjtes.2013.08684

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


ORIGIN A L A R T IC L E

Microsurgical reconstruction in pediatric patients: a series of 30 patients Arzu Akçal, M.D.,1 Semra Karşıdağ, M.D.,2 Deniz Özgür Sucu, M.D.,2 Gürsel Turgut, M.D.,2 Kemal Uğurlu, M.D.2 1

Deparment of Plastic and Reconstructive Surgery, Akdeniz University Faculty of Medicine, Istanbul;

2

Deparment of Plastic and Reconstructive Surgery, Sisli Etfal Training and Research Hospital, Istanbul

ABSTRACT BACKGROUND: Free flap surgery in the pediatric population has gained widespread acceptance regarding its technical utility and reliability. Initial concerns as to the feasibility and reliability of the procedure in children were resolved over time. METHODS: Thirty children (15 boys, 15 girls) were treated in Sisli Etfal Training and Research Hospital, Plastic and Reconstructive Surgery Clinic. Their mean age was 10.8 years. Defects were located on the lower extremity (n=22), head and neck (n=5) and upper extremity (n=3). The etiologies of the defects included vehicle accident, sequelae of burn, traumatic contractures, crush injury, epulis in the maxilla, and gunshot wound. RESULTS: The free flaps performed in our series were latissimus dorsi muscle flap, combined latissimus dorsi and serratus muscle flaps, serratus anterior muscle flap, cross latissimus dorsi muscle flap, scapular osteomyocutaneous flap, parascapular fasciocutaneous flap, fibular osteocutaneous flap, anterolateral thigh flap, medial circumflex femoral artery perforator flap, and crista iliaca osteocutaneous flap. CONCLUSION: The advantages of free flaps in children, which include better adaptation of the flap growth and better learning capacity of the children, provide the surgeon with more satisfactory functional and aesthetic results. Key words: Free flap, pediatric population, perforator flap.

INTRODUCTION Free flaps are a useful reconstructive option in the management of soft tissue defects, even in the pediatric population.[1,2] Microsurgery was first performed in children in the mid 1970s, a few years after performing the procedure in adults. The first publications[1,2] were sporadic, suggesting the microsurgical transfer was possible in children.[3,4] Free flap surgery in the pediatric population has gained widespread acceptance after doubts about the technical utility and reliability of the procedure were resolved. Initial concerns as to the feasibility and

Address for correspondence: Arzu Akçal, M.D. Akdeniz Üniversitesi, Plastik ve Rekonstrüktif Cerrahi ABD., Kat: 2 Dumlupınar Bulvarı 07058 Kampüs, Antalya 07058 Antalya, Turkey Tel: +90 242 - 249 60 00 E-mail: ozcanarzu79@yahoo.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):411-416 doi: 10.5505/tjtes.2013.09515 Copyright 2013 TJTES

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

reliability of the procedure in children were readily overcome by the fact that the relative size of the pedicle vessels is larger than those in adults.[4] In absolute size, though, the vessels can be rather small, which means that flaps with sizable pedicles and a reliable anatomy were preferentially selected. However, different authors have published successful results of free tissue transfers in children in various clinical situations, proving the utility and effectiveness of the microsurgical procedure, with a success rate comparable to that of the adult group.[5,6] Perforator flaps have the advantage of well-known, sizable source vessels. Furthermore, their pedicles have enough length to allow for anastomoses out of the site of injury, and the skin islands cover the same area as conventional myocutaneous flaps, without any donor-site morbidity. The perforator vessels can be relatively small in children, though their relative size compared with the size of the child’s body is greater than that in adults.[7] Our current study reports a series of 30 free flaps performed in children for various reconstructions. Seven of these flaps were perforator flaps, which are valuable reconstructive options even in pediatric patients. 411


Akçal et al. Microsurgical reconstruction in pediatric patients

MATERIALS AND METHODS From January 1997 to January 2010, 30 children (15 boys, 15 girls) were treated in Sisli Etfal Training and Research Hospital, Plastic and Reconstructive Surgery Clinic. The children were assessed according to their age, sex, etiology of the defects, location of the defects, operation time, type of flap, recipient vessels, postoperative care, postoperative complications, follow-up period after the operation, and the childâ&#x20AC;&#x2122;s growth. The types of flap and anastomosis in the patients who developed complications were also examined. Seven patients reconstructed with perforator flap were investigated according to age, sex, etiology of the defect, localization of the defect, flap type, recipient artery, operation time, and complications.

RESULTS From January 1997 to January 2010, 30 children (15 boys, 15 girls) were treated. Their mean age was 10.8 (range, 2-17) years. Defects were located on the lower extremity in 22 (73.3%), upper extremity in 3 (10%), and head and neck in 5 (16.6%). The etiologies of the defects included vehicle accident (n=16), sequelae of burn (n=7), traumatic contractures (n=3), crush injury (n=2), epulis in the maxilla (n=1), and gunshot wound (n=1). The free flaps performed in our series included latissimus dorsi muscle flap (n=7), combined latissimus dorsi and serratus muscle flaps (n=2), serratus anterior muscle flap (n=4), cross latissimus dorsi muscle flap (n=1), scapular osteomyocutaneous flap (n=1), parascapular fasciocutaneous flap (n=6), fibular osteocutaneous flap (n=1), anterolateral thigh flap (n=6), medial circumflex femoral artery perforator flap (n=1), and crista iliaca osteocutaneous flap (n=1). The flaps used to cover the defects are shown in Table 1. The mean size of the soft tissue defect was 10x8 cm on the lower extremity, 6x4 cm on the upper extremity and 6x5 cm on the head and neck. Free flaps that were used to cover defects due to vehicle accidents and crush injuries were performed often in the first week of injury. All patients were operated under general anesthesia. All anastomoses were performed with interrupted sutures of 9-0 or 10-0 nylon, end-to-side on the artery and end-to-end on the deep vein. Mean operating time was 6 hours. Broad spectrum antibiotics were given intravenously for 3-5 days according to the type of injury. Bed rest and prudent monitoring of temperature, color, capillary refill, and Doppler examinations were provided for 10 days. The success rate of free tissue transfer was 93.75% (30 of 32). The parascapular fasciocutaneous flap that was used to cover a traumatic defect on the scalp was lost with venous occlusion on the 7th postoperative day. The serratus anterior muscle flap that was used to cover the defect occurring after burn contracture release on the dorsum of the foot 412

failed due to arterial insufficiency. Partial flap necrosis was seen in two flaps (1 parascapular fasciocutaneous flap used to cover the defect on the dorsum of the foot and 1 latissimus muscle flap on the lateral aspect of the foot). These two patients underwent reanastomosis in the first 24 hours and the flaps were salvaged. Minor complications, including partial flap losses of less than 10% of the surface and small wound dehiscence, were noted in about 20% of our patients. These complications were treated conservatively or could be resolved by secondary suturing. The mean follow-up period was 49 months. Seven perforator flaps were performed in the lower extremity defects. Six of them were anterolateral thigh flap and one was medial circumflex femoral artery perforator flap. The mean age of these patients was 10.8 years. We did not observe any partial or total flap loss. Small wound dehiscence was seen in one of the anterolateral thigh flaps. We did not determine any regression in child development during our follow-up period.

Representative Cases Case 1- A five-year-old boy was admitted to the emergency department with avulsion of the entire leg skin and exposure of the tibia due to vehicle accident. Fracture stabilization was provided with external fixator. After serial debridements, the size of the defect consisted of the entire leg and heel. Combined latissimus dorsi and serratus anterior muscle flaps were preferred due to the large size of the defect (Fig. 1a-d). Free flap transfer was performed on the 10th day of injury. The anastomosis was performed to the posterior tibial artery in end-to-side fashion. Two concomitant venous anastomoses were performed. Split-thickness skin grafts from the posterolateral thigh were transferred for flap coverage. Flap monitoring was performed by means of capillary refill, temperature, and Doppler ultrasound. Total flap survival with no tissue loss occurred. One year after the free flap transfer, the external fixator was removed and tibiofibular syndesmosis was performed (Fig. 1e, f). Case 2- A 13-year-old girl was admitted to our department with epulis lesion of the maxilla. After the lesion was excised with tumor free margins, a free vascularized crista iliaca flap was used to reconstruct the maxilla and hard palate (Fig. 2a-d). The anastomosis was performed to the superficial temporal artery, and concomitant venous anastomosis was performed. Flap monitoring was performed by means of capillary refill, temperature, and Doppler ultrasound. Total flap survival with no tissue loss occurred. Six months after the free flap transfer, all the mucosal surfaces were intact (Fig. 2e, f ). Case 3- A 13-year-old boy was admitted to our department

due to burn contracture on the plantar area of his right foot. Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


Akรงal et al. Microsurgical reconstruction in pediatric patients: a series of 30 patients

Table 1. Study data

No

Gender

Age

Location of the defect

Flap type

Complication

1

Female

10

Right foot

Anterolateral thigh

Wound dehiscence

2

Female

16

Right elbow

Parascapular

Wound dehiscence

3

Female

5

Left foot

Parascapular

Burn contracture

4

Female

17

Neck

Anterolateral thigh

5

Female

17

Right cruris

Cross-latissimus

6 Male 9 Neck

Parascapular

7

Male

15

Right heel

Anterolateral thigh

8

Female

17

Left foot

Serratus

9

Male

16

Right hand

Serratus

10

Female

11

Left foot

Serratus

Traumatic contractures

Wound dehiscence

Total necrosis

Traumatic defect

11

Male

8

Left foot

Anterolateral thigh

12

Female

3

Left heel

Latissimus

13

Male

17

Left heel

Latissimus

14 Male 11 Right foot-1st metacarpal defect

Free fibula

15

Male

5

Right cruris

Latissimus+serratus

16

Female

13

Left foot-dorsum

Anterolateral thigh

17

Male

13

Right foot

Anterolateral thigh

18

Male

4

Scalp

Parascapular fasciocutaneous

19

Male

2

Left cruris

Latissimus

20

Female

7

Right cruris

Latissimus

21

Male

6

Right foot

Latissimus

22

Female

15

Left heel

Serratus

23

Male

8

Right dorsum of foot

Latissimus

24

Female

14

Left arm-forearm

Latissimus-serratus

25

Male

12

Left foot

Parascapular

26

Female

9

Right cruris

Latissimus

27

Female

13

Left foot

Parascapular

28 Male 6 Right foot

Total necrosis

Partial necrosis

Partial necrosis

Medial circumflex femoral artery perforator flap

Gunshot injury

29

Male

12

Mandible

Scapular osteomyocutaneous

30

Female

13

Maxilla

Crista iliaca

Epulis

After the release of the contracture, anterolateral thigh flap was performed to cover the plantar surface of the foot. The anastomosis was performed to the tibialis posterior artery in end-to-side fashion. Two concomitant venous anastomoses were performed. Flap monitoring was performed by means of capillary refill, temperature, and Doppler ultrasound. Total flap survival with no tissue loss occurred. He could wear his shoes comfortably by the end of one year (Fig. 3a-e). Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

DISCUSSION In recent years, there has been significant doubt about the technical versatility and feasibility of microsurgery in children. Initial concerns as to the feasibility and reliability of these procedures were overcome rapidly.[3,4,7] Microsurgeries succeed in children more often than in adults for two reasons. The first issue is that the relative size of the vessels when 413


Akçal et al. Microsurgical reconstruction in pediatric patients (a)

(b)

(c)

(d)

(e)

(f)

Figure 1. (a) Avulsion of the entire leg skin and exposure of the tibia due to vehicle accident. Fracture stabilization was provided with external fixator. After the serial debridements, the size of the defect consisted of the entire leg and heel. (b) Combined latissimus dorsi and serratus anterior muscle flaps were harvested due to the large size of the defect. (c) After the serial debridements, the size of the defect consisted of the entire leg and heel. (d) The anastomosis of the combined latissimus dorsi and serratus anterior muscle flap was performed to the posterior tibial artery in end-to-side fashion. Two concomitant venous anastomoses were performed. (e) Anterior view of the leg at postoperative one year. (f) One year after the free flap transfer, the external fixator was removed, and tibiofibular syndesmosis was performed.

compared with the childâ&#x20AC;&#x2122;s body is greater than that of adults, and the second issue is that children have minimal comorbidities like smoking, diabetes, hypertension, or peripheral vessel disease. In absolute size, though, the vessels can be rather small, which means that flaps with sizable pedicles and a reliable anatomy were preferentially selected. Parry et al.[4] stated that vascular spasm and atherosclerosis of the vessels are not issues in children.

The first flaps that were performed in children were skin flaps, which are not used today. Skin flaps are no longer preferred by surgeons due to the rather variable and small vasculature.despite the low donor site morbidity.[9] Irigaray described the inclusion of an anterior strip of the latissimus dorsi to increase the reliability of the flap, which could mean a myocutaneous or even the first compound latissimus dorsi flap. The flap in use in the early days of microsurgery was the

(a)

(b)

(c)

(d)

(e)

(f)

Figure 2. (a) A 13-year-old girl was admitted to our department with epulis lesion in the maxilla. (b, c) Free vascularized crista iliaca flap was used to reconstruct the maxilla and hard palate. (d) The anastomosis was performed to the superficial temporal artery and concomitant venous anastomosis was performed. (e) Free vascularized crista iliaca flap was adapted to the maxilla and hard palate. (f) View at the postoperative 6th month - all the mucosal surfaces were intact.

414

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


Akçal et al. Microsurgical reconstruction in pediatric patients (a)

(b)

(c)

(d)

(e)

Figure 3. (a) A 13-year-old boy with burn contracture on the plantar area of his right foot. (b) Anterolateral thigh flap was planned to release the contracture. (c) Donor area of the anterolateral thigh flap was sutured primarily. (d, e) Early view of the flap.

lateral thoracic flap[1] as reported by Irigaray et al.[9] In the same regard, we used to perform flaps dependent on the subscapular artery system. In 61% of our patients, we chose to harvest the free flap from this system for two reasons. First, the larger and more reliable thoracodorsal artery increased the success of the operation and second, the donor site scar could be concealed underneath clothes. In the perforator era, we started to harvest perforator flaps due to their minimal donor site morbidity. We thus harvested anterolateral thigh flaps in six of 32 patients and one medial circumflex femoral artery flap. There are a limited number of articles reporting perforator flaps in children, and the medial circumflex femoral perforator flap is not one of the flaps that might be chosen as a primary free flap. However, we performed the medial circumflex femoral artery perforator flap in a seven-year-old boy, and we did not see any partial or total flap necrosis in the early and late period.[10] Today, we have begun to perform the perforator flaps because of the minimal donor site scar and their proven technical feasibility and reliability. Most pediatric trauma series, as in ours, indicate that these injuries arise most commonly from road traffic accidents, and that males are more often involved than females. The choice of the free flap in pediatric reconstructive surgery seems to depend essentially on the size of the defect and the surgeonâ&#x20AC;&#x2122;s preferences. In our series, we decided to harvest combined latissimus dorsi and serratus muscles flaps to cover the entire leg Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

in two cases, and we covered large and dirty defects with latissimus dorsi muscle flaps. Our success rate approached 100% with these large muscle flaps due to their large caliber vessels. Vascular integrity in children (absence of atheroma) is certainly one of the essential reasons for the high success rates of the pediatric series. Although vessel diameter in the child is smaller than in the adult, no major technical difficulties were encountered in our series. Even though 20% of our series consisted of perforator flaps, our success rate was almost 94%, which was consistent with the reported success rates of the other series (85% and 90%). However, while the success rate with the perforator flap is given as 96% in the literature8, we did not see any partial or total flap failure with perforator flaps in our series. The two major criticisms of free flaps are the deficit at the donor site and possible effects on normal growth. Canales et al.[11] and Chiang et al.[12] found no growth disturbances at the donor or injury site over a longer follow-up period. Yu[13] also showed that bilateral harvesting of the latissimus dorsi in children can be performed without long-term effects. These problems were not encountered in our series, although the follow-up period may be too short (mean, 49 months). The advantages of the free flaps in children included better adaptation of the flap growth and better learning capacity of the children, which provided the surgeon with more satisfactory functional and aesthetic results. 415


Akçal et al. Microsurgical reconstruction in pediatric patients

We can suggest to all clinics with experienced microsurgical teams that free flaps can be used safely in pediatric patients despite the technical difficulties. Conflict of interest: None declared.

REFERENCES 1. Harii K, Ohmori K. Free groin flaps in children. Plast Reconstr Surg 1975;55:588-92. 2. Ohmori K, Harii K, Sekiguchi J, Torii S. The youngest free groin flap yet? Br J Plast Surg 1977;30:273-6. 3. Van Beek AL, Wavak PW, Zook EG. Microvascular surgery in young children. Plast Reconstr Surg 1979;63:457-62. 4. Parry SW, Toth BA, Elliott LF. Microvascular free-tissue transfer in children. Plast Reconstr Surg 1988;81:838-40. 5. Shenaq SM, Dinh TA. Pediatric microsurgery. Replantation, revascularization, and obstetric brachial plexus palsy. Clin Plast Surg 1990;17:77-83. 6. Duteille F, Lim A, Dautel G. Free flap coverage of upper and lower limb tissue defects in children: a series of 22 patients. Ann Plast Surg

2003;50:344-9. 7. Van Landuyt K, Hamdi M, Blondeel P, Tonnard P, Verpaele A, Monstrey S. Free perforator flaps in children. Plast Reconstr Surg 2005;116:15969. 8. Iwaya T, Harii K, Yamada A. Microvascular free flaps for the treatment of avulsion injuries of the feet in children. J Trauma 1982;22:15-9. 9. Irigaray A, Roncagliolo A, Fossati G. Transfer of a free lateral thoracic flap in a child. Plast Reconstr Surg 1979;64:259-63. 10. Karsidag S, Akcal A, Yesiloglu N, Ugurlu K. Medial circumflex femoral artery perforator flap in a seven-year-old boy for a degloving ankle injury: a case report in immediate reconstruction. The Foot and Ankle Online Journal 2010;3:1. Available at: http://faoj.org/2010/05/01/may-2010/. 11. Canales F, Lineaweaver WC, Furnas H, Whitney TM, Siko PP, Alpert BS, et al. Microvascular tissue transfer in paediatric patients: analysis of 106 cases. Br J Plast Surg 1991;44:423-7. 12. Chiang YC, Jeng SF, Yeh MC, Liu YT, Chen HT, Wei FC. Free tissue transfer for leg reconstruction in children. Br J Plast Surg 1997;50:33542. 13. Yu ZJ. The use of bilateral latissimus dorsi myocutaneous flaps to cover large soft tissue defects in the lower limbs of children. J Reconstr Microsurg 1988;4:83-8.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Çocuk hastalarda mikrocerrahi rekonstrüksiyon: 30 olguluk seri Dr. Arzu Akçal,1 Dr. Semra Karşıdağ,2 Dr. Deniz Özgür Sucu,2 Dr. Gürsel Turgut,2 Dr. Kemal Uğurlu2 1 2

Akdeniz Üniversitesi, Plastik ve Rekonstrüktif Cerrahi Anabilim Dalı, Antalya; Şişli Etfal Eğitim ve Araştırma Hastanesi, Plastik ve Rekonstrüktif Cerrahi Kliniği, Istanbul

AMAÇ: Pediatrik popülasyonda serbest doku aktarımı teknik yararlılığı ve güvenililirliği nedeni ile geniş kabul görmektedir. Cerrahi işlemin uygunluğu ve güvenililirliğini içeren başlangış süpheleri artık giderilmiştir. GEREÇ VE YÖNTEM: Otuz çocuk hasta (15 erkek, 15 kız) Şişli Etfal Eğitim ve Araştırma Hastanesi’nde serbest doku aktarımı uygulanarak tedavi edildi. Hastaların defektleri alt ekstremitede (n=22), baş ve boyunda (n=5) ve üst ekstremitede (n=3) yerleşimli idi. Defektlerin etiyolojileri araba kazalarını, yanık sekellerini, travmatik kontraktürlerini, ezilme yaralanmalarını, maksillada epulisi ve ateşli silah yaralanmalarını içerdi. BULGULAR: Çalışmamızda aktarılan serbest dokular latissimus dorsi kas flebi, kombine latissimus dorsi ve serratus kas flepleri, serratus anterior kas flebi, çapraz latissimus dorsi kas flebi, skapüler osteomyokutanöz flebi, paraskapüler fasyokutanöz flebini, fibuler osteokutanöz flebi, anterolateral uyluk flebini ve medial sirkumfleks femoral arter perforatör flebi ve crista iliaca osteocutanöz flebini içeriyordu. TARTIŞMA: Serbest doku aktarımının çocuklardaki avantajları arasında yer alan çocuğun daha iyi flep büyümesine adaptasyonu ve çocuğun öğrenme kapasitesi sayesinde cerrahlar daha iyi ve fonksiyonel ve estetik sonuçlar sağlamaktadırlar. Anahtar sözcükler: Serbest doku aktarımı, çocuk hasta popülasyonu, perforatör flepler. Ulus Travma Acil Cerr Derg 2013;19(5):411-416

416

doi: 10.5505/tjtes.2013.09515

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


ORIGIN A L A R T IC L E

Epidemiologic and clinical characteristics and outcomes of scorpion sting in the southeastern region of Turkey Fevzi Yılmaz, M.D.,1 Engin Deniz Arslan, M.D.,1 Ali Demir, M.D.,1 Cemil Kavalci, M.D.,2 Tamer Durdu, M.D.,1 Muhittin Serkan Yılmaz, M.D.,1 Cihat Yel, M.D.,1 Sami Akbulut, M.D.3 1

Department of Emergency Medicine, Numune Training and Research Hospital, Ankara

2

Department of Emergency Medicine, Baskent Universty Faculty of Medicine, Ankara

3

Department of General Surgery, Diyarbakir Training and Research Hospital, Diyarbakır

ABSTRACT BACKGROUND: Scorpion sting resulting in envenomation is a life-threatening emergency and causes serious health problems in tropical and subtropical regions. The aim of this study was to present the epidemiologic and clinical features of 123 cases presenting with symptoms of scorpion poisoning, a cause of preventable mortality and morbidity. METHODS: This study retrospectively analyzed the epidemiologic and demographic features of a total of 123 patients who presented to Diyarbakır State Hospital Emergency Service with scorpion sting between January 2008 and December 2009. RESULTS: Among 123 patients who presented to Diyarbakır State Hospital Emergency Service with scorpion sting between January 2008 and January 2009, 62.6% (n=77) were female and 37.4% (n=46) were male. The mean age of the patients was 33.5±17.3 years (2-80), and 27 (22%) patients were younger than 18 years. The place of residence was rural region in 98 (79.7%) patients and the city center in 25 (20.3%). The majority of victims were stung by scorpions while they were at active work (42.3%) or asleep (19.5%) in bed. Eleven (8.95%) patients were stung by a scorpion while putting on their own clothes. CONCLUSION: This simple descriptive study will hopefully help healthcare providers take measures to prevent scorpion stings, which should take into consideration local epidemiological features.

Key words: Epidemiology, pain, scorpion sting.

INTRODUCTION Scorpion sting (SS) cases are particularly common in the southeastern Anatolian region of Turkey due to geographical location, climate and the socioeconomic structure.[1,2] There are 1500 subspecies of scorpions worldwide, with 50 subspecies having venom dangerous for humans. In South America, North Africa, and the Middle East, the Leiurus quinquestriatus, Androctonus crassicauda, and Buthus occitonus subspecies are dangerous. Turkey is estimated to host 13 scorpion

Address for correspondence: Fevzi Yılmaz, M.D. Ankara Numune Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Altındağ, 06100 Ankara, Turkey Tel: +90 312 - 508 40 00 E-mail: fevzi_yilmaz2002@yahoo.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):417-422 doi: 10.5505/tjtes.2013.52333 Copyright 2013 TJTES

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

subspecies. SSs are relatively common in the eastern and southeastern Anatolian regions of our country, and the most common subspecies responsible for stings are the A. crassicauda and L. quinquestriatus species.[3] Scorpion venom shows variability by subspecies and has a complex structure composed of neurotoxic proteins, salts, acidic proteins, and organic compounds, thereby having neurologic, cardiovascular, hematologic, and renal side effects, in addition to local effects such as redness, pain, burning, and swelling.[4] Mortality due to SSs is associated with cardiac dysfunction and pulmonary edema.[5] The clinical picture depends on the anatomical location of the sting and the victim’s age, weight and health status.[2,6] Although SSs are more common in adults and males, mortality is higher in children.[7,8] Scorpion stings (SSs) in our country usually have a mild course. Approximately 94% of the incidents take place at night in homes in the countryside; 88% of cases do not require hospital admission.[1] In SSs, mortality and morbidity can be remarkably decreased by timely anti-venom administration, adequate fluid resuscitation, cardiac monitoring, and 417


Yılmaz et al. Scorpion sting in the southeastern region of Turkey

renal function monitoring.[9] In Turkey, Refik Saydam Hygiene Center (RSHC) manufactures the antivenom from A. crassicauda venom. This antivenom is in use for all SS cases.[10] The aim of this study was to present the epidemiologic and clinical features of 123 cases presenting with symptoms of scorpion poisoning, a cause of preventable mortality and morbidity.

MATERIALS AND METHODS This study retrospectively analyzed the epidemiologic and demographic features of a total of 123 patients who presented to Diyarbakır State Hospital Emergency Service with SS between January 2008 and January 2009. Age, sex, place of the incident, sting location on body, time to hospital admission, color of the scorpion, presenting complaint, systemic symptoms, treatment received, and seasonal admission rates were assessed. The clinical severity of each case was evaluated by Abroug’s classification (Table 1).[11] The patients were monitored after history-taking and physical examination were completed. Depending on the severity of toxicity, all cases were given one or two 5 ml scorpion polyvalent antivenom ampoules (Refik Saydam Hygiene Center, Turkey) on admission. In addition, tetanus toxoid was also administered when necessary. Statistical analyses of the study data were performed with the help of the Statistical Package for the Social Sciences (SPSS) v. 16.0 software package. Descriptive data were expressed as frequency and percentage. Intergroup differences were analyzed using chi-square or Fisher test, depending on the features of the data. A p value below 0.05 was considered statistically significant.

RESULTS Among 123 patients who presented to Diyarbakır State Hospital Emergency Service with SS between January 2008 and January 2009, 62.6% (n=77) were female and 37.4% (n=46) were male. The mean age of the patients was 33.5±17.3 years (range, 2-80), and 27 (22%) patients were younger than 18 years. Statistical analysis showed a significant difference between genders in terms of SSs (p<0.005). Patient distribution according to age and gender is given in Table 2. The place of residence was rural region in 98 (79.7%) patients and the city center in 25 (20.3%). There was a significant difference between SS incidents in terms of place of residence (p<0.005). The patients admitted to the emergency service in a mean of 4.3±3.5 (1-14) hours after the trauma. The majority of the victims were stung by scorpions while they were at active work (42.3%) or asleep (19.5%) in bed. Eleven (8.95%) patients were stung by a scorpion while putting on their clothes. The circumstances under which other sting incidents took place are given in Table 3. 418

Table 1. Abroug’s classification Grade

Signs and symptoms

Grade I

Pain and/or paresthesia at the scorpion sting site.

Grade II

Fever, chills, excessive sweating, nausea-vomiting, diarrhea, hypertension and priapism.

Grade III Cardiovascular, respiratory, and/or neurologic symptoms.

Table 2. The distribution of the scorpion sting cases according to age and sex Age (year)

Female

Male

Total

n % n % n %

0-5

2 1.6 1 0.8 3 2.4

6-11

5 4

4 3.3 9 7.3

12-18

9 7.3 6 4.9 15 12.2

19-49

48 39 27 22 75 61

50-65

7 5.7 5 4.1 12 9.8

>65

6 4.9 3 2.4 9 7.3

Total

77 62.6 46 37.4 123 100

Scene of the SS incident was the patient’s own home in 85 (69.1%) and outdoors in 38 (30.9%). Sixty-six (53.7%) patients were stung by a black scorpion and 38 (30.9%) by a yellow scorpion, whereas the color of the scorpion could not be identified in 19 (15.4%) patients. With respect to the time of the sting, 56.4% of the patients were stung from 08:00-17:00, 18.3% between 17:00-24:00, and 25.3% between 24:00-08:00. The majority (76%) of SSs took place in the summer through-

Spring (7%)

Autumn (15%)

Winter (2%)

Summer (76%)

Figure 1. The seasonal distribution of the cases.

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


Yılmaz et al. Scorpion sting in the southeastern region of Turkey

Table 3. Demographic and epidemiological characteristics

n

%

District Urban

25 20.3

Rural

98 79.7

Color of scorpion Black

66 53.7

Yellow

38 30.9

Unknown

19 15.4

The activity being undertaken at the time of the sting

Putting on clothes

11

8.9

Sleeping

24 19.5

Working

52 42.3

12

Eating a meal

Sitting

9.8

24 19.5

Site of scorpion sting Head

3

2.4

Neck

2

1.6

Fingers

76 61.8

Toes

32 26.2

Ankle

2

1.6

Leg

4

3.2

Trunk

3

2.4

Thigh

1

0.8

0-1

32

26

1-2

56 45.5

Time to admission after scorpion sting

2-3

22 17.9

3-4

9

7.3

≥4

4

3.3

Local signs

Local pain

Hyperemia

117

95.1

95 77.2

Swelling

24 19.5

Itching

23 18.7

57

46.3

8

6.5

Extremity tenderness

Numbness

out Diyarbakır (Fig. 1). SSs were located on the fingers in 76 (61.7%) patients, toes in 32 (26%) patients, and other parts of the body in 15 (12.3%) patients (Table 3). There was a marked local pain in 117 (95.1%) patients, redness in 95 (77.2%), local edema in 24 (19.5%), itching in 23 (18.7%), numbness in the extremity in 8 (6.5%), and tenderness in 57 (46.3%). There were no significant differences between genders in terms of local edema, numbness in the extremity, local tenderness, and Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

local pain (p>0.05 for all symptoms), while fingers of females tended to be more commonly traumatized (p=0.002) and they had more redness (p=0.001). No patient developed cardiac dysfunction, myocardial damage, or death due to major systemic poisoning. First aid or treatment was offered in all cases and included intravenous hydration, analgesia, antivenom therapy, and ice or cold pack. Antihistamines and steroids were used in nearly all patients (92% for both). No adverse reactions occurred against any of the drugs administered, including the antivenom.

DISCUSSION Scorpions are distributed worldwide, but dangerous SSs more commonly take place in southwestern parts of the United States, Mexico, middle and northern regions of South America, India, and Middle Eastern countries. In our country, cases of SS are common in the south and southeastern Anatolian regions in the summer. Annually, nearly 100,000 SS cases are reported worldwide, 800 of which result in fatality.[12-14] Scorpions live in jungles, deserts, and rocky areas; they become active at night and feed on insects and sometimes small rodents.[15] They possess a wide range of colors, ranging from straw color to yellow, from light brown to black.[16] Stings of L. quinquestriatus and A. crassicauda, also known as yellow and black scorpions, are encountered especially in countrysides in the summer and at nights.[13] The clinical picture of SS poisoning depends on the subspecies, age, size, venom amount, and feeding characteristics of the scorpion as well as seasonal conditions.[14] The scorpion venom is a water-soluble antigenic complex mixture of neurotoxin, cardiotoxin, nephrotoxin, hemolysins, phosphodiesterases, phospholipase, hyaluronidases, histamine, and other chemicals.[17] Different scorpion subspecies may possess different venoms. Scorpion venom may also cause systemic effects in addition to local effects within the first 12-24 hours following the sting. Pain, heat, edema, and hematoma are commonly observed locally (Grade 1). Systemically, hypotension or hypertension, respiratory failure, cardiovascular toxicity, hemolysis, renal failure, and hemorrhages at various sites may be observed.[18,19] Severity of SS is considered to be indicated by neurological signs, which are observed in two-thirds of hospitalized patients.[14,20,21] These manifestations vary greatly, from simple hyperthermia and muscarinics syndrome to severe neurological manifestations (coma and/or convulsions, myosis, mydriasis, anisocoria, nystagmus, squint, and erratic eye movements).[6] In our study, pain, redness and extremity tenderness were signs and symptoms that were localized most commonly (Grade I). No patient developed systemic symptoms. 419


Yılmaz et al. Scorpion sting in the southeastern region of Turkey

A hospital-based study from the Kingdom of Saudi Arabia reported an age range of 2 months to 101 years in SS cases; 70.6% of the cases were under 20 years of age.[22] In contrast, Nunes et al.[23] from Brazil reported that most victims were equal to or older than 50 years. In our study, the majority of cases were between 19-49 years; 16,9% were above 50 years of age, while 21.8% were children. We consider that this high incidence of stings among children originates from their higher inquisitive nature and risk-taking behavior, such that they lift up stones and put on their clothes and shoes without checking for scorpions. Jahan et al.[24] reported a male/female ratio of 1.9/1, which was similar to 2.6/1 reported by another study from Saudi Arabia.[22] On the contrary, two studies from the United States and Australia reported that females were more commonly stung than males.[15,25] In agreement with these results, our study had a female/male ratio of 1.6/1. Age range in SSs has shown variability in previous studies. In Qassim, Saudi Arabia, a lower mean age was reported (23.1±16.8).[24] Pardal et al.[26] from Brazil reported a mean age of 33.6±18.3 for SS cases. Our results (mean age, 33.5±17.3 years) were consistent with the latter study. Jahan et al.[24] reported that 49% of the SSs were caused by black scorpions, 38% by yellow scorpions, and the remaining (13%) by other subspecies. In our study, 53.7% of SSs were by black scorpions and the rest (30.9%) by yellow scorpions; no death occurred. Clinical and experimental studies have reported that scorpion venom is distributed throughout the body very rapidly, and thus the time between SS and antivenom management is of critical importance.[27,28] A delay in medical aid leads to an unfavorable prognosis; the risk is even higher in patients brought for medical care two hours after the sting.[12] According to our data, 71.5% of SS cases were admitted to hospital and administered antivenom within two hours following the SS. The majority of the previous studies have reported that SS cases are more prevalent in summer than winter, and this finding matches with the others in different studies.[22,29] Morocco has a high incidence of SSs between June and September, Saudi Arabia between May and September, and Iran between April and October.[12,24,30] SSs were most frequently reported in May and June in Texas.[31] We also found that a majority (76%) of stings took place during the summer (Fig. 1). This result is consistent with previous studies investigating the seasonal variation of SSs in our country.[1,10,32-34] In addition, people in Diyarbakır and nearby sleep on the roof and balcony or in the summer house because of the excessive heat between June and August, and the incidence of SS is higher in this group. Isbister et al.,[35] in a prospective study in Australia, reported that 71% of SSs occurred at night, 420

86% occurred indoors, 15% occurred in bed, and 14% occurred while the patients were dressing. In our study, the corresponding figures were 43.4%, 61.7%, 35.1%, and 10%, respectively. Epidemiologic studies have reported that SSs are more common in the extremities.[6,10,30,33,36] We also found that the 95.2% of stings took place in the extremities, including hands, arms, legs, thighs, and feet. Although SSs commonly involve the upper extremity in our country, literature data suggest a lower extremity predominance (58.6%).[10,33,34,37] In our study, stings most commonly involved the upper extremity (61.8%). The reason for a higher incidence of stings that involve the extremities include people wearing sandals during hot seasons due to the low socioeconomic structure of Diyarbakır and the agriculture-based way of life in the rural area, agricultural laborers working in the fields unprotected, and children walking around with bare feet and carelessly lifting up stones and searching for scorpions at home with their bare hands. Stings to the head, neck, and other body parts typically take place during sleep or while putting clothes on. In cases with SS, the level of consciousness, airway, respiration, and circulation should be checked. Vital signs should be monitored, and ECG and blood gas analysis should be carried out. External examination of the extremities should be performed, and peripheral pulses should be palpated.[38] The region of the SS should be thoroughly washed with NaHCO3, KMnO4, or abundant water, and wound cleaning should be done at once. The patient and the involved extremity should be stabilized and intermittently bandaged to prevent the venom from spreading to the body. It may be beneficial to administer cold packs (10-15°C) for 1-2 hours, but cold injury should be avoided. Hypothermia prevents spreading of the venom and protects against an anaphylactic reaction; however, it should be begun in the first minutes of the sting.[38-40] Some measures with no scientific background, such as sucking, application of henna or oil, or drinking milk are absolutely contraindicated.[12] Treatment for SSs includes fluid and electrolyte replacement, antibiotics in some cases, tetanus toxoid, scorpion serum, analgesics to relieve pain, and calcium gluconate for muscle spasm. In cases with severe pulmonary edema, neurotoxicity, circulatory failure, and hematologic findings, oxygen, sublingual nifedipine, digoxin, furosemide, aminophylline, dopamine, vitamin K, and fresh frozen plasma may be given, and phenobarbital and dexamethasone may be administered for 48 hours in cases with convulsions.[38,39,41] Prazosin is reserved for cases with tachycardia, coldness and paleness in the extremities, hypertension, hypersalivation, and sweating.[42] Antivenom therapy is still debated. Many authors consider it unnecessary, while others recommend it.[6,12,28,43,44] In general, mild symptoms should be controlled with analgesics and Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


Yılmaz et al. Scorpion sting in the southeastern region of Turkey

antihistamines, whereas those with systemic signs should be administered antivenom after measures against an anaphylactic reaction have been taken.[1,19] In our study, antihistaminic drugs and steroids were applied in almost all patients (92%).

13. Bawaskar HS, Bawaskar PH. Management of scorpion sting. Heart 1999;82:253-4. 14. Gümüştekin M. Çevresel toksinler: Hayvan ısırma ve sokmaları. Türkiye Klinikleri. Farmakoloji Toksikoloji Özel Sayısı 2003;1:53-7. 15. Altıntaş K. Tıbbi parazitoloji MN Medikal Nobel 2002;364-7.

In conclusion, conscientious medical care is of paramount importance in scorpion stings, which remain an important healthcare issue in our country. The results of this study have shown that scorpion stings were more common among females. Distal parts of the extremities were the most common site for scorpion stings. Scorpion stings in and around the Diyarbakır region do not appear to have severe or lifethreatening effects, and all patients were discharged home without sequelae. This simple descriptive study will hopefully help healthcare providers to take measures to prevent scorpion stings, which should take into consideration local epidemiological features. This information can also be utilized to identify population groups most in need of education on the prevention and treatment of scorpion stings. Conflict of interest: None declared.

16. Özcel MA, Daldal N. Parazitolojide arthropod hastalıkları ve vektörler. Türkiye Parazitoloji Derneği Yayını, No: 13, İzmir: 1997. s. 461-4. 17. Bawaskar HS, Bawaskar PH. Scorpion sting: update. J Assoc Physicians India 2012;60:46-55. 18. Kaya E, Çıkım K, Kuku İ, Şavlı H, Aydoğdu İ. Yılan ve akrep sokmalarında hastalarda görülen hematolojik bozukluklar ve klinik seyir. Turkish Journal of Heamatology 2002;19:161-2. 19. Özsu E, Saylan B, Tavlı V, Mese T, Sarıtas T. Akrep sokması sonrası gelisen geçici kardiyak sistolik disfonksiyon: olgu sunumu. Ege Pediatri Bülteni 2007;14:119-22. 20. Bahloul M, Ben Hamida C, Chtourou K, Ksibi H, Dammak H, Kallel H, et al. Evidence of myocardial ischaemia in severe scorpion envenomation. Myocardial perfusion scintigraphy study. Intensive Care Med 2004;30:461-7. 21. Elatrous S, Nouira S, Besbes-Ouanes L, Boussarsar M, Boukef R, Marghli S, et al. Dobutamine in severe scorpion envenomation: effects on standard hemodynamics, right ventricular performance, and tissue oxygenation. Chest 1999;116:748-53.

REFERENCES

22. Al-Asmari AK, Al-Saif AA. Scorpion sting syndrome in a general hospital in Saudi Arabia. Saudi Med J 2004;25:64-70.

1. Al B, Yılmaz D, Söğut Ö, Orak M, Üstündağ M, Bokurt S. Epidemiological, clinical characteristics and outcome of scorpion envenomation in Batman, Turkey: An Analysis of 12O Cases. JAEM 2009;8:3.

23. Nunes CS, Bevilacqua PD, Jardim CC. Demographic and spatial aspects of scorpion stings in the northwest region of Belo Horizonte City, Minas Gerais, 1993-1996. [Article in Portuguese] Cad Saude Publica 2000;16:213-23. [Abstract]

2. Tuuri RE, Reynolds S. Scorpion envenomation and antivenom therapy. Pediatr Emerg Care 2011;27:667-75. 3. Canpolat M, Per P, Gümüs H, Narin N, Kumandaş S. Convulsions as a rare complication of scorpion bite. Erciyes Medical Journal 2008;30:1759. 4. Ismail M, Abd-Elsalam MA, al-Ahaidib MS. Androctonus crassicauda (Olivier), a dangerous and unduly neglected scorpion-I. Pharmacological and clinical studies. Toxicon 1994;32:1599-618. 5. Razi E, Malekanrad E. Asymmetric pulmonary edema after scorpion sting: a case report. Rev Inst Med Trop Sao Paulo 2008;50:347-50. 6. de Roodt AR, García SI, Salomón OD, Segre L, Dolab JA, Funes RF, et al. Epidemiological and clinical aspects of scorpionism by Tityus trivittatus in Argentina. Toxicon 2003;41:971-7. 7. Celis A, Gaxiola-Robles R, Sevilla-Godínez E, Orozco Valerio Mde J, Armas J. Trends in mortality from scorpion stings in Mexico, 1979-2003. [Article in Spanish] Rev Panam Salud Publica 2007;21:373-80. [Abstract]

24. Jahan S, Mohammed Al Saigul A, Abdul Rahim Hamed S. Scorpion stings in Qassim, Saudi Arabia-a 5-year surveillance report. Toxicon 2007;50:302-5. 25. Isbister GK, Volschenk ES, Balit CR, Harvey MS. Australian scorpion stings: a prospective study of definite stings. Toxicon 2003;41:877-83. 26. Pardal PP, Castro LC, Jennings E, Pardal JS, Monteiro MR. Epidemiological and clinical aspects of scorpion envenomation in the region of Santarém, Pará, Brazil. [Article in Portuguese] Rev Soc Bras Med Trop 2003;36:349-53. [Abstract] 27. Petricevich VL. Scorpion venom and the inflammatory response. Mediators Inflamm 2010;2010:903295. 28. Ghalim N, El-Hafny B, Sebti F, Heikel J, Lazar N, Moustanir R, et al. Scorpion envenomation and serotherapy in Morocco. Am J Trop Med Hyg 2000;62:277-83.

8. Gueron M, Ilia R, Sofer S. The cardiovascular system after scorpion envenomation. A review. J Toxicol Clin Toxicol 1992;30:245-58.

29. Bosnak M, Ece A, Yolbas I, Bosnak V, Kaplan M, Gurkan F. Scorpion sting envenomation in children in southeast Turkey. Wilderness Environ Med 2009;20:118-24.

9. Akdur O, İkizceli İ, Avşaroğulları L, Özkan S, Sözüer EM. Akrep antiveni uygulamasına bağlı akut ürtiker: Olgu sunumu. Akademik Acil Tıp Dergisi 2007;5:39-40.

30. Pipelzadeh MH, Jalali A, Taraz M, Pourabbas R, Zaremirakabadi A. An epidemiological and a clinical study on scorpionism by the Iranian scorpion Hemiscorpius lepturus. Toxicon 2007;50:984-92.

10. Adiguzel S, Ozkan O, Inceoglu B. Epidemiological and clinical characteristics of scorpionism in children in Sanliurfa, Turkey. Toxicon 2007;49:875-80.

31. Forrester MB, Stanley SK. Epidemiology of scorpion envenomations in Texas. Vet Hum Toxicol 2004;46:219-21.

11. Abroug F, Nouira S, Saguiga H. Envenomations scorpionniques: avences chimiques, physiopathologiques et therapeutiquis. Monograph 1994;168. 12. Abourazzak S, Achour S, El Arqam L, Atmani S, Chaouki S, Semlali I. Epidemiological and clinical characteristics of scorpion stings in children in Fez, Morocco. J Venom Anim Toxins inci Trop Dis 2009;15:255-67.

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

32. Uluğ M, Yaman Y, Yapici F, Can-Uluğ N. Scorpion envenomation in children: an analysis of 99 cases. Turk J Pediatr 2012;54:119-27. 33. Ozkan O, Adigüzel S, Yakiştiran S, Cesaretli Y, Orman M, Karaer KZ. Androctonus crassicauda (Olivier 1807) scorpionism in the Sanliurfa provinces of Turkey. Turkiye Parazitol Derg 2006;30:239-45. 34. Altınkaynak S, Ertekin V, Alp H. Scorpion envenomation in children. Turk Arch Pediatr 2002;37:48-54.

421


Yılmaz et al. Scorpion sting in the southeastern region of Turkey 35. Isbister GK, Volschenk ES, Balit CR, Harvey MS. Australian scorpion stings: a prospective study of definite stings. Toxicon 2003;41:877-83. 36. Jarrar BM, Al-Rowaily MA. Epidemiological aspects of scorpion stings in Al-Jouf Province, Saudi Arabia. Ann Saudi Med 2008;28:183-7. 37. Söker M, Haspolat K. Scorpion sting in children. Çocuk Sağlığı Hastalıkları Derg 2000;43:43-51. 38. Kurtoğlu S. Zehirlenmeler, teşhis ve tedavi. Kayseri: Erciyes Üniversitesi Yayınları, 1992. 39. Söker M, Haspolat K. Güneydoğu ve Anadolu bölgesinde çocuklarda akrep sokması: 64 vakanın değerlendirilmesi. Çocuk Sağlığı ve Hastalıkları Dergisi 2000;43:43-50.

40. Santhanakrishnan BR, Gajalakshmi BS. Pathogenesis of cardiovascular complications in children following scorpion envenoming. Ann Trop Paediatr 1986;6:117-21. 41. el-Amin EO, Elidrissy A, Hamid HS, Sultan OM, Safar RA. Scorpion sting: a management problem. Ann Trop Paediatr 1991;11:143-8. 42. Koseoglu Z, Koseoglu A. Use of prazosin in the treatment of scorpion envenomation. Am J Ther 2006;13:285-7. 43. Bawaskar HS, Bawaskar PH. Clinical profile of severe scorpion envenomation in children at rural setting. Indian Pediatr 2003;40:1072-5. 44. Ismail M. Treatment of the scorpion envenoming syndrome: 12-years experience with serotherapy. Int J Antimicrob Agents 2003;21:170-4.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Türkiye’nin Güneydoğu Anadolu Bölgesi’nde akrep sokmalarının epidemiyolojik, klinik özellikleri ve sonuçları Dr. Fevzi Yılmaz,1 Dr. Engin Deniz Arslan,1 Dr. Ali Demir,1 Dr. Cemil Kavalci,2 Dr. Tamer Durdu,1 Dr. Muhittin Serkan Yılmaz,1 Dr. Cihat Yel,1 Dr. Sami Akbulut3 Ankara Numune Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Ankara Başkent Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Ankara 3 Diyarbakır Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Diyarbakır 1 2

AMAÇ: Zehirlenmelere neden olan akrep sokmaları yaşamı tehdit eden acil bir durumdur ve tropikal ve subtropikal bölgelerde ciddi sağlık sorunlarına neden olurlar. Bu çalışmanın amacı mortalite ve morbiditenin önlenebilir nedenlerinden olan akrep sokması nedeni ile başvuran 123 hastanın epidemiyolojik ve klinik özelliklerini belirlemektir. GEREÇ VE YÖNTEM: Bu çalışmada Ocak 2008 ile Eylül 2009 arasında Diyarbakır Devlet Hastanesi Acil Servis’ine akrep sokması nedeni ile başvuran 123 hastanın demografik ve epidemiyolojik özellikleri geriye dönük olarak incelendi. BULGULAR: Çalışmaya alınan 123 hastanın %62.6’sı (n=77) kadın ve %37.4’ü (n=46) erkekti. Olguların ortalama yaşı 33.5±17.3 (dağılım, 2-80) yıl ve 27 (%22) hasta 18 yaşından daha gençti. Hastaların 98’i (%79.7) kırsal alandan, 25’i (%20.3) şehir merkezindendi. Olguların çoğunluğu (%42.3) aktif çalışma sırasında ve uykuda (%19.5) akrep sokmasına maruz kaldı. On bir (%8.95) hasta da evde çamaşırlarını yerleştirirken akrep sokmasına maruz kalmıştı. TARTIŞMA: Bu çalışmanın yöresel epidemiyolojik özellikleri göz önünde tutarak, sağlık çalışanlarına akrep sokmalarından korunma için gerekli önlemlerin alınmasında yardımcı olabileceğini umarız. Key words: Ağrı, akrep sokması, epidemiyoloji. Ulus Travma Acil Cerr Derg 2013;19(5):417-422

422

doi: 10.5505/tjtes.2013.52333

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


ORIGIN A L A R T IC L E

Details of motorcycle accidents and their impact on healthcare costs Serkan Emre Eroğlu, M.D.,1 Sıddıka Nihal Toprak, M.D.,2 Ebru Akoğlu, M.D.,3 Özge Ecmel Onur, M.D.,1 Arzu Denizbaşı, M.D.,1 Çiğdem Özpolat, M.D.,1 Haldun Akoğlu, M.D.1 1

Department of Emergency Medicine, Marmara University Pendik Training and Research Hospital, Istanbul

2

Department of Emergency Service, Mersin Toros State Hospital, Mersin

3

Department of Emergency Service, Ataturk State Hospital, Emergency Service, Zonguldak

ABSTRACT BACKGROUND: Of overall traffic accidents in 2011 in Turkey, 7.58% (n=21,107) were motorcycle accidents. Motorcycle accidents and their impact on healthcare costs are investigated in our study. METHODS: Motorcycle accidents that occurred with/without a collision between 1 July 2010 and 30 June 2011 were studied prospectively through the inspection of patients visiting the Emergency Service. The healthcare costs relevant to each person injured in a motorcycle accident were investigated via forms. Data were analyzed using frequencies, Kolmogorov-Smirnov, Mann-Whitney U, and chi-square tests on the SPSS v16.0 program. RESULTS: Ninety-one people involved in accidents, with a mean age of 28.47 years, were studied. The average healthcare expenditure for the 91 patients studied between reception and discharge was US$253.02 (median, US$55.90; range, US$11.52 - 7137.19). According to our study, there was no definitive correlation between the healthcare costs and the time of the accident, motorcycle type, nature of the road surface, protective equipment, weather, or daylight. CONCLUSION: According to the current study, the risk of an accident increases with young adults. Concordantly, healthcare costs increase. Thus, it is important that the legal rules with respect to the age and education necessary for receiving a license to operate a motorcycle should be redefined, and if necessary, regulated.

Key words: Emergency department, healthcare costs, motorcycle accidents, trauma.

INTRODUCTION It is estimated that 1.2 million people are killed and 50 million injured worldwide due to traffic accidents each year.[1] Based on the Turkish National Police Traffic Services Department, in 2011, 2,582 fatalities were reported in Turkey resulting from 278,353 traffic accidents. Of Turkey’s overall traffic accidents, 7.58% (n=21,107) were motorcycle-related.[2] Today, motorcycles are regarded as a good solution to bypass heavy traffic,

Address for correspondence: Serkan Emre Eroğlu, M.D. Marmara Üniversitesi Pendik Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Pendik, 34890 İstanbul, Turkey Tel: +90 216 - 657 06 06 E-mail: drseroglu@gmail.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):423-428 doi: 10.5505/tjtes.2013.06767 Copyright 2013 TJTES

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

and as an economical and convenient vehicle, and this suggests that the number of motorcycle accidents is likely to increase in the future. We may also assume that motorcycle accidents will cause higher fatalities and result in higher healthcare costs. Motorcycle accidents and the impact of these accidents on healthcare costs are investigated in this study.

MATERIALS AND METHODS Setting We surveyed motorcycle and pillion riders involved in accidents with or without collision between 1 July 2010 and 30 June 2011 who were treated in the Emergency Service of Mersin Toros State Hospital. During this prospective study, we planned that the injured people as well as the witnesses would be required to fill in the forms in the presence of the physician on duty. Study form The form contained data fields concerning the demographic features of the injured person, the type of motorcycle, details 423


EroÄ&#x;lu et al. Details of motorcycle accidents and their impact on healthcare costs

of the accident, weather and road conditions during the accident, and the protective equipment worn, as well as the healthcare features and the total expenditures generated. The total expenditure for the total period of hospitalization was entered in the forms later by the surveyors. The expenditures were recorded in Turkish lira and converted to US dollar using the exchange rate of 1.71 TL/US$, which was the average rate of exchange between 1 July 2010 and 1 July 2011. Data analysis The data collected were analyzed with the Statistical Package for the Social Sciences (SPSS) v16.00 software. The average values are presented with a 95% confidence interval (CI) in this study. The concordance of the relative variables to the normal distribution was evaluated via the KolmogorovSmirnov (K-S) test. For the statistics of non-parametrical data, the chi-square and Mann-Whitney U tests were employed. Ethical issues The Institutional Review Board approved the study. Verbal consent was obtained after explaining the consent statement. The study was conducted in accordance with the principles of the Declaration of Helsinki. Informed consent was acquired from all interviewees.

RESULTS Characteristics of the patients and the collision The mean age of the 91 people involved in an accident was 28.47 years (95% CI, 25.94-31.01), while the median age was 25 years (range, 5-67). Thirteen people (27.65%) involved in accidents with a collision who presented to the Emergency Service were below 18 years old, 15 (31.91%) were between 18 and 25, 9 (19.14%) were between 26 and 34, and 10 (21.27%) were between 35 and 50 years. Only 2 (4.25%) of the injured were over 50. Of all the people studied, 81 (89%) were male; 74.7% (n=68) of patients were riders and 25.3% (n=23) were pillion riders. Of the injured, 50.5% (n=46) were wearing helmets and 3.3% of the injured had other protective equipment. Only 3% of the patients were helmet-wearing pillion riders. Among the 10 injured females, only 1 was wearing a helmet. All the females not wearing helmets were pillion riders. The average speed of the motorcycles (n=91) was 31.15 km/h (95% CI 27.61 - 34.69; range, 0 - 100 km/h), and the other vehicles in motion during the accident had an average speed of 38.08 km/h (95% CI 30.61 - 45.56 km/h; range, 5-100 km/h). Forty-seven of the accidents (51.6%) involved a collision (no pedestrians involved), 41 of the accidents (45.1%) did not involve a collision (fall, skid, etc.), and 3 of the accidents involved a collision with a pedestrian. Nine of the accidents with a collision (19.2%) involved smashing a parked car, and 4 of them involved a fixed object (wall, barrier, etc.). Seasonal, environmental and situational factors The greatest number of injuries (n=24, 26.4%) occurred in 424

the month of March, while the least number of injuries (n=1, 1.1%) occurred in August. The distribution of motorcycle accidents that involved injuries are broken down by season as follows: 16 injuries in summer (June, July, August) (17.6%), 11 in autumn (September, October, November) (12.1%), 15 in winter (December, January, February) (16.5%), and 49 in spring (March, April, May) (53.8%). Of the accidents, 79.1% (n=72) occurred during daylight. Fourteen of 19 (73.7%) nighttime accidents occurred under artificial light conditions, and 12 of the day-time accidents (16.7%) occurred during cloudy weather (Table 1). 15.4% of all accidents (n=14) occurred during rainy weather, and 2.2% (n=2) occurred during misty weather. No snow was encountered in any of the accidents studied. No statistically significant difference was encountered between patient discharge and the daylight status, lighting of the accident area (sunny, cloudy, dark, artificial light), or rain condition (p=0.097, p=0.372, p=0.192, respectively). Roads/boulevards and local streets were the most common locations reported for the accidents (Table 1). 80.2% of accidents (n=73) occurred on dry-asphalt, whereas 11.0% (n=10) occurred on slippery surfaces (Table 1). Sixty-three patients involved in accidents on asphalt (dry) surfaces and 9 patients involved in accidents on slippery surfaces were discharged. No statistically significant difference was found between the methods of discharge from the Emergency Service and the condition of the surface. Method of discharge from the Emergency Service Seventy-nine of the patients (86.8%) were discharged, 1 (1.1%) was transferred to another health institution, 10 (11.0%) were hospitalized, and 1 died in the Emergency Service during treatment. Four of the hospitalized patients were observed in the intensive care unit. The only patient who died was female, and she was a pillion rider not wearing a helmet. Of the 68 motorcycle riders involved in accidents, 61 (89.7%) were discharged, 4 (5.9%) were hospitalized, and 3 (4.4%) were monitored in the intensive care unit. Of 23 pillion riders, 18 (78.3%) were discharged, 2 (8.7%) were hospitalized, and 1 (4.3%) was monitored in the intensive care unit. Situations that affect the pattern of discharge from emergency service Gender In our study, 60.0% (n=6) of female patients and 90.1% of male patients were discharged. The discharge pattern (discharge, overnight stay, transfer, exitus) of patients showed a statistically significant relationship with gender (p=0.001, Ď&#x2021;2 test). According to the additional analysis undertaken on the relationship between gender and the method of discharge from the Emergency Service, the relationship was statistically significant at a level of p<0.001 (Mann-Whitney U test), while other patterns of discharge from the Emergency Service showed no relationship (hospitalization, transfer). Thus, Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


EroÄ&#x;lu et al. Details of motorcycle accidents and their impact on healthcare costs

Table 1. Medium and mechanism of accidents and motorcycle data

Accident medium and motorcycle data

n

Mechanism of accident %

Place of accident

n

%

Type of accident

Highway

5

5.5

With collision (vehicle, fixed object)

47

51.6

Main street/boulevard

36

39.6

Without collision (fall, skid)

41

45.1

Side street

29

31.9

Collision with pedestrian

3

3.3

Road junction

7

7.7

Traffic light

4

4.4

40

44.0

Other

10 11.0

Surface

Asphalt (dry)

73

First point of impact - motorcycle

80.2

Front

Slippery

10 11.0 Rear

13 14.3

Soil

4

4.4 Sides

38 41.8

Other

4

4.4

Lighting condition

First point of impact - person

Daytime-sunny

60 65.9 Head/neck

10 11.0

Daytime-cloudy

12 13.2 Shoulder

6

Night-time-dark

5

5.5 Arm/forearm

13 14.3

14

15.4

19

20.9

Chest

3

3.3

Abdomen

3

3.3

Motorcycle type

Night-time-lightened medium

Hand/wrist

5

5.5

19 20.9 Hip/pelvis

4

4.4

Off-road/endurance

3

3.3 Led/mid-calf

15 16.5

Scooter/moped

61

67.0

Foot/ankle

19

12.1

Chopper-cruiser

1

1.1

Left blank

2

2.2

7

7.7

Sports

Other

discharge of patients from the Emergency Service was higher among females than males. Mechanism of the accident Of the patients involved in an accident with a collision, 38 (48.1%) were discharged, and of those that were involved in an accident without a collision, 38 (48.1%) were discharged. The number of people admitted to the intensive care unit was also the same. Two people involved in an accident without a collision were admitted to the intensive care unit. The only patient who died presented to the Emergency Service after an accident that involved a collision. No statistically significant difference was detected between the pattern of discharge and the nature of the accident (with collision, without collision, collision with a pedestrian). Further, no statistically significant difference was detected between the pattern of discharge and the use of helmets or other protective gear (with collision, without collision, collision with a pedestrian). Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

Waist/back

6.6

Type of motorcycles Among the types of motorcycles involved in accidents, scooter or mopeds (n=61, 67.0%) were the most common (Table 1). Of those, 54 of the injured (88.5%) were discharged from the Emergency Service, 3 (4.9%) were hospitalized in various services, and 2 (3.3%) were admitted to the intensive care unit. The oldest of 19 patients who had accidents riding a sports motorcycle (the second most common) was 44 years old, the median age was 22 years, and the mean age was 26.37 years (95% CI 20.78 - 31.96). Sixteen of these patients were discharged from the Emergency Service (84.2%), and 2 were admitted to the intensive care unit (10.5%). Upon evaluation, no statistically significant difference was found between the pattern of discharge from Emergency Service and the type of motorcycle ridden. The first area of impact of the motorcycle and the body Using the information supplied by the people involved in the accidents or from witnesses, it was found that for 54.9% 425


EroÄ&#x;lu et al. Details of motorcycle accidents and their impact on healthcare costs

(n=50) of the incidents, the component having the first impact was the person. The most common first area of impact of the body was the hand and wrist, and the most common first area of impact of the motorcycle was the front (Table 1). Whether the first point of contact was the person or the motorcycle made no difference on the fact that the most common first area of impact of the body was the hand and wrist. In our study, there was a statistically significant difference between the first point of impact on the person and the pattern of discharge from the Emergency Service (p=0.009). On the other hand, no statistically significant difference was found between the first point of impact on the motorcycle and the pattern of discharge from the Emergency Service. Since the K-S test did not show normal distribution, Mann-Whitney U test was performed, and it detected no statistically significant difference in the healthcare expenditures with regard to whether the motorcycle or the person suffered the fist impact. Main symptoms on admission Of the patients hospitalized after a motorcycle accident, 87 of 91 (95.6%) were conscious and 1 was unconscious (1.1%) during admission. Two patients (2.2%) were drowsy, and 1 was in cardiac arrest. Seventy-nine (90.8%) of the 87 patients who were conscious at the time of admission were discharged from the Emergency Service. The correlation between the state of consciousness at the time of admission and the type of discharge was statistically significant (p<0.001). According to the statements of patients or accompanying people, the most common injury involved the extremities (n=56, 61.5%) of the body. This was followed by the head and neck (n=20, 22.0%) and torso (n=13, 14.3%). Two patients presented without injury. Eleven patients suffered cuts, and all 11 were discharged. No statistically significant difference was observed between method of discharge and the patients with cuts. Four of six patients (66.7%) requiring service follow-ups were brought into the Emergency Service with complaints about the extremities, whereas three of four patients (75.0%) requiring intensive care were brought with complaints regarding the torso. One patient who was admitted to the intensive care unit was observed with consciousness problems. Of 79 patients discharged, 51 (64.6%) were brought to the Emergency Service with injuries of the extremities. The second most common injury observed in the patients who were discharged concerned the head and neck (n=18, 22.8%). The correlation between the method of discharge and the localization of injuries was statistically significant (p=0.005). Other situations No statistically significant difference was found upon analysis between the methods of discharge and whether the injured was a rider or on a pillion. On the contrary, the correlation between the road type and the method of discharge was statistically significant (p=0.014). All of the injured people involved in accidents occurring at traffic lights and road junc426

tions were discharged (n=4, n=7, respectively). Six patients were hospitalized, and of these, three were involved in accidents that occurred on main streets/boulevards, and the other three were involved in accidents that occurred on side streets. Again, three of four patients who were admitted to the intensive care unit were involved in accidents that occurred on local streets. Seventy-nine patients were discharged, of whom, 33 (41.8%) were involved in accidents that occurred on main streets/boulevards, and 23 (29.1%) were involved in accidents that occurred on side streets. Healthcare costs During this study, the healthcare costs for the scanning and treatment of the injured were also noted. According to our study, the most common scanning technique was X-ray monitoring (n=78, 85.7%), followed by blood testing (n=65, 71.4%), computed tomography (n=26, 28.6%), ultrasonography (n=5, 5.5%) and magnetic resonance monitoring (n=2, 2.2%). The healthcare expenditure of 91 people studied between reception and check-out was US$253.02 on average (95% CI 55.01 - 451.03), the midpoint being US$55.90. The lowest healthcare expenditure was US$11.52 and the highest was US$7,137.19. The total healthcare expenditure for all presenting patients was US$23,025. Using a K-S test, it was observed that there was not a normal distribution for the healthcare costs of either the female or male patients. MannWhitney U test was carried out for this purpose, and it was observed that there was no statistically significant difference between genders in terms of healthcare cost. In this study, the injured parts of the body and the healthcare expenditures were studied independently, and there was no difference in the average healthcare expenditures between injuries of the upper and lower extremities. However, the average healthcare costs for head and neck injuries were higher than for the upper or lower extremities, and this showed a statistically significant difference (p=0.03 and p=0.02, MannWhitney U test). Further, the healthcare costs were studied in relation to the site of the accident. No statistically significant difference was found in the average healthcare costs according to site of the accident, as on a main street/boulevard or side street, or at a road junction. However, a statistically significant difference was observed between accidents that took place on these roads and those occurring on highways (p=0.02, Mann-Whitney U test). Healthcare expenditure was observed to be higher with respect to the highway accidents.

DISCUSSION Our study was conducted in the Emergency Service of Toros State Hospital in Turkey. Mersinâ&#x20AC;&#x2122;s hospitals cover the healthcare needs of the 1,648,000 inhabitants of this province (15,737 m2).[3] According to the Turkish National Institute, the city in which this study was conducted reportedly had 444,734 registered motorized land vehicles, of which, 131,394 (29.5%) were motorcycles.[4] Based on information from the Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


EroÄ&#x;lu et al. Details of motorcycle accidents and their impact on healthcare costs

Turkish National Police Traffic Services Department, the number of total traffic accidents in 2011 was 6,510, resulting in 78 deaths.[2] The healthcare expenditures related to these accidents are not well known. In our study, we investigated the factors influencing these expenditures. The risk of an accident increases with young adults As shown in our study, the majority of the people involved in accidents were between 20 and 30 years of age, which is a result consistent with many other studies.[5-8] Also consistent with these same studies, we found that motorcycle accidents more frequently involved young adults, and the risk of being involved in an accident with a collision decreased with increased age. It may be suggested that age is a factor that affects the choice of vehicles, but this should not be taken as the only and absolute reason, since another study carried out in Turkey on judicial cases reported that young people tend to take actions with greater risk due to their inexperience, and as a result, they have the highest risk of being injured in motorized vehicle accidents.[9] In parallel with our study, most of the people injured in an accident with a sports bike (whether as a rider or on the pillion) are young, supporting this opinion. In contrast to the literature, the injuries are related to the upper extremity In contrast to many studies in the related literature, most of the applications were related to upper extremity injuries.[10-13] Our records show that injuries to the upper limb were in the majority. The first point of impact of the body was also highest for the upper extremity. This fact has remained constant regardless of the nature of the accident, and this may be associated with age. The average age in our study was young. Because of more rapid reflex responses in younger people, they are able to use their hands more easily to protect their head and body during an accident. This may have contributed to this result. In addition, since the accidents mostly occurred in the city areas, this may cause motorcycles to move slower and thus result in less severe accidents. Finally, this can be seen as another reason for having fewer organ injuries than extremity injuries. We also found in our study that highway accidents are associated with a higher expenditure although they are fewer in number. It is also important to note that the severity of highway accidents covered in our study was not severe. Another result also helps us to conclude that the severity of accidents covered in our study is low: We did not observe any statistically significant relationship between the time of accident, motorcycle type, road surface, weather and daylight conditions, or the nature of the discharge of the patient from the Emergency Service (discharged, hospitalized, or exitus). The use of the helmet alone is not effectively related to healthcare costs Many studies from the past[14-16] showed many results indicating the importance of wearing helmets. Brown et al.[16] found that riding and crashing a motorcycle without a helmet is associated with more frequent and more severe injuries, longer Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

hospitalizations, increased mortality, and significantly higher hospital charges, which are often not covered by healthcare insurance. Nevertheless, although the helmet use in women is low, their rate of discharge was higher compared to that of men, a fact that demonstrates that helmet use alone is not effective in relation to the healthcare costs. However, since 8 of 11 of the hospitalized patients were not wearing helmets, it remains an important factor. The effect of the type of the accident is compatible with previous studies The most common type of accident encountered in our study was front collision, which agrees with that reported by Zulkipli et al.[17] We also found that the number of accidents occurring at traffic lights and junctions is lower. This can lead us to consider that front collisions may be a result of careless riding or failure to maintain a safe following distance. Thus, in an effort to reduce motorcycle accidents, it is necessary to improve the traffic awareness of motorcyclists as well implement into practice a penalty mechanism. In conclusion, many factors can influence the healthcare costs related to the way in which motorcycle accident victims pass through an emergency room. We did not observe any statistically significant relationship between the time of the accident, motorcycle type, road surface, weather and daylight conditions, or the protective equipment used, although these variables looked promising. The main factor that determines the healthcare costs is the first part of the body receiving the impact. Another important result is that motorcycle accidents have become a form of trauma specific to the young. It is important that the legal authorities redefine the rules, and if necessary, regulate the age and education necessary to receive a license to operate motorcycles. The facts that this study was held in one city and in a single healthcare center (far from the highway) are the most serious limiting factors, preventing this study from including many severe multi-trauma patients. Future studies planned involving multiple healthcare centers, with more detailed questions on the accidents, will better outline the factors that influence healthcare costs.

Acknowledgements We would like to thank Dr. Ray Guillery for the English edition of the manuscript and also thank the Institutional Review Board for their kind approval of this study. Conflict of interest: None declared.

REFERENCES 1. Peden M, Scurfield R, Sleet D, Mohan D, Hyder A, Jarawan E, et al. World report on road traffic injury prevention. Geneva: World Health Organization; 2004. 2. Turkish National Police, Traffic Services Department [Homepage on the

427


Eroğlu et al. Details of motorcycle accidents and their impact on healthcare costs internet]. Ankara: Traffic statistics yearbook 2011, Turkey. 3. Eroglu SE, Toprak SN, Urgan O, Onur OE, Denizbasi A, Akoglu H, et al. Evaluation of non-urgent visits to a busy urban emergency department. Saudi Med J 2012;33:967-72. 4. Turkish statistical institute [Homepage on the internet]. Ankara: Road motor vehicles by province, Turkey [cited 2012 June 20]. Available from: http://www.turkstat.gov.tr/PreHaberBultenleri.do?id=10861. 5. Monk JP, Buckley R, Dyer D. Motorcycle-related trauma in Alberta: a sad and expensive story. Can J Surg 2009;52:235-40. 6. Elliott MA, Baughan CJ, Sexton BF. Errors and violations in relation to motorcyclists’ crash risk. Accid Anal Prev 2007;39:491-9. 7. Zambon F, Hasselberg M. Socioeconomic differences and motorcycle injuries: age at risk and injury severity among young drivers. A Swedish nationwide cohort study. Accid Anal Prev 2006;38:1183-9. 8. Nakahara S, Chadbunchachai W, Ichikawa M, Tipsuntornsak N, Wakai S. Temporal distribution of motorcyclist injuries and risk of fatalities in relation to age, helmet use, and riding while intoxicated in Khon Kaen, Thailand. Accid Anal Prev 2005;37:833-42. 9. Ayoğlu F, Isık AF, Bumin MA. Gazi Üniversitesi Tıp Fakültesi Acil Servisi’ne başvuran adlî vakaların analizi. V. Ulusal Halk Sağlığı Kon-

gresi. İstanbul: 1996. s. 96-100. 10. Chiu WT, Kuo CY, Hung CC, Chen M. The effect of the Taiwan motorcycle helmet use law on head injuries. Am J Public Health 2000;90:793-6. 11. Özkan S, İkizceli İ, Akdur O, Durukan P, Güzel M, Vardar A. Injuries due to motorcycle accidents. JAEM 2009;8:25-9. 12. Lateef F. Riding motorcycles: is it a lower limb hazard? Singapore Med J 2002;43(11):566-9. 13. Koçak S, Uçar K, Bayır A, Ertekin B. Characteristics of the cases of bicycle and motorcycle accidents referred to the Emergency Department. TJ Emerg Med 2010;10:112-8. 14. Hinds JD, Allen G, Morris CG. Trauma and motorcyclists: born to be wild, bound to be injured? Injury 2007;38:1131-8. 15. Liu BC, Li L, Gao M, Wang YL, Yu JR. Microinflammation is involved in the dysfunction of arteriovenous fistula in patients with maintenance hemodialysis. Chin Med J (Engl) 2008;121:2157-61. 16. Brown CV, Hejl K, Bui E, Tips G, Coopwood B. Risk factors for riding and crashing a motorcycle unhelmeted. J Emerg Med 2011;41:441-6. 17. Zulkipli ZH, Abdul Rahmat AM, Mohd Faudzi SA, Paiman NF, Wong SV, Hassan A. Motorcycle-related spinal injury: crash characteristics. Accid Anal Prev 2012;49:237-44.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Motorsiklet kazaları detayları ve sağlık maliyetleri üzerine etkileri Dr. Serkan Emre Eroğlu,1 Dr. Sıddıka Nihal Toprak,2 Dr. Ebru Akoğlu,3 Dr. Özge Ecmel Onur,1 Dr. Arzu Denizbaşı,1 Dr. Çiğdem Özpolat,1 Dr. Haldun Akoğlu1 1 2 3

Marmara Üniversitesi Pendik Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, İstanbul Mersin Toros Devlet Hastanesi, Acil Servis, Mersin Atatürk Devlet Hastanesi, Acil Servis, Zonguldak

AMAÇ: Türkiyede 2011 yılındaki tüm trafik kazalarının %7.58’ini (n=21107) motorsiklet kazaları oluşturmaktadır. Çalışmamızda, motorsiklet kazaları ve bu kazalara ait detayların, sağlık maliyetlerindeki rolleri araştırıldı. GEREÇ VE YÖNTEM: 1 Temmuz 2010-30 Haziran 2011 tarihleri arasında çarpışmalı ya da çarpışmasız motorsiklet kazaları ile acil servise gelen hastalar ileriye dönük olarak incelendi. Kazazede ve kazaya ait detaylı bilgileri içeren formlar motorsiklet kazası ile getirilen tüm yaralılara doldurularak sağlık maliyetleri araştırıldı. Veriler, SPSS v16 programında frekans, Kolmogorov-Smirnov, Mann-Whitney U ve ki-kare testleri kullanılarak analiz edildi. BULGULAR: Değerlendirmeye alınan 91 kazazedenin, yaş ortalaması 28.47. Değerlendirmeye alınan 91 kazazedenin başvurusundan taburculuğuna kadar olan sağlık maliyetleri ortalaması 253.02$, ortancası 55.90$ idi (dağılım, 11.52- 7137.19$). Çalışmaya göre, sağlık maliyetleri ile kaza saati, motorsiklet tipi, yolun yüzeyi, koruyucu ekipman, hava ya da gün ışığı arasında kesin bir korelasyon yoktu. TARTIŞMA: Çalışmaya göre, kaza riski genç erişkinlerle artmaktadır. Buna bağlı olarak da, sağlık maliyetleri artmaktadır. Bu sebeple, yasal kuralları yeniden belirlenmesi ve gerekiyorsa motorsiklet ehliyeti alma yaşı ve de eğitimleri düzenlenmelidir. Anahtar sözcükler: Acil servis, sağlık maliyetleri, motorsiklet kazaları, travma. Ulus Travma Acil Cerr Derg 2013;19(5):423-428

428

doi: 10.5505/tjtes.2013.06767

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


ORIGIN A L A R T IC L E

The reflection of the Syrian civil war on the emergency department and assessment of hospital costs Ali Karakuş, M.D.,1 Erhan Yengil, M.D.,2 Seçkin Akkücük, M.D.,3 Cengiz Cevik, M.D.,4 Cem Zeren, M.D.,5 Vedat Uruc, M.D.6 Departments of 1Emergency Medicine, 2Family Medicine, 3General Surgery, 4Otorhinolaryngology, 5

Forensic Medicine, 6Orthopedics, Mustafa Kemal University Faculty of Medicine, Hatay

ABSTRACT BACKGROUND: In the present study, it was aimed to assess the demographics, clinical features, and treatment costs of cases referred to our hospital after the Syrian civil war. METHODS: Of 1355 Syrian civil war victims referred to our hospital during the 14-month period between June 2011 and July 2012, 482 cases presenting to the emergency department were included in the study. The electronic data of these patients were retrospectively analyzed. RESULTS: Of 482 cases, 428 were male (88.8%) and 54 (11.2%) were female, with a mean age of 30.4±14.9 years (1-79 years). The mean age was 30.8±17.2 years (1-79 years) in males and 27.3±16.9 years (1.5-66 years) in females. There was a significant difference in terms of sex (p=0.007). It was found that the majority of the cases (41.1%) were aged 21-30 years. The highest number of admissions was recorded in June 2011 (159 patients, 33%), whereas the lowest number of admissions was in September 2011 (5 patients, 1%). All cases were transported to our hospital from nearby district hospitals and camps by emergency medical services. The most frequent presenting complaint was gunshot injury (338 cases, 70.1%). The most common diagnosis was extremity injury (153 cases, 31.7%). The number of forensic cases was found as 364 (75.5%). Of all the cases, 136 cases (28.2%) were managed in the emergency service, and the remaining cases were admitted to other services. They were most frequently admitted to the orthopedics ward (146 cases, 30.3%). The mean length of the hospital stay was 9.9 days (1-141).Overall, 456 cases (94.6%) were discharged, 22 cases died, and 4 cases were transferred to other facilities. The mean cost per case was estimated as 3723Turkish lira (TL) (15-69556). A positive correlation was found between cost and length of hospital stay. CONCLUSION: Among all Syrian cases, the majorities of young males and gunshot injuries was striking. Most of the cases were discharged after appropriate management. Preventive measures can avoid these negative outcomes and so avoidable costs will not occur, and this can preclude the damage to the budgets of the countries.

Key words: Avoidable costs, gunshot injury, Syrian case.

INTRODUCTION Wars and conflicts are among the preventable causes of disease, which adversely affect human life and result in lifethreatening conditions or death in addition to disability. These combats have existed from the beginning of human history, and have continued throughout all eras in distinct locations of Address for correspondence: Ali Karakuş, M.D. Mustafa Kemal Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Hatay, Turkey Tel: +90 326 229 10 00 / 2602 E-mail: drkarakus@yahoo.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):429-433 doi: 10.5505/tjtes.2013.78910 Copyright 2013 TJTES

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

the world. It was reported that over 160 wars have occurred since the Second World War.[1] Recent examples include the United States-Iraq and Israel-Palestine wars as well as wars and conflicts in countries such as Afghanistan, Libya and Egypt. As they threaten human health regarding disability, complications, and epidemic diseases, they pertain closely to the medical field. It was suggested that 190 million people have died due to wars and conflicts in the twentieth century, and that the majority are civilian deaths.[1,2] In the present study, we aimed to contribute to the literature by observing the effect of a civil war on an emergency department and by identifying demographics, clinical features and avoidable costs.

MATERIALS AND METHODS Of 1355 Syrian civil war victims who were referred to our hospital, a tertiary healthcare facility, during a 14-month period between June 2011 and July 2012, 482 cases presenting to the emergency department were included in the study. Patients 429


Karakuş et al. The reflection of the Syrian civil war and hospital costs

Statistical Analysis The Statistical Package for the Social Sciences (SPSS) for Windows 13.0 software was used in the statistical analysis. Continuous variables were evaluated using KolmogorovSmirnov test for normality. Associations between nominal variables were evaluated using the chi-square test, while differences in median values between groups were assessed by Kruskal-Wallis and Mann-Whitney U tests. The linear regression model was applied to reveal factors effective on hospital costs. A value of p<0.05 was considered as significant in all statistical analyses.

RESULTS Between June 2011 and July 2012, 281,356 patients were admitted to our hospital, and 1355 (0.48%) of them were Syrian; 27,398 patients were admitted to the emergency department, and 482 (1.75%) of them were victims of the Syrian civil war. Four hundred twenty-eight of 482 cases were male (88.8%) and 54 (11.2%) were female, with a mean age of 30.4±14.9 years (1-79 years). The mean age was found as 30.8±17.2 years (1-79 years) in males and 27.3±16.9 years (1.5-66 years) in females. A significant difference was found in terms of sex (p=0.007). It was found that the majority of the cases (198 cases, 41.1%) were aged 21-30 years (Fig. 1). The highest number of admissions was recorded in June 2011 (159 patients, 33%) and the lowest in September 2011 (5 patients, 1%).

150 21.00% 100 12.45% 50

0

When diagnosis and age groups were considered, it was found that extremity injury (153 cases, 31.7%) was most common. 430

11.2%

5.30%

0-10

11-20

21-30

31-40

41-50

7.88%

51 and above

Age

Figure 1. Age distribution of cases.

Of the 482 cases presenting to the emergency department, it was found that 364 cases (75.5%) were in the forensic case group (Table 1). When management and outcomes were considered, it was found that the number of patients managed in the emergency department/total number of patients admitted to emergency department was 136/607 patients (26.8%). Of the 136 cases, 127 patients (26.4%) were discharged on an outpatient basis, 6 patients (1.2%) died in the emergency department, and 3 patients (0.6%) were transferred from the emergency department. Of the 482 cases, 346 (71.8%) were admitted to hospital, of whom one was transferred to another facility and 16 died. Overall, 456 patients (94.6%) were discharged, while 22 patients (4.6%) died and 4 (0.8%) were transferred. When the ward of admission and outcomes were considered, it was seen that patients were most frequently admitted to the orthopedics ward (146 cases, 30.3%) (Table 2). The mean length of hospital stay was 9.9 days (1-141 days). The mean Other forensic Other cases diagnosis (4%) Surgical (3.73%)

All cases were transported to our hospital from nearby district hospitals and camps by emergency medical services. These patients were recorded in the Hatay Antakya Public Stateless and Exile Agency and Hatay Disaster Agency registry. The most frequent presenting complaint was gunshot injury (338 cases, 70.1%). Gunshot injuries included lead injury, injury related to the shell, mine explosion, and bullet wounds. The medical emergency group included chest pain, shortness of breath, intoxication, and snake bites. There were causes of abdominal pain and of headache in the surgical emergency group, while traffic accidents and falls were recorded in other forensic case groups. Green code diseases, which were directed to outpatient clinics other than the non-traumatic emergency department, were included into the other diagnosis group (Fig. 2).

41.00%

200

Frequency

presenting to clinics other than the emergency department were excluded. The electronic data of these patients were analyzed retrospectively. Patients were reviewed in terms of gender, age, time of presentation, place from which he/she was transferred, presenting complaint, diagnosis, forensic case status, ward of admission, length of stay, outcome, and cost.

emergency (4.3%)

Stab wound (0.03%) Beaten (2.28%)

İnternal emergency (13.6%)

Gunshot wounds (70.12%)

Figure 2. Distribution of presenting complaints according to cases.

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


KarakuĹ&#x; et al. The reflection of the Syrian civil war and hospital costs

Table 1. Age groups and diagnosis Age and diagnosis

0-10

11-20

21-30

31-40

41-50

51 and above

Total (n)

Head injury

1

4

20

11

3

1

40

Internal disease

9

10

27

11

11

25

93

Maxillofacial trauma

1

1

12

11

3

2

30

Spinal injury

0

1

3

7

1

0

12

Cardiac injury

0

1

1

2

2

0

6

Chest injury

0

5

23

6

9

1

44

Abdominal injury

0

4

16

10

9

2

41

Pelvic injury

0

0

7

1

1

0

9 153

Extremity injury

6

29

66

35

11

6

Ocular injury

1

4

15

6

2

1

29

Surgical emergency

8

1

8

6

2

0

25

Total (n)

26

60

198

106

54

38

482

Table 2. Admissions and outcomes Department of admission

Discharged

and outcomes

n %

Died

Transferred

n %

n %

Total n %

Orthopedics

145

30.1

1

0.2

0

0

146

3.3

Emergency

127

26.3

6

1.2

3

0.6

136

28.2

General Surgery

42

8.7

9

1.9

0

0

51

10.6

Ophthalmology

31 6.4

0 0

1 0.2

32 6.6

Cardiology

24 5.0

2 0.4

0 0

26 5.4

Neurosurgery

22 4.6

3 0.6

0 0

25 5.2

Otorhinolaryngology

25

5.2

0

0

0

0

25

5.2

Plastic Surgery

18

3.7

0

0

0

0

18

3.7

Thoracic Surgery

11

2.3

0

0

0

0

11

2.3

Pediatrics

4

0.8

0

0

0

0

4

0.8

Urology

3 0.6

Pediatric Surgery

2

Neurology

1 0.2

1 0.2

0 0

2 0.4

1

0

0

1

Obstetrics & Gynecology Total

0.4 0.2

0 0

0 0

3 0.6

0

0

2

0 0

0 0

0.4 0.2

456 94.6 22 4.65 4 0.8 482 100

length of hospital stay was 10.1 days (min: 1 - max: 141) in the 456 cases discharged, 11.5 days (min: 1 - max: 30) in the patients transferred and 6.5 days (min: 1 - max: 20) in the exitus patients. No significant relationship was found between outcomes and length of hospital stay (p=0.45). When outcomes and age were considered, it was found that the mean age was lower in cases discharged compared to those who died (p=0.015) (Fig. 3). When a correlation test was performed with continuous variables, a positive correlation was detected between cost and length of hospital stay (p=0.000) (Fig. 4). Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

When diagnosis and costs were considered, it was found that the maximum cost occurred in patients who admitted to the hospital due to head-neck injury with an intracranial event (n: 40, 10287.90 Turkish lira (TL) [130 TL - 67912 TL]). During this period, the number of patients in the emergency department was increased about 50% when compared to the prewar period. This overload caused staff insufficiency and new staff requirements. Further, new services and additional intensive care units were activated. All these caused additional costs and workloads.

DISCUSSION Wars and conflicts negatively affect human life. The chaos 431


Karakuş et al. The reflection of the Syrian civil war and hospital costs

Age

50

40

30

20 Discharge

Exitus Result

Dispatch

Figure 3. Assessment of age-outcome.

Partial regression plot Dependent variable: cost 60.000 Coast

40.000 20.000 0

R Sq Linear=0.231

0

50 Length of stay (day)

100

Figure 4. The relationship between cost and length of stay.

state in a country drives people to migrate to other countries, forcing them into refugee status. It particularly affects the young population and changes the structure of the general population. In the previous studies, it was suggested that the migrated population is mostly male (70-100%) and in young age groups (16-34 years of age).[3-5] This inevitably affects the population in all respects. The finding that, of our 482 cases, 428 were male (88.8%) with a mean age of 30.4±14.9 years (1-79 years) is consistent with the literature. This may indicate that the young, male population is responsible for working, maintaining life, and protecting the family and family circle. All healthcare staff should be trained for natural disasters, accidents including multiple casualties, and conflicts and wars. It has been suggested that firearms have four mechanisms of action.[6] In the first mechanism, there is an initial explosion, shock waves and visceral effects.[7,8] The second mechanism is the shell effect of materials in the bomb. The third mechanism includes blunt trauma caused by force, and the fourth mechanism includes burns after flames. The first mechanism is considered as the most important mechanism causing disability and death. In the studies, it has been suggested that all casualties managed had gunshot injury.[4,5] In our study, gunshot injury was the most common presenting complaint and mechanism of action. Among these, injuries caused by shell effect were the most frequent, followed by those caused by the effects of the initial explosion, blunt trauma and burns, 432

and this may explain the lower mortality rates in our series. All bodily structures may be involved after injury and may threaten life. In a study by Mushtaque et al.,[5] it was found that extremities (47.9%), abdomen (36.3%) and lungs (31.3%) were involved. In other studies, extremity injuries ranked first.[4,9-11] In agreement with the literature, it was seen that extremities were the most commonly involved structures in our cases. This may suggest that structures with mobility are vulnerable in terms of injuries and may be more excessively involved. Depending on their clinical status, patients may be discharged from the emergency department after management on an outpatient basis, while severe cases should be managed in wards and intensive care units. In one study, 59.5% of the patients were discharged from the emergency department after management on an outpatient basis, while 346 of 482 cases (71.8%) were admitted to hospital in our series.[5] Of the 136 patients managed in the emergency department on an outpatient basis in this series, 127 (26.4%) were discharged. Patients may be discharged after management, or death may occur. Death usually occurs either as a result of the primary disease or potential secondary complications. In one study, it was found that 53.7% of the cases underwent surgery, and 3.03% of these cases died.[5] In another study, it was found that the number of deaths caused by disease were more than deaths caused by injury during war (deaths caused by disease 24870 [3.5%] vs. 130121 [18.3%]).[12] In a case series including 31 cases, only 2 deaths occurred due to gunshot injury. [4] Of the 482 cases in our study, 456 cases (94.6%) were discharged and 22 cases (4.6%) died (6 patients in the emergency department and 13 patients in wards because of clinical status and complications caused by gunshot injury and 3 due to cardiac failure, myocardial infarction and intracranial event in cardiology and neurology wards). The disposition of most patients in this series might be attributed to appropriate diagnosis and treatment on site. In Article 14 of the Universal Declaration of Human Rights, it is proposed that “Everyone has the right to seek and to enjoy in other countries asylum from persecution”.[3] According to the registry of the United Nation’s Refugee Agency, there were about 11,000 refugees in December 2008.[13] This number was 25,459 in December 2011.[14] The Act of Insurance and General Health Insurance (#5510; 60/1c) included stateless people and refugees in the scope of general health insurance. Because the conflict in Syria started in April 2011, 80,000 Syrian citizens had entered our country by August 2012, while 30,000 had returned to their country. Driven by AFAD (Agency of Disaster and Emergency Management), five tent camps were constructed in Hatay, two camps in Şanlıurfa and one camp in Gaziantep. There was also a shelter in Kilis including containers. Of the remaining 50,000 refugees, about 500 are still in hospitals.[15] Over the previous one-year period, approximately 2100 casualties were transferred to Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


Karakuş et al. The reflection of the Syrian civil war and hospital costs

hospitals from the Syrian border, and it was reported that expenses reached 150 million dollars as per April 2012.[16,17] Patients transferred to our hospital were managed after being reported to the Hatay, Antakya Public Stateless and Exile Agency. In our cost analysis, it was found the mean cost per case was 3723 TL (15-69556 TL). This might have been caused by poor prognosis and prolonged length of stay. In conclusion, wars and conflicts as avoidable causes negatively affect human life. Among all Syrian cases, the majority of patients were young males, and gunshot injury was the striking cause of trauma. Most of the cases were discharged after appropriate management. Following precautionary measures, these negative outcomes and avoidable costs can be prevented, and strains on the budgets of the receiving countries may be precluded.

Journal of Arts and Social Sciences 2012;5:1-5. 5. Mushtaque M, Mir MF, Bhat M, Parray FQ, Khanday SA, Dar RA, et al. Pellet gunfire injuries among agitated mobs in Kashmir. Ulus Travma Acil Cerrahi Derg 2012;18:255-9. 6. Cömert B. Conditions of War Intensive Care Unit. Intensive Care Medicine 2006;6:16-21. 7. Wightman JM, Gladish SL. Explosions and blast injuries. Ann Emerg Med 2001;37:664-78. 8. Mayorga MA. The pathology of primary blast overpressure injury. Toxicology 1997;121:17-28. 9. Gourgiotis S, Schmidt R. The experience of military surgeons from a north Afghanistan deployment and lessons for the future. Ulus Travma Acil Cerrahi Derg 2011;17:289-92. 10. Hebrang A, Henigsberg N, Golem AZ, Vidjak V, Brnić Z, Hrabac P. Care of military and civilian casualties during the war in Croatia. [Article in Croatian] Acta Med Croatica 2006;60:301-7. [Abstract] 11. Zouris JM, Walker GJ, Dye J, Galarneau M. Wounding patterns for U.S. Marines and sailors during Operation Iraqi Freedom, major combat phase. Mil Med 2006;171:246-52.

Conflict of interest: None declared.

REFERENCES 1. İz FB. Savaş ve çevre. Maltepe University School of Nursing Science and Art Journal 2009;2:113-7. 2. Pyakuryal P, Uprety K Economic & legal ımpact of conflict on states & people in south asia with specific reference to nepal. The Journal of Social, Political and Economic Studies 2005;30:234-40. 3. Buz S. The social profile of asylum seekers in Turkey. Turkish Journal of Police Studies 2008;10:1-14. 4. Zeren C, Arslan MM, Aydogan A, Ozkalipci O, Karakuş A. Firearm injuries documented among Syrian refugees in Antakya Turkey. British

12. Uçar M, Deniz S. Turkish History Military Health Services. TAF Preventive Medicine Bulletin 2012;11:103-18. 13. Karadağ O,Altıntaş KH. Mülteciler ve sağlık. TAF Preventive Medicine Bulletin 2010;9:55-62. 14. http//www.amnesty.org.tr/ai/node/1872. 27 Feb 2012 - in the field of social security arrangements and access to health care of refugees and asylum-seekers. (Accessed: 08/10/2012). 15. http//www. last minute. com. (Accessed: 08/10/2012). 16. http//www. news. com. (Accessed: 08/10/2012). 17. http//www. news 10. com. (Accessed: 08/10/2012).

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Suriye’deki çatışmaların acil servise yansıyan yönü ve hastane maliyetlerinin değerlendirilmesi Dr. Ali Karakuş,1 Dr. Erhan Yengil,2 Dr. Seçkin Akkücük,3 Dr. Cengiz Cevik,4 Dr. Cem Zeren,5 Dr. Vedat Uruc6 Mustafa Kemal Üniversitesi, Tıp Fakültesi, 1Acil Tıp Anabilim Dalı, 2Aile Hekimliği Anabilim Dalı, 3Genel Cerrahi Anabilim Dalı, 4 Kulak Burun Boğaz Anabilim Dalı, 5Adli Tıp Anabilim Dalı, 6Ortopedi ve Travmatoloji Anabilim Dalı, Hatay

AMAÇ: Bu çalışmada, Suriye’de yaşanan çatışmalar sonrası hastanemize getirilen olguların demografisi, klinik özellikleri ve yapılan harcamaların değerlendirilmesi amaçlandı. GEREÇ VE YÖNTEM: Bu amaçla Haziran 2011-Temmuz 2012 yılları arasındaki 14 aylık dönemde hastanemize getirilen 1355 Suriyeli olgunun acil servis girişi olan 482’si çalışmaya alındı. Hastaların bilgisayar verileri geriye dönük olarak incelendi. BULGULAR: Olguların 428’i (%88.8) erkek, 54’ü (%11.2) kadın, yaş ortalamaları 30.4±14.9 yıl (min: 1, maks: 79), erkeklerin yaş ortalaması 30.8±17.2 yıl (min: 1, maks: 79), kadınların yaş ortalaması ise 27.3±16.9 yıl (min: 1.5, maks: 66) olarak belirlendi, cinsiyet bakımından aralarında istatistiksel olarak anlamlı bir fark saptandı (p=0.007). Olguların en çok 21-30 yaş grubunda (%41.1) olduğu belirlendi. En fazla başvurunun 159 (%33) kişiyle Haziran 2011, en az ise beş kişi (%1) ile Eylül 2011’de olduğu tespit edildi. Hastalar 112 Acil Servis ambulansları ile çevre ilçe hastaneleri ve kamplardan getirildi. Acil servise başvuru sebebi en sık 338 olgu (%70.1) ile ateşli silah yaralanması idi. En sık konulan tanı ise ekstremite yaralanmasıydı (153 olgu, %31.7). Adli olgu sayısı 364 (%75.5) tespit edildi. Yüz otuz altı (%28.2) hastanın acil servisde takip ve tedavisi yapıldı. Hastalar en sık ortopedi ve travmatoloji bölümüne yatırılarak tedavi edildi (146 olgu, %30.3). Ortalama yatış süresi 9.9 gün (1-141 gün) idi. 456 olgu (%94.6) taburcu edilirken, 22 olgu (%4.6) öldü, dört olgu (%0.8) ise sevk edildi. Olguların maliyeti ortalama 3723 TL (min: 5 TL, maks: 69556 TL) olarak bulundu. Sürekli değişkenler arası korelasyon testi yapıldığında maliyeti ve yatış süresi arasında pozitif korelasyon saptandı (p=0.000). TARTIŞMA: Getirilen olgular içinde genç erkek ve ateşli silah yaralanması olgularının çokluğu dikkat çekti. Olguların çoğunluğu uygun takip ve tedavi sonrasında taburcu edildi. Alınacak tedbirler sonrasında bu kötü sonuçlar engellenebilecek, önlenebilir maliyetler ortaya çıkmayacak ve ülke bütçelerinin zarar görmesi önlenebilecektir. Anahtar sözcükler: Önlenebilir maliyet, ateşli silah yaralanması, Suriyeli olgu. Ulus Travma Acil Cerr Derg 2013;19(5):429-433

doi: 10.5505/tjtes.2013.78910

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

433


ORIGIN A L A R T IC L E

The synergy between endoscopic assistance and extraoral approach in subcondylar fracture repair: a report of 13 cases Lütfi Eroğlu, M.D.,1 İbrahim Alper Aksakal, M.D.,1 Musa Kemal Keleş, M.D.,1 Çağlayan Yağmur, M.D.,2 Ozan Aslan, M.D.,3 Tekin Şimşek, M.D.1 1

Department of Plastic, Reconstructive and Aesthetic Surgery, Ondokuz Mayis University Faculty of Medicine, Samsun

2

Department of Plastic, Reconstructive and Aesthetic Surgery, Samsun Training and Research Hospital, Samsun

3

Department of Plastic, Reconstructive and Aesthetic Surgery, Samsun Gazi Public Hospital, Samsun

ABSTRACT BACKGROUND: We aimed to present the primary experience of one surgeon with a new surgical technique performed on the first 13 cases and to evaluate outcomes following an extraoral endoscopic approach to subcondylar fractures. METHODS: Fifteen subcondylar fractures in 13 patients, who were treated at Ondokuz Mayis University Hospital between January 2010 and June 2011, were included in this study. Patients were operated on using either endoscopic or open approach. RESULTS: Rigid plate fixation was completed endoscopically using extraoral approach in nine fractures, while six fractures were plated by conversion to a full-open approach. In all six fractures that could not be fixed endoscopically, the proximal fragments were medially displaced, whereas seven of nine fractures that were successfully fixed endoscopically were laterally displaced. CONCLUSION: An extraoral endoscopic approach for subcondylar fractures is feasible and can be carried out with decreased morbidity. This approach is recommended for those with limited experience in endoscopy to treat low laterally displaced subcondylar fractures as their initial cases.

Key words: Endoscopy, endoscopic assistance, subcondylar fracture, subcondylar fracture treatment.

INTRODUCTION Subcondylar fractures of the mandible are common and account for 9-45% of all mandibular fractures; treatments for these fractures remain controversial.[1-8] Although closed reduction and maxillomandibular fixation is the method most widely employed to treat subcondylar fractures, accurate reduction of the fracture and anatomically restoring condylar position are rarely achieved. Open reduction and internal fixation (ORIF) is a reliable method for anatomical restoration of condylar position and for minimizing the risk of malocclu-

Address for correspondence: Çağlayan Yağmur, M.D. Samsun Eğitim ve Araştırma Hastanesi, Merkez, Samsun, Turkey Tel: +90 362 - 3111515 E-mail: caglayanyagmur@gmail.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):434-440 doi: 10.5505/tjtes.2013.77292 Copyright 2013 TJTES

434

sion, internal derangement and degenerative osteoarthritis. [9] However, ORIF has some major drawbacks, such as poor access and visualization, facial nerve deficits, facial scarring, salivary fistulas, and delayed functional rehabilitation. Many open subcondylar fracture repair techniques to minimize these limitations and complications have been described.[3] The endoscopic approach to the repair of subcondylar fractures was first described by Jacobovicz et al. in 1998.[9] Subsequently, this minimally invasive technique was advocated by many authors for fracture management with a potential for decreased patient morbidity.[10] Endoscopic subcondylar fracture repair has evolved to achieve equivalent or superior results with decreased morbidity. Compared with open techniques (preauricular approach), the endoscopic approach to the condylar region remains extracapsular and does not affect cartilage or synovial fluid.[11] The purpose of this study was to present the primary experience of one surgeon with an endoscopic surgical technique performed on the first 13 cases and to evaluate outcomes following an extraoral endoscopic approach to subcondylar fractures. Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


Eroğlu et al. Subcondylar fracture repair

MATERIALS AND METHODS

(a)

This study was approved by the Ondokuz Mayis University Hospital Institutional Review Board, and all participants signed an informed consent agreement. Fifteen subcondylar fractures in 13 consecutive patients, who were treated at Ondokuz Mayis University Hospital between January 2010 and June 2011, were included in this study. All operations were performed by one surgeon (LE). The total follow-up period for patients was 18 months. Ten males (77%) and three females (23%), with an age range of 23-59 years, were included. The mechanisms of the fractures included falls (6 cases), motor vehicle accidents (6 cases), and assault (1 case). Two patients had bilateral subcondylar fractures. The subcondylar fractures were dislocated medially in seven cases and laterally in the remainder. Ten patients had concurrent facial fractures (Table 1).

(b)

The main findings in the cases diagnosed as subcondylar fractures were pain, malocclusion, open bite, and mandibular asymmetry. Localization and type of fractures, degree of displacement, and the presence of additional facial fractures were evaluated by panoramic radiographs and computed tomography (CT) scans. The procedures were performed under general anesthesia using endoscopic instruments (30° angled 4-mm diameter straight endoscope). Five of the 15 fractures were explored using two ports (submandibular and intraoral), whereas nine were explored through a single submandibular port. One fracture was explored by using a previous laceration.

Surgical Technique It is recommended that the patient be in the supine position and nasotracheally intubated. This positioning allows the

Figure 1. (a) Our specially designed plate holder clamp. (b) The head part of the clamp is compatible with the plate. This enables the surgeon to perform fine manipulations with great ease.

surgeon and assistant to stand on either side of the head of the patient. Visualization requires an endoscope and a camera attachment. The endoscopic view is projected on a video monitor that can be viewed by both the surgeon and the assistant. The surgeon should also have access to appropriate instrumentation. Some specialized instruments have been designed specifically to facilitate this procedure (Fig. 1a, b). Arch bars were applied (if the patient was dentate) for postoperative occlusal training and mandibulomaxillary fixation (MMF). If there were any other fractures in the mandible, these were repaired first. All of our endoscopic surgery was performed using a submandibular incision combined with an intraoral incision in initial cases. A preauricular incision was used for the open reductions (bail out procedure) (Table 2).

Table 1. Patients with concurrent facial fractures No

Age

1 38 2 56 3 38 4 26 5 47 6 23 7 24 8 32 9 24 10 44 11 49 12 59 13 45

Fracture

Dislocation

Concurrent fracture

Left→Subcondylar Right→Medial Yes Right→Subcondylar Left→Lateral Left→Subcondylar Lateral No Right→High subcondylar Medial Yes Right→Subcondylar Lateral Yes Left→Subcondylar Lateral Yes Left→Subcondylar Medial Yes Left→Subcondylar Lateral No Right→Subcondylar Medial Yes Right→Subcondylar Right→Medial Left→Subcondylar Left→Lat Yes Right→Subcondylar Lateral No Left→Subcondylar Medial Yes Right→Subcondylar Lateral Yes Left→Subcondylar Medial Yes

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

435


Eroğlu et al. Subcondylar fracture repair

Table 2. Bail-out procedure No

Incision(s)

1 2 3 4 5 6 7 8 9 10 11 12 13

Right→Submandibular-Intraoral Right→Endoscopic-Open Left→Submandibular-Preauricular Left→Endoscopic Submandibular Endoscopic Submandibular-Preauricular Endoscopic-Open Submandibular-Intraoral Endoscopic-Open Submandibular-Intraoral Endoscopic-Second Submandibular-Intraoral Endoscopic AN (own incision) Endoscopic Submandibular-Intraoral Endoscopic Right→Submandibular, Preauricular Right→Endoscopic-Open Left→Submandibular Left→Endoscopic Submandibular Endoscopic Submandibular-Preauricular Endoscopic-Open Submandibular Endoscopic Submandibular-Preauricular Endoscopic-Open

After the injection with a hemostatic agent, 1% lidocaine with 1:100.000 epinephrine, a 1.5-2 cm incision was made one finger-breadth below a line from the mandibular angle. The angular part of the mandible was dissected meticulously using a fine-tipped scissor to protect the marginal mandibular nerve. A blind subperiosteal dissection was then performed to create an optical cavity. A lag screw was passed through a 1.5-mm drill hole at the mandibular angle to allow the surgeon to distract the distal segment. The fracture lines were identified endoscopically. A long-handled, narrowtipped clamp was used to grasp the condylar neck and to position the condylar head in the fossa. After ensuring that the fractures were reduced, fixation was achieved by placing titanium mini-plates and screws via a preauricular stab incision and trocar.

Operation Type(s)

Mini-plate(s) Right (1) Left (1) 1 2 1 2 2 2 1 Right (1) Left (2) 1 1 1 1

proximal fragments were medially displaced, whereas seven of nine fractures that were successfully fixed endoscopically were laterally displaced. Two fractures that were fixed endoscopically were minimally medially displaced. Ten subcondylar fractures were fixed with one mini-plate. Five cases underwent fixation with two mini-plates (Table 2). The mean operating time was 150 minutes (min), including MMF. Panoramic radiographs and CT scans (coronal, axial, and three-dimensional CT) were taken postoperatively. Adequate consolidation of the fracture was observed in all patients at the end of the follow-up period (Fig. 3).

RESULTS Fifteen subcondylar fractures were explored in 13 patients using an endoscopic approach. Two of the 13 patients had bilateral fractures. Rigid plate fixation was completed endoscopically in nine fractures (Fig. 2); six fractures that could not be reduced endoscopically were plated by conversion to a fullopen approach (bail-out procedure). According to the postoperative radiographs, only one endoscopically operated case had inadequate reduction on one side. That patient underwent re-fixation three days later, which ultimately resulted in a successful functional outcome with normal occlusion as with the remaining endoscopically fixed fractures. Mandibulomaxillary fixation (MMF) was used for 14 days in six cases in whom stabilization was questionable. All patients in this series ultimately developed normal occlusion and function. In all six fractures that could not be fixed endoscopically, the 436

Figure 2. Endoscopic assistance in rigid plate fixation.

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


Eroğlu et al. Subcondylar fracture repair (a)

(b)

(c)

(d)

Figure 3. (a) Right-sided medially displaced subcondylar fracture in a coronal section CT scan. Coronal (b), panoramic mandibular (c) and 3D-reconstructed CT scan image (d) of the same fracture after endoscopically assisted fixation using an external approach.

Facial nerve weakness was detected in two of six patients who underwent open technique (33%) and in one of nine cases who underwent endoscopic technique (11%). Normal nerve function had recovered before the postoperative 5th month in these patients in both groups. One patient (7%) who underwent open technique developed a visible scar. The mean

maximal interincisal mouth opening was 42.28 mm in endoscopically assisted operations. Three patients had a temporomandibular joint (TMJ) click; two of them had undergone an open technique. Three patients who underwent open technique complained of a persistent headache and one patient complained of TMJ pain (Table 3).

Table 3. Complications No

TFNW

Vs

MO (mm)

Click

Headache

TMJ Pain

Operation technique

1 No No 40 Yes (Right) No No Right→Endoscopic-Open, Left→Endoscopic 2 No No 39 No No No Endoscopic 3 Yes Yes 38 No Yes No Endoscopic-Open 4 No No 46 No No No Endoscopic-Open 5 No No 46 No No No Endoscopic 6 Yes No 43 Yes No No Endoscopic 7 No No 44 No No No Endoscopic 8 No No 41 No No No Endoscopic 9 Yes (Right) No 53 No Yes (Right) Yes (Right) Right→Endoscopic-Open, Left→Endoscopic 10 No No 40 No No No Endoscopic 11 No No 42 No Yes No Endoscopic-Open 12 No No 43 No No No Endoscopic 13 No No 44 Yes No No Endoscopic-Open TFNW: Transient facial nerve weakness; Vs: Visible scar; MO: Mouth opening; TMJ Pain: Temporomandibular joint pain.

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

437


Eroğlu et al. Subcondylar fracture repair

DISCUSSION The criteria for successful treatment of mandibular subcondylar fractures include reestablishment of preinjury occlusion, pain-free jaw opening of ≥40 mm, good excursion of the jaw in all directions, minimal facial scarring, and facial symmetry.[12,13] The indications for open reduction or nonsurgical treatment remain controversial, and closed reduction remains the most widely used method.[3,6,8] Although superior functional outcomes following anatomical reduction compared with nonsurgical treatment have been reported for displaced fractures,[3,4,7,8] there is a relatively high risk of injury to the facial nerve, poor access and visualization, facial scaring, salivary fistulas, and delayed functional rehabilitation.[3,14,15] Endoscopic techniques using limited incisions have been described to minimize complications related to a surgical approach. Minimally invasive techniques achieve equivalent or superior results with decreased morbidity when compared with standard techniques.[12,16-25] Five of our patients who were operated on using open technique had pain (headache or TMJ pain) or TMJ click, while one patient in whom endoscopic approach was used had TMJ click (Table 3). This might be due to the endoscopic approach, which remains extracapsular and does not affect cartilage or synovial fluid.[11] Two endoscopic techniques to approach subcondylar fractures have been developed.[27] One technique uses an intraoral incision followed by a dissection along the mandibular ramus.[16-22] The second technique uses an incision inferior to the mandibular angle as a mini-Risdon type of approach. [24-27] Kellman[20] and Mueller et al.[23] reported the technical details of endoscopic approaches. Kellman also described the main incisions (intraoral and submandibular) as major ports; that is, a larger incision through which endoscopic visualization is performed. Transoral approaches have been used with great success to treat subcondylar fractures.[16,17,19,21,22,29-34] The transoral approach, which is minimally invasive, can reduce a subcondylar fracture without facial scarring or facial nerve injury. Troulis and Kaban described an extraoral endoscopic approach to manage subcondylar fractures.[25] They reported that a submandibular incision significantly reduces dissection, bleeding, and swelling, and they suggested that this allows better visualization and a more comfortable orientation, making the learning curve of the procedure shorter than that for the intraoral approach.[25,26] The major advantage of the intraoral approach is the lack of facial scarring and facial nerve palsy, whereas the major disadvantage is less visualization. Kellman stated that alignment of the posterior border is a reliable finding for a fracture reduction that can be evaluated more precisely via a submandibular approach.[20] In our initial cases, we used intraoral incisions as a major port. However, achieving the proper orientation to reduce the fracture was challenging; thus, we used a submandibular incision as a second major port. In later cases, it was decided 438

to use a submandibular incision as the major port, which allows for significantly better visualization and orientation. None of the patients developed permanent facial nerve palsy, and only one case of transient nerve weakness occurred. As application of endoscopic assistance reduced the size of the required incision, the final scar with regard to external approach was smaller. The direction of the proximal fragment displacement is an important factor when assessing the applicability of intra- or extraoral approaches. Chen et al.[16] reported that endoscopic subcondylar fracture repair is particularly easy to perform in patients presenting with lateral override at the fracture site. In contrast, a medial override subcondylar fracture is particularly difficult to repair. Mueller[12] reported that lateral displacement of the proximal segment is the most favorable for endoscopic repair of subcondylar fractures and that medial override of the proximal fragment is considered a contraindication. Schön et al. treated 17 patients using both intra- and extraoral approaches and reported that the intraoral approach was a reliable method for reducing fractures, even laterally displaced subcondylar fractures. He stated that the extraoral approach is indicated for severely dislocated fractures and medially displaced subcondylar fractures. In view of this knowledge, we still employed extraoral approach in cases with lateral displacement. The main cause for this otherwise “over precise” way of fixing subcondylar fractures was our desire to synergize the advantages of endoscopic assistance with the abilities of an extraoral approach. Limited angulation and minimal medial overriding of the proximal fragment can be reduced endoscopically. We achieved reduction of medially displaced subcondylar fractures in two cases. One case had limited medial displacement and the other had minimal overriding of the proximal fragment. Many authors use an intraoral approach to treat medially displaced subcondylar fractures. However, the intraoral approach has not been adopted as a routine technique due to its higher technical difficulty compared to extraoral approaches, which also provide better visibility.[18,22,33] In fact, whatever method is used, the endoscopic approach is technically challenging, and there is a steep learning curve. Medially displaced subcondylar fractures in six patients could only be plated after conversion to a full open approach as a bail-out procedure, and one endoscopically operated case with inadequate reduction on one side was subsequently reoperated. Troulis and Kaban[25] reported 60 min and Lauer and Schmelzeisen[24] reported 210 min for conducting the extraoral approach. Using an intraoral approach, Miloro[11] and Lee et al.[16] reported 109±32 and 143±63 min, respectively. The mean operating time in our cases was 150 min. These operation times are shorter than those of open reduction for subcondylar fracture treatment. In fact, the difficulty of fracture reduction in a limited two-dimensional visual field and the long Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


Eroğlu et al. Subcondylar fracture repair

learning curve are the major drawbacks of endoscopy for subcondylar fractures. Kellman[35] pointed out that once experience has been gained, the procedure can be performed in a reasonable amount of time. The use of specialized equipment also seems to be a disadvantage of the endoscopic technique as monitors, light sources, and other equipment are currently available in most operating rooms. However, proper instruments such as retractors, plate holders and specific trocars are important for successful completion of the entire procedure. The 1.5-mm mini-plates were used for fracture reduction because they allow a particular degree of malleability during adaptation. Two plates were utilized for fracture stabilization if possible. MMF was performed 14 days later in six cases in whom fracture stability was questionable. In conclusion, an extraoral endoscopic approach for subcondylar fractures is feasible and can be carried out with decreased morbidity. This approach is recommended for those with limited experience in endoscopy to treat low laterally displaced subcondylar fractures as their initial cases, and the extraoral approach can be used as the major port. Conflict of interest: None declared.

REFERENCES 1. Ellis E 3rd, Moos KF, el-Attar A. Ten years of mandibular fractures: an analysis of 2,137 cases. Oral Surg Oral Med Oral Pathol 1985;59:120-9. 2. Dahlström L, Kahnberg KE, Lindahl L. 15 years follow-up on condylar fractures. Int J Oral Maxillofac Surg 1989;18:18-23. 3. Ellis E 3rd, Dean J. Rigid fixation of mandibular condyle fractures. Oral Surg Oral Med Oral Pathol 1993;76:6-15. 4. Ellis E 3rd, Simon P, Throckmorton GS. Occlusal results after open or closed treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg 2000;58:260-8. 5. Ellis E, Throckmorton GS. Treatment of mandibular condylar process fractures: biological considerations. J Oral Maxillofac Surg 2005;63:11534. 6. Walker RV. Condylar fractures: nonsurgical management. J Oral Maxillofac Surg 1994;52:1185-8. 7. Widmark G, Bågenholm T, Kahnberg KE, Lindahl L. Open reduction of subcondylar fractures. A study of functional rehabilitation. Int J Oral Maxillofac Surg 1996;25:107-11. 8. Zide MF, Kent JN. Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 1983;41:89-98. 9. Jacobovicz J, Lee C, Trabulsy PP. Endoscopic repair of mandibular subcondylar fractures. Plast Reconstr Surg 1998;101:437-41. 10. Mueller R. Endoscopic treatment of facial fractures. Facial Plast Surg 2008;24:78-91. 11. Miloro M. Endoscopic-assisted repair of subcondylar fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:387-91. 12. Mueller RV. Endoscopic mandible fracture management: Techniques. In: Mathes SJ, Hentz VR, editors. Mathes plastic surgery. Philadelphia PA: Saunders; 2005. p. 511-40. 13. Miloro M. Considerations in subcondylar fracture management. Arch

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

Otolaryngol Head Neck Surg 2004;130:1231-2. 14. Arcuri F, Brucoli M, Baragiotta N, Benech R, Ferrero S, Benech A. Analysis of complications following endoscopically assisted treatment of mandibular condylar fractures. J Craniofac Surg 2012;23:196-8. 15. Weinberg MJ, Merx P, Antonyshyn O, Farb R. Facial nerve palsy after mandibular fracture. Ann Plast Surg 1995;34:546-9. 16. Lee C, Mueller RV, Lee K, Mathes SJ. Endoscopic subcondylar fracture repair: functional, aesthetic, and radiographic outcomes. Plast Reconstr Surg 1998;102:1434-45. 17. Chen CT, Lai JP, Tung TC, Chen YR. Endoscopically assisted mandibular subcondylar fracture repair. Plast Reconstr Surg 1999;103:60-5. 18. Schön R, Schramm A, Gellrich NC, Schmelzeisen R. Follow-up of condylar fractures of the mandible in 8 patients at 18 months after transoral endoscopic-assisted open treatment. J Oral Maxillofac Surg 2003;61:4954. 19. Kellman RM. Endoscopically assisted repair of subcondylar fractures of the mandible: an evolving technique. Arch Facial Plast Surg 2003;5:24450. 20. Kellman RM. Endoscopic approach to subcondylar mandible fractures. Facial Plast Surg 2004;20:239-47. 21. Schön R, Fakler O, Gellrich NC, Schmelzeisen R. Five-year experience with the transoral endoscopically assisted treatment of displaced condylar mandible fractures. Plast Reconstr Surg 2005;116:44-50. 22. Cho-Lee GY, Rodríguez Campo FJ, González García R, Muñoz Guerra MF, Sastre Pérez J, Naval Gías L. Endoscopically-assisted transoral approach for the treatment of subcondylar fractures of the mandible. Med Oral Patol Oral Cir Bucal 2008;13:511-5. 23. Mueller RV, Czerwinski M, Lee C, Kellman RM. Condylar fracture repair: use of the endoscope to advance traditional treatment philosophy. Facial Plast Surg Clin North Am 2006;14:1-9. 24. Lauer G, Schmelzeisen R. Endoscope-assisted fixation of mandibular condylar process fractures. J Oral Maxillofac Surg 1999;57:36-40. 25. Troulis MJ, Kaban LB. Endoscopic approach to the ramus/condyle unit: Clinical applications. J Oral Maxillofac Surg 2001;59:503-9. 26. Troulis MJ. Endoscopic open reduction and internal rigid fixation of subcondylar fractures. J Oral Maxillofac Surg 2004;62:1269-71. 27. Schön R, Gutwald R, Schramm A, Gellrich NC, Schmelzeisen R. Endoscopy-assisted open treatment of condylar fractures of the mandible: extraoral vs intraoral approach. Int J Oral Maxillofac Surg 2002;31:23743. 28. Schubert W, Jenabzadeh K. Endoscopic approach to maxillofacial trauma. J Craniofac Surg 2009;20:154-6. 29. Schoen R, Fakler O, Metzger MC, Weyer N, Schmelzeisen R. Preliminary functional results of endoscope-assisted transoral treatment of displaced bilateral condylar mandible fractures. Int J Oral Maxillofac Surg 2008;37:111-6.. 30. Ducic Y. Endoscopic treatment of subcondylar fractures. Laryngoscope 2008;118:1164-7. 31. González-García R, Sanromán JF, Goizueta-Adame C, RodríguezCampo FJ, Cho-Lee GY. Transoral endoscopic-assisted management of subcondylar fractures in 17 patients: an alternative to open reduction with rigid internal fixation and closed reduction with maxillomandibular fixation. Int J Oral Maxillofac Surg 2009;38:19-25. 32. Domanski MC, Goodman J, Frake P, Chaboki H. Pitfalls in endoscopic treatment of mandibular subcondylar fractures. J Craniofac Surg 2011;22:2260-3. 33. Schmelzeisen R, Cienfuegos-Monroy R, Schön R, Chen CT, Cunningham L Jr, Goldhahn S. Patient benefit from endoscopically assisted fixation of condylar neck fractures--a randomized controlled trial. J Oral

439


Eroğlu et al. Subcondylar fracture repair Maxillofac Surg 2009;67:147-58.

tional and radiologic assessment. J Oral Maxillofac Surg 2007;65:1470-6.

34. Veras RB, Kriwalsky MS, Eckert AW, Schubert J, Maurer P. Long-term outcomes after treatment of condylar fracture by intraoral access: a func-

35. Kellman RM, Cienfuegos R. Endoscopic approaches to subcondylar fractures of the mandible. Facial Plast Surg 2009;25:23-8.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Mandibular subkondil kırıkların onarımında endoskop yardımı ve ağız dışından yaklaşımın sinerjisi: 13 olgu deneyimi Dr. Lütfi Eroğlu,1 Dr. İbrahim Alper Aksakal,1 Dr. Musa Kemal Keleş,1 Dr. Çağlayan Yağmur,2 Dr. Ozan Aslan,3 Dr. Tekin Şimşek1 Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Samsun Samsun Eğitim ve Araştırma Hastanesi, Plastik Rekonstrüktif ve Estetik Cerrahi Kliniği, Samsun 3 Samsun Gazi Devlet Hastanesi, Plastik Rekonstrüktif ve Estetik Cerrahi Kliniği, Samsun 1 2

AMAÇ: Maksillofasiyal travma tek başına veya diğer travmalara eşlik edecek şekilde görülebilir. Bu travmalarda mandibula kırığı görülme oranı yüksektir. Mandibulanın tüm kırıkları arasında subkondil bölgesine ait kırıklar özel bir yaklaşım gerektirir. Açık redüksiyonla yapılan internal sabitlemelerde; yüzde istenmeyen skar oluşumu, geçici/kalıcı fasiyel sinir felci gibi ek morbiditeler oluşabilir. Subkondil kırıklarında endoskopik yaklaşımla bu sorunları azaltmak mümkündür. GEREÇ VE YÖNTEM: Çalışmamızda birbirini takip eden 13 hastadaki subkondil kırıklarına ağız dışından endoskopik yaklaşımla gerçekleştirdiğimiz onarımlara ilişkin tecrübelerimizi aktarmayı amaçladık. Ocak 2010 ve Haziran 2011 tarihleri arasında Ondokuz Mayıs Üniversitesi Tıp Fakültesi Hastanesi Plastik Rekonstrüktif ve Estetik Cerrahi Kliniği’ne acilden başvuran 13 hastadaki 15 subkondiler kırık bu çalışmaya dahil edildi. BULGULAR: Hastalara endoskopik veya açık yaklaşım kullanılarak girişimde bulunuldu. Kırıklardan dokuz tanesine ağız dışından yapılan endoskopik yaklaşımla başarılı biçimde plak-vida sabitlemesi yapıldı. Endoskopik onarım yapılan kırıkların yedi tanesinde proksimal parçalar laterale deplaseydi. Kırıkların geri kalan altı tanesine ise endoskopik olarak başlandıktan sonra tam açık yaklaşıma dönülerek girişim yapıldı. Bu altı kırığın hepsinde de proksimal parçalar mediyale deplase haldeydi. TARTIŞMA: Subkondil kırıklarında ağız dışından endoskopik yaklaşımla onarım yapmak mümkündür. Bu yaklaşımda amaç işleme bağlı ek morbiditeyi etkili biçimde azaltmaktır. Endoskopik cerrahi ile tecrübesi az olan meslektaşlarımıza tavsiyemiz başlangıç olgusu olarak laterale deplase olmuş düşük seviyedeki subkondil kırıklarını seçmeleridir. Key words: Endoskopi, endoskopik asistans, subkondiler kırık, subkondil kırığı. Ulus Travma Acil Cerr Derg 2013;19(5):434-440

440

doi: 10.5505/tjtes.2013.77292

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


ORIGIN A L A R T IC L E

Three-year experience in the Emergency Department: the approach to patients with spinal trauma and their prognosis Hızır Ufuk Akdemir, M.D.,1 Dursun Aygün, M.D.,2 Celal Katı, M.D.,1 Mehmet Altuntaş, M.D.,1 Cengiz Çokluk, M.D.3 1

Department of Emergency Medicine, Ondokuz Mayıs University Faculty of Medicine, Samsun

2

Department of Neurology, Ondokuz Mayıs University Faculty of Medicine, Samsun

3

Department of Neurosurgery, Ondokuz Mayıs University Faculty of Medicine, Samsun

ABSTRACT BACKGROUND: Spinal cord injuries result in critical pecuniary and/or non-pecuniary losses due to the developing neurological problems. The objective of this study was to evaluate spinal injuries in terms of clinical severity and prognosis. Spinal injuries lead to serious clinical results due to the high rates of morbidity and mortality; however, there is a lack of reliable information on spinal injuries in our country. METHODS: Following the approval of the Faculty Ethics Committee, this retrospective study was conducted on 91 patients aged ≥18 (59 male, 32 female) with spinal trauma who were admitted to the Emergency Department of Ondokuz Mayis University over three years. The patients were assessed in terms of demographics, clinical severity, developing complications, and mortality. RESULTS: Forty-three patients had complete injuries, while 48 had incomplete injuries. Forty-six patients suffered spinal injuries due to fall from height, 35 patients due to traffic accidents, and 10 patients due to other reasons. Several complications were observed in 52 patients, while no complication occurred in 39 patients. We determined that 19 of 92 patients involved in this study died, while 72 were discharged from the hospital. CONCLUSION: Spinal cord injuries generally result in unfavorable clinical results. Therefore, an appropriate approach (early diagnosis and true treatment) in emergency services has great significance.

Key words: Clinical severity, complication, prognosis, spinal trauma.

INTRODUCTION A spinal cord injury is one of the uncommon Emergency Department admissions. Studies on the frequency of spinal cord injuries in Emergency Departments are highly rare in the literature. Spinal cord injuries and subsequent neurological problems affect a person’s social life and result in serious pecuniary and/or non-pecuniary losses.[1] Acute spinal cord injuries are Address for correspondence: Hızır Ufuk Akdemir, M.D. Rasathane Mahallesi 100. Yıl Bulvarı, Direr Apartmanı, No: 150, K: 7, D: 13, İlkadım 55050 Samsun, Turkey Tel: +90 362 - 435 25 93 E-mail: hufukakdemir@hotmail.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):441-448 doi: 10.5505/tjtes.2013.21456 Copyright 2013 TJTES

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

reported to occur at a rate of 20-40/1.000.000.[2] It is reported that spinal cord injuries occur more frequently in young persons, with a male/female ratio of 4/1, and that the most common cause of spinal cord injuries is motor vehicle accidents, at a rate of 40%.[2] Spinal cord injuries are classified as complete (ASIA-A) or incomplete (ASIA-B, C, D) by the American Spinal Injury Association (ASIA).[3,4] By the means of this classification, neurological recovery or deterioration that may occur during the patient follow-up is assessed more clearly. Approximately half of the patients with spinal cord injuries have complete transection. Currently, there remains no effective medical treatment to restore neurological function in patients with complete spinal cord injuries, except for methylprednisolone.[5] Methylprednisolone is suggested to be beneficial because it is a radical scavenger, prevents lipid peroxidation and has neuroprotective effects.[6] The incidence of complete spinal cord injuries has decreased depending on such actions as timely and properly rendered first aid, more 441


Akdemir et al. The approach to patients with spinal trauma and their prognosis

favorable resuscitation, and the fastening of seat belts. All these factors positively influence the recovery process.[7]

ed the patients admitted to the Emergency Department after more than eight hours.

Epidemiological information on spinal traumas is generally obtained from the international literature because there is no reliable information on the incidence of spinal cord injuries in our country. In this study, we retrospectively assessed the demographics of the spinal trauma patients admitted to our Emergency Department, lesion locations, type of neurological impairment, clinical severity according to the results of ASIA assessment during first admission and discharge, treatment efficacy, complications, and the mortality rate.

Routine physical and neurological examination of the patients was performed by the emergency physicians. For each patient, vital signs were obtained, muscle strength (Medical Research Council (MRC) score 0 to 5 scale) and spinal reflexes were tested, and sensory examination was performed. Following these assessments, each patient was graded on ASIAIMSOP Impairment Scale, and thus their injuries were defined as complete or incomplete.

MATERIALS AND METHODS Following the approval of the Faculty Ethics Committee, 91 patients with spinal trauma older than 18 years who were admitted to our Emergency Department over three years were included in the study. Exclusion criteria were: a) spinal cord impairment with a nontraumatic cause, and b) initiation of treatments at another center. The patients were divided into two groups as those with complete injuries (Grade A/Group 1) and those with incomplete injuries (Grades B, C, D/Group 2) according to the clinical findings during admission based on ASIA-International Medical Society of Paraplegia (IMSOP) Impairment Scale (Table 1). The patients were divided into three subgroups as <45 years of age, 45-65 years of age and >65 years of age. Data on the complete injury group and the incomplete injury group were compared. The patients were divided into two groups based on their admission time to the Emergency Department after the spinal trauma. The first group consisted of the patients admitted to the Emergency Department within the first eight hours following spinal trauma, while the second group includ-

Computed radiography (CR) images of the spinal cord, direct radiography (DR) images and magnetic resonance imagings (MRI) were obtained. The patients with complete and incomplete injuries were divided into two groups as those who received steroid treatment and those who did not. The patients were also divided into groups according to the type of the treatment (medical and/or surgical). The patients with complete and incomplete injuries were compared regarding the treatment, developing complications and mortality. Predischarge neurological findings of the patients in the complete (ASIA-IMSOP Grade A/Group 1) and incomplete (ASIA-IMSOP Grades B, C, D/Group 2) injury groups were obtained from their file information. By means of this information, final ASIA-IMSOP Impairment Scale grades of the patients were determined, and the patients were reassessed in terms of recovery and deterioration in locomotor functions. Intergroup or intragroup changes were defined by the ASIAIMSOP Impairment Scale. All data of the patients were recorded in pre-prepared study forms and analyzed using the Statistical Package for the Social Sciences (SPSS) 20 software. The relationship between the

Table 1. ASIA-IMSOP Impairment Scale[3] Grade

Injury Type

Neurological Assessment

Grade A

Complete

No motor or sensory function is preserved in the sacral segments S4-S5.

Grade B

Incomplete

Sensory but not motor function is preserved below the neurological

level zand the injury includes the sacral segments S4-S5.

Grade C

Motor function is preserved below the neurological level and more than

Incomplete

half of key muscles below the neurological level have a muscle grade of

less than 3.

Grade D

Motor function is preserved below the neurological level and at least

Incomplete

half of the key muscles below the neurological level have a muscle grade

of 3 or more.

Grade E

Normal motor and sensory function

Normal

ASIA-IMSOP: American Spinal Injury Association-International Medical Society of Paraplegia.

442

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


Akdemir et al. The approach to patients with spinal trauma and their prognosis

types of injury (complete and incomplete) and demographic characteristics was analyzed using chi-square test. Lesion sites, accompanying traumas, developing complications, and mortality rates were analyzed using two-proportion z test. The level of statistical significance was accepted as p<0.05.

RESULTS In three years, 36.430 patients, 91 of whom had spinal trauma, were admitted to our Emergency Department. We calculated the frequency of spinal cord injuries in all emergency admissions each year as 0.25%, and the frequency of spinal cord injuries in trauma patients as 2%. In our study, the frequency of vertebral column injuries in all emergency admissions each year was 7%, and the frequency of vertebral column injuries in trauma patients was 5.6%. Forty-three (47%) of the 91 patients with spinal trauma had complete injuries, while 48 (53%) had incomplete injuries. Fifty-nine (65%) of the 91 patients with spinal trauma were male, while 32 (35%) were female. The numbers of male patients were higher in both the complete and incomplete injury groups. No statistically significant difference was found for gender between the two groups (p>0.05). In our study, the male/female ratio was 1.8/1. Forty-three patients (47%) were under 45 years of age, 37 patients (41%) were 45-65 years of age, and 11 patients (12%) were over 65 years of age. No statistically significant differ-

ence was found for age between the patients with complete and incomplete injuries (p>0.05). Forty-six patients (50.5%) were exposed to spinal trauma by fall from height, 35 patients (38.5%) in traffic accidents, and 10 patients (11%) due to other reasons (diving into water, being struck by a falling object). A comparison of the patients with complete and incomplete injuries for trauma mechanisms did not reach statistical significance (p>0.05). Twenty patients (22.0%) suffered spinal trauma in the spring, 34 (37.4%) in the summer, 27 (29.7%) in the autumn, and 10 (11.0 %) in the winter. As seen, most emergency admissions were in the summer, followed by autumn, spring and winter, respectively. The complaints of 43 patients with complete spinal injuries were pain (36 patients, 86%), numbness-tingling (38 patients, 88%), and loss of muscle strength (100%). The complaints of 48 patients with incomplete spinal injuries were pain (43 patients, 90%), numbness-tingling (44 patients, 92%) and muscle weakness (40 patients, 83%). Comparison of the complaints of the patients with complete and incomplete injuries during emergency visits did not reach statistical significance (p>0.05). Table 2 shows the demographic data of the patients with complete and incomplete spinal injuries. The patients diagnosed with spinal trauma were divided into two groups as those with complete injuries (Group 1) and

Table 2. Demographic data on the patients with complete and incomplete injuries

Complete (n=43)

Incomplete (n=48)

n

n

%

n

Female

14

32.6

18

37.5

32

Male

29

67.4

30

62.5

59

p

%

Sex p>0.05

Age group

Under 45 years of age

18

51.2

25

50.0

43

45-65 years of age

18

39.5

19

37.5

37

Over 65 years of age

7

9.3

4

12.5

11

p>0.05

Cause of trauma

Fall from height

22

51.2

24

50.0

46

Traffic accident

17

39.5

18

37.5

35

4

9.3

6

12.5

10

Spring

7

16.3

13

27.1

20

Summer

14

32.6

20

41.7

34

Autumn

18

41.9

9

18.8

27

Winter

4

9.3

6

12.5

10

Other

p>0.05

Season p>0.05

p<0.05 significance level.

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

443


Akdemir et al. The approach to patients with spinal trauma and their prognosis

those with incomplete (Group 2) injuries according to their ASIA-IMSOP Impairment Scale grades during admission. All of the complete injuries (n=43, 100%) were classified as A according to the ASIA Impairment Scale. Twenty-seven (56%) of the incomplete injuries were classified as C, while 21 (44%) were classified as D. Locomotor functions were restored in 3 (7.5%) of 43 patients (ASIA A) in the complete injury group according to the clinical assessment during admission. Two (4%) of 48 patients (27 ASIA C, 21 ASIA D) in the incomplete injury group according to the clinical assessment during admission were classified as A, 3 patients (6%) as E, 18 patients (38%) as C, and 25 patients (52%) as D. Two of 27 patients in the incomplete injury group according to the clinical assessment during admission and classified as AISA C suffered deterioration to ASIA A, while 7 of them recovered to ASIA D. Three of 21 patients in the incomplete injury group according to the clinical assessment during admission and classified as ASIA D recovered to ASIA E. Locomotor functions were restored in 10 of 48 (27 ASIA C, 21 ASIA D) patients in the incomplete injury group according to the clinical assessment during admission. Comparison of the patients with complete and incomplete injuries by recovery status was close to reaching statistical significance in favor of the incomplete injury group (p<0.05). Thirty-nine (91%) of the patients with complete injuries suf-

fered paraplegia, and 4 (9%) suffered quadriplegia. Nineteen (39%) of the patients with incomplete injuries suffered paraparesis, 18 (38%) suffered quadriparesis, and 11 (23%) suffered hemiparesis. Table 3 shows the distribution of patients with complete and incomplete spinal injuries by lesion sites. Twenty-four (55.8%) of the patients with complete injuries had accompanying trauma, while 15 (31.2%) of the patients with incomplete injuries had accompanying trauma. Table 4 shows the comparison of the patients with complete and incomplete injuries by accompanying trauma. Forty-one of the patients (95%) with complete injuries and 39 of the patients (81%) with incomplete injuries were admitted to the Emergency Department within the first eight hours, while two patients with complete injuries and nine patients with incomplete injuries admitted to the Emergency Department within 8-12 hours. Eighty (87.9%) of the patients involved in our study received steroid treatment. Forty-one (95%) of the patients with complete injuries received steroid treatment, while 39 (81%) of the patients with incomplete injuries received steroid treatment. Sixty-three (69.2%) of the patients received both medical and

Table 3. Comparison of the patients with complete and incomplete injuries by lesion sites

Complete (n=43)

Incomplete (n=48)

p

n %

n

%

Cervical

19 44.2

24 50.0

p>0.05

Thoracic

15 34.8

6 12.5

p=0.010*

Lumbar

9 21.0

18 37.5

p>0.05

*p<0.05 significance level.

Table 4. Comparison of the patients with complete and incomplete injuries by accompanying trauma

Complete (n=43) n

Incomplete (n=48)

%

n

%

p

Head trauma

4

9.3

3

6.3

p>0.05

Thoracic trauma

7

16.3

4

8.3

p>0.05

Abdominal trauma

4

8.3

Pelvic trauma

2

4.7

p>0.05

p=0.037*

Extremity trauma

1

2.3

2

4.2

p>0.05

Multiple trauma

10

23.3

2

4.2

p=0.007*

No additional trauma

19

44.2

33

68.8

p=0.015*

*p<0.05 significance level.

444

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


Akdemir et al. The approach to patients with spinal trauma and their prognosis

Table 5. Complication and mortality rates of the patients with complete and incomplete injuries

Complete (n=43)

Incomplete (n=48)

n %

n

%

Surgical site infection

2

4.7

2

4.2

Urinary tract infection

5

11.6

5

10.4

Pneumonia

3 7

– –

p

p>0.05 p>0.05 p>0.05

GI hemorrhage

2

4.7

p>0.05

Bleeding (except GI)

11

25.6

7

14.6

p>0.05

Respiratory failure

12

27.9

3

6.3

p=0.005*

Total complication

35

81.5

17

35.5

p=0.0001*

Mortality

16 37.2

3

6.3

p=0.0001*

surgical treatment, while 28 (30.8%) received only medical treatment. Twelve (27.9%) of the patients with complete injuries received only medical treatment, while 31 (72.1%) received both medical and surgical treatment. Sixteen (33.3%) of the patients with incomplete injuries received only medical treatment, while 33 (66.7%) received both medical and surgical treatment. No significant difference was found in the type of treatment between the patients with complete and incomplete injuries (p>0.05). Fifty-two (57.1%) of the patients developed several complications, while 39 (42.9%) developed no complications (Table 5). In our study, 19 patients died; 37.2% (n=16) of them were in the complete injury group and 6.3% (n=3) were in the incomplete injury group (p<0.05).

DISCUSSION The frequency of spinal cord injuries in patients admitted to Emergency Departments due to spinal trauma is not clearly known. Nawar et al. could not report any rate of spinal injuries because the spinal injuries did not meet standards of reliability or precision. In the same study, all spinal disorders accounted for 2.5% of the visits to hospital Emergency Departments. They reported that the frequency of vertebral column injuries accounted for 4.8% of all trauma patients.[8] In our study, we found a similar frequency of vertebral column injuries in all traumas. However, we could not draw any comparisons with spinal cord injuries due to the insufficient literature data. Studies on spinal cord injuries take the ASIA classification as a guide and classify spinal cord injuries as complete (ASIAA) and incomplete (ASIA-B, C, D) according to this guide. [3,4] The literature suggests that the complete injury rate is 45%, while the incomplete injury rate is 55%.[2] Our data of complete and incomplete injuries in our study was consistent with the literature. Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

We determined ASIA-IMSOP Impairment Scale grades of the patients during discharge and investigated any clinical recovery or deterioration. Nearly one in ten patients with a complete injury (Grade A) during admission improved to incomplete injury. Four percent of the incomplete injuries progressed to complete. Peker et al.[9] reported that 23% of the spinal injuries classified as Grade A according to the clinical findings during admission improved to incomplete. Peker et al. had twice as many recovered patients when compared with our study. We attributed this result to the fact that the number of patients in their study was lower, and the rate of the injuries that improved to incomplete was higher. It is known that spinal cord injuries occur more frequently in young people, that the male/female ratio is 4/1, and that motor vehicle accidents are the most common cause of spinal injuries.[2] According to the data in our country, the male/ female ratio is 2.5/1, and the rate of motor vehicle accidents is 48.8%.[10] The male/female ratio was lower in our study when compared with the literature because the numbers of falls from height (from a tree) were higher in our study, and these falls mainly occurred in women. A study conducted in the southeastern Anatolia region reported that the male/female ratio was 5.8/1, and the most common cause of spinal injuries was fall from height (37.5%).[11] In our study, a great majority of the patients were men and under 45 years of age, which was consistent with the literature. Etiological factors of spinal cord injuries vary in different geographical regions, and the most common causes are motor vehicle accidents, violence and falls from height.[2,10] Hagen et al.[8] reported that common causes of spinal cord injuries were falls and motor vehicle accidents. A study conducted in our region reported that etiological factors in spinal cord injuries were falls from height, traffic accidents and diving into water, respectively.[12] The most common etiological factor in our study was falls from height (50.5%). This result derived from our study was consistent with the study conducted in our region by Gündüz et al.[12] While spinal cord injuries due 445


Akdemir et al. The approach to patients with spinal trauma and their prognosis

to motor vehicle accidents are more common in the United States or Europe, spinal cord injuries due to falls from height are more common in developing countries.[2,10] Thus, it is true to say that there are inter-country and intra-country regional differences. The literature reports that spinal cord injuries generally occur on the weekends or during holidays and the summer.[2] A great majority of the patients in our study suffered spinal trauma in the summer. Symptoms of spinal cord injuries are variable, and patients generally report pain, numbness-tingling, muscle weakness, urinary-fecal incontinence, respiratory distress, erythema, and temperature increase.[13] The most common complaint of the patients in our study was numbness-tingling, followed by muscle weakness and pain, respectively. Most of the patients reported more than one complaint, and this was a little higher in the complete injury group. A great majority of the patients with complete injuries suffered paraplegia, while a few suffered quadriplegia. The incidences of paraparesis and quadriparesis in the complete and incomplete injured patients were comparable. Önder et al.[14] studied 65 patients, and reported that 6 (9.2%) of the patients suffered paraparesis, 4 (6.2%) suffered paraplegia, 13 (20%) suffered quadriparesis, 21 (32.3%) suffered quadriplegia, and 7 (10.8%) suffered either hyposthenia or anesthesia, while 14 (21.5%) had no neurological deficit. Gündüz et al.[12] reported that 4.6% of the patients suffered paraparesis, 16.2% suffered paraplegia, and 11.6% suffered quadriplegia, while 29 patients (67.4%) had no neurological deficit. This result is likely to be attributed to the fact that all patients involved in our study had neurological deficit associated with the spinal trauma during admission, one of these reference studies included only patients with lower cervical injuries, the number of patients was lower, and the study also involved patients with no neurological deficit. Moreover, neither of these studies involved comparing or grouping the complete and incomplete injuries. In their study involving 238 patients, Hagen et al.[8] reported that the distribution according to the part of the vertebral column affected was cervical vertebrae (50%), thoracic vertebrae (33%), and lumbar vertebrae (17%), respectively. In their study involving 43 patients, Gündüz et al.[12] reported that cervical injuries were the most common. In our study, almost half of the patients with complete and incomplete injuries had cervical lesion. Injury risk in the movable segments of the spinal column is very high. In their study involving 126 skiers with spinal cord injuries, Prall et al.[1] reported that vertebral fractures resulting in spinal cord injuries occurred most commonly in C6, T12 and L1. In our study, the most commonly fractured levels in the patients with cervical lesions were C5-6. 446

The thoracolumbar region is an anatomical and functional transition between the thoracic and lumbar parts as well as the most movable part of the spine.[13] Therefore, T12 is defined as the transition vertebra. The thoracolumbar spine is the region most exposed to trauma, and almost 60% of all vertebral body fractures occur between the T12 and L2 vertebrae.[13] In our study, almost one-third of the patients with complete and incomplete injuries had thoracolumbar fractures. The most common fractures in patients with complete and incomplete injuries who had thoracolumbar lesions were at L1 and T12. In our study, the most common mechanisms of trauma in the patients with thoracic trauma were falls from height and traffic accidents, and their incidences were equal. The most common etiological factor in thoracolumbar injuries was fall from height. In their study, Armagan et al.[15] reported that 26% of the patients had lumbar spine injuries. We determined that 30.7% of the patients involved in our study had lumbar spine injuries. Armagan et al.[15] reported that traffic accidents were the etiological factor in half of the lumbar spine injuries, while falls from height were responsible in the other half. In our study, the most common mechanism of trauma in the patients with lumbar spine injuries was fall from height, followed by traffic accidents. It is reported that spinal cord injuries are generally accompanied by head, thoracic or abdominal trauma.[2] Almost half of the patients involved in our study had accompanying trauma. The incidence of multiple traumas in the patients with complete injuries was higher than in the incomplete injury group. Almost two-thirds of the patients with incomplete injuries had no accompanying trauma. Methylprednisolone is suggested to be beneficial for spinal cord injuries because it is a radical scavenger, acts to prevent lipid peroxidation and has neuroprotective effects.[6] Methylprednisolone infusion improves motor and sensory recovery in complete and incomplete spinal cord injuries. However, this expected positive result is based on using the steroid at the proper time and proper dose.[2] A great majority of the patients in our study received steroid treatment. In our study, three patients who were first assessed as having complete injuries according to the clinical examination during admission and who later showed recovery in their ASIA grades received surgical treatment as well as steroid treatment. All of 10 patients who were first assessed as having incomplete injuries according to the clinical examination during admission and later showed recovery in their ASIA grades received surgical treatment as well as steroid treatment. Armagan et al.[15] reported that half of the hospitalized patients had neurological deficit, 78.9% of the patients with neurological deficit received surgical treatment while approximately 20% were treated through conservative care, and 29.4% of the patients with no neurological deficit received Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


Akdemir et al. The approach to patients with spinal trauma and their prognosis

surgical treatment for stabilization. The authors reported that 55.5% of the patients received both medical and surgical treatment, while 44.5% received only medical treatment.[15] In our study, almost one-third of the patients received only medical treatment, while two-thirds received both medical and surgical treatment. Spinal cord injury recovery is inversely proportional to the trauma severity. The probability of locomotor function recovery after complete spinal cord injuries is around 1%, while functional neurological recovery occurs in many patients with incomplete injuries.[7] The factors affecting the recovery in patients with traumatic spinal cord injuries were reported as the initial level of injury, initial muscle strength, and patient age.[9,16] Peker et al.[9] reported that the mean age of the patients (being age over 30) and injuries with ASIA Grade A were the factors affecting recovery. Armagan et al.[15] reported that almost half of the hospitalized patients had neurological deficit, and 21% of them were fully recovered while 58% were partially recovered. 14.2% of the patients in our study had functional recovery according to the ASIA-IMSOP Impairment Scale. Functional recovery occurred in 20.8% of the patients with incomplete injuries and in 7% of the patients with complete injuries. The patients first assessed as having complete injuries made little recovery. Complications of spinal cord injuries are divided into two groups as acute and chronic. It was reported that the mortality and morbidity rates of acute complications were higher than those of chronic complications.[13] Patients with spinal trauma developed complications associated with high-dose steroid treatment such as pneumonia, sepsis, injury infection, thromboembolism, gastrointestinal hemorrhage, and delayed recovery.[2] Several respiratory problems may manifest themselves during the acute phase. It was reported that pulmonary complications of the patients with cervical spine injuries during the acute phase played a more crucial role than the level of injury in determining the hospitalization period.[17] Complication rates in the patients with complete injuries are higher than in those with incomplete injuries. The morbidity and mortality rates based on complications were higher in the patients with complete injuries.[2,13] In their study involving 27 patients, Peker et al.[9] reported that the most common complication was urinary tract infection (81%), followed by pressure ulcers, urolithiasis, heterotopic ossification, pneumonia, and autonomic dysreflexia. Campos[18] reported that pressure ulcers and urinary problems occurred most commonly. In their study, Balcı et al.[19] reported that urinary tract infections and pressure ulcers were common complications. We determined that the most common complications that occurred in the patients involved in our study were hemorrhage (except for gastrointestinal hemorrhage), respiratory failure and urinary tract infection. Both the incidence of complications and the mortality rates were higher in the complete injury group. Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

According to the literature data, the mortality rates in the patients with spinal cord injuries vary between 4.4% and 16.7%. [13] However, it is reported that the rates in complete and incomplete injuries are different, and the morbidity and mortality rates in complete injuries are higher.[2] Burney et al.[20] reported that the hospital mortality rate of the patients with spinal cord injuries was 17%. In their study involving 43 patients, Gündüz et al.[12] reported that the in-hospital mortality rate was 6.9%. Almost one-fifth of the patients involved in our study died, which was consistent with the literature. However, the mortality rate in our study was higher than in the other study conducted in our region. We attribute this result to the fact that all patients involved in our study had spinal cord injuries, while the other study conducted in our region involved the patients with spine and/or spinal cord injuries. A great majority of the deceased patients were male. More than half of the deceased patients had no accompanying trauma; however, a great majority of the patients with additional trauma had multiple traumas. The most common cause of death was respiratory failure. Most of the patients who died from respiratory failure had isolated cervical spine injuries. In conclusion, our study presents data on the frequency of acute spinal trauma in emergency admission, its clinical picture, emergency care, follow-up, and prognosis. The results of our study show the significance of the Emergency Department approach (early diagnosis and true treatment) in acute spinal trauma cases. An emergency physician can decrease the incidence of unfavorable clinical results through both primary care and by taking necessary measures against possible complications. Conflict of interest: None declared.

REFERENCES 1. Prall JA, Winston KR, Brennan R. Spine and spinal cord injuries in downhill skiers. J Trauma 1995;39:1115-8. 2. Baron BJ, McSherry KJ, Larson JL Jr, Scalea TM. Spinal cord injuries. In: Tintinalli JE, Kelen GD, Stapczynski JS, editors. Emergency medicine. A comprehensive study guide. 7th ed. New York: McGraw-Hill; 2011. p. 1709-30. 3. Maynard FM Jr, Bracken MB, Creasey G, Ditunno JF Jr, Donovan WH, Ducker TB, et al. International Standards for Neurological and Functional Classification of Spinal Cord Injury. American Spinal Injury Association. Spinal Cord 1997;35:266-74. 4. Sütbeyaz ST, Cay HF, Sezer N, Köseoglu F, Albayrak N. Demographic characteristics and complications of traumatic and nontraumatic spinal cord injured patients: A retrospective study. J PMR Sci 2006;9:6-10. 5. Hurlbert RJ. Methylprednisolone for acute spinal cord injury: an inappropriate standard of care. J Neurosurg 2000;93:1-7. 6. Topsakal C, Erol FS, Ozveren MF, Yilmaz N, Ilhan N. Effects of methylprednisolone and dextromethorphan on lipid peroxidation in an experimental model of spinal cord injury. Neurosurg Rev 2002;25:258-66. 7. Tator CH. Strategies for recovery and regeneration after brain and spinal cord injury. Inj Prev 2002;8:33-6. 8. Hagen EM, Aarli JA, Grønning M. Patients with traumatic spinal cord

447


Akdemir et al. The approach to patients with spinal trauma and their prognosis injuries at the department of neurology, Haukeland Hospital 1952-99. [Article in Norwegian] Tidsskr Nor Laegeforen 2001;121:3273-5. [Abstract] 9. Peker O, Senocak O, Akalın E, Bircan C, Oncel S. Clinical characteristics of traumatic spinal cord injury patients and results of rehabilitation. The Journal of Turkish Spinal Surgery 2000;11:34-7. 10. Dryden DM, Saunders LD, Rowe BH, May LA, Yiannakoulias N, Svenson LW, et al. The epidemiology of traumatic spinal cord injury in Alberta, Canada. Can J Neurol Sci 2003;30:113-21. 11. Karacan I, Koyuncu H, Pekel O, Sümbüloglu G, Kirnap M, Dursun H, et al. Traumatic spinal cord injuries in Turkey: a nation-wide epidemiological study. Spinal Cord 2000;38:697-701. 12. Gündüz A, Narcı H, Türedi S, Yandı M. Retrospective evaluation of spinal cord injury victims presented to the emergency department. Tr J Emerg Med 2005;5:28-31. 13. Kiriş T, Görgülü A. Omurilik travmaları. In: Ertekin C, Taviloğlu K, Güloğlu R, Kurtoğlu M, editors. Travma. 1 th ed. İstanbul: İstanbul Medikal Yayıncılık; 2005. p. 805-18. 14. Önder A, Kadıoglu HH, Barlas E, Aydın İH. The prognosis of lower cervical spinal injury associated with multiple system trauma. Türk

Nöroşirürji Dergisi 1994;4:63-6. 15. Armagan E, Al G, Erdem M, Ozguc H, Tokyay R. An epidemiological and prognostic evaluation in patients with vertebral and/or spinal injuries who were admitted to first aid and emergency room at medical school of uludağ university. Ulus Travma Acil Cerr Derg 2000;6:110-3. 16. Kirshblum SC, O’Connor KC. Levels of spinal cord injury and predictors of neurologic recovery. Phys Med Rehabil Clin N Am 2000;11:1-27. 17. Winslow C, Bode RK, Felton D, Chen D, Meyer PR Jr. Impact of respiratory complications on length of stay and hospital costs in acute cervical spine injury. Chest 2002;121:1548-54. 18. da Paz AC, Beraldo PS, Almeida MC, Neves EG, Alves CM, Khan P. Traumatic injury to the spinal cord. Prevalence in Brazilian hospitals. Paraplegia 1992;30:636-40. 19. Balcı N, Sepici V, Sever A. Evaluation of the results of rehabilitation of our spinal cord injured patients. Romatoloji ve Tıbbi Rehabilitasyon Dergisi 1993;4:96-100. 20. Burney RE, Maio RF, Maynard F, Karunas R. Incidence, characteristics, and outcome of spinal cord injury at trauma centers in North America. Arch Surg 1993;128:596-9.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Acil serviste üç yıllık deneyim: Spinal travmalı hastalara acil servis yaklaşımı ve prognozları Dr. Hızır Ufuk Akdemir,1 Dr. Dursun Aygün,2 Dr. Celal Katı,1 Dr. Mehmet Altuntaş,1 Dr. Cengiz Çokluk3 1 2 3

Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Samsun Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Nöroloji Anabilim Dalı, Samsun Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Samsun

AMAÇ: Spinal kord yaralanmaları gelişen nörolojik problemler nedeni ile oldukça ciddi maddi ve/veya manevi kayıplara neden olmaktadır. Bu çalışmanın amacı yüksek morbidite ve mortalite oranları nedeni ile ciddi klinik sonuçlara yol açan, ancak ülkemize ait sağlıklı verilerin az olduğu spinal yaralanmaların klinik şiddet ve prognoz açısından değerlendirilmesidir. GEREÇ VE YÖNTEM: Bu geriye dönük çalışma, fakültemiz etik kurulundan izin alındıktan sonra Acil servisimize üç yıl içinde başvuran 18 yaş ve üzerindeki spinal travmalı 91 hasta (59 erkek, 32 kadın) üzerinde gerçekleştirildi. Hastalar demografik özellikler, klinik şiddet, gelişen komplikasyonlar ve mortalite açısından değerlendirildi. BULGULAR: Hastaların 43’ü komplet, 48’i ise inkomplet yaralanmalı idi. Hastaların 46’sı yüksekten düşme, 35’i trafik kazası ve 10’u diğer nedenlerden dolayı spinal yaralanmaya maruz kalmıştı. Hastaların 52’sinde çeşitli komplikasyonlar görülürken 39’unda herhangi bir komplikasyon gelişmediği saptandı. Çalışma grubumuzda yer alan 91 hastanın 19’unun öldüğü 72’sinin ise hastaneden taburcu olduğu saptandı. TARTIŞMA: Spinal kord yaralanmaları genellikle kötü klinik sonuçlara yol açmaktadır. Bu nedenle acil servisteki uygun yaklaşımın (erken tanı ve doğru tedavi) önemi oldukça yüksektir. Bu hasta grubunda hem primer bakım hem de komplikasyonların önlenmesi bakımından gerekli önlemlerin alınması klinik sonuçları olumlu yönde etkileyecektir. Key words: Klinik şiddet; komplikasyon; prognoz; spinal travma. Ulus Travma Acil Cerr Derg 2013;19(5):441-448

448

doi: 10.5505/tjtes.2013.21456

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


ORIGIN A L A R T IC L E

Retrospective analysis of 132 patients with orbital fracture Halil Hüseyin Çağatay, M.D.,1 Metin Ekinci, M.D.,1 Can Pamukcu, M.D.,2 Mehmet Ersin Oba, M.D.,1 Arzu Akçal Özcan, M.D.,3 Semra Karşıdağ, M.D.4 1

Department of Ophthalmology, Kafkas University Faculty of Medicine, Kars

2

Department of Ophthalmology, Sehitkamil State Hospital, Gaziantep

3

Department of Plastic, Reconstructive and Aesthetic Surgery, Akdeniz University Faculty of Medicine, Antalya

4

Department of Plastic, Reconstructive and Aesthetic Surgery, Sisli Etfal Training and Research Hospital, Istanbul

ABSTRACT BACKGROUND: The aim of this study was to evaluate the clinical and epidemiological features of 132 patients with orbital wall fracture who were treated at Şişli Etfal Teaching and Research Hospital, Istanbul, between 2005-2012. METHODS: The medical records of the patients with a diagnosis of orbital fracture were reviewed and analyzed. The patients were evaluated by age, gender, etiology, symptoms, examination findings, fracture location, associated injuries, treatment, and complications. RESULTS: The mean follow-up time was 9 (6-16) months. The male-to-female ratio was 5.3-1. The average age was 32 (6-82) years. The leading causes of orbital fractures were traffic accidents (36%) followed by assaults (32%). The most frequently affected orbital wall was the medial wall (33%). The main symptom was throbbing pain in the traumatized area (100%), and the main examination finding was periorbital edema and ecchymosis (100%). The most frequent associated injury was cerebral trauma (14%). Sixty-seven patients (50.1%) were managed with medical treatment, and 65 patients (49.9%) underwent surgical treatment. The most common complication in the late period was dermatomal sensory loss (11%). CONCLUSION: This study makes clear that the frequency of orbital injuries may be decreased by preventing traffic accidents, by taking precautions in the event they occur, and by promulgating social and educational work against violence.

Key words: Epidemiology, demography, orbital fracture, trauma.

INTRODUCTION Orbital fracture usually occurs as a result of blunt orbital and facial traumas and may involve ocular injuries. In general, patients are polytraumatized and their functional and cosmetic treatments are performed in different medical specialities such as ophthalmology, otorhinolaryngology, neurosurgery, and plastic and reconstructive surgery clinics. Many epidemiological studies of orbital fracture have been described in the literature, with reports of variable diagnostic Address for correspondence: Halil Hüseyin Çağatay, M.D. Kafkas Üniversitesi Tıp Fakültesi, Göz Hastalıkları Anabilim Dalı, Kampüs, 36100 Kars, Turkey Tel: +90 474 - 225 11 50 E-mail: drhhcgty@gmail.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):449-455 doi: 10.5505/tjtes.2013.99389 Copyright 2013 TJTES

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

criteria, medical and surgical treatment modalities and complication rates, depending on whether the patient primarily consulted an ophthalmological or a maxillofacial surgery clinic.[1-4] These variations may also be explained by differences in the socioeconomic and cultural levels of the populations studied. The purpose of this study was to investigate the epidemiological and demographic characteristics of patients with orbital fracture who were treated in the Ophthalmology and Plastic and Reconstructive Surgery Clinics of a tertiary healthcare institution, to which complicated cases were referred from surrounding areas.

MATERIALS AND METHODS The records of 132 patients with orbital fractures were examined retrospectively, after Local Ethics Committee approval. These patients had been treated at Şişli Etfal Training and Research Hospital in the Second Ophthalmology Clinic and Plastic and Reconstructive Surgery Clinic from 2005 to 2012, and followed for at least six months. 449


Çağatay et al. Retrospective analysis of 132 patients with orbital fracture

The patients were evaluated according to the involved side, age and sex distribution, trauma etiologies, symptoms, examination findings, fracture localizations, treatment time after the trauma, treatment procedure, and complications after treatment.

Table 3. Ophthalmological findings in patients with orbital fracture Determined finding

n

%

Periorbital edema and ecchymosis

79

59.8

The orbital wall fractures were classified as isolated fractures involving one orbital wall or combined fractures involving more than one orbital wall. Isolated orbital fractures were classified as orbital floor, roof, medial, and lateral orbital wall fractures. In combined fractures, the affected walls were also evaluated together.

Decrease in vision

47

35.6

Dermatomal sensory loss in the periorbital area

47

35.6

Crepitation with palpation

45

34.1

Step in palpation

34

25.7

Limitation in globus movements

29

22

Defects in light reflexes

21

15.9

RESULTS

Corneal epithelial erosion

5

3.8

Hyphema

5 3.8

Traumatic uveitis

5

3.8

Corneal perforation

3

3.8

Pupil sphincter rupture

3

2.3

Affected orbital wall

n

%

Medial wall

39

51.3

Lateral wall

21

27.6

Orbital floor

13

17.1

One hundred eleven patients were male (84%) and 21 were female (16%). The mean follow-up time was 9 (range, 6-16) months. The average age was 32 (±17, 6-82) years. The orbital fractures occurred most frequently in the 31-40 age range (n=32, 24.2%), followed by the age groups of 21-30 (n=29, 22%) and 11-20 (n=29, 22%) (Table 1). The principal etiology of orbital bone fractures was traffic accidents (n=47, 35.6%), followed by assaults (n=42, 31.8%), falls (n=37, 28%), work accidents (n=3, 2.3%), and sports injuries (n=3, 2.3%) (Table 2). With respect to the involved side, right orbital involvement occcurred in 66 patients (50%), left orbital involvement in 60

Table 4. Distribution of isolated wall fractures

Orbital roof

3

3.9

Total isolated fractures

76

100

Table 1. Distribution of orbital fractures according to age groups Age (Year)

Male

Female

%

0-10

8

11-20

26 3 29 22

21-30

24 5 29 22

31-40

21 11

32 24.2

41-50

10 0

10 7.6

51-60

17

17 12.9

>60

5 0

Total

2

Total

0

10 7.6

5 3.8

111 21 132 100

Table 2. Etiology of orbital fractures Reasons for orbital fracture

n

%

Traffic accident

47

35.6

Assault

42 31.8

Fall

37 28

Work accident

3

2.3

Sports injury

3

2.3

patients (45.5%) and bilateral orbital involvement in 6 patients (4.5%). The complaints included throbbing pain in the traumatized area (n=100, 75.8%), various degrees of vision loss (n=53, 40.1%), nose bleed (n=31, 23.5%), and diplopia (n=29, 22%). Ophthalmological examination findings were periorbital edema and ecchymosis (n=132, 100%), subconjuctival hemorrhage (n=79, 59.8%), decrease in vision (n=47, 35.6%), dermatomal sensory loss in the periorbital area (n=47, 36%), subcutaneous emphysema (n=45, 34.1%), bone fracture giving step sign at palpation (n=34, 25.8%), limitation of ocular movements (n=29, 22%), defects in light reflexes (n=21, 15.9%), corneal epithelial erosion (n=5, 3.8%), hyphema (n=5, 3.8%), traumatic uveitis (n=5, 3.8%), corneal perforation (n=3, 2.3%), and pupillary sphincter rupture (n=3, 2.3%) (Table 3). The orbital fractures were evaluated according to the number of walls involved, and fracture of one orbital wall was diagnosed in 76 patients (57.6%). Their distribution was 39 medial wall fractures (51.3%), 21 lateral wall fractures (27.6%), 13 orbital floor fractures (17.1%), and 3 orbital roof fractures (3.9%) (Table 4). A combined wall fracture was identified in 56 patients

450

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


Çağatay et al. Retrospective analysis of 132 patients with orbital fracture

(42.4%). Their distribution was 21 lateral wall-floor fractures (37.5%), 8 medial wall-floor fractures (14.3%), 8 medial wallroof fractures (14.3%), 8 lateral wall-roof fractures (14.3%), 5 lateral wall-floor-roof fractures (8.9%), 3 medial-floor-lateral fractures (5.4%), and 3 medial-floor-lateral-roof fractures (5.4%) (Table 5). The distribution of combined and isolated fractures considered together was as follows: 61 medial wall fractures (33%), 53 lateral wall fractures (28.6%), 53 orbital floor fractures (28.6%), and 18 orbital roof fractures (9.7%) (Table 6). Sixty-seven patients underwent conservative medical treatment. They were treated with the application of cold compresses, by keeping the patient’s head elevated and by systemic/local antibiotics and anti-inflammatory agents. Sixty-five patients received surgical treatment within the first day to three weeks (mean, 2 weeks) after the trauma. The surgical intervention consisted of open reduction of the fracture and fixation of titanium miniplates in 47 patients and bone graft (crista iliaca) in 12 patients. A closed reduction of the fracture was performed in 5 patients, while 1 patient underwent orbital decompression surgery. In 44 patients (33.3%), the orbital fracture was accompanied by systemic injuries. The distribution of systemic injuries was

Table 7. Distribution of systemic injuries accompanying orbital fractures Systemic injuries

n

%

Cerebral trauma

18

13.6

Maxilla front wall fracture

10

7.6

Extremity fracture

8

6.1

Nasal fracture

5

3.8

Acute abdomen

2

1.5

Pelvic fracture

1

0.8

Table 8. Late ophthalmological complications of orbital fractures Complications

n %

Dermatomal sensory loss

15

11.4

Enophthalmos

7

5.3

Hypoglobus

5 3.8

Irregularity on the lower eyelid

2

Diplopia

1 0.8

Optic atrophy

1

0.8

Phthisis bulbi

1

0.8

Lacrimal pump dysfunction

1

0.8

1.5

Table 5. Distribution of combined orbital wall fractures Affected orbital walls

n

%

Lateral wall + Orbital floor

21

37.5

Medial wall + Orbital floor

8

14.3

Medial wall + Orbital roof

8

14.3

Lateral wall + Orbital roof

8

14.3

Lateral wall + Orbital floor + Orbital roof

5

8.9

Medial wall + Orbital floor + Lateral wall

3

5.4

Medial wall + Orbital floor + Lateral wall +

3

5.4

56

100

Orbital roof Total combined fractures

Table 6. Distribution of combined and isolated fractures evaluated together Affected orbital walls

n

%

Medial wall

61

33

Lateral wall

53

28.6

Orbital floor

53

28.6

Orbital roof

18

9.7

Total fractured orbital walls

185

100

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

cerebral trauma in 18 (13.6%), extremity fracture in 8 (6.1%), maxilla front wall fracture in 8 (6.1%), and nasal bone fracture in 5 (3.8%) patients. Two patients (1.5%) had an acute abdominal pathology, and 1 patient (0.8%) had a pelvic fracture (Table 7). Ophthalmologic complications of the surgical treatments were early transitory periorbital edema, ecchymosis and subconjuctival hemorrhage. In the late period, dermatomal sensory loss in the periorbital area (n=15, 11.4% ), enophthalmos (n=7, 5.3%), hypoglobus (n= 5, 3.8%), and diplopia (n=1, 0.8% ) were observed. Cicatricial cutaneous shrinkage on the lower eyelids (n=2, 1.5%), epiphora due to orbicularis muscle weakness-lacrimal pump dysfunction (n=1, 0.8%), phthisis bulbi (n=1, 0.8%), and optic atrophy (n=1, 0.8%) were observed (Table 8).

DISCUSSION This study investigated the epidemiological and demographic features of patients with orbital fractures who consulted the Ophthalmological and Plastic and Reconstructive Surgery Clinics of a tertiary healthcare institution located in the province of Istanbul to which complicated cases from surrounding areas were referred.

451


Çağatay et al. Retrospective analysis of 132 patients with orbital fracture

The etiology of orbital fractures varies according to the socioeconomic and cultural levels of the studied population, as well as to the country and geographical region in which the study is conducted. We believe that the findings of this study will help to determine the optimal protection and clinical management strategies of patients with orbital fractures. Two mechanisms play a particular role in the occurrence of orbital wall fractures.The first mechanism is related to the “buckling theory”. The buckling theory asserts that the forces that affect the orbital rim cause flexion movements rather than fracture, and this deformation secondarily creates fractures of thin walls of the orbita such as the medial wall. In contrast, the hydraulic theory suggests that the mechanism involved is an increase in the intraorbital pressure and subsequent formation of wall fractures. Biomechanical studies performed on cadavers have demonstrated that in the etiology of orbital blowout fractures, both mechanisms may play a role.[5] In the literature, it is emphasized that the orbito-zygomatic area and the orbital floor are the most frequently affected orbital regions.[6] In our study, contrary to the literature, we found that medial wall fractures occurred more frequently than lateral wall fractures. We think that this difference may be due to the fact that medial wall fractures are probably underdiagnosed because of lack of symptoms. When they are suspected, the diagnosis is made by orbital computerized tomography (CT) examination.[7] The difference between our rates of medial wall fractures and those in the literature may be due to the systematic use of CT in all of our cases. In 391 patients with orbital fracture reported by Hwang et al.,[8] the rate of isolated wall fractures was 47.1% and of combined multiple bone fractures was 52.9%. In our study, we found that the rate of isolated fractures was 57.6%. Our study also shows that in the etiology of orbital fractures, the rates of falling and forensic incidents were higher in comparison with the literature. We think that this difference occurred because of the socioeconomic and cultural differences of the local population studied.[1-3] In the epidemiological literature, it has been reported that the principal etiology of orbital fractures was traffic accidents, followed by, in decreasing order of frequency, physical assault, sports injuries and falls.[9,10] In their review, Cruz and Eichenberger[11] indicated that the most common cause of orbital fractures in urban areas is traffic accidents. The study conducted by Shere et al.[3] on American soldiers determined that assault was the most frequent etiology, followed by traffic accidents. The etiology of orbital fractures in our cases was traffic accidents, assaults and falls, in order of decreasing frequency. This study showed that orbital fractures occurred predominantly in male patients (84%) versus females (16%), and the mean age was 32 (6-82) years. Our results are similar to the 452

previously published studies.[6,12-14] Tan Başer et al.[15] reported that the ocular findings that accompany orbital fractures are periorbital ecchymosis (87.0%), periorbital paresthesia (33.3%), diplopia (12.96%), restricted eye movements (11.1%), and enophthalmos (7.4%). The ocular findings in our patients were edema and ecchymosis in the traumatized area (n=132, 100%), subconjuctival hemorrhage (n=79, 60%), decrease in vision (n=47, 36%), dermatomal sensory loss (n=47, 36%), subcutaneous crepitation at palpation (n=45, 34%), “bony step” sign at palpation (n=34, 26%), limitation in ocular movements (n=29, 22%), defects in light reflexes (n=21, 16%), corneal epithelial erosion (n=5, 4%), hyphema (n=5, 4%), traumatic uveitis (n=5, 4%), corneal perforation (n=3, 2%), and pupillary sphincter rupture (n=3, 2%). Gacto et al.[9] determined the rate of ocular damage accompanying orbital traumas to be 15.3%, and Jabaley et al.[16] detected a rate between 11% and 29%. The ocular pathologies in our patients were enophthalmos (n=7, 5.3%), corneal epithelial erosion (n=5, 4%), hyphema (n=5, 4%), traumatic uveitis (n=5, 4%), corneal perforation (n=3, 2%), and pupillary sphincter rupture (n=3, 2%). In our study, ocular involvement was detected in 23 patients (17%). These results were consistant with previous publications.[10,15,16] Burm et al.[17] indicated in their study that the facial fractures most frequently associated with orbital fractures were nasal bone fractures folllowed by zygomatic and mandibular fractures. Gacto et al.[9] determined that the most frequent accompanying facial fracture was zygomatic fracture.[10,17] In our study, maxilla front wall fractures (n=8, 6%) and nasal bone fractures (n=8, 6%) were the most frequent accompanying facial fractures. Martello and Vasconez,[18] who studied 621 patients with systemic injuries associated with orbital trauma, determined that extremity and pelvic traumas (33%) occurred most frequently, followed by chest traumas (7%) and intraabdominal traumas (5%). Gewalli et al.[19] reported soft tissue traumas in 19 (34%), extremity and pelvic traumas in 14 (25%), and chest traumas in 5 (9%) patients. The systemic traumas of our patients were cerebral traumas (n=18, 14%), extremity fractures (n=8, 6%), acute abdominal injuries (n=2, 2%), and pelvic fractures (n=2, 2%). In our study, 67 patients were managed conservatively with cold applications, keeping the patient’s head elevated, systemic and local antibiotherapy, and anti-inflammatory treatment. Orbital emphysema, which was determined in 45 patients (34%) in our study, was treated conservatively in accordance with the treatment protocol recommended in the study by Oba et al.[20] None of our patients developed the degree of compartment syndrome or optic neuropathy that would have necessitated surgical intervention. Surgical intervention criteria for our patients with orbital Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


Çağatay et al. Retrospective analysis of 132 patients with orbital fracture (a)

(b)

(c)

(d)

Figure 1. The photograph of the patient injured in a traffic accident with bilateral combined orbital fracture. (a) Pre-operative view of the patient. (b) Three months after bilateral orbital fracture reconstruction surgery via subciliary incision. (c, d) Pre-operative three-dimensional computed tomography scans.

traumas were permanent diplopia, apparent orbital wall defect, compression of soft tissue and/or extraocular muscles incarcerated in the fracture line, restricted eye movements, and optic nerve involvement.[21-23] Gazioğlu et al.[22] emphasized that early optic nerve decompression surgery provides recovery in 60% of patients in cases where the optic nerve is affected, and vision could partially be restored even in amaurotic patients. In our study, 47 patients with apparent orbital wall defect, compression of soft tissue and/or extraocular muscles in the fracture line, and restricted eye movements were treated with open surgery with the reduction-fixation of titanium miniplates. A bone graft (crista iliaca) was used in the surgical reconstruction in 12 patients, closed reduction of a zygomatic fracture was performed in 5 patients, and orbital decompression surgery for an apex fracture accompanied by a piece of free bone was performed in 1 patient. The literature reports that surgical repair of orbital fractures can be performed using different routes such as transconjunctival, subtarsal, transcaruncular, and subciliary, but the Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

two most preferred routes are subciliary and transconjunctival.[24] Each incision location has associated risks and benefits. Using a transconjunctival incision, De Riu et al.[25] observed canthal malposition in 3 of their 24 patients (12.5%), and Novelli et al.,[26] in their group of 56 patients, reported trichiasis in 2 patients (3.5%) and partial entropion in 2 patients (3.5%). Schmäl et al.[27] noticed cheloid formation at the lateral canthotomy site, necessitating surgical repair in 2 of 209 patients (1%), and Mullins et al.[28] reported conjunctival granuloma in 8 of 400 patients (2%). Using a subciliary incision, De Riu et al.[25] observed lagophthalmus in 5 of 23 (21.7%) and cutaneous scarring in 10 of 23 (43%) patients. In our study, the transcutaneous subciliary approach was the routinely used incision method during open reduction procedures of the orbital floor and lateral wall fractures. This approach gave us a large surgical field and facilitated surgical manipulations with a minimal rate of complications. This subciliary approach caused the formation of excessive scar tissue in the postoperative period, with a lower eyelid ectropion and a retraction of the lower eyelid in 2 (2%) of our 453


Çağatay et al. Retrospective analysis of 132 patients with orbital fracture

patients. We believe that the surgeon’s preference and comfort play a pivotal role in influencing the decision regarding which incision to use. In patients who required a surgical intervention, we observed that 15 (63%) had multiple and displaced fractures (Fig. 1). In our study, 67 patients underwent conservative medical treatment. A conservative approach was adopted when there was a stable fracture, no enophthalmos and no muscle-orbital soft tissue compression, and also when surgical intervention was refused by the patients. In conclusion, we present the demographics, mechanism of injury, and associated injuries in one of the largest series of orbital fractures reported in the literature from our country. This study makes clear that the frequency of orbital injuries may be reduced significantly by preventing traffic accidents and assaults, by taking precautions in the event they occur, and also by promulgating social programs against violence. Although patients with orbital fractures are usually treated by a multitude of specialists, we believe that oculoplastic surgeons have a major role in the primary and secondary care of all orbital fractures because most complications of these fractures are related to the globe. This study demonstrates important differences in the demographics and clinical presentation of patients that help to predict concomitant injuries and sequelae and facilitate a more accurate diagnosis in patients with orbital fracture. Conflict of interest: None declared.

REFERENCES 1. Motamedi MH. An assessment of maxillofacial fractures: a 5-year study of 237 patients. J Oral Maxillofac Surg 2003;61:61-4. 2. Gewalli F, Sahlin P, Guimarães-Ferreira J, Lauritzen C. Orbital fractures in craniofacial trauma in Göteborg: trauma scoring, operative techniques, and outcome. Scand J Plast Reconstr Surg Hand Surg 2003;37:69-74. 3. Shere JL, Boole JR, Holtel MR, Amoroso PJ. An analysis of 3599 midfacial and 1141 orbital blowout fractures among 4426 United States Army Soldiers, 1980-2000. Otolaryngol Head Neck Surg 2004;130:164-70. 4. Jatla KK, Enzenauer RW. Orbital fractures: a review of current literature. Curr Surg 2004;61:25-9. 5. Ahmad F, Kirkpatrick WN, Lyne J, Urdang M, Garey LJ, Waterhouse N. Strain gauge biomechanical evaluation of forces in orbital floor fractures. Br J Plast Surg 2003;56:3-9. 6. Carinci F, Zollino I, Brunelli G, Cenzi R. Orbital fractures: a new classification and staging of 190 patients. J Craniofac Surg 2006;17:1040-4. 7. Lee HJ, Jilani M, Frohman L, Baker S. CT of orbital trauma. Emerg Radiol 2004;10:168-72. 8. Hwang K, You SH, Sohn IA. Analysis of orbital bone fractures: a 12year study of 391 patients. J Craniofac Surg 2009;20:1218-23.

454

9. Gacto P, de Espinosa IM. Retrospective survey of 150 surgically treated orbital floor fractures in a trauma referral centre. Eur J Plast Surg 2009;32:23-8. 10. Amrith S, Saw SM, Lim TC, Lee TK. Ophthalmic involvement in cranio-facial trauma. J Craniomaxillofac Surg 2000;28:140-7. 11. Cruz AA, Eichenberger GC. Epidemiology and management of orbital fractures. Curr Opin Ophthalmol 2004;15:416-21. 12. Dimitroulis G, Eyre J. A 7-year review of maxillofacial trauma in a central London hospital. Br Dent J 1991;170:300-2. 13. Haug RH, Prather J, Indresano AT. An epidemiologic survey of facial fractures and concomitant injuries. J Oral Maxillofac Surg 1990;48:92632. 14. Starkhammar H, Olofsson J. Facial fractures: a review of 922 cases with special reference to incidence and aetiology. Clin Otolaryngol Allied Sci 1982;7:405-9. 15. Tan Başer N, Bulutoğlu R, Celebi NU, Aslan G. Clinical management and reconstruction of isolated orbital floor fractures: the role of computed tomography during preoperative evaluation. Ulus Travma Acil Cerrahi Derg 2011;17:545-53. 16. Jabaley ME, Lerman M, Sanders HJ. Ocular injuries in orbital fractures. A review of 119 cases. Plast Reconstr Surg 1975;56:410-8. 17. Burm JS, Chung CH, Oh SJ. Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture. Plast Reconstr Surg 1999;103:1839-49. 18. Martello JY, Vasconez HC. Supraorbital roof fractures: a formidable entity with which to contend. Ann Plast Surg 1997;38:223-7. 19. Gewalli F, Sahlin P, Guimarães-Ferreira J, Lauritzen C. Orbital fractures in craniofacial trauma in Göteborg: trauma scoring, operative techniques, and outcome. Scand J Plast Reconstr Surg Hand Surg 2003;37:69-74. 20. Oba E, Pamukcu C, Erdenöz S. Traumatic orbital emphysema: a case report. Ulus Travma Acil Cerrahi Derg 2011;17:570-2. 21. Rhim CH, Scholz T, Salibian A, Evans GR. Orbital floor fractures: a retrospective review of 45 cases at a tertiary health care center. Craniomaxillofac Trauma Reconstr 2010;3:41-7. 22. Gazioğlu N, Çetinkale O, Gazioğlu E, Akar Z, Özer G, Kuday C. Early surgery and multidisiplinary approach to the fractures of bones surrounding orbital cavity. [Article in Turkish] Ulus Travma Acil Cerr Derg 1996;2:198-203. 23. Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology 2002;109:1207-10. 24. Hwang K, You SH, Sohn IA. Analysis of orbital bone fractures: a 12year study of 391 patients. J Craniofac Surg 2009;20:1218-23. 25. De Riu G, Meloni SM, Gobbi R, Soma D, Baj A, Tullio A. Subciliary versus swinging eyelid approach to the orbital floor. J Craniomaxillofac Surg 2008;36:439-42. 26. Novelli G, Ferrari L, Sozzi D, Mazzoleni F, Bozzetti A. Transconjunctival approach in orbital traumatology: a review of 56 cases. J Craniomaxillofac Surg 2011;39:266-70. 27. Schmäl F, Basel T, Grenzebach UH, Thiede O, Stoll W. Preseptal transconjunctival approach for orbital floor fracture repair: ophthalmologic results in 209 patients. Acta Otolaryngol 2006;126:381-9. 28. Mullins JB, Holds JB, Branham GH, Thomas JR. Complications of the transconjunctival approach. A review of 400 cases. Arch Otolaryngol Head Neck Surg 1997;123:385-8.

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5


Çağatay et al. Retrospective analysis of 132 patients with orbital fracture

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Orbita kırığı saptanan 132 hastanın geriye dönük analizi Dr. Halil Hüseyin Çağatay,1 Dr. Metin Ekinci,1 Dr. Can Pamukcu,2 Dr. Mehmet Ersin Oba,1 Dr. Arzu Akçal Özcan,3 Dr. Semra Karşıdağ4 Kafkas Üniversitesi Tıp Fakültesi, Göz Hastalıkları Anabilim Dalı, Kars Şehitkamil Devlet Hatanesi, Göz Hastalıkları Kliniği, Gaziantep 3 Akdeniz Üniversitesi Tıp Fakültesi, Plastik ve Rekonstrüktif Cerrahi Anabilim Dalı, Antalya 4 Şişli Etfal Eğitim ve Araştırma Hastanesi, Plastik ve Rekonstrüktif Cerrahi Kliniği, İstanbul 1 2

AMAÇ: Bu çalışmada; 2005-2012 yılları arasında orbita kırığı tanısıyla İstanbul Şişli Etfal Eğitim ve Araştırma Hastanesi’nde tedavi edilen 132 hastanın klinik ve epidemiyolojik özellikleri değerlendirilmesi amaçlandı. GEREÇ VE YÖNTEM: Orbita kırığı nedeniyle tedavi edilen hastalara ait kayıtlar geriye dönük olarak incelendi. Hastaların yaş ve cinsiyete göre dağılımları, travma etiyolojileri, semptomları, muayene bulguları, kırık lokalizasyonları, eşlik eden sistemik yaralanmalar, uygulanan tedavi prosedürü ve tedavi sonrası saptanan komplikasyonlar değerlendirildi. BULGULAR: Ortalama takip süresi 9(6-16) ay olan hastaların erkek-kadın oranı 5.3-1 idi. Ortalama yaş 32 (6-82) yıl idi. En sık etiyolojik neden trafik kazaları (%36) ve darp (%32) olarak saptandı. En sık etkilenen duvar medial orbital duvardı (%33). Hastalarda en sık görülen semptom travma bölgesinde zonklayıcı ağrı (%100) ve saptanan bulgu ise periorbital ödem ve ekimozdu (%100). En sık eşlik eden sistemik yaralanma ise serebral travmaydı (%13.6). Hastaların %50.1’i tıbbi tedavi ile konservatif olarak takip edilirken, %49.9’una cerrahi tedavi uygulandı. Tedavi sonrası en sık gözlenen komplikasyonun dermatomal duyu kaybı (%11) olduğu görüldü. TARTIŞMA: Bu çalışma orbital kırıklarının görülme sıklığının azaltılabilmesi için trafik kazalarını ve olası kaza durumunda yaralanmayı önleyiciyi tedbirlerin alınmasının, eğitim programlarının geliştirilmesinin önemini vurgulamaktadır. Anahtar sözcükler: Epidemiyoloji, demografi, orbita kırığı, travma. Ulus Travma Acil Cerr Derg 2013;19(5):449-455

doi: 10.5505/tjtes.2013.99389

Ulus Travma Acil Cerr Derg, September 2013, Vol. 19, No. 5

455


K Lİ NİK Ç A LI ŞM A

Femur boyun kırıklarına parsiyel protez uygulamasında anterior ve posterior kapsüler açılımın sonuçları Dr. Sinan Zehir,1 Dr. Ercan Şahin,2 Dr. Serkan Sipahioğlu,3 Dr. İbrahim Azboy,4 Dr. Ümit Yar5 1

Hitit Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Çorum

2

Sağlık Bakanlığı Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, Şanlıurfa

3

Harran Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Şanlıurfa

4

Dicle Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Diyarbakır

5

BSK Hastanesi, Ortopedi ve Travmatoloji Kliniği, Konya

ÖZET AMAÇ: Çalışmamızda anterior veya posterior cerrahi yaklaşımla bipolar protez uygulanan femur boyun kırıklı hastaların fonksiyonel durumları ve ortaya çıkan komplikasyonlar geriye dönük olarak değerlendirildi. GEREÇ VE YÖNTEM: Kasım 2007-Şubat 2011 tarihleri arasında femur boyun kırığı nedeni ile bipolar parsiyel protez uygulanan, takip süresi en az bir yıl olan 224 hasta (96 erkek, 128 kadın) değerlendirildi. Cerrahi yaklaşıma göre iki grup oluşturuldu. Kalça eklem kapsülü anteriordan açılan (grup 1) grupta 92 (46 erkek, 46 kadın; ortalama yaş 78.4 yıl dağılım 70-97) hasta, kapsülün posteriordan açıldığı (grup 2) grupta ise 132 (50 erkek, 82 kadın ortalama yaş 77.9 dağılım 70-96) hasta vardı. Grup 1’deki hastaların ortalama takip süresi 16.4 ay (12-34), grup 2’deki hastaların ortalama takip süresi 18.9 ay (12-39) idi. BULGULAR: Ortalama Harris puanı grup 1’de 81.7±7.6 grup 2’de ise 79.2±6.9 olarak bulundu. Grup 1’de 19 hastada çok iyi, 52 hastada iyi, 15 hastada orta ve 6 hastada yetersiz sonuç, grup 2’de ise 29 hastada çok iyi, 74 hastada iyi, 21 hastada orta ve 8 hastada yetersiz sonuç elde edildi. Grup 2’de daha fazla çıkık (%3.78) ve enfeksiyon (%3.03) görülsede; iki grup arasında fonksiyonel puanlama ve komplikasyonlar açısından anlamlı fark bulunmadı (p>0.05). SONUÇ: Kalça eklemine parsiyel protez uygulamasında cerrahi yaklaşım fonksiyonel sonuçları etkilememektedir. Kalça eklemine parsiyel protez uygulamasında kapsülün anterior açılımı çıkık ve enfeksiyon açısından daha güvenli olabilir.

Anahtar sözcükler: Femur boynu, kırık, parsiyel protez, yaklaşım.

GİRİŞ Yaşlı hastalarda kapsül içi kalça kırıklarının sıklığı giderek artmaktadır. Bu hastaların en kısa sürede ayağa kaldırılması, kırık öncesi yaşam düzeylerine döndürülmesi oluşması muhtemel birçok komplikasyonun önlenmesi açısından önemlidir. Bu bölge kırıklarında kanlanma özelliğine bağlı olarak kaynamama ve avasküler nekroz sık görülür. Tedavide internal tespit veya parsiyel protez uygulanması konusunda tam bir fikir birliği sağlanamamıştır.[1-3]

Sorumlu yazar: Dr. Sinan Zehir, Hitit Üniversitesi Çorum Eğitim Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, 19100 Çorum Tel: +90 364 - 223 03 00 E-posta: sinanzehir@yahoo.com Ulus Travma Acil Cerr Derg 2013;19(5):456-462 doi: 10.5505/tjtes.2013.74340 Telif hakkı 2013 TJTES

456

İnternal tespit yöntemleri sonrası hareketsizlik nedeni ile ölümcül kalp akciğer problemleri, tromboemboli ve yatak yaraları görülme olasılığı yüksektir. Bu nedenle ileri yaş hastalarda erken harekete izin vermesi nedeni ile parsiyel protez uygulamaları daha çok tercih edilmektedir.[4] Parker ve Partanen bir dizi randomize çalışmaları derlemişler ve ayrılmış femur boyun kırıklarında parsiyel protez grubuna kıyasla açık redüksiyon ve internal fiksasyon grubunda yeniden ameliyat edilme oranının anlamlı olarak daha yüksek olduğunu bildirmişlerdir.[5,6] Parsiyel protez uygulanan olgularda çıkık önemli bir sorun olarak yerini korumaktadır. Son kırk yılda yayınlanmış 133 makalenin incelenmesi sonucunda parsiyel protez uygulanan hastalarda çıkık riskinin implant tipine, cerrahi yaklaşıma ve çimento kullanımına bağlı olduğu bildirilmiştir.[7] Kalça eklemine posterior cerrahi yaklaşımın çıkık riskini artırdığını bildiren çalışmalar mevcuttur.[8,9] Posterior yaklaşımda kapsül tamiri yapılsa da çıkık oranının anterior yaklaşıma göre daha yüksek olduğu bildirilmektedir.[9] Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5


Zehir ve ark. Femur boyun kırıklarına parsiyel protez uygulaması

Ülkemizde bu konuyla ilgili yeterli çalışma mevcut değildir. Bu çalışmanın amacı anterior veya posterior cerrahi yaklaşımla bipolar protez uyguladığımız kapsül içi kalça kırıklarının ameliyat sonrası fonksiyonel durumlarını ve ortaya çıkan komplikasyonları geriye dönük olarak değerlendirmektir.

GEREÇ VE YÖNTEM Kasım 2007- Şubat 2011 tarihleri arasında femur boyun kırığı nedeni ile bipolar parsiyel protez uygulanan ve takip süresi en az bir yıl olan 224 hasta (96 erkek, 128 kadın) geriye dönük olarak değerlendirildi. Hastalar cerrahi yaklaşıma göre iki gruba ayrıldı. Kalça eklem kapsülü anteriordan açılan (Grup 1) grupta 92 (46 erkek, 46 kadın; ortalama yaş 78.4 yıl dağılım 70-97) hasta, kapsülün posteriordan açıldığı (Grup 2) grupta ise 132 (50 erkek, 82 kadın ortalama yaş 77.9 dağılım 70-96) hasta vardı. Grup 1’deki hastaların ortalama takip süresi 16.4 ay (dağılım 12-34), grup 2’deki hastaların ortalama takip süresi 18.9 ay (dağılım 12-39) idi. Çoklu travması olan ve kırık öncesi kısmi felci bulunan hastalar çalışmaya alınmadı. Kalça eklem kapsülüne posterior yaklaşım kırık taraf üste olacak şekilde yan yatar posiyonda diz eklemi en az 45 derece fleksiyonda iken Kocher-Langenbeck insizyonu ile yapıldı. Uygun diseksiyon ile kaslar açıldı kuadratus femoris dışındaki kısa dış rotatorler büyük trokanterden ayrılıp mediale çekildi ve kapsül femor boynu boyunca uzunlamasına posteriordan açıldı. Cerrahi işlem son aşamasında posterior kapsül tamiri yapıldı. Anterior yaklaşım ise hasta sırtüstü yatar pozisyonda büyük trokanter masanın kenarında olacak şekilde iken Watson-Jones insizyonu ile yapıldı. Kaslar uygun diseksiyon ile ayrıldı ve eklem kapsülü femur boynu boyunca uzunlamasına açıldı.[10] Hastaların tümüne 1. kuşak sefalosporin ile antibiyotik proflaksisi uygulandı. 147 hastaya çimentouz, 77 hastaya çimentolu protez uygulandı. Çimento-

lu femoral stem düz, kobalt-krom alaşımlı, pürüzsüz ve stem ucuna sentralize edici başlık takılmıştı. Çimentosuz femoral stem ise proksimal pres fit olacak şekilde dizayn edilmiş proksimal 1/3 kısım yüzeyi hidroksiapatit kaplanmış idi. Tüm hastalarda kobalt-krom alaşımlı 28 mm baş ve aynı özellikte bipolar kap kullanıldı. Çimentolu protez uygulamalarında üçüncü generasyon çimentolama tekniği kullanıldı. Derin ven tranbozu proflaksisi için 0.4 mgr/gün cilt altı düşük molekül ağırlıklı heparin (enoksaparin) başlandı ve 10 gün uygulandı. Ameliyat sonrası tüm hastalara antiembolik çorap giydirildi. Ameliyat sonrası birinci günde aspiratif direnler sonlandırıldı, kalça ve diz kaslarını güçlendirici egzersizler başlandı. Bütün hastalar ameliyat sonrası 24-48 saat içinde ağrıyı tolere edebildikleri andan itibaren yürüteç ile yürütüldü. Hastalar taburcu olduktan sonra 6. haftada, 3. ayda, 6. ayda, 1. yılda ve daha sonra yılda bir kez olmak üzere kontrole çağrıldı. Değerlendirmeler kalçanın ön-arka ve lateral grafisi ve Harris kalça değerlendirme skalası ile yapıldı. İstatiksel analiz Mann-Whitney U test ve ki-kare testleri ile yapıldı. Tüm analizler SPSS 15.0 Windows istatistik paket programında yapıldı. P<0.05 değeri istatistiksel olarak anlamlı kabul edildi.

BULGULAR İki hasta grubu arasında yaş, cinsiyet ve hasta takip süreleri açısından anlamlı fark saptanmadı (p>0.05). Grup 1’de bulunan hastaların hastanede kalış süreleri ortalama 10 gün (4-24), grup 2’de ise 11 gün (3-28) olarak saptandı. Hastaların hastanede kalış süreleri, aksama, ağrı ve ameliyattan memnun olup olmadıkları değerlendirildiği zaman iki grup arasında anlamlı bir fark olmadığı görüldü (p>0.05). Ortalama Harris puanı grup 1’de 81.7±7.6 grup 2’de ise

Tablo 1. Olguların demografik özellikleri ve komplikasyonlar Cinsiyet Erkek Kadın Yaş 70-79 80-89 ≥90 Fiksayon tipi Çimentolu Çimentosuz Çıkık (n=6) Enfeksiyon (n=5) Periprostetik kırık (n=11) Bası ülseri (n=7)

Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5

Anterior (n=92)

Posterior (n=132)

n %

n %

46 50 46 50

50 38 82 62

52 56.6 36 39.1 4 4.3

81 61.4 44 33.3 7 5.3

43 46.7 49 53.3 1 1.08 1 1.08 4 4.34 3 3.26

34 25.8 98 74.2 5 3.78 4 3.03 7 5.30 4 3.03

457


Zehir ve ark. Femur boyun kırıklarına parsiyel protez uygulaması

79.2±6.9 olarak tespit edildi. Grup 1’de 19 hastada çok iyi, 52 hastada iyi, 15 hastada orta ve 6 hastada yetersiz sonuç, grup 2’de ise 29 hastada çok iyi, 74 hastada iyi, 21 hastada orta ve 8 hastada yetersiz sonuç elde edildi ve iki grup arasında istatistiksel olarak anlamlı bir fark tespit edilemedi (p>0.05). Gelişen komplikasyonlar açısından değerlendirme yapıldığında (Tablo 1); grup 1’de bir hastada ve grup 2’de dört hastada enfeksiyon görüldü. İkinci grupta bulunan enfeksiyonların ikisi derin enfeksiyon şeklinde idi. Bu hastalardan birinde insülin bağımlı diyabetes mellitus ve börek yetersizliği diğerinde ise insülin bağımlı diyabetes mellitus mevcut idi. Bu hastalar iki aşamalı revizyon ameliyatı ile tedavi edildi. Diğer enfeksiyon görülen olgular ise yüzeyel enfeksiyon şeklinde idi ve kültür antibiyogram sonuçlarına göre tedavi edildi. Enfeksiyon açısından iki grup arasında istatistiksel olarak anlamlı fark bulunamadı (p>0.05). Kliniğe geç başvuran 7 hastada sakral bölgede bası ülseri gelişti. Bu hastalar cerrahi girişime gerek duyulmadan dekübitis bakım ve tedavi yöntemleri ile tedavi edildi. Bası yarası açısından iki grup arasında istatistiksel olarak anlamlı fark bulunamadı (p>0.05). (a)

(c)

(b)

Hepsi ameliyat sonrası erken dönemde olmak üzere 6 hastada posterior çıkık görüldü. Beş hasta grup 2’de ve bir hasta ise grup 1’de idi. Üç hastada genel anestezi altında kapalı redüksiyon yapıldı. İki hastada kapalı redüksiyon sırasında bipolar baş ile femoral baş arasında ayrılma olması nedeni ile açık redüksiyon yapıldı (Şekil 1). Grup 1’de yer alan hastada ise kapalı redüksiyon sonrası tekrarlayan çıkık oluşması üzerine revizyon ameliyatı yapıldı. Grup 2’de daha fazla hastada çıkık görülsede iki grup arasında anlamlı fark bulunamadı (p>0.05). Dört hastada çıkık çömelme şeklinde kalçanın hiperfleksiyon pozisyonunda uzun süre kalması sonucu oluşurken iki hastada çıkık yüksekten düşme sonrası oluşmuş idi. Çıkık görülen hastaların tedavisi için açık redüksiyon uygulanan ve posterior yaklaşım yapılan olgularda kapsül tamiri uygulanmış bütün hastalara protez ile yaşam şekli konusunda eğitim verilmiştir. İki grup yapılan kan transfüzyon miktarları açısından değerlendirildiğinde. Grup 1’deki hastalara daha yüksek oranda kan transfüzyonu yapılmış olsada iki grup arasında anlamlı bir fark tespit edilememiştir (Tablo 2). Ameliyat sırasında oluşan periprostetik kırık açısından değerlendirme yapıldığında grup 1’deki dört, grup 2’deki yedi hastada protez yerleştirilmesi sırasında boyun kırığından distale doğru uzanan fissür tarzında yeni kırık oluştuğu görüldü. Bu kırıkların tamamı çimentosuz protez uygulanan grupta idi ve bu kırıklar kablo ile tespit edildikten sonra uygun çaptaki protez yerleştirilerek ameliyat sonlandırıldı (Şekil 2). Bu hastaların ameliyat sonrası rehabilitasyonu diğer hastalar ile aynı şekilde yapıldı ve takiplerinde herhangi bir sorunla karşılaşılmadı. Ameliyat sırasında oluşan periprostetik kırık açısından iki grup arasında anlamlı bir fark bulunamadı.

(d)

Hastaların son kontrollerindeki radyolojik değerlendirmelerinde çimentolu protez uygulanan beş hastada femoral stem çevresinde çimento ile kemik korteks arasında 2 mm’den büyük radyolusen alan saptandı, bu hastaların tamamı ameliyat sonrası üçüncü yıl kontrollerinde idi. İki hastada ise asetabular erezyon mevcut idi. Bu hastaların klinik durumları ve ek sorunları nedeni ile hiçbir hastaya revizyon önerilmedi.

TARTIŞMA

Şekil 1. (a) Femur boyun kırığı nedeniyle posterior yaklaşım ile bipolar parsiyel protez uygulanan hastanın ameliyat sonrası görüntüsü, (b) ameliyat sonrası yedinci gün posterior çıkık oluştu, (c) genel anestezi altında denenen kapalı redüksiyon sonrası bipolar baş ile femoral baş birbirinden ayrıldı, (d) uygulanan açık redüksiyon sonrası görüntü.

458

Ortalama yaşam süresinin artmasına bağlı olarak ileri yaşta görülen femur boyun kırığı sıklığı giderek artmaktadır. Bu bölgenin kanlanma özelliğinden dolayı avasküler nekroz ve kaynamama oranları diğer bölge kırıklarından fazladır. İnternal tespit yapılan olgularda parsiyel protez yapılan olgulara oranla daha fazla komplikasyon görülmesine rağmen tedavi yöntemi ile ilgili tam bir fikir birliği sağlanamamıştır.[11] Parsiyel protez uygulanan hastalarda tekrar ameliyat gereksiniminin daha az olduğunu ve fonksiyonel soUlus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5


Zehir ve ark. Femur boyun kırıklarına parsiyel protez uygulaması

Tablo 2. Uygulanan kan transfüzyon mikatarı dağılımı

Kan transfüzyonu Yok

1 ünite

2 ünite

Toplam ≥3

n %

n %

n %

n %

n %

Lateral Posterior Toplam

35 38.2 45 34.2 80 35.7

11 11.9 12 9.1 23 10.3

21 22.8 48 36.3 69 30.8

25 27.1 27 20.4 52 23.2

92 100 132 100 224 100

nuçların daha iyi olduğunu bildiren çalışmalar mevcuttur.[2,12,13] Yaşlı hastalarda femur boyun kırığından sonra bipolar veya unipolar protez seçimi konusunda tartışmalar devem etmektedir. [14-16] Bipolar protezlerin daha iyi stabilite, daha erken ağırlık taşıma, daha fazla hareket açıklığı sağlaması ve ikincil ameliyatlara daha az ihtiyaç duyulması nedeni ile tercih edildiği görülmektedir.[2,15,17-19] Bunun yanında bipolar protezlerin yaşam beklentisi fazla olmayan yaşlı hastalarda unipolar protezlere fazla bir üstünlüğü olmadığı öne sürülmüştür.[14] Bhattacharyya ve arkadaşları[20] bipolar protezlerin eklem hareket aralığını genişlettiğini ve gerçek asetabulum üzerine binen yükü azalttığını bildirmişlerdir. Swiontkowski[16] yaşlı olsalarda aktif hastalarda bipolar protez kullanılması gerektiğini bildirmiştir. Çalışmamızda yer alan bütün hastalara bipolar parsiyel protez uygulanmıştır. Arpacıoğlu ve arkadaşları[21] posterior yaklaşım ile moduler düz stem parsiyel kalça protezi uyguladıkları çalışmalarında

(a)

Harris kalça değerlendirmesine göre %89.4 çok iyi ve iyi, %10.6 kötü sonuç elde edildiğini bildirmektedirler. Şen ve arkadaşları[22] posterior yaklaşım ile moduler düz saplı parsiyel protez uyguladıkları çalışmasında Harris kalça değerlendirmesine göre %80 çok iyi ve iyi %15 orta ve %5 yetersiz sonuç bildirmişlerdir. Inan ve arkadaşları[23] posterior yaklaşım ile çimentosuz bipolar hemiartroplasti uyguladıkları çalışmalarında ortalama Harris skorunu 79.4 puan olarak bildirmiş ve 70 yaş üzeri hasta grubunda kalça skorunun azaldığını bildirmişlerdir.Çalışmamızda bulunan 224 hastanın yaş ortalaması 78.1 idi ve hastalar Harris kalça skoruna göre değerlendirildiğinde 174 (%77.6) hastada çok iyi ve iyi 36 (%16.2) hastada orta ve 14 (%6.2) hastada yetersiz sonuç olarak bulundu. Ortalama Harris puanı grup 1’de 81.7±7.6 grup 2’de ise 79.2±6.9 olarak tespit edildi. Kalça protezi uygulanan hastlarda en ciddi ameliyat sonrası komplikasyon enfeksiyondur ve görülme sıklığı %1.7 ile %7.2 arasında bildirilmiştir.[24] Jalovaara ve arkadaşları[25] posterior yaklaşım uygulanan çalışmalarında %4 derin enfeksiyon bildir-

(b)

Şekil 2. (a) Femur boyun kırıklı hastanın görüntüsü, (b) hastaya uygulanan çimentosuz parsiyel protez ve uygulama sırasında oluşan fissür şeklindeki kırık tespiti için kullanılan kablonun görüntüsü.

Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5

459


Zehir ve ark. Femur boyun kırıklarına parsiyel protez uygulaması

mişlerdir. Solak ve arkadaşları[26] posterior yaklaşım uyguladıkları 40 olguluk çalışmalar��nda üç (%7.5) hastada enfeksiyon görüldüğünü bildirmişlerdir. Şen ve arkadaşları[22] posterior yaklaşım uyguladıkları 27 olguluk çalışmalarında bir (%3.7) olguda yüzeyel enfeksiyon geliştiğini bildirmişlerdir. Çalışmamızda beş (%2.2) olguda enfeksiyon görüldü iki (%0.9) olguda derin enfeksiyon üç (%1.3) olguda ise yüzeyel enfeksiyon mevcut idi. Kapsülün anteriordan açıldığı bir olguda enfeksiyon görülmüş iken kapsülün posteriordan açıldığı grupta dört olguda enfeksiyon görüldü. Şen ve arkadaşları[22] 6 (%22) hastada bası yarası geliştiğini ve bu olguların hiç birinde cerrahi girişime gerek duyulmadığını bildirmişlerdir. Çalışmamızda 7 (%3.1) hastada bası yarası oluşmuştu, 3 hasta anterior yaklaşım uygulanan grupta 4 hasta ise posterior yaklaşım uygulanan grupta idi. Bası yaralarının tamamı yara bakımı yöntemleri ile tedavi edildi. Cerrahi yaklaşımın bası yarası oluşmasına etkisinin olmadığını ve hastaların yaralanma sonrası erken dönemde tedavilerinin yapılıp yürütülmesinin en önemli önleyici faktör olduğunu düşünmekteyiz. Femur boyun kırıklarının parsiyel protez ile tedavisinde çeşitli cerrahi yaklaşımlar kullanılabilir. Çıkık riskinin implant tipine (unipolar veya bipolar), cerrahi yaklaşıma ve çimento kullanımına bağlı olabileceği bildirilmiş ve implant tipi, çimento kullanımı gibi risk faktörleri içerisinde cerrahi yaklaşımın en önemli risk grubunu oluşturduğu belirtilmiştir.[7] Posterior yaklaşım uygulanan hastalarda çıkık riskinin %8-9 olduğu bildirilmiştir.[8] Enocson ve arkadaşları[9] posterior yaklaşımın çıkık riskini artıran en önemli faktör olduğunu ve posterior tamir yapılmayan olgularda çıkık oranının %6.9, posterior tamir yapılan olgularda ise çıkık oranını %3.9 olarak bildirmişlerdir. Ayrıca yaş, cinsiyet, cerrahi tecrübe ve hemiartroplasti tipinin istatistiksel olarak çıkık oranını etkilemediğini bildirmişlerdir. Posterior tamir yapılsa bile çıkık riskinin anterior yaklaşımdan daha yüksek olduğu belirtilmiştir. Ancak bipolar kalça hemiartroplastisinin iki eklem oluşturması nedeni ile kaygan yüzeyi artırdığı ve dolayısıylada çıkık riskini azalttığı da rapor edilmiştir.[27] Jalovaara ve arkadaşları[25] posterior yaklaşım yapılan serisinde çıkık oranını %6.5 olarak bildirmişlerdir. Bush ve arkadaşları[28] posterior yaklaşım ve anterior yaklaşım yapılan olguları karşılaştırmış ve posterior yaklaşım yapılan olguların %4.5’inde çıkık olduğunu ve bu hastaların tamamının bunak olduğunu bildirmişlerdir. Anterior yaklaşım uygulanan olgularda çıkık bildirilmemiştir. Poulain ve arkadaşları[29] posterior yaklaşım tercih etmiş olduğu çalışmasında çıkık oranını %3.4 olarak bildirmişlerdir. Çalışmamızda hepsi ameliyat sonrası erken dönemde olmak üzere altı hastada posterior çıkık görüldü. Beş (%3.78) hasta posterior yaklaşım yapılan grupta ve 1 (%1.08) hasta ise anterior yaklaşım yapılan grupta idi. Yaş, cinsiyet ve çimento uygulamasının istatistiksel olarak çıkık oranını etkilemediği tespit edildi. Bütün olgulara bipolar kalça hemiartroplastisi uygulandığı için implant tipi ile ilgili değerlendirme yapılamamıştır. Çalışmaya alınan olgularda bunak hasta bulunmamasının çıkık oranının düşük çıkmasında etken olabileceği kanısındayız. 460

Parsiyel kalça protezi uygulaması sonrası çıkık görülen olgularda redüksiyon için mutlaka anestezi önerilmektedir. Açık redüksiyon yapılacaksa implantların değiştirilmesini ve farklı bir cerrahi yaklaşımın özelliklede anterolateral yaklaşımın tercih edilmesi önerilmektedir.[30] Açık redüksiyon yapılan olgularda posterior girişimin olumsuz etkisini azaltmak amacı ile posterior kapsül onarımıda önerilmektedir.[9] Başka bir çalışmada ise çıkık riskini azaltmak için bipolar implant ve anterolateral yaklaşım yapılması önerilmiştir.[7] Çalışmamızda çıkık oluşan bütün olgularda genel anestezi altında kapalı redüksiyon denenmiş üç olguda kapalı redüksiyon yapılmış, iki hastada kapalı redüksiyon sırasında bipolar baş ile femoral baş arasında ayrılma olması nedeni ile açık redüksiyon yapılmış ve femoral baş ile bipolar baş değiştirilmiştir. Bu olgularda cerrahi yaklaşım posteriordan yapıldığı için kapsül onarımı yapılmıştır. İlk girişimi anterior yaklaşımla yapılan bir olguda ise kapalı redüksiyon sonrası tekrar çıkık gelişmesi nedeni ile anterior yaklaşımla açık redüksiyon yapılmış mevcut implantlar değiştirilmiştir. Bütün hastalara fizyoterapist eşliğinde nasıl yürüyeceği, kalçasını doksan dereceden fazla fleksiyona getirmeksizin yaşamını nasıl devam ettirebileceği, ev ortamında basamaklar halı eğim gibi engellerin üstesinden nasıl gelebileceği ve düşmesine neden olabilecek faktörlerden nasıl sakınabileceği konusunda eğitim verildi. Parsiyel protez uygulanan hastalarda yapılan çalışmaların uzun dönem takip sonuçlarında, gevşeme ve asetabular erozyon yönünden yazarlar arasında görüş birliği yoktur.[14,15,31,32] Nakata ve arkadaşlarının[33] yaptıkları çalışmada bipolar protezler de %26 oranında osteolizis ve migrasyon görüldüğü bildirilmiştir. Jalovaara ve arkadaşlarının[25] 185 olguluk çalışmalarında iki (%1.08) asetabular protruzyon ve dört (%2.1) hastada protez gevşemesi bildirilmiştir. Solak ve arkadaşlarının[26] çalışmasında 5 (%12.5) hastada asetabular erozyon ve 6 (%15) hastada ise femoral stemde gevşeme bulguları görüldüğünü bildirilmiştir. Çalışmamızda iki (%0.9) hastada asetabular erezyon 5 (%2.3) hastada ise femoral stem çevresinde 2 mm’den büyük radyolusen alan tespit edildi. Bu hastaların hiç birine revizyon ameliyatı önerilmedi. Bu komplikasyonların cerrahi yaklaşım şeklinden çok hastanın aktivite düzeyi ile ilişkili olduğunu düşünmekteyiz. Ancak ortalama takip süremizin kısa olması bu konuda kesin bir yargı oluşmasına engel olmaktadır. İleri yaş grubundaki hastaların femur boyun kırıklarının tedavisinde bipolar parsiyel protezler; hastalara erken dönemede hareket yeteneği kazandırması, yatağa bağımlılığı azaltması, ikincil ameliyat oranlarının düşük olması ve protezde bulunan ikincil eklemin hareket aralığını genişletip asetabuluma binen yükü azaltması nedeni ile yaygın kullanım alanı bulmuştur. Kalça eklemine parsiyel protez uygulaması çeşitli cerrahi yaklaşımlar ile yapılabilir. Kalça eklemine parsiyel protez uygulamasında cerrahi yaklaşım fonksiyonel sonuçları etkilememektedir. Kalça eklem kapsülünün posterior ya da anteriordan açılmasının ameliyat sonrası erken ve geç komplikasyonlar üzerine istatistiksel olarak anlamlı bir etkisi bulunamamıştır. Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5


Zehir ve ark. Femur boyun kırıklarına parsiyel protez uygulaması

Ancak istatistiksel olarak anlamlı olmasa da posterior yaklaşım uygulanan hastalarda daha fazla çıkık ve enfeksiyon görülmektedir. Kalça eklemine protez uygulamasında kapsülün anterior açılımı çıkık ve enfeksiyon açısından daha güvenli olabilir. Daha yüksek sayıda hastanın bulunduğu çok merkezli ve uzun dönem takip sonuçlarının bulunduğu çalışmalara ihtiyaç olduğu kanaatindeyiz. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

KAYNAKLAR 1. Parker MJ, Pryor GA. Internal fixation or arthroplasty for displaced cervical hip fractures in the elderly: a randomised controlled trial of 208 patients. Acta Orthop Scand 2000;71:440-6. 2. Bray TJ, Smith-Hoefer E, Hooper A, Timmerman L. The displaced femoral neck fracture. Internal fixation versus bipolar endoprosthesis. Results of a prospective, randomized comparison. Clin Orthop Relat Res 1988;230:127-40. 3. Sikorski JM, Barrington R. Internal fixation versus hemiarthroplasty for the displaced subcapital fracture of the femur. A prospective randomised study. J Bone Joint Surg Br 1981;63:357-61. 4. Gjertsen JE, Vinje T, Engesaeter LB, Lie SA, Havelin LI, Furnes O, et al. Internal screw fixation compared with bipolar hemiarthroplasty for treatment of displaced femoral neck fractures in elderly patients. J Bone Joint Surg Am 2010;92:619-28. 5. Parker MJ, Blundell C. Choice of implant for internal fixation of femoral neck fractures. Meta-analysis of 25 randomised trials including 4,925 patients. Acta Orthop Scand 1998;69:138-43. 6. Partanen J, Saarenpää I, Heikkinen T, Wingstrand H, Thorngren KG, Jalovaara P. Functional outcome after displaced femoral neck fractures treated with osteosynthesis or hemiarthroplasty: a matched-pair study of 714 patients. Acta Orthop Scand 2002;73:496-501. 7. Varley J, Parker MJ. Stability of hip hemiarthroplasties. Int Orthop 2004;28:274-7. 8. Unwin AJ, Thomas M. Dislocation after hemiarthroplasty of the hip: a comparison of the dislocation rate after posterior and lateral approaches to the hip. Ann R Coll Surg Engl 1994;76:327-9. 9. Enocson A, Tidermark J, Tornkvist H, Lapidus LJ. Dislocation of hemiarthroplasty after femoral neck fracture: better outcome after the anterolateral approach in a prospective cohort study on 739 consecutive hips. Acta Orthop 2008;79:211-7.

15. Bochner RM, Pellicci PM, Lyden JP. Bipolar hemiarthroplasty for fracture of the femoral neck. Clinical review with special emphasis on prosthetic motion. J Bone Joint Surg Am 1988;70:1001-10. 16. Swiontkowski MF. Intracapsular hip fractures. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, editors. Skeletal trauma: fractures, dislocations and ligamentous injuries. Philedelphia: W.B. Saunders Company, 1992. p. 1369-442. 17. Davison J, Harper WM, Gregg PJ. Which treatment for displacement fractures of femoral neck? A prospective randomised camparison of three surgical procedures. J Bone Joint Surg 1997; Supp.II 79-B:243. 18. Nottage WM, McMaster WC. Comparison of bipolar implants with fixed-neck prostheses in femoral-neck fractures. Clin Orthop Relat Res 1990;251:38-43. 19. Wada M, Imura S, Baba H. Use of osteonics UHR hemiarthroplasty for fractures of the femoral neck. Clin Orthop Relat Res 1997;338:172-81. 20. Bhattacharyya T, Koval KJ. Unipolar versus bipolar hemiarthroplasty for femoral neck fractures: is there a difference? J Orthop Trauma 2009;23:426-7. 21. Arpacıoğlu MO, Kıral A, Rodop O, Kuşkucu M, Sarıoğlu A, Kaplan H. İleri yaş grubunda intrakapsüler femur boyun kırıklarının primer tedavisinde düz saplı(straight stem) parsiyel protez uygulaması. Acta Orthop Traumatol Turc 1997;31:26-30. 22. Şen C, Akman Ş, Boynuk B, Aşık M, Tözün R. Hemiarthroplasty wıth straıght stem endoprothesisi in over 70 years old patients who have femoral neck fractures. Ulus Travma Acil Cerrahi Derg 2000;6:160-5. 23. Inan U, Ozateş N, Omeroğlu H. Early clinical results of cementless, bipolar hemiarthroplasty in intracapsular femur neck fractures. Eklem Hastalik Cerrahisi 2011;22:2-7. 24. Cordero-Ampuero J, de Dios M. What are the risk factors for infection in hemiarthroplasties and total hip arthroplasties? Clin Orthop Relat Res 2010;468:3268-77. 25. Jalovaara P, Virkkunen H. Quality of life after primary hemiarthroplasty for femoral neck fracture. 6-year follow-up of 185 patients. Acta Orthop Scand 1991;62:208-17. 26. Solak Ş, Oğuz T, Bektaşer B, Adabağ C. Comparison of the two types of endoprosthesis in the treatment of intracapsular hip fractures in elderly patients. Joint Dis Rel Surg 2002;13:1-4. 27. Macaulay W, Pagnotto MR, Iorio R, Mont MA, Saleh KJ. Displaced femoral neck fractures in the elderly: hemiarthroplasty versus total hip arthroplasty. J Am Acad Orthop Surg 2006;14:287-93. 28. Bush JB, Wilson MR. Dislocation after hip hemiarthroplasty: anterior versus posterior capsular approach. Orthopedics 2007;30:138-44.

10. Crenshaw AH Jr. Surgical techniques and approaches. In: Canale ST, Beaty JH, editors. Campbell’s operative orthopaedics. Vol 1. 11th ed. Philadelphia: Mosby; 2003. p. 3-122.

29. Poulain S, Bauer T, Bégué T, Hardy P. Prospective study assessing quality-of-life after hemiarthroplasty for hip fracture. [Article in French] Rev Chir Orthop Reparatrice Appar Mot 2005;91:423-31. [Abstract]

11. Parker M, Johansen A. Hip fracture. BMJ 2006;333:27-30.

30. Loubignac F, Boissier F. Cup dissociation after reduction of a dislocated hip hemiarthroplasty. [Article in French] Rev Chir Orthop Reparatrice Appar Mot 1997;84:469-72. [Abstract]

12. Bhandari M, Devereaux PJ, Swiontkowski MF, Tornetta P 3rd, Obremskey W, Koval KJ, et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am 2003;85:1673-81. 13. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am 2006;88:249-60. 14. Calder SJ, Anderson GH, Jagger C, Harper WM, Gregg PJ. Unipolar or bipolar prosthesis for displaced intracapsular hip fracture in octogenarians: a randomised prospective study. J Bone Joint Surg Br 1996;78:391-4.

Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5

31. Gebhard JS, Amstutz HC, Zinar DM, Dorey FJ. A comparison of total hip arthroplasty and hemiarthroplasty for treatment of acute fracture of the femoral neck. Clin Orthop Relat Res. 1992;282:123-31. 32. Meyer S. Prosthetic replacement in hip fractures: a comparison between the Moore and Christiansen endoprostheses. Clin Orthop Relat Res 1981;160:57-62. 33. Nakata K, Ohzono K, Masuhara K, Matsui M, Hiroshima K, Ochi T. Acetabular osteolysis and migration in bipolar arthroplasty of the hip: five- to 13-year follow-up study. J Bone Joint Surg Br 1997;79:258-64.

461


Zehir ve ark. Femur boyun kırıklarına parsiyel protez uygulaması

ORIGINAL ARTICLE - ABSTRACT OLGU SUNUMU

Results of anterior and posterior capsular approaches in bipolar hemiarthroplasty patients with femoral neck fractures Sinan Zehir, M.D.,1 Ercan Şahin, M.D.,2 Serkan Sipahioğlu, M.D.3 İbrahim Azboy, M.D.,4 Ümit Yar, M.D.5 Department of Orthopaedics and Traumatology, Hitit University Faculty of Medicine, Çorum Department of Orthopaedics and Traumatology Clinic, Health Ministery Education and Investigation Hospital, Şanlıurfa Department of Orthopaedics and Traumatology, Harran University Faculty of Medicine, Şanlıurfa 4 Department of Orthopaedics and Traumatology, Dicle University Faculty of Medicine, Diyarbakır 5 Department of Orthopaedics and Traumatology, BSK Hospital, Konya 1 2 3

BACKGROUND: We evaluated the functional status and postoperative complications of bipolar hemiarthroplasty patients with femoral neck fractures, which we operated using anterior and posterior approaches. MEHTOHDS: Between November 2007 and February 2011, 224 patients were evaluated according to their surgical exposure type in two groups. The first group, which was approached anteriorly to the joint capsule, included 92 patients, and the second group, approached posteriorly, included 132 patients. The mean follow-up period for group 1 was 16.4 months and for group 2 was 18.9 months. RESULTS: Harris hip score of group 1 was 81.7 and of group 2 was 79.2. In group 1, 19 patients had very good, 52 patients good, 15 patients moderate, and 6 patients insufficient results. In group 2, 29 patients had very good, 74 patients good, 21 patients moderate, and 8 patients insufficient results. Although we had higher hip dislocation and infection rates in group 2, there were no statistical differences between the two groups. DISCUSSION: Surgical exposure type does not affect functional outcome in bipolar hip arthroplasty patients. Although statistically insignificant, we had higher hip dislocation and infection rates using the posterior approach in the selected femoral neck fracture patients. An anterior approach to the joint capsule appears to be more reliable. Key words: Femur neck; fracture; approach; hemiarthroplasty. Ulus Travma Acil Cerr Derg 2013;19(5):456-462

462

doi: 10.5505/tjtes.2013.74340

Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5


K Lİ NİK Ç A LI ŞM A

Türkiye’deki genel cerrahların penetran karın travmalarına yaklaşımı: Uygulama anketi Dr. Faruk Karateke,1 Dr. Sefa Özyazıcı,1 Dr. Koray Daş,1 Dr. Ebru Menekşe,1 Dr. Safa Önel,1 Dr. Mehmet Özdoğan,2 Dr. Mehmet Mahir Özmen,3 Dr. Fatih Ağalar,4 Dr. Cemalettin Ertekin5 Numune Eğitim Araştırma Hastanesi, Genel Cerrahi Kliniği, Adana Medline Hastanesi, Genel Cerrahi Kliniği, Adana 3 Hacettepe Üniversitesi Tıp Fakültesi, Genel Cerrahi ve Acil Tıp Anabilim Dalı, Ankara 4 Anadolu Sağlık Merkezi Hastanesi, Genel Cerrahi Kliniği, Kocaeli 5 İstanbul Üniversitesi, İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul 1 2

ÖZET AMAÇ: Penetran karın travmalı (PKT) hastalarda selektif non-operatif yönetim (SNOY) genel kabul gören yaklaşım haline gelmiştir. Bu çalışma ülkemizdeki genel cerrahların SNOY ile ilgili görüşlerini ve klinik uygulamadaki eğilimlerini belirlemek amacıyla yapıldı. GEREÇ VE YÖNTEM: Anket soruları cerrahlara online olarak sunuldu. Ankette katılımcıların demografik özellikleri, PKT’li hastaların yönetimi ve SNOY ile ilgili görüşleri ve klinik uygulamalardaki eğilimleri araştırıldı. Veriler Microsoft® Excel®’de kayıt edilerek analiz edildi. BULGULAR: Çalışmaya toplam 180 genel cerrahi uzmanı katıldı. Delici-kesici alete bağlı karın yaralanması (DKAY) olan hastalarda SNOY yaklaşımını klinik pratikte uygulayanların oranı %64 iken, bu oran ateşli silaha bağlı karın yaralanması (ASY) olan hastalarda %52 idi. Ancak cerrahların %90’dan fazlası hem DKAY’de, hem de ASY’de SNOY yaklaşımını uygulamadan önce ek görüntüleme ve ilave incelemelere gerek olduğunu savundu. SNOY yaklaşımını klinik pratiklerinde uygulamayan cerrahların büyük çoğunluğu ise hem hastanın yaşamını hem de kendilerini adli olarak riske etmek istemediklerini belirtti. SONUÇ: Ülkemizdeki genel cerrahların penetran karın travması olan hastaların yönetimindeki güncel yaklaşımlar hakkında olumlu görüş ve eğilimleri olmasına rağmen yaklaşık yarısının çeşitli sebeplerden dolayı pratikte yeteri kadar uygulamadıkları saptandı. Travma ve acil cerrahinin yan dal olarak kabul edilmesi ve travma merkezlerinin yapılandırılmasının bu eksiklikleri ortadan kaldıracağını düşünmekteyiz. Anahtar sözcükler: Anket, genel cerrah, penetran karın travması, selektif non-operatif yönetim.

GİRİŞ 1960’lı yıllara kadar tüm penetran karın travmalı (PKT) hastalara tanısal laparotomi (TL) yapılmakta iken ilk defa Shaftan delici-kesici alete bağlı karın yaralanmalarında sadece peritonit bulguları veya hemodinamik instabilite varlığında TL yapılmasını savunmuş ve “selektif konservatizm” kavramını travma literatürüne katmıştır.[1] Penetran karın travmalı hastaların yönetiminde temel hedefler; mortalite ve morbiditiyi en aza indirmek, negatif veya Sorumlu yazar: Dr. Faruk Karateke, Numune Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Adana Tel: +90 312 - 508 40 00 E-posta: karatekefaruk@hotmail.com Kare kod Ulus Travma Acil Cerr Derg 2013;19(5):463-468 doi: 10.5505/tjtes.2013.76281 Telif hakkı 2013 TJTES

Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5

non-terapötik laparotomiden kaçınmak ve maliyeti azaltmaktır.[2-4] Bu amaçlar doğrultusunda birçok travma merkezinde acil laparotomi endikasyonu olmayan delici-kesici alete bağlı karın yaralanmalarında (DKAY) ‘selektif non-operatif yönetim’ (SNOY) genel kabul gören yaklaşım haline gelmiştir.[5-10] Son yirmi yılda özellikle gelişmiş görüntüleme teknikleri sayesinde SNOY yaklaşımının ateşli silaha bağlı karın yaralanmalarında da (ASY) etkili ve güvenilir olduğu gösterilmiştir.[11-16] The Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee yayınladığı kılavuzda PKT’de hangi hastaların güvenle non-operatif olarak takip edilebileceğini belirtmiştir. Ancak non-operatif yönetim uygulanacak hastalarda gözden kaçan yaralanma veya tanıda gecikme riskinin dikkate alınması ve bu yüzden non-operatif yönetim uygulanacak hastaların seçimine özen gösterilmesi ve görüntüleme teknikleri rehberliğinde yakın klinik takip önermektedir.[17] SNOY ile ilgili çalışmalara daha çok batı literatüründe rastlanmaktadır ve ülkemizde bu konuyla ilgili yeterli çalışma yoktur. 463


Karateke ve ark. Türkiye’deki genel cerrahların penetran karın travmalarına yaklaşımı

Bu anket çalışması ülkemizdeki genel cerrahların PKT’li hastalara yaklaşımı, SNOY ile ilgili görüşleri ve klinik uygulamadaki eğilimlerini belirlemek amacıyla yapıldı.

GEREÇ VE YÖNTEM Bu anket çalışmasında Türkiye’de kamuda ve özel sektörde görev yapan genel cerrahi uzmanları hedef kitle olarak seçildi. Çalışma için oluşturulan anket soruları ve dizaynı Ulusal Travma ve Acil Cerrahi Derneği’nin (UTD) katkılarıyla Adana Numune Eğitim ve Araştırma Hastanesi Genel Cerrahi Kliniği tarafından hazırlandı ve UTD ile Türk Cerrahi Derneği (TCD) yönetim kurulunca onaylandı. https://docs.google.com/ web adresinde hazırlanan anket linki UTD’ye ve derneğin travma e-posta grubuna üye olan genel cerrahi uzmanlarına elektronik posta olarak gönderildi. Ayrıca anket UTD ile TCD web sitelerinde Ocak 2013-Şubat-2013 tarihleri arasında ilan edilerek katılımcılara online olarak sunuldu. Yirmi altı sorudan oluşan ankette cerrahların demografik özellikleri, penetran karın travmalarına yaklaşımı, SNOY ile ilgili görüşleri soruldu. Katılımcıların SNOY yaklaşımını klinik pratikte hangi durumlarda uyguladığı, eğer uygulamıyorsa nedenleri irdelendi. Katılıcımların cevapları Microsoft® Excel®’de kayıt altına alındı, gruplandı ve analiz edildi.

BULGULAR

Tablo 1. Cerrahların demografik özellikleri Yaş aralığı (yıl)

Katılımcıların yaklaşık %75’i‚ penetran karın travmalarında ‘Selektif non-operatif yönetime doğru bir eğilim vardır’ fikrine katıldığını bildirdi (Şekil 1). Selektif non-operatif yönetimin

6

DKAY’de etkili ve güvenilir bir yaklaşım olduğunu düşünenlerin oranı %62 iken, ASY’de bu oran %22 idi (Şekil 2). Ancak cerrahların %90’dan fazlası kendilerini daha rahat ve güvende hissetmek için hem DKAY’de, hem de ASY’de SNOY yaklaşımını uygulamadan önce ek görüntüleme ve ilave incelemelere gerek olduğunu savundu (Şekil 3). Cerrahların %90’dan fazlası ASY’de peritonit ve hemodinamik instabilite bulguları,

100

90

90

DKAY ASY

80

n=133

70

70

60

60

50

50

%

%

11

PKT: Penetran karın travması.

100

40

n=112

n=106

40

30

30

20

n=18

10 0

%

<30 2 1 30-39 73 41 40-49 72 40 50-59 31 17 60-69 2 1 Çalışmakta olduğu kurum Üniversite hastanesi 46 26 Eğitim-araştırma hastanesi 55 30 Devlet hastanesi 58 32 Özel hastane 21 12 Uzmanlık süresi (yıl) <5 57 32 5-9 27 15 10-19 63 35 20-29 27 15 >29 6 3 Bireysel çalışanlar 76 42 Ekip olarak çalışanlar 104 58 Bir yılda karşılaşılan PKT’lı hasta sayısı <10 61 34 10-25 arası 66 37 26-50 arası 31 17 51-75 arası 11 6 75+

Çalışmaya 168’i erkek, 12’si kadın olmak üzere toplam 180 genel cerrahi uzmanı katıldı. Katılımcıların demografik özellikleri Tablo 1’de gösterildi. Katılımcıların %64’ü çalıştıkları kurumun acil servisinde hem ultrasonografi (USG) hem bilgisayarlı tomografi (BT), %26’sı sadece BT, %3’ü sadece USG imkanı olduğunu, %7’si ise her ikisinin de olmadığını bildirdi.

80

n

Katılıyorum/Kesinlikle katılıyorum

Kararsızım

n=29

n=41

20

n=27

n=33

n=41

10 Katılmıyorum/Kesinlikle katılmıyorum

0

Katılıyorum/Kesinlikle katılıyorum

Kararsızım

Katılmıyorum/Kesinlikle katılmıyorum

Şekil 1. Penetran karın travmalarına yaklaşımda selektif non-operatif yöne-

Şekil 2. SNOY delici-kesici alete bağlı karın yaralanmalarında (DKAY) / ateş-

time doğru bir eğilim vardır.

li silaha bağlı karın yaralanmalarında (ASY) etkili ve güvenilir bir yaklaşımdır.

464

Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5


Karateke ve ark. Türkiye’deki genel cerrahların penetran karın travmalarına yaklaşımı

90 80

70

70

60

60

50

50

%

80

40

40

30

30

20

20 10

n=4

0

Katılmıyorum/Kesinlikle katılmıyorum

DKAY’de ise yaklaşık %70’i N/G sondada kan olması veya rektal tuşede kan olması varlığında SNOY yaklaşımın kontrendike olduğunu ifade etti (Tablo 2). Cerrahların PKT’li hastalarda yaralanmanın peritona nafiz olup olmadığını araştırırken dijital muayene, lokal yara yeri eksplorasyonu ve görüntüleme yöntemlerini kombine olarak kullanmayı tercih ettikleri tespit edildi. Cerrahların %4’ü ise peritona nafiz olup olmadığını araştırmayıp direkt nafiz olarak kabul ettiğini belirtti (Şekil 4). Cerrahların yaklaşık %50’si hemodinamisi stabil olan PKT’li hastalarda BT incelemede peritona veya retroperitona ulaşan yaralanma saptanırsa, buna karşın solid organ yaralanmasına ait bulgu yok ise non-operatif yaklaşımı tercih ettiğini belirtti. Arteryel kontrast kaçağının olduğu solid organ yaralanmalarında non-operatif yaklaşımı tercih edenlerin oranı ise yaklaşık %10 idi (Tablo 3). Delici-kesici alete bağlı karın yaralanması olan hastalarda net acil laparotomi endikasyonunun olmadığı durumlarda SNOY yaklaşımını klinik pratikte uygulayanların oranı %64 iken, bu oran ASY’si olan hastalarda %52 idi. Cerrahların yaklaşık üçte biri sol torakoabdominal yaralanması olan hastalarda acil laparotomi veya torakotomi endikasyonu yok ise, diyafragmayı değerlendirmek amacıyla rutin laparaskopi yaptığını bildirdi (Tablo 3). SNOY yaklaşımı klinik pratiklerinde uygulamayanlara neden uygulamadıkları sorulduğunda cerrahların büyük çoğunluğu hem hastanın yaşamını hem de kendilerini adli olarak riske etmek istemediklerini belirtti (Şekil 5). Ancak SNOY yaklaşımı uygulamayanların %34’ü ‘büyük bir merkezde ekip olarak çalışsa ve yeterli imkanları olsa’ SNOY yaklaşımını klinik pratiklerinde uygulayabileceğini belirtti.

TARTIŞMA Günümüzde pek çok cerrah penetran karın travmalı hastalarda çeşitli nedenlerden dolayı halen rutin laparotomi yapma eğilimindedir. Ancak yoğun travma merkezlerinden yapılan yaUlus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5

Lokal yara eksplorasyonu ile

Görüntüleme yöntemleri ile

Direkt nafiz kabul ediyorum

Şekil 4. Penetran karın travmalı hastalarda peritona nafiz olup olmadığını nasıl araştırıyorsunuz?

100

DKAY ASY

90 80 70 60 50 40 30 20 10 0

r

Şekil 3. DKAY/ASY’da SNOY yaklaşımını uygulamadan önce ek görüntüleme ve ek incelemelere gerek olduğunu düşünüyorum.

Dijital muayene ile

as

Kararsızım

n=9

H

Katılıyorum/Kesinlikle katılıyorum

n=2

ey im yo im k

n=3

en

0

%

10

D

%

100

ASY

90

iğe

DKAY

n=174

D

n=168

ta nı ris n ya ist ke şa em e m iyo tm ını ru ek m ol ar K ak e r n ist iske dim em e i a iyo tm dli ru ek SN m O Y in yak an la m şım ıyo ı ru na m

100

Şekil 5. Penetran karın travmalı hastalarda SNOY yaklaşımını klinik pratikte neden uygulamıyor sunuz? (Diğer: Görüntüleme yöntemlerim yetersiz, Bireysel çalışıyorum vs.). DKAY: Delici-kesici alete bağlı karın yaralanmaları; ASY: Ateşli silaha bağlı karın yaralanmaları.

yınlarda DKAY’si olan hastalarda negatif ve non-terapötik laparotomi oranlarının %50’lere kadar ulaştığı ve buna bağlı olarak önemli ölçüde ameliyat sonrası komplikasyonların (%15) görüldüğü bildirilmektedir.[2,8,18] Büyük serilerde anterior delici-kesici alet yaralanması olan hastaların %50-70 oranında terapötik cerrahi girişime gerek kalmadan takip edilebildiği ve başlangıçta konservatif takip kararı alınan hastalarda gecikmiş cerrahi gereksiniminin %10-15’lerde kaldığı ortaya konulmuştur.[17-19] Posterior yaralanması olan hastaların %80’den fazlasının konservatif olarak tedavi edilebildiği ve gözden kaçmış yaralanma nedeniyle gecikmiş cerrrahi tedavi ihtiyacının ise %2-3 gibi çok düşük oranlarda olduğu bildirilmiştir.[18] Bu bilgiler ışığında özellikle DKAY’si olan hastalarda SNOY yaklaşımı son dönemlerde yaygın olarak uygulanmaktadır.[4,7,8,10] Son yirmi yılda görüntüleme teknolojisindeki gelişmelere ve daha kolay erişilebilirliğe bağlı olarak SNOY ateşli silaha bağlı 465


Karateke ve ark. Türkiye’deki genel cerrahların penetran karın travmalarına yaklaşımı

Tablo 2. DKAY/ASY’da non-operatif yaklaşımın kontrendike olduğu durumlar size göre hangileridir?

DKAY ASY

n % n %

Peritonit Hemodinamik instabilite veya şok bulguları (herhangi bir anda) Hemodinamik instabilite (resüsitasyon sonrası) Değerlendirilemeyen hasta (bilinç bozukluğu vs) Omental evisserasyon İntestinal evisserasyon N/G sondadan kan gelmesi

103 57 84 47 104 58 79 44 39 22 61 34 119 66

162 92 140 79 160 90 140 79 104 59 125 71 141 80

Rektal tuşede ve ya rektoskopide kan olması

115

133

64

75

DKAY: Delici-kesici alete bağlı karın yaralanmaları; ASY: Ateşli silaha bağlı karın yaralanmaları.

Tablo 3. Cerrahların PKT’lerinin yönetiminde klinik uygulamaları

DKAY ASY

Hemodinamisi stabil olan PKT’lı hastalarda tomografide aşağıdaki bulguların hangilerinin varlığında non-operatif yaklaşımı uygularsınız?

n

%

n

%

Peritona veya retroperitona nafiz olmaması

110

62

147

87

Peritona veya retroperitona nafiz, ancak solid organ yaralanması yok

85

48

83

49

Peritona veya retroperitona nafiz, ancak arteryel kontrast kaçağının olmadığı KC veya böbrek yaralanması

79

45

80

47

Peritona veya retroperitona nafiz, ancak arteryel kontrast kaçağının olmadığı dalak yaralanması

79

44

68

41

Peritona veya retroperitona nafiz, arteryel kontrast kaçağının olduğu K.C veya böbrek yaralanması

15

9

15

9

Peritona veya retroperitona nafiz, arteryel kontrast kaçağının olduğu dalak yaralanması

11

6

11

7

Tanjensiyel yaralanmalar

66

39

Acil laparotomi endikasyonu olmayan PKT’de SNOY metodunu uyguluyor musunuz?

Evet

115 64 94 52

Sol torakoabdominal yaralanması olan hastalarda acil laparotomi veya torakotomi endikasyonu yok ise, diyafragmayı değerlendirmek amacıyla rutin laparoskopi yapıyormusunuz?

Evet

60 33 56 31

PKT: Penetran karın travmalı; DKAY: Delici-kesici alete bağlı karın yaralanmaları; ASY: Ateşli silaha bağlı karın yaralanmaları; SNOY: Selektif non-operatif yönetim.

karın yaralanmalarında da güvenli ve etkili bir şekilde kullanılmaya başlamıştır.[11-16] Ancak bununla ilgili veriler kısıtlıdır ve sadece Amerika ve Güney Afrika’daki birkaç merkezden bildirilmiştir. Ateşli silaha bağlı anterior yaralanmaların 1/3’ü, posterior yaralanmaların ise 2/3’ünün cerrahi girişime gerek olmadan konservatif olarak takip edilebilir olduğu ve %47 oranda ciddi klinik yaralanma olmadığı gösterilmiştir.[13,18] Yakın zamanda Jansen ve arkadaşları tarafından batı ülkelerindeki genel cerrahların ve travma cerrahlarının penetran karın travmalarında non-operatif yönetim ile ilgili görüşlerini 466

ve pratikteki uygulamalarını araştıran iki farklı anket çalışması yayınlandı.[10,16] Biz de bu anket çalışmasını ülkemizdeki genel cerrahların bu konuyla ilgili eğilimlerini ve klinik uygulamalarını değerlendirmek amacıyla planladık. Jansen ve arkadaşlarının yaptığı çalışmalarda travma cerrahlarının genel cerrahlara kıyasla daha fazla oranda hem DKAY’si hem de ASY’si olan hastaların yönetiminde non-operatif yaklaşımı etkili ve güvenilir bulduğu ve klinik pratiklerinde uyguladığı saptandı. Travma cerrahlarının yaklaşık %15’i DKAY’de, %40’ı ise ASY’de kendilerini rahat ve güvende hissetmek için ek inceleme veya görüntüleme tekniklerine ihtiyaç duyduklarını belirttiler.[10,16] Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5


Karateke ve ark. Türkiye’deki genel cerrahların penetran karın travmalarına yaklaşımı

Ülkemizdeki cerrahların ise genel olarak DKAY’si olan hastaların non-operatif yönetimi ile ilgili olumlu görüş ve eğilimleri olmasına rağmen, büyük çoğunluğunun ASY’si olan hastalarda non-operatif yönetimin güvenilir olmadığı yönünde görüş bildirdiği saptandı. Ek inceleme veya görüntüleme tekniklere gerek olduğunu düşünenlerin oranı ise yaklaşık %90 idi. Mevcut literatüre göre PKT’li hastalarda peritonit veya hemodinamik instabilite bulgularının varlığı kesin laparotomi endikasyonudur.[18-20] PKT’de omental veya intestinal evisserasyon varlığında acil laparotomi tartışmalıdır ve çoğu travma merkezinde rölatif laparotomi endikasyonu olarak kabul edilmektedir.[18,20] Jansen ve arkadaşlarının çalışmalarında travma cerrahlarının tamamına yakını peritonit ve hemodinamik instabilite, omental veya intestinal evisserasyon varlığında laparotomi yapılması gerektiğini belirtmiştir. Ancak anketimize katılan cerrahların yaklaşık yarısı DKAY’si olan hastalarda peritonit veya hemodinamik instabilite bulgularını acil laparotomi endikasyonu olarak değerlendirmediklerini, büyük çoğunluğu ise DKAY’si olan hastalarda omental veya intestinal evisserasyon varlığında non-operatif takip uygulayabileceğini belirtmiştir. Kuzey Amerika’daki Level 1 travma merkezlerinden bildirilen büyük çalışmalarda PKT’sine bağlı izole solid organ yaralanması olan hastaların hemodinamisi stabil ise özellikle BT gibi ileri görüntüleme teknikleri sayesinde güvenli bir şekilde konservatif olarak takip ve tedavi edilebildiği bildirilmektedir. [10-16] Jansen ve arkadaşlarının çalışmalarında travma cerrahlarının önemli bir kısmının PKT’sine bağlı izole solid organ yaralanması olan hastalarda non-operatif yönetimi tercih ettiği görüldü. Ancak anketimizdeki katılımcıların tamamına yakını hemodinamisi stabil olan PKT’li hastalarda arteryel kontrast kaçağının olduğu solid organ yaralanmalarında konservatif tedaviyi tercih etmediği saptandı. Özellikle sol torakoabdominal yaralanması olan hastalarda acil laparotomi veya torakotomi endikasyonu yok ise diyafram yaralanmalarının gözden kaçmasını önlemek ve buna bağlı ileriki dönemlerde oluşabilecek komplikasyonları engellemek amacıyla rutin laparoskopi yapılması önerilmektedir.[10,16,18,20-22] Bizim çalışmamıza katılan cerrahların ise sadece üçte biri diyaframı değerlendirmek amacıyla rutin laparoskopi yaptığını belirtmiştir. Buna karşılık travma cerrahlarının yaklaşık %80’i bu hasta grubunda rutin laparoskopi yapmaktadırlar.[10] Genel olarak ülkemizdeki genel cerrahların travma cerrahlarına benzer şekilde PKT’de non-operatif yönetim ile ilgili olumlu görüşleri ve eğilimleri olmasına rağmen, çeşitli sebeplerle klinik pratiklerinde yeterince uygulamadığı saptandı. Bu sebepler arasında en fazla göze çarpanlar deneyim eksikliği, bireysel çalışma ve adli riskler idi. Bir diğer önemli nokta ise, ülkemizdeki cerrahların PKT’si olan hastaların hangi durumlarda konservatif olarak takip edilebileceği konusunda yeterli bilgi düzeylerine sahip olmamasıydı. Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5

Amerika’da travma cerrahisi bir yan daldır ve bu hastaların yönetimi genel cerrahlardan ziyade travma cerrahları tarafından ve merkezileştirilmiş travma merkezlerinde yapılmaktadır. Ülkemizde ise travma hastalarının yönetimi Avrupa ülkerindekine benzer şekilde genel cerrahların sorumluluğundadır ve özelleşmiş travma merkezleri yoktur. Bu nedenle genel cerrahların travmalı hastaların yönetimindeki eğilim ve klinik uygulamaları travma cerrahlarına göre farklılık göstermektedir. Ülkemizde travma ve acil cerrahinin bir üst ihtisas dalı ya da yan dal olarak kabul edilmesi ve travma bakımının merkezileştirilmesi için travma merkezlerinin kurulmasının travma hastalarına verilen sağlık hizmetinin kalitesini artıracağını düşünmekteyiz. Bu anket çalışmasının bazı kısıtlılıkları vardır. Genel olarak tüm anket çalışmalarında olduğu gibi bu çalışmada da katılımcı sayısı azdır. Katılımın az sayıda olmasının nedenleri arasında soru saysının fazla olması, travma cerrahisine olan ilginin yeterli olmaması vs. gibi sebepler sayılabilir. Buna karşın, bu anketin ülkemizdeki genel cerrahların travma hastasına yaklaşımları konusunda oldukça önemli fikir verdiğini düşünüyoruz. Sonuç olarak, bu çalışmada ülkemizdeki genel cerrahların penetran karın travması olan hastaların yönetimindeki modern yaklaşımlar hakkında bilgi sahibi ve bu yaklaşımları uygulama konusunda istekli olduğu, ancak çeşitli nedenlerle uygulama eksiklikleri bulunduğu saptanmıştır. Travma ve acil cerrahinin yan dal olarak kabul edilmesi ve travma merkezlerinin yapılandırılmasının bu eksiklikleri ortadan kaldırabileceğini düşünüyoruz. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

KAYNAKLAR 1. Shaftan GW. Indications for operation in abdominal trauma. Am J Surg 1960;99:657-64. 2. Demetriades D, Vandenbossche P, Ritz M, Goodmann D, Kowalszik J. Non-therapeutic operations for penetrating trauma: early morbidity and mortality. Br J Surg 1993;80:860-1. 3. Leppäniemi A, Salo J, Haapiainen R. Complications of negative laparotomy for truncal stab wounds. J Trauma 1995;38:54-8. 4. Taviloglu K, Günay K, Ertekin C, Calis A, Türel O. Abdominal stab wounds: the role of selective management. Eur J Surg 1998;164:17-21. 5. Plackett TP, Fleurat J, Putty B, Demetriades D, Plurad D. Selective nonoperative management of anterior abdominal stab wounds: 1992-2008. J Trauma 2011;70:408-14. 6. Demetriades D, Rabinowitz B. Indications for operation in abdominal stab wounds. A prospective study of 651 patients. Ann Surg 1987;205:129-32. 7. Leppäniemi AK, Haapiainen RK. Selective nonoperative management of abdominal stab wounds: prospective, randomized study. World J Surg 1996;20:1101-6. 8. Ertekin C, Yanar H, Taviloglu K, Güloglu R, Alimoglu O. Unnecessary laparotomy by using physical examination and different diagnostic modalities for penetrating abdominal stab wounds. Emerg Med J 2005;22:790-4. 9. McAlvanah MJ, Shaftan GW. Selective conservatism in penetrating abdominal wounds: a continuing reappraisal. J Trauma 1978;18:206-12.

467


Karateke ve ark. Türkiye’deki genel cerrahların penetran karın travmalarına yaklaşımı 10. Jansen JO, Inaba K, Rizoli SB, Boffard KD, Demetriades D. Selective non-operative management of penetrating abdominal injury in Great Britain and Ireland: survey of practice. Injury 2012;43:1799-804. 11. Demetriades D, Velmahos G, Cornwell E 3rd, Berne TV, Cober S, Bhasin PS, et al. Selective nonoperative management of gunshot wounds of the anterior abdomen. Arch Surg 1997;132:178-83. 12. Velmahos GC, Demetriades D, Cornwell EE 3rd, Belzberg H, Murray J, Asensio J, et al. Selective management of renal gunshot wounds. Br J Surg 1998;85:1121-4. 13. Velmahos GC, Demetriades D, Toutouzas KG, Sarkisyan G, Chan LS, Ishak R, et al. Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care? Ann Surg 2001;234:395-403. 14. Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P, et al. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg 2006;244:620-8. 15. Inaba K, Barmparas G, Foster A, Talving P, David JS, Green D, et al. Selective nonoperative management of torso gunshot wounds: when is it safe to discharge? J Trauma 2010;68:1301-4. 16. Jansen JO, Inaba K, Resnick S, Fraga GP, Starling SV, Rizoli SB, et al. Se-

lective non-operative management of abdominal gunshot wounds: survey of practise. Injury 2013;44:639-44. 17. Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR, Tandoh MA, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma 2010;68:721-33. 18. Özdoğan M. Karın travmaları. İçinde: Sayek İ, editör. Temel cerrahi. 4. Baskı, Güneş Tıp Kitapevleri; s. 489-506. 19. Butt MU, Zacharias N, Velmahos GC. Penetrating abdominal injuries: management controversies. Scand J Trauma Resusc Emerg Med 2009;17:19. 20. Demetriades D, Velmahos GC. Indications for and techniques of laparotomy. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008. p. 607-21. 21. Ertekin C, Onaran Y, Güloğlu R, Günay K, Taviloğlu K. The use of laparoscopy as a primary diagnostic and therapeutic method in penetrating wounds of lower thoracal region. Surg Laparosc Endosc 1998;8:26-9. 22. Karateke F, Özdoğan M, Özyazici S, Daş K, Menekşe E, Gülnerman YC, et al. The management of penetrating abdominal trauma by diagnostic laparoscopy: a prospective non-randomized study. Ulus Travma Acil Cerrahi Derg 2013;19:53-7.

ORIGINAL ARTICLE - ABSTRACT OLGU SUNUMU

General approach to penetrating abdominal traumas of Turkish general surgeons: survey of practice Faruk Karateke, M.D.,1 Sefa Özyazıcı, M.D.,1 Koray Daş, M.D.,1 Ebru Menekşe, M.D.,1 Safa Önel, M.D.,1 Mehmet Özdoğan, M.D.,2 Mehmet Mahir Özmen, M.D.,3 Fatih Ağalar, M.D.,4 Cemalettin Ertekin, M.D.5 Department of Surgery, Numune Training and Research Hospital, Adana; Department of General Surgery, Medline Hospital, Adana; Department of Emergency and Surgey, Hacettepe University Faculty of Medicine, Ankara; 4 Department of General Surgery, Anadolu Sağlık Merkezi Hospital, Kocaeli; 5 Department of Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul 1 2 3

BACKGROUND: In patients with penetrating abdominal traumas (PATs), selective non-operative management (SNOM) has been widely accepted. This study was designed to investigate the practice trends among Turkish surgeons regarding SNOM. MEHTOHDS: The study was conducted as an online survey. Participants’ demographic characteristics and their management trends and opinions regarding patients with PATs and SNOM were studied. Data were recorded using MS Excel® and analyzed. RESULTS: A total of 180 surgeons participated in the survey. SNOM approach rate in patients with stab injuries (SI) was 64%, whereas in patients with gunshot injuries (GSI), this rate was 52%. However, more than 90% of the surgeons declared that additional diagnostic studies were required before selecting SNOM approach in both SI and GSI. In addition, most of the surgeons who did not use SNOM in practice reported that they did not want to risk the patients’ lives or their careers. DISCUSSION: Although our surgeons have constructive opinions and tendencies regarding contemporary approaches in the management of PATs, it is seen that nearly half of them prefer not to perform SNOM in practice for various reasons. We believe that approval of trauma and emergency surgery disciplines as subspecialties and funding- centralized trauma centers might correct this deficiency. Key words: Survey, general surgeon, penetrating abdominal trauma, selective non-operative management. Ulus Travma Acil Cerr Derg 2013;19(5):463-468

468

doi: 10.5505/tjtes.2013.76281

Ulus Travma Acil Cerr Derg, Eylül 2013, Cilt. 19, Sayı. 5


CAS E R EP O RT

Emergency abdominal surgery in a patient anticoagulated with dabigatran Jonas Paul DeMuro, M.D. Department of Surgery, Division of Trauma & Critical Care, Winthrop University Hospital, Mineola, New York, USA

ABSTRACT Dabigatran is a newer oral anticoagulant, indicated for chronic atrial fibrillation anticoagulation. Experience with an emergent laparotomy in a patient on dabigatran is presented. Difficulties of this medication and strategies to deal with the coagulopathy from this direct thrombin inhibitor are described. Key words: Coagulopathy, dabigatran, direct thrombin inhibitor, perioperative bleeding, reversal of coagulopathy.

INTRODUCTION Dabigatran (Pradaxa, Boehringer Ingelheim Pharma) is a direct thrombin inhibitor. It is a potent anticoagulant that is prescribed for chronic atrial fibrillation.[1] Over a million prescriptions were written in the first 10 months of its approval,[2] with the benefit of no monitoring of blood work. Ideally, dabigatran should be stopped several days in advance of any invasive procedures; however, when emergency surgery is indicated, this presents a severe challenge. The experience with such a case is related herein, and is believed to be the first published case of emergency abdominal surgery in a patient on dabigatran.

CASE REPORT A 69-year-old female presented to the Emergency Department with a one-day history of nausea, vomiting, and obstipation. Her medical history was significant for morbid obesity (165 kg), hypertension, atrial fibrillation, hypothyroidism, and oxalate nephropathy. The surgical history included a jejunoileal bypass almost 40 years prior, with a subsequent revision one year later, and an incisional hernia repair 30 years prior. Her medications on admission included calcium, levothyrox-

Address for correspondence: Jonas Paul DeMuro, M.D. 259 First Street 11501 Mineola, United States Tel: +90 5166638700 E-mail: jdemuro@winthrop.org Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):469-471 doi: 10.5505/tjtes.2013.59908 Copyright 2013 TJTES

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

ine, losartan, and dabigatran 75 mg orally two times daily (adjusted for decreased renal function). On admission, her vital signs were normal and she was afebrile. The physical exam was significant for a moderately distended abdomen with tenderness in the left upper quadrant, but no peritoneal signs. Her admission white blood cell count was 16.2 K/ÎźL, with a hematocrit of 42.3% and a platelet count of 271 K/ÎźL. Admission chemistries showed bicarb 10, blood urea nitrogen 33 mg/dl, creatinine 1.6 mg/dl, and glucose 218 mg/dl, with an anion gap of 20. The coagulation profile showed a prothrombin time of 14.2 seconds, international normalized ratio of 1.29, and a partial thromboplastin time of 44.9 seconds. An arterial blood gas had a pH of 7.21 and a base excess of -11.6. The EKG showed atrial fibrillation at a heart rate of 87 beats per minute. Due to the clinical obstruction and the chronic creatinine elevation, a noncontrast computerized tomography (CT) was performed. The study showed a complete small bowel obstruction with pneumatosis and extraluminal air (Fig. 1a). The maximal diameter of the small bowel was 10.5 cm. After emergency consultation with a hematologist, despite the normal coagulation profile, 2 units of fresh frozen plasma were quickly transfused in preparation for the exploratory laparotomy, following published recommendations.[3] In the operating room, the abdomen was entered via a midline incision, and on exploration, a volvulus of the small bowel was found with pneumatosis of the wall (Fig. 1b). The previously bypassed small and large bowel had twisted around each other, requiring resection of both due to vascular compromise. The resections were done with a vascular loaded stapler for the bowel, and the mesentery of the bowel was divided using the LigaSure device (Covidien). 469


DeMuro. Emergency abdominal surgery in a patient anticoagulated with dabigatran (a)

(b)

Figure 1. (a) Noncontrast CT of the abdomen and pelvis revealed a small bowel obstruction secondary to a small bowel volvulus. Note the pneumatosis in the bowel lumen (three white triangles) and the small amount of extraluminal air present (single white arrow). (b) Intraoperative image shows the significantly dilated small bowel with pneumatosis.

Despite these efforts, the hemostasis of the mesentery was inadequate, and did not respond to conventional measures, including electrocautery, additional LigaSure applications, suture ligation, and clips. With active external rewarming, the patient remained normothermic throughout the procedure, although the acidosis worsened with an intraoperative pH that dropped to 7.14. The bleeding was not arterial, but diffuse, coagulopathic, and increasing, when the decision was made to apply damage control techniques, foregoing any attempt at an anastomosis. A temporary abdominal closure device (AbVAC) was utilized. The total estimated blood loss for the procedure was 1200 cc. In the Surgical Intensive Care Unit, the platelets and coagulation profile remained normal, but the drainage from the abdomen was 500 to 600 cc every 12 hours. This continued over the next 72 hours, and the patient was reexplored in the operating room, and another 600 cc of blood was lost from coagulopathic bleeding with no other interventions other than for hemostasis. When the patient was brought back on postoperative day 5 from the original surgery, she was finally no longer coagulopathic.

DISCUSSION Dabigatran, a direct thrombin inhibitor, is a potent anticoagulant. Standard blood coagulation studies reassure rather than reveal how coagulopathic a patient is on this medication, and they should not be used to determine the anticoagulation effects of any direct thrombin inhibitor.[4] Dabigatran can be monitored with an ecarin clotting time (ECT),[5] but this is not readily available in most institutions. The long 14-17-hour half-life of dabigatran[6] contributes to a prolonged potential for bleeding when emergent surgery is needed. 470

There is limited experience with reversal of dabigatran coagulopathy. As the majority of dabigatran is not bound to plasma proteins, acute hemodialysis can be used in severe cases to reverse coagulopathy.[7] Prothrombin complex concentrate (PCC), used in an experimental model of healthy volunteers, did not reverse the effects of dabigatran.[8] In the case presented above, the author does not believe the fresh frozen plasma that was administered had any clinical effect on the coagulopathy of the patient. There is preliminary data that recombinant factor VIIa may partially reverse another direct thrombin inhibitor.[9] Finally, there is one isolated report of a multifactorial approach with hemodialysis, fresh frozen plasma and recombinant factor VIIa used successfully to reverse another direct thrombin inhibitor (bivalrudin) after cardiac surgery.[10] Ideally, surgery should be delayed for several days in the setting of a patient on dabigatran. This case illustrates the hazards of an operation in a patient on this medication, and based on the authorâ&#x20AC;&#x2122;s literature search, it is the first reported case of an emergent laparotomy in a patient on dabigatran. In general, only the most emergent cases in patients on dabigatran should be undertaken, realizing the high risk of operating on such a severely coagulopathic patient. Reversal of the dabigatran will be incomplete at best in the immediate perioperative period, and should be multimodal including hemodialysis. Early and liberal use of damage control operative techniques is advisable for those patients on dabigatran that require an immediate abdominal operation. Conflict of interest: None declared.

REFERENCES 1. Gutierrez C, Blanchard DG. Atrial fibrillation: diagnosis and treatment.

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


DeMuro. A patient anticoagulated with dabigatran Am Fam Physician 2011;83:61-8. 2. FDA Drug Safety Communication: Safety Review of post-market reports of serious bleeding events with the anticoagulant Pradaxa (dabigatran etexilate mesylate), available at, http://www.fda.gov/drugs/drugsafety/ucm282724.htm, accessed April 4th, 2012. 3. van Ryn J, Stangier J, Haertter S, Liesenfeld KH, Wienen W, Feuring M, et al. Dabigatran etexilate--a novel, reversible, oral direct thrombin inhibitor: interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost 2010;103:1116-27. 4. Di Nisio M, Middeldorp S, Büller HR. Direct thrombin inhibitors. N Engl J Med 2005;353:1028-40. 5. Schaden E, Kozek-Langenecker SA. Direct thrombin inhibitors: pharmacology and application in intensive care medicine. Intensive Care Med 2010;36:1127-37. 6. Tsiara S, Pappas K, Boutsis D, Laffan M. New oral anticoagulants: should they replace heparins and warfarin? Hellenic J Cardiol 2011;52:52-67.

7. Schulman S, Crowther MA. How I treat with anticoagulants in 2012: new and old anticoagulants, and when and how to switch. Blood 2012;119:3016-23. 8. Eerenberg ES, Kamphuisen PW, Sijpkens MK, Meijers JC, Buller HR, Levi M. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects. Circulation 2011;124:1573-9. 9. Wolzt M, Levi M, Sarich TC, Boström SL, Eriksson UG, ErikssonLepkowska M, et al. Effect of recombinant factor VIIa on melagatran-induced inhibition of thrombin generation and platelet activation in healthy volunteers. Thromb Haemost 2004;91:1090-6. 10. Stratmann G, deSilva AM, Tseng EE, Hambleton J, Balea M, Romo AJ, et al. Reversal of direct thrombin inhibition after cardiopulmonary bypass in a patient with heparin-induced thrombocytopenia. Anesth Analg 2004;98:1635-9.

OLGU SUNUMU - ÖZET

Dabigatran ile antikoagüle edilen hastada acil karın cerrahisi Dr. Jonas Paul DeMuro Winthrop Üniversitesi Hastanesi, Cerrahi Bölümü, Travma ve Acil Kliniği, Mineola, New York, ABD

Dabigatran, kronik atriyum fibrilasyonunda antikoagülasyon için kullanılan yeni bir pıhtı önleyici ilaçtır. Dabitagran alan bir hastada acil laparotomi deneyimi sunulmaktadır. Bu ilaç tedavisinin zorlukları ve bu direkt trombin inhibitörü nedeniyle oluşan koagülopati ile başa çıkma stratejileri tanımlanmıştır. Anahtar sözcükler: Koagülopati, dabigatran, direkt trombin inhibitörü, perioperatif kanama, koagülopati sürecinin çevrimi. Ulus Travma Acil Cerr Derg 2013;19(5):469-471

doi: 10.5505/tjtes.2013.59908

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

471


CAS E R EP O RT

Posttraumatic tricuspid valve injury and severe tricuspid valve regurgitation Esra Gucuk Ipek, M.D. Department of Cardiology, Polatli State Hospital, Ankara

ABSTRACT A 66-year-old male was brought to our hospital following a car accident. He had subarachnoid hemorrhage, multiple rib fractures, and left hemopneumothorax. He was referred to the Cardiology Department for elevated troponin levels (42 ng/ml, reference 0-1 ng/ml). The electrocardiogram was free of ischemia, whereas the transthoracic echocardiography revealed dilated right heart chambers, enlarged tricuspid annulus and coaptation failure of the tricuspid valvular leaflets. There was rupture on the subvalvular apparatus of the anterior leaflet of the tricuspid valve with accompanying prolapse, causing severe tricuspid valvular regurgitation. The patient did not present right ventricular failure signs and symptoms; he was referred to surgery after the resolution of associated thoracic and cranial injuries. Key words: Tricuspid valve injury, trauma.

INTRODUCTION Posttraumatic tricuspid regurgitation is a rare complication of non-penetrating chest trauma.[1] The hemodynamic consequences are often well tolerated, and some cases may even be diagnosed several years after the incidental trauma.[2,3] In this case report, we present a patient who developed severe tricuspid valve regurgitation following a car accident.

CASE REPORT A 66-year-old male was brought to our hospital following a car accident. He had no previously reported medical problem. He had subarachnoid hemorrhage, multiple rib fractures, and left hemopneumothorax. There were no penetrating injuries over his chest. His hemodynamic status was stable after performance of tube thoracostomy. He was consulted to the Cardiology Department for elevated troponin levels (42 ng/ ml, reference 0-1 ng/ml). His physical examination showed diminished breathing sounds over his left hemithorax, and a systolic murmur on the left lower sternal border. The electrocardiogram was normal without an ischemic finding, but Address for correspondence: Dr. Esra Gucuk Ipek, Department of Cardiology, Polatl覺 State Hospital, Polatl覺, Ankara, Turkey Tel: +90 312 - 621 25 00 E-mail: esragucuk@hotmail.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):472-474 doi: 10.5505/tjtes.2013.45144 Copyright 2013 TJTES

472

the transthoracic echocardiography revealed dilated right chambers, enlarged tricuspid annulus, and coaptation failure of the tricuspid valvular leaflets and flail of the tricuspid valvular leaflets (Figure 1). There was rupture on subvalvular segments of the anterior tricuspid valve leaflet with accompanying prolapse leading severe tricuspid valvular regurgitation (Figure 2). The patient was not demonstrating right heart failure symptoms and signs; after managing his multiple posttraumatic injuries, he was referred to the surgery.

DISCUSSION In recent decades, we have been encountering cardiac injuries caused by blunt trauma more often as a result of increase in vehicle accidents. Blunt cardiac trauma may also occur after cardiopulmonary resuscitations or falls.[4] Traumatic cardiac injuries vary from simple myocardial contusion to severe damage of intracardiac structures, leading life- threatening hemodynamic instability.[5] Right atrium is the most vulnerable part of the heart in case of a blunt trauma because of its relatively thin wall. Cardiac valve damage is less common, and the most frequent traumatic valvular injury occurs on aortic valve, followed by mitral and tricuspid valves.[6,7] Traumatic tricuspid insufficiency is rare, but the frequency of this disease is probably underestimated, as tricuspid regurgitation has generally slowly progress and causes few symptoms.[7] The main mechanism is the compression of the right ventricle between the sternum and spine, when the valves are closed and the ventricular pressure is high.[5,8] That generates severe tension on both leaflets and subvalvular structures, causing subsequent rupture. Patients generally are asymptomatic, and the disease can progress insidiously, while right cardiac chambers and the annulus dilate progressively.[9] Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


Gücük İpek. Posttraumatic tricuspid valve injury and severe tricuspid valve regurgitation (a)

(b)

Figure 1. (a, b) Two-dimensional transthoracic echocardiographic views showing dilated right chambers, coaptation failure and flail of the tricuspid valve with prolapsing subvalvular segments.

In conclusion, transthoracic echocardiography should be performed in all patients with non-penetrating chest wall trauma if cardiac injury is suspected. Early detection of tricuspid valve damage with an optimal timing of surgical intervention will prevent right ventricular failure and increase the probability of valvular repair. Conflict of interest: None declared.

REFERENCES

Figure 2. Color Doppler view demonstrating severe tricuspid valvular insufficiency (color Doppler regurgitation area/right atrial area >0.4).

Progressive dilatation increases tricuspid valve regurgitation, which consequently induces right ventricular failure. The timing of surgical intervention after traumatic tricuspid regurgitation is controversial. Symptomatic heart failure is a strong indication for surgery. Even if the patient is not symptomatic, severe tricuspid regurgitation can result in right ventricular myocardial dysfunction and ventricular dilatation. Hence, an early operation allows preservation of myocardial reserve by preventing secondary myocardial changes.[10] With favorable surgical anatomy, repair of the tricuspid valve is preferred strategy.[10] In delayed cases, excessive fibrosis and shortening of the chordae can occur, and repair cannot be performed, in which case replacement of the prosthetic valve is the only choice of treatment.[9] Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

1. Parmley LF, Manion WC, Mattingly TW. Nonpenetrating traumatic injury of the heart. Circulation 1958;18:371-96. 2. van Son JA, Danielson GK, Schaff HV, Miller FA Jr. Traumatic tricuspid valve insufficiency. Experience in thirteen patients. J Thorac Cardiovasc Surg 1994;108:893-8. 3. Bortolotti U, Scioti G, Milano A, Guglielmi C, Benedetti M, Tartarini G, et al. Post-traumatic tricuspid valve insufficiency. 2 cases of delayed clinical manifestation. Tex Heart Inst J 1997;24:223-5. 4. Gerry JL Jr, Bulkley BH, Hutchins GM. Rupture of the papillary muscle of the tricuspid valve. A complication of cardiopulmonary resuscitation and a rare cause of tricuspid insufficiency. Am J Cardiol 1977;40:825-8. 5. Krasna MJ, Flancbaum L. Blunt cardiac trauma: clinical manifestations and management. Semin Thorac Cardiovasc Surg 1992;4:195-202. 6. Bernabeu E, Mestres CA, Loma-Osorio P, Josa M. Acute aortic and mitral valve regurgitation following blunt chest trauma. Interact Cardiovasc Thorac Surg 2004;3:198-200. 7. Lin SJ, Chen CW, Chou CJ, Liu KT, Su HM, Lin TH, et al. Traumatic tricuspid insufficiency with chordae tendinae rupture: a case report and literature review. Kaohsiung J Med Sci 2006;22:626-9. 8. Naja I, Pomar JL, Barriuso C, Mestres C, Mulet J. Traumatic tricuspid regurgitation. J Cardiovasc Surg (Torino) 1992;33:256-8. 9. Tütün U, Aksöyek A, Parlar AI, Cobanoğlu A. Post-traumatic tricuspid insufficiency: a case report. Ulus Travma Acil Cerrahi Derg 2011;17: 563-6. 10. Maisano F, Lorusso R, Sandrelli L, Torracca L, Coletti G, La Canna G, et al. Valve repair for traumatic tricuspid regurgitation. Eur J Cardiothorac Surg 1996;10:867-73.

473


Gücük İpek. Posttraumatic tricuspid valve injury and severe tricuspid valve regurgitation

OLGU SUNUMU - ÖZET OLGU SUNUMU

Travma sonrası gelişen triküspit kapak hasarı ve önemli triküspit kapak yetersizliği Dr. Esra Gücük İpek Polatlı Devlet Hastanesi Kardiyoloji Kliniği, Ankara

Altmış altı yaşında erkek hasta araç içi trafik kazası sonrası hastanemize getirildi. Travmaya bağlı subaraknoid kanama, çoklu kosta kırığı ve sol hemopnömotoraks mevcuttu. Troponin değerlerinin yükselmesi (42 ng/ml, referans 0-1 ng/ml) nedeniyle kardiyoloji bölümüne konsülte edilen hastanın elektrokardiyografisinde iskemi bulgusu yoktu ancak yapılan transtorasik ekokardiyografide sağ boşluklar ile triküspit kapak anulusu genişlemiş, triküspit kapak koaptasyonu bozulmuş olarak izlendi. Triküspit kapak anterior leaflete ait subvalvuler yapılarda rüptür ve prolapsus mevcuttu; buna bağlı önemli triküspit yetersizliği prolapsusa eşlik ediyordu. Sağ ventriküler yetersizlik bulguları bulunmayan hasta travmaya ait diğer tedavilerin tamamlanmasının ardından cerrahi kliniğine gönderildi. Anahtar sözcükler: Triküspit kapak hasarı, travma. Ulus Travma Acil Cerr Derg 2013;19(5):472-474

474

doi: 10.5505/tjtes.2013.45144

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


CAS E R EP O RT

A case report of multiple fractures with arterial vasospasm associated with ergotamine use Abdullah Küçükalp, M.D.,1 Kemal Durak, M.D.,2 Muhammet Sadık Bilgen, M.D.2 1

Department of Orthopedics and Traumatology, Sussehri State Hospital, Sivas

2

Department of Orthopedics and Traumatology, Uludag University Faculty of Medicine, Bursa

ABSTRACT Vasospasm that develops in association with ergotamine use is a rarely seen but well-understood complication. A case is presented here of multiple fractures in which arteriospasm affecting all the arteries of the lower limb on the same side occurred 10 days posttrauma. In this case, the arteriospasm resulting from ergotamine addiction and high doses of ergotamine, which may be confused with post-traumatic angiospasm, was treated with a marcaine infusion by epidural catheter and heparin, iliomedin and nitronal infusion intravenously. This clinical condition should be borne in mind for all trauma cases determined to have arterial vasospasm, and the use of ergotamine must be queried when taking the anamnesis from the patient. Key words: Ergotamine addiction, migraine, multiple fractures, vasospasm.

INTRODUCTION Non-atherosclerotic causes of acute leg ischemia, such as traumatic vasospasm, arteritis, conditions that accelerate clotting, compartment syndrome, artery dissection, and arterial pressure as in popliteal cysts, are side effects associated with medications. Particularly when high doses of ergotamine derivatives are used alone or together with certain other medications, the increased effect on the blood may lead to arterial vasospasm.

tivates the sympathetic nervous system and is used in the treatment of migraines.[4-6] Ergot alkaloids affect a-receptors, dopamine receptors and 5-HT (serotonin) receptors. [7,8] Although ergotamine-induced ischemia is seen rarely, it can lead to the serious complications of vasospasm and thrombosis. Toxicity may occur from doses used for chronic treatment, following high doses in acute cases, and in highly sensitive patients.[9-11] This condition, known as ergotism, may affect coronary, mesenteric, renal, and extremity arteries.[12]

The pathophysiology of traumatic angiospasm is unknown, but is thought to be a normal response to pain and venous stasis.[1,2] Post-traumatic vasospasm is one of the body’s protective reactions. However, if the whole arterial tree of the extremity is affected, trophic changes, fibrosis and clinical changes resembling Volkmann ischemic contracture may occur in the extremity.[3]

We present here a case in which, as a result of high-dosage use of ergotamine, arterial vasospasm developed in the same side lower extremity 10 days post-trauma (displaced hip, Pipkin type 1 femoral head fracture and Gustilo-Anderson type 3a Schatzker type 6 tibial plateau fracture).

Ergotamine is an alkaloid produced from fungi, which ac-

On Sunday, 13 December, at approximately 4:00 p.m., a 46-year-old male was taken to Tekirdağ Çorlu State Hospital after having been involved in a traffic accident. The patient had left-side hip dislocation, Pipkin type 1 femoral head fracture, Gustilo-Anderson type 3a open Schatzker type 6 tibial plateau fracture, and an avulsion fracture of the tibial tuberosity, and he was taken for surgery (Fig. 1a-e).

Address for correspondence: Dr. Abdullah Küçükalp, Department of Orthopedics and Traumatology, Sussehri State Hospital, Sivas, Turkey Tel: +90 346 - 311 54 65 E-mail: karalama@mynet.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):475-479 doi: 10.5505/tjtes.2013.63626 Copyright 2013 TJTES

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

CASE REPORT

Closed reduction was performed for the left hip dislocation; following debridement, the wound was sutured and supracondylar skeletal traction was applied. A full leg plaster was applied, and the patient was monitored in the intensive care unit. One day later, he was moved to the Orthopedic and 475


Küçükalp et al. A case report of multiple fractures with arterial vasospasm associated with ergotamine use

Traumatology Clinic, and on the second day, at the patient’s request, he was transferred to the Orthopedic and Traumatology Clinic of Uludağ University Medical Faculty. From the patient anamnesis, there was no chronic disease or regular use of any medication. In the physical examination, a sutured wound approximately 12 cm in length was seen on the medial left knee. Motor and sensory examination was determined as normal in the lower extremity. Peripheral arteries could be palpated by hand. On the same day, plain radiographs were taken. Arterial Doppler ultrasonography (USG) of the left lower extremity and computerized tomography (CT) images of the pelvis and left knee were taken. No pathology was determined from the USG (Fig. 1f). After six days of traction (7 kg) and wound care, Doppler USG was taken due to widespread pain in the left lower extremity; the distal left knee was cold and pale, and the peripheral arteries could not be palpated (Fig. 2a). Blood flow in the tibialis posterior artery and the dorsalis pedis veins could not be encoded in the Doppler USG. The skeletal traction was terminated. An emergency cardiovascular surgical consultation was requested for the patient. From the cardiovascular surgical evaluation, an emergency angiograph was administered. The angiograph results determined widespread arterial spasm starting

(a)

(d)

from the proximal femoral artery in the left lower extremity (Fig. 2b-d). When arterial vasospasm was seen on the 10th day post-trauma, traumatic vasospasm was considered as a priority. The patient anamnesis was examined in greater depth, and it was revealed that, for 10 years, the patient had been taking 4-5 ergotamine tartrate (0.75 mg) tablets daily in an irregular and uncontrolled manner. This medication was immediately ceased. Treatment recommended by the cardiovascular surgical department was started: intravenous (IV) glycerol trinitrate (20 cc (20 mg) glycerol trinitrate + 30 cc 0.9% NaCl) 2 cc/hour, IV heparin infusion (5 cc heparin (25000 IU) + 45 cc 0.9% NaCl, activated partial thromboplastin time (aPTT) value 60-80) and iloprost tromethamine (iloprost tromethamine 20 mcg/ ml + 100 cc 0.9% NaCl) 5 cc/s (for 10 days). Heat was applied locally to the left lower extremity, and the Algology Department was consulted with respect to sympathetic system blockage. On the same day, the Algology Department started the administration of 40 cc bupivacaine hydrochloride (5 mg/ ml) and 10 cc fentanyl (0.05 mg/ml), in a 110 cc 0.9% NaClprepared solution at 5 cc bolus/hour via epidural catheter. This infusion was continued for approximately 10 days, during which time the findings of ischemia receded, the peripheral arteries again became palpable, and the coldness and pallor of the lower extremity resolved (Fig. 2e).

(b)

(e)

(c)

(f)

Figure 1. (a, b) Pipkin type 1 femoral head fracture. (c-e) Tibial plateau fracture. (f) Arterial Doppler USG.

476

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


Kßçßkalp et al. Multiple fractures with arterial vasospasm associated with ergotamine use

The heparin infusion administered to the patient was stopped on 2 December 2011, and enoxaparin-natrium 2x40 mg was started. After removing the sutures in the medial left knee, the patient underwent surgery on 12 December 2011. An anterolateral incision was made to the proximal tibia, and the extensor mechanism was repaired with number 5 non-absorbable polyfilament suture. After reduction of the plateau fracture, fixation was done using a tibial plate (Fig. 2f, g). There were no perioperative complications. On evaluation by the cardiovascular surgeon, it was recommended to continue the existing treatment without any additions. When the patient was observed to be stable and the findings of ischemia had completely receded, he was discharged with the recommendation of following foot stretching and strengthening exercises.

or compartment syndrome. Together with pulse evaluation, it is necessary to clinically examine the leg for findings of ischemia. The absence or reduction of a pulse, spreading hematoma, advanced swelling, continued arterial bleeding, and damage to anatomically related nerves are indications for arteriography.[14] The pathophysiology of traumatic angiospasm is not known, but is thought to be the normal response to pain and venous stasis. In fractures and non-weight-bearing feet, this physiological vasomotor reflex may lead to coldness and cyanosis in the lower extremity.[2] When peripheral pulses cannot be taken, circulation in the distal arteries should be evaluated by Doppler USG. This is particularly useful for distal pulses that are difficult to feel in vasospasm.[15]

In the current case, although no vascular pathology was determined by Doppler USG and physical examination immediately post-trauma, on the 10th day, acute arterial occlusion Fractured hip dislocations and tibial plateau fractures are ofwas considered due to the development of pain, coldness ten associated with severe soft tissue damage, and open fracand pallor and because blood flow could not be encoded in tures occur in many cases.[13] As the injuries arise from highthe tibialis posterior and dorsalis pedis veins from the Dopenergy trauma, there is a high risk of vascular nerve damage pler USG. An angiograph was taken, which determined widespread va(a) (f) sospasm from the proximal femoral artery extending to the distal arteries. Differential diagnoses of Buerger disease and Raynaud phenomenon were considered because of the angiographic images, but the clinical table and the angiographic findings differed from that of diffuse spasm.[16] The occlusion in the leg arteries in Buerger disease is seen as collateral formation, with the occlusion extending in a (b) (c) (d) corkscrew fashion along the arteries. The occlusion in the proximal arteries was normal and widespread spasm was not seen. Raynaud phenomenon (g) is more often seen in upper extremity arteries and usually responds to the application of intra-arterial vasodilator. Generally, the symptoms do (e) not cause an acute deterioration.[17] In the current case, as arterial vasospasm occurred on the 10th day, and the diagnosis of traumatic vasospasm was made. When the anamnesis was examined in greater depth, it was learned that, for approximately 10 years, the patient had been taking 4-5 tablets ergotamine tartrate (0.75 mg) daily due to migraine in an irregular Figure 2. (a) Ischemic changes in the left foot. (b-d) Angiograph showing widespread arterial and uncontrolled manner. vasospasm in the left lower extremity. (e) The left foot after treatment. (f, g) Fixation of the tibial

DISCUSSION

plateau fracture.

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

477


Küçükalp et al. A case report of multiple fractures with arterial vasospasm associated with ergotamine use

Migraine is seen as one or two headache attacks per week. It is thought that patients who experience headaches daily and feel the need for ergotamine derivatives for relief become addicted to ergotamine. In this clinical situation, patients find themselves in a vicious circle of taking increasing doses of ergotamine to relieve the migraine attacks. The only way to break this cycle is to discontinue the ergotamine.[18] For approximately 10 years and eventually because of daily headaches, our patient had been taking 4-5 tablets ergotamine tartrate (0.75 mg) daily. As the patient was thought to be addicted to ergotamine, that medication was terminated, and nonsteroidal naproxen sodium was started for headache relief.

for an additional supporting medial plate.[22] The femoral head fracture was treated conservatively.

In patients with angiospasm associated with ergotism, the extremities are seen to be pale and cold, peripheral pulses cannot be taken, and intermittent or chronic pain affects the extremities. The angiographic findings of widespread and segmental vasospasm are seen as regular vascular narrowing. The changes are generally symmetrical at an equivalent level in both extremities.[19] The case reported here is different, in that having been exposed to trauma, only one extremity was affected, and it was determined that vasospasm was affecting all the arteries of that extremity. The toxic effects of ergotamine are more often seen from chronic usage, but acute toxicity can develop from a single excessive dose. The vasospastic effect of ergotamine is known to increase in some situations, such as fever, infection, poor nutrition, thyrotoxicosis, liver and renal insufficiency, and peripheral artery disease.[20,21] To treat arterial vasospasm, it is necessary to inhibit reflex vasoconstrictor signals. To this end, an intra-arterial vasodilator, calcium channel blockers, beta-blockers, periarterial sympathetic block, local anesthetic infusion via epidural catheter, and preganglionic sympathectomy may be applied. In addition, anticoagulant treatment must be administered. In the current case, as soon as the diagnosis of arterial vasospasm had been made, the avmigran tablets, which he had been taking without our knowledge, were prohibited. IV glycerol trinitrate, IV heparin infusion and iloprost tromethamine infusion were started. An epidural catheter was applied, and epidural marcaine for sympathetic blockage and fentanyl infusion for analgesia were started.

Conflict of interest: None declared.

After approximately two weeks of treatment, the patient was fit to undergo surgery. To reduce the surgical problems to a minimum, careful preoperative planning was essential regarding the choice of incision and techniques for fracture reduction and fixation. The vascular network of the long bones comes from feeder veins to the cortex internal two-thirds and from adjacent soft tissues to the external third of the cortical bone. Most studies have shown that classical plate fixation techniques significantly damage the vascular network feeding the bone. In our case, as the wound had been sutured medially and a single incision had been made, we applied a minimally invasive locked tibial plate (tibia - LISS) enabling fixation of both the medial and lateral plateau with no need 478

Having followed the analgesia and early rehabilitation program in the postoperative period, the patient was discharged without any problems. In our country, as ergotamine-derivative drugs are not subject to control, patients can easily obtain them unrecorded. Work is ongoing for similar drugs to come under the control of the Ministry of Health. That this clinical situation of traumatic angiospasm can arise 10 days posttrauma should be known and should be borne in mind for all trauma cases; it is necessary to take a detailed anamnesis for all the facts to come to light.

REFERENCES 1. Keller U, Zocher R, Kleinkauf H. Biosynthesis of ergotamine in protoplasts of Claviceps puvpurea. Journal of General Microbiology 1980;118:485-94. 2. Pistorius MA, Connault J, Kalassy C, Goueffic Y, Planchon B. Acute posttraumatic ischemia of the limbs: algodystrophy or related syndrome? A prospective study on a series of 25 patients. Angiology 2008;59:301-5. 3. Kirtley JA. Arterial injuries in a theater of operations. Ann Surg 1945;122:223-34. 4. Thrush Q. Does work ergotamine for migraine? In: Warlow C, Garfield J, editors. Magement in the dilemmas of the neurological patient. Edinburgh: Churchill Livingstone; 1984. p. 106-13. 5. Merhoff GC, Porter JM. Ergot intoxication: historical review and description of unusual clinical manifestations. Ann Surg 1974;180:773-9. 6. Wilkinson M. Ergotamine headaches. In: Carroll JD, Pfaffenrath V, Sjaastad O, editors. Migraine and beta-blockkade. Uddevalla: Bohuslaeningens Boktryckeri; 1985. p. 176-9. 7. Meyler WJ. Side effects of ergotamine. Cephalalgia 1996;16:5-10. 8. Katzung BG. Histamine, serotonin and the ergot alkaloids. In: Katzung BG, editor. Basic and clinical pharmacology. 6th ed. New York, NY: McGraw Hill; 2007. p. 255-26. 9. Ala-Hurula V, Myllylä V, Hokkanen E. Ergotamine abuse: results of ergotamine discontinuation, with special reference to the plasma concentrations. Cephalalgia 1982;2:189-95. 10. Young JR, Humphries AW. Severe arteriospasm after use of ergotamine tartrate suppositories. Report of a case. JAMA 1961;175:1141-5. 11. Felix RH, Carroll JD. Upper limb ischaemia due to ergotamine tartrate. Practitioner 1970;205:71-2. 12. Feneley MP, Morgan JJ, McGrath MA, Egan JD. Transient aortic arch syndrome with dysphasia due to ergotism. Stroke 1983;14:811-4. 13. Weiner LS, Kelley M, Yang E, Steuer J, Watnick N, Evans M, et al. The use of combination internal fixation and hybrid external fixation in severe proximal tibia fractures. J Orthop Trauma 1995;9:244-50. 14. Watson JT, Wiss DA. Fractures of the proximal tibia and fibula. In: Rockwood C, Green D, Bucholz R, editors. Fractures in adults. 5th ed. Philadelphia: Lippincott Williams-Wilkins Company; 2001. p. 180141. 15. Boğa M. Akut ekstremite iskemisi. Türk Aile Hek Derg 2009;13:11-5. 16. Pope JE. The diagnosis and treatment of Raynaud’s phenomenon: a practical approach. Drugs 2007;67:517-25. 17. Mills JL, Friedman EI, Taylor LM Jr, Porter JM. Upper extremity ischemia caused by small artery disease. Ann Surg 1987;206:521-8. 18. İnan L, Tulunay C, Güvener A. Ergotamin baş ağrısı ve Ergot bağımlılığı.

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


Küçükalp et al. Multiple fractures with arterial vasospasm associated with ergotamine use Turkiye Klinikleri J Med Sci 1989;9:198-200. 19. McKiernan TL, Bock K, Leya F, Grassman E, Lewis B, Johnson SA, et al. Ergot induced peripheral vascular insufficiency, non-interventional treatment. Cathet Cardiovasc Diagn 1994;31:211-4. 20. Ghali R, De Léan J, Douville Y, Noël HP, Labbé R. Erythromycin-associated ergotamine intoxication: arteriographic and electrophysiologic analysis of a rare cause of severe ischemia of the lower extremities and

associated ischemic neuropathy. Ann Vasc Surg 1993;7:291-6. 21. Fukui S, Coggia M, Goëau-Brissonnière O. Acute upper extremity ischemia during concomitant use of ergotamine tartrate and ampicillin. Ann Vasc Surg 1997;11:420-4. 22. Cole PA, Zlowodzki M, Kregor PJ. Treatment of proximal tibia fractures using the less invasive stabilization system: surgical experience and early clinical results in 77 fractures. J Orthop Trauma 2004;18:528-35.

OLGU SUNUMU - ÖZET

Çoklu kırıklı bir olguda ergotamin kullanımına bağlı arteriyel vazospazm Dr. Abdullah Küçükalp,1 Dr. Kemal Durak,2 Dr. Muhammet Sadık Bilgen2 1 2

Suşehri Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Sivas Uludağ Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Bursa

Ergotamin kullanımına bağlı gelişen vazospazm nadir görülen ve iyi bilinen bir komplikasyondur. Bu yazıda çoklu kırığı olan ve travma sonrası 10. günde görülen ve aynı taraf alt ekstremitede tüm arterlerin etkilendiği arteriyospazm olgusu sunuldu. Bu olguda travma sonrası anjiyospazm ile karışabilecek olan ergotamin bağımlılığı ve aşırı doz egotamin kullanımı sonucu ortaya çıkan arteriyospazm; epidural kateter aracılığı ile marcain infüzyonu, intravenöz yolla heparin, iliomedin ve nitronal infüzyonu ile tedavi edildi. Tüm arteryel vazospazm saptanan travma olgularında bu klinik durum akılda tutulmalı ve hastadan anamnez alınırken ergotamin kullanımı mutlaka sorgulanmalıdır. Anahtar sözcükler: Ergotamin bağımlılığı, migren, çoklu kırık, vazospazm. Ulus Travma Acil Cerr Derg 2013;19(5):475-479

doi: 10.5505/tjtes.2013.63626

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

479


CAS E R EP O RT

Hepatic duct confluence injury in blunt abdominal trauma a diagnostic dilemma Saurabh Garge, M.D., Kannan Lakshmi Narasimhan, M.D., Shraddha Verma, M.D., Virender Sekhon, M.D. Department of Pediatric Surgery, Pgimer, Chandigarh, India

ABSTRACT Isolated hepatic duct confluence injury due to trauma is unusual. Two cases of isolated bile duct injury are presented, which were diagnosed and managed successfully at our institution. Key words: Hepatobiliary iminodiacetic acid scan, isolated hepatic duct injury.

INTRODUCTION Extra-hepatic bile duct injury is rare, and injury at the hepatic duct confluence is even rarer. The majority of bile duct injuries in children are caused by blunt abdominal trauma and are associated with other hepatic and pancreaticobiliary injuries. In our cases, the injury was an isolated duct injury and was also in an unusual site. Duct injuries without any associated hepato- or pancreaticobiliary injuries, i.e., isolated common hepatic duct injuries, are rarer. The diagnosis poses a challenge and hence is often delayed. This report presents two cases of isolated hepatic duct confluence injury, with their successful management.

CASE REPORT Case 1â&#x20AC;&#x201C; A four-year-old male child was brought with H/O alleged blunt trauma to the abdomen from a car about one month before. The child had been admitted and managed conservatively at a peripheral hospital for moderate hemoperitoneum and splenic laceration of about 1.5x1.5 cm in the upper splenic pole diagnosed by abdominal sonography. Three days after discharge, the child was brought to us with c/o abdominal pain, abdominal distension, multiple episodes

Address for correspondence: Saurabh Garge, M.D. Department of Pediatric Surgery, Pgimer, Chandigarh, India Tel: +90 9878691012 E-mail: saurabhgarge8@gmail.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):480-484 doi: 10.5505/tjtes.2013.67026 Copyright 2013 TJTES

480

of non- bilious vomiting, and intermittent fever. Clinical examination revealed presence of tenderness in the epigastric region and left hypochondrium with presence of free fluid in the abdomen. The child was icteric. The biochemistry showed total serum bilirubin 5.5 g% with direct fraction 2.5 g%. The serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels were found to be normal, with gross elevation of the alkaline phosphatase (ALP) levels (2836 IU) s/o cholestasis. A contrast-enhanced computed tomography (CECT) scan of the abdomen was done, which showed the presence of a linear laceration in the upper pole of the spleen of about 1.5x2.0 cm s/o grade 2 splenic injury with moderate hemoperitoneum. All other viscera were essentially normal (Fig. 1). The child was managed conservatively for two days, but due to persistent abdominal signs and jaundice, bile duct injury was suspected, and a HIDA (hepatobiliary iminodiacetic acid) scan was done. The HIDA scan showed normal hepatic uptake with absence of bilioenteric drainage and a bile leak in the peritoneum (Fig. 2). The patient underwent a diagnostic laparoscopy, which revealed the presence of gross biliary fluid in the peritoneal cavity with bile staining at the porta hepatis. An intraoperative cholangiogram was performed, which showed the dye passing in the small bowel, showing patency of the distal tract and absence of any other ductal injuries (Fig. 3a). This was done because our case had a delayed presentation of bile leak, suggesting the presence of ischemic necrosis, which usually results in multiple sites of duct injury. A 0.5x0.8 cm perforation was found at the region of the confluence of the hepatic ducts. A 10 Fr T-tube was placed through the tear and was brought outside the abdomen via the right lateral port, and the abdomen was closed with a subhepatic drain from the midline port. Postoperatively, the patient had an uneventful course. A repeat HIDA scan performed on postoperative day Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


Garge et al. Hepatic duct confluence injury in blunt abdominal trauma

Figure 1. Computerized tomography scan showing splenic injury with hemoperitoneum.

6 showed no obstruction and normal drainage with no e/o bile leak (Fig. 3b). The T-tube was clamped subsequently. A T-tube cholangiogram performed on the 10th postoperative day showed a patent biliary tract with no leak. The T-tube was removed, and the patient was discharged on the 11th postoperative day with no specific complaints. Case 2â&#x20AC;&#x201C; A 10-year-old male child presented with alleged h/o blunt trauma to the abdomen due to being run over by the front wheel of a three-wheeler. The patient had no h/o unconsciousness, ear-nose-throat (ENT) bleed or respiratory distress. He had c/o a few episodes of vomiting but these were relieved with medications. The child was managed in a peripheral hospital where he had persistent hematuria on catheterization. An ultrasound performed showed presence of a renal injury. The patient was referred to our institution for further management. On arrival, the patient was found

Right and left hepatic duct

Gall bladder

to be anemic and received 2 units of packed red cells. He had stable vitals and thus was conservatively managed. A CT scan was performed, which showed the presence of a linear hypodense region measuring 1.5 cmx0.7 cm in the midpolar region of the right renal cortex at its lateral margin. There was no evidence of any dye extravasation in the perinephric region. Adrenal hemorrhage on the right side was suspected. The other viscera including the liver were reported to be normal apart from some fluid collection in the lesser sac region (Fig. 4a). The patient had persistent abdominal distension while the hematuria subsequently subsided. The abdominal distension initially was gaseous but later became fluid with shifting dullness being elicitable. All the investigations in the patient were shown to be normal except for the bilirubin levels, which were persistently raised and showed an increasing trend. A HIDA scan was done to rule out presence of any bile leak. HIDA scan was s/o injury at the hepatic duct confluence (Fig. 4b). The patient underwent immediate exploration. Intraoperatively, there was confirmation of a defect in the region of the hepatic duct confluence of 0.5x1.0 cm. The peritonealized surface of the gallbladder was used for closing the tear. The patient had an uneventful postoperative course and was discharged on the 8th postoperative day with the cholecystostomy clamped. The cholecystostomy was removed on the 14th postoperative day.

DISCUSSION Since the initial case report of bile duct rupture secondary to blunt trauma[1] in 1799, there have been only about 30 reports in the English-language literature from 1929 to 1995 involving injuries to the right and left hepatic ducts, either independently or at their bifurcation.[2,3] The mechanisms of injury to the proximal bile duct are nu-

Leaked dye from the perforation

Duodenum

Figure 2. Intraoperative cholangiogram.

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

481


Garge et al. Hepatic duct confluence injury in blunt abdominal trauma

(a)

(b) Figure 3. (a) Preoperative HIDA scan. (b) Postoperative HIDA scan.

(a)

(b) Figure 4. (a) Computerized tomography scan showing renal injury with collection in the lesser sac. (b) Preoperative HIDA scan.

merous and largely speculative, and include shearing forces applied to a distended bile duct at the area of maximum fixation.[3-8] These areas of maximal fixation are (1) the origin of the left hepatic duct, (2) the bifurcation of the hepatic ducts, and (3) the pancreaticoduodenal junction. Fletcher[9] attributed three important factors to bile duct injury in blunt trauma: (1) a short cystic duct with rapid emptying of the gallbladder, 482

(2) direct force on the gallbladder causing its rapid emptying, and (3) shearing force applied to the distended gallbladder causing it to tear at its points of fixation, i.e., its point of exit from the liver or its point of entry into the pancreas. The fact that our second patient had a delayed bile leak, secondary to injury of the confluence of the hepatic ducts, suggests an ischemic necrosis of the duct. Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


Garge et al. Hepatic duct confluence injury in blunt abdominal trauma

Bile duct injuries can often be missed unless an assiduous search is made in any suspicious injury. The clinical course of these injuries is insidious and often delayed, with an average time of 18 days, until the development of obvious abdominal signs and symptoms.[4-6] Our cases were diagnosed 5 and 6 days’ post-admission. Bile is sterile and can produce minimal peritoneal irritation, so the course of presentation can be chronic, and consists of mild peritoneal signs, jaundice, lowgrade fever, and weight loss. Accumulation of free fluid in the abdominal cavity with subsequent diagnostic puncture, or an abdominal drain draining bile-stained fluid, may draw attention to a possible injury of the biliary system.[10] In the first case, the diagnosis was made after the 5th day of admission to the hospital but two months after the blunt trauma. The diagnosis was made based on the persistently raised bilirubin level, presence of subtle abdominal signs, biliary paracentesis, and the HIDA scan showing presence of bile leak. Preoperative diagnosis of biliary tree injuries is difficult. CT scans, HIDA scans, endoscopic retrograde pancreatography (ERCP), and intraoperative cholangiograms have been used to detect occult ductal injuries in high-risk patients in whom there is a high index of suspicion. CT and ultrasonography are useful for revealing peritoneal fluid collection or biliary dilatation. The CT can also help in diagnosing significant injury to the liver, especially segment II, III, or IV, or the presence of bile staining of the retroperitoneum.[2,3,5,8] These associated liver injuries should raise the suspicion of the biliary injury and lead to a HIDA scan for the diagnosis of ductal injuries. In our case, no associated liver injury was sustained. HIDA scanning is the preferred screening tool for suspected bile duct injury. Delayed images should always be obtained if bile leakage is suspected, even if the study is normal at one hour. HIDA scanning can also be used for following the patient postoperatively.[11] Endoscopic retrograde cholangiopancreatography (ERCP) has been used to detect extravasation of contrast medium from the injured site in selected patients with biliary injury.[12] A variety of treatment options have been used for biliary tract injuries, with the choice of treatment being dictated by the type and degree of injury and the general condition of the patient. Small tears have been treated using any of the following options: ERCP and stenting,[13] primary repair,[15] and patch repair with vein, serosa or jejunal patch.[13,14] In addition, T-tube decompression[15] and entero-hepato-duodenal ligamentostomy[16] have been used in difficult cases. Choledochoenterostomy and hepaticoenterostomy have been used for major injuries of the ducts, including complete transection.[10,13,14] In our cases, we used T-tube repair of the duct perforation in the first case, while in the second case, the peritonealized surface of the gallbladder was used as a patch to cover the perforation.

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

In conclusion, a high index of suspicion and an awareness of vague abdominal signs are necessary for an early diagnosis. In our opinion, bilirubin elevation, bilious paracentesis, and hepatic fracture involving the porta hepatis as shown on CT should prompt appropriate investigation to exclude extrahepatic biliary injury. 99m-Tc-dimethyl acetanilide iminodiacetic acid (HIDA) scanning is the preferred screening tool for suspected bile duct injury. Delayed images should always be obtained if bile leakage is suspected, even if the study is normal at one hour. A normal HIDA scan in the face of continued symptoms requires further evaluation, mainly ERCP. Conflict of interest: None declared.

REFERENCES 1. Wainwright T, ‘Letter’. Med Phys;362-4. 2. Michelassi F, Ranson JH. Bile duct disruption by blunt trauma. J Trauma 1985;25:454-7. 3. Dawson DL, Johansen KH, Jurkovich GJ. Injuries to the portal triad. Am J Surg 1991;161:545-51. 4. Busuttil RW, Kitahama A, Cerise E, McFadden M, Lo R, Longmire WP Jr. Management of blunt and penetrating injuries to the porta hepatis. Ann Surg 1980;191:641-8. 5. Bade PG, Thomson SR, Hirshberg A, Robbs JV. Surgical options in traumatic injury to the extrahepatic biliary tract. Br J Surg 1989;76:2568. 6. Zollinger RM Jr, Keller RT, Hubay CA. Traumatic rupture of the right and left hepatic ducts. J Trauma 1972;12:563-9. 7. Muin A, Leong YP, Tay SK. Laceration of the common hepatic duct bifurcation by blunt abdominal trauma. Injury 1992;23:422-3. 8. Feliciano DV. Biliary injuries as a result of blunt and penetrating trauma. Surg Clin North Am 1994;74:897-912. 9. Fletcher WS. Nonpenetrating trauma to the gallbladder and extrahepatic bile ducts. Surg Clin North Am 1972;52:711-7. 10. Bourque MD, Spigland N, Bensoussan AL, Garel L, Blanchard H. Isolated complete transection of the common bile duct due to blunt trauma in a child, and review of the literature. J Pediatr Surg 1989;24:1068-70. 11. Bin Yahib S, Al Rabeeah A, Al Sammarrai A. An unusual bile duct injury in a child after blunt abdominal trauma. J Pediatr Surg 1999;34:1161-3. 12. Sugimoto K, Asari Y, Sakaguchi T, Owada T, Maekawa K. Endoscopic retrograde cholangiography in the nonsurgical management of blunt liver injury. J Trauma 1993;35:192-9. 13. Eid A, Almogy G, Pikarsky AJ, Binenbaum Y, Shiloni E, Rivkind A. Conservative treatment of a traumatic tear of the left hepatic duct: case report. J Trauma 1996;41:912-3. 14. Monk JS Jr, Church JS, Agarwal N. Repair of a traumatic noncircumferential hepatic bile duct defect using a vein patch: case report. J Trauma 1991;31:1555-7. 15. Ivatury RR, Rohman M, Nallathambi M, Rao PM, Gunduz Y, Stahl WM. The morbidity of injuries of the extra-hepatic biliary system. J Trauma 1985;25:967-73. 16. Bar-Maor JA, Shoshany G. Traumatic rupture of the choledochus treated temporarily by Roux-en-Y entero-hepato-duodenal ligamentostomy. J Pediatr Surg 1994;29:1578-9.

483


Garge et al. Hepatic duct confluence injury in blunt abdominal trauma

OLGU SUNUMU - ÖZET

Künt karın travmasında kompleks hepatik kanal yaralanması-tanısal ikilem Dr. Saurabh Garge, Dr. Kannan Lakshmi Narasimhan, Dr. Shraddha Verma, Dr. Virender Sekhon Çocuk Cerrahisi Kliniği, Pgimer, Chandigarh, Hindistan

Travmaya bağlı izole ve kompleks hepatik kanal yaralanmaları seyrek görülmektedir. Merkezimizde başarılıyla tanı ve tedavisi yapılan iki izole safra kanalı yaralanması sunulmaktadır. Anahtar sözcükler: Hepatobiliyer iminodiasetik asit tarama, izole hepatik kanal yaralanması. Ulus Travma Acil Cerr Derg 2013;19(5):480-484

484

doi: 10.5505/tjtes.2013.67026

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


CAS E R EP O RT

Long-term follow-up results of a pediatric brachial plexus laceration Sinan Öksüz, M.D., Hüseyin Karagöz, M.D., Yalçın Külahçı, M.D., Ersin Ülkür, Asım Uslu, M.D. Department of Plastic and Reconstructive Surgery and Burn Unit, GATA Haydarpasa Training Hospital, Istanbul

ABSTRACT A rare case of pediatric brachial plexus laceration is presented. A five-year-old boy who sustained a sharp laceration on his right axillary region was immediately operated. The axillary artery, radial, ulnar and musculocutaneous nerve branches of the brachial plexus, and the lateral root of the median nerve were totally lacerated. The medial root of the median nerve was partially transected. All of the lacerated brachial plexus elements and axillary artery were immediately repaired. Significant functional recovery was determined even six months after the repair. Motor and sensory functions of the affected extremity were almost totally restored at the postoperative 21st month, except for the ulnar nerve motor functions. There was no cold intolerance or trophic change at the injured extremity. Primary repair of a brachial plexus laceration injury in the pediatric population can be expected to produce successful functional recovery results, even in a relatively short period after the repair. Key words: Brachial plexus laceration; isolated; pediatric.

INTRODUCTION Obstetric brachial plexus injuries constitute the majority of the reported peripheral nerve injury cases in the pediatric population. However, isolated sharp laceration injuries of the brachial plexus and the outcomes after repair are rarely reported. We report a rare case of pediatric brachial plexus laceration and the long-term follow-up results after repair.

CASE REPORT A five-year-old boy presented with a skin laceration on the axillary region of the dominant right extremity, 10 hours after the injury. The skin had been lacerated by glass. Radial and ulnar artery pulses could barely be determined by hand-held Doppler. Nevertheless, there was no evident major circulation problem. However, total motor and sensory neurologic functional loss was determined at the affected extremity. The existing laceration was extended and subcutaneous structures were exposed for exploration (Fig. 1a). Address for correspondence: Sinan Öksüz, M.D. Selimiye Mah., Tibbiye Cad., Uskudar, 34668 Istanbul, Turkey Tel: +90 216 - 542 20 20 E-mail: sinanoksuz@gmail.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2013;19(5):485-487 doi: 10.5505/tjtes.2013.07717 Copyright 2013 TJTES

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

The short head of the biceps brachii and coracobrachialis muscles were totally lacerated at the injury site. The pectoralis major muscle was also partially injured at its insertion. The axillary artery was completely lacerated. The radial, musculocutaneous and ulnar nerve branches of the brachial plexus and the lateral root of the median nerve were totally transected. The medial root of the median nerve was partially (30%) lacerated as well (Fig. 1b, c). The proximal ends of the nerve elements could be anatomically identified by means of early exploration. Distal nerve elements were determined with the assistance of a nerve stimulator. The clear-cut nature of the injury did not cause any tissue loss. All of the lacerated brachial plexus elements were repaired under microscope magnification with primary epineural sutures after the axillary artery repair. The muscle injuries were also repaired at the end of the operation. The radial and ulnar arteries could be well palpated postoperatively. The right upper extremity was immobilized for two weeks in a long arm cast. Passive mobilization of the hand and wrist was commenced on the postoperative 3rd day. An intensive physiotherapy program was applied for the entire upper extremity two weeks later. Throughout the postoperative first three months, splints were applied to prevent deformities, except during the physiotherapy sessions. Significant functional motor recovery was determined at the injured extremity even six months after the repair. The tendency to flexion posture at the fourth and fifth digits was 485


Ă&#x2013;ksĂźz et al. Pediatric brachial plexus laceration (a)

(b)

(c)

(d)

(e)

Figure 1. (a) Initial appearance at the exploration. (b) The transected brachial plexus elements. (c) An illustration demonstrating the brachial plexus laceration. (d) Postoperative 10th month view with diminished ulnar nerve deficiency. (e) Postoperative 21st month view with functional recovery.

prominent in the early postoperative period, but diminished over the prolonged follow-up (Fig. 1d). As any intervention to repair the mentioned deformity would mean the loss of some recovered functions, no secondary surgery was addressed as an option. Hand, forearm, elbow, and shoulder motor functions were almost totally restored at postoperative 21 months (Fig. 1e). Sensation was totally restored as well. The child could efficiently perform his daily activities. There was no cold intolerance or trophic change at the injured extremity.

DISCUSSION Sharp laceration injuries of the pediatric brachial plexus and the outcomes after repair are sparse in the literature. Reports exhibit diversity depending on the level and type of the injury and the nerve affected.[1] Traumatic causes of brachial 486

plexus injuries can be classified as: stretch/contusion injuries, gunshot wounds and lacerations.[2] Clear-cut sharp lacerations of the nerves without tissue loss indicates immediate primary repair.[3,4] Laceration injuries generally transect just some elements of the brachial plexus, but total plexus lacerations are reported scarcely.[2] Outcomes of sharp laceration injury repair for median and radial nerves at various levels are reported to be equally good and better than for the ulnar nerve. Muscles innervated by median and radial nerves are not responsible for delicate movements; however, the ulnar nerve supplies the distal fine intrinsic hand muscles. This physiologic feature may be responsible for the prominent functional loss after the repair of the ulnar nerve.[1] Moderate claw hand posture was noticed in this presented case as well. Motor functional Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5


Öksüz et al. Pediatric brachial plexus laceration

outcomes were better for the median, radial and musculocutaneous nerves. Even though the relationship between nerve regeneration and patient age is controversial,[5,6] the motor functional recovery observed within six months can be attributed to the age of the patient in this case. Clear-cut lacerations are expected to yield better results than avulsion and crush injuries.[7] The reports about injuries to the upper extremity nerves indicate that as the injury level shifts to proximal, the functional outcome deteriorates.[1] Even though the nature of the injury was favorable, the level of the laceration in this case was challenging. However, despite the high level of injury, the functional outcome did not deteriorate. Arterial circulation failure of an extremity can remain obscure among pediatric patients. Instant surgical exploration is indicated to eliminate both vascular and neural injury in case of a sharp laceration. In the pediatric population, primary repair of a brachial plexus laceration can be expected to produce successful results regarding functional motor and sensory recovery.

Conflict of interest: None declared.

REFERENCES 1. Murovic JA. Upper-extremity peripheral nerve injuries: a Louisiana State University Health Sciences Center literature review with comparison of the operative outcomes of 1837 Louisiana State University Health Sciences Center median, radial, and ulnar nerve lesions. Neurosurgery 2009;65:11-7. 2. Kim DH, Cho YJ, Tiel RL, Kline DG. Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center. J Neurosurg 2003;98:1005-16. 3. Kim DH, Murovic JA, Tiel RL, Kline DG. Lacerations to the brachial plexus: surgical techniques and outcomes. J Reconstr Microsurg 2005;21:435-40. 4. Giuffre JL, Kakar S, Bishop AT, Spinner RJ, Shin AY. Current concepts of the treatment of adult brachial plexus injuries. J Hand Surg Am 2010;35:678-88. 5. Ertem K, Denizhan Y, Yoloğlu S, Bora A. The effect of injury level, associated injuries, the type of nerve repair, and age on the prognosis of patients with median and ulnar nerve injuries. Acta Orthop Traumatol Turc 2005;39:322-7. 6. Gilbert A, Pivato G, Kheiralla T. Long-term results of primary repair of brachial plexus lesions in children. Microsurgery 2006;26:334-42. 7. Jaquet JB, Luijsterburg AJ, Kalmijn S, Kuypers PD, Hofman A, Hovius SE. Median, ulnar, and combined median-ulnar nerve injuries: functional outcome and return to productivity. J Trauma 2001;51:687-92.

OLGU SUNUMU - ÖZET

Pediatrik brakiyal pleksus kesisinin uzun dönem takip sonuçları Dr. Sinan Öksüz, Dr. Hüseyin Karagöz, Dr. Yalçın Külahçı, Dr. Ersin Ülkür, Dr. Asım Uslu Gülhane Askeri Tıp Akademisi Haydarpaşa Eğitim Hastanesi, Plastik ve Rekonstrüktif Cerrahi Servisi ve Yanık Ünitesi, İstanbul

Bu yazıda nadir bir pediatrik brakial pleksus kesisi olgusu sunuldu. Sağ aksiller bölgeyi etkileyen kesici cisim yaralanmasına maruz kalan beş yaşındaki erkek çocuk acil olarak ameliyata alındı. Aksiller arter, brakial pleksusun radial, ulnar ve muskulokutan sinir dalları ile median sinirin lateral kökü tam olarak kesilmişti. Median sinirin medial kökü ise parsiyel kesilmişti. Brakiyal pleksusun kesilen tüm elemanları ve aksiller arter acil olarak onarıldı. Onarımdan altı ay sonra bile belirgin bir fonksiyonel iyileşme saptandı. Ameliyat sonrası 21. ayda, etkilenen ekstremitenin motor ve duyu fonksiyonları, ulnar sinir motor fonksiyonları dışında, tama yakın düzeldi. Yaralanan ekstremitede soğuk intoleransı veya atrofik değişiklikler gözlenmedi. Pediatrik yaş grubunda brakiyal pleksus kesici yaralanmalarının primer onarımı, onarımdan sonra görece kısa sürede bile, başarılı fonksiyonel iyileşme sonuçları verebilir. Anahtar sözcükler: Brakiyal pleksus kesisi, izole, pediatrik. Ulus Travma Acil Cerr Derg 2013;19(5):485-487

doi: 10.5505/tjtes.2013.07717

Ulus Travma Acil Cerrahi Derg, September 2013, Vol. 19, No. 5

487


OLGU SUNUMU

Amyand fıtığında apendektomi yapılmalı mıdır? İki olgu sunumu Dr. Emine Burcu Çığşar, Dr. Çetin Ali Karadağ, Dr. Nihat Sever, Dr. Ali İhsan Dokucu Şişli Etfal Eğitim ve Araştırma Hastanesi, Çocuk Cerrahisi Kliniği, İstanbul

ÖZET Fıtık kesesi içerisinde apendiks vermiformis bulunması Amyand hernisi olarak adlandırılır. Hastalık ismini İlk kez 1735 yılında tanımlayan Claudius Amyand’dan almıştır. Yetişkinlerde görülme sıklığı %0.51-%1 olarak bildirilmiş olmasına rağmen çocuk hasta grubunda olgu azlığı nedeniyle, bildirilmiş bir oran bulunmamaktadır. Bu yazıda ameliyat edilen iki Amyand hernili olgu sunuldu. Birinci olgu yenidoğan döneminde ultrasonografi ile strangüle Amyand hernisi tanısı konularak ameliyat edildi. İkinci olgu, kasık fıtığı tanısı ile elektif şartlarda ameliyat edilirken ameliyat sırasında tanı alan hastaydı. Birinci olguda apendiksin dolaşımının bozulmuş olduğu görülerek fıtık onarımına ek olarak apendektomi yapıldı. İkinci olguda salim bulunan apendiks alınmadı. Amyand hernisinde apendikse yapılacak işlem ile ilgili standart bir yaklaşım yoktur. Apendikste dolaşım bozukluğu gibi komplikasyonların görüldüğü olgular dışında apendektomi yapılması zorunlu değildir. Anahtar sözcükler: Amyand fıtığı, apendektomi, çocuk, boğulmuş kasık fıtığı.

GİRİŞ Kasık fıtığı kesesinde apendiksin bulunması Amyand hernisi olarak tanımlanır. Hastalık, 1735 yılında Londra’da, 11 yaşında bir çocuğun kasık fıtığı kesesinde perfore apendiks bularak başarılı bir apendektomi yapan Kral II. George’un cerrahı Claudius Amyand’ın adıyla literatüre geçmiştir.[1] Yetişkin hastalara uygulanan herniyoplastilerde fıtık kesesinde apendiks vermiformis bulunma sıklığı %0.51; akut apandisit bulunma sıklığı ise %0.10 olarak bildirilmiştir.[2] Sunumuzda boğulmuş kasık fıtığı nedeniyle ameliyat edilen bir yenidoğan ile elektif herniyoplasti sırasında karşılan bir pediatrik Amyand hernisi olgularını literatür eşliğinde değerlendirdik.

OLGU SUNUMU Olgu 1– İki gündür devam eden ağlama, huzursuzluk ve bir gündür eşlik eden safralı kusma şikâyetleriyle acil polikliniği-

İletişim adresi: Dr. Çetin Ali Karadağ, Dilek Sok., Çiçek Apt., No: 12/4, Dikilitaş, Beşiktaş, 34349 İstanbul Tel: +90 212 - 373 50 00 / 6187 E-posta: cakaradag@yahoo.com Kare kod

Ulus Travma Acil Cerr Derg 2013;19(5):488-490 doi: 10.5505/tjtes.2013.14306 Telif hakkı 2013 TJTES

488

mize başvuran on beş günlük erkek hastanın yapılan sistem muayenelerinde özellik yoktu; sağ kasık bölgesinin bölgesel incelemede palpasyona duyarlı 2-3 cm çapında redükte olmayan şişlik vardı. Boğulmuş kasık fıtığı ön tanısıyla istenilen ayakta direkt karın grafisinde özellik saptanmadı. Ultrasonografide (USG) ise kitle içerisinde aperistaltik nonkomprese dolaşımı bozulmuş apendiks olduğu öngörülen bağırsak ansı görülmesi üzerine hasta acil şartlarda ameliyata alındı. Sağ kasık transvers kesi ile girilerek indirekt fıtık kesesine ulaşıldı. Kese açıldığında içerisinde, mezenteri ile birlikte apendiksin bulunduğu ve orta kısımdan distale doğru dolaşımının bozulmuş olduğu görüldü (Şekil 1). İleri derecede dolaşım bozukluğuna rağmen henüz perforasyon olmamıştı. Aynı kesiden apendektomi yapıldıktan sonra standart fıtık onarımı ile işlem sonlandırıldı. Ameliyat sonrası takiplerinde özellik saptanmayan hasta ertesi gün sorunsuz taburcu edildi. Olgu 2– Bir hafta önce sağ kasığında şişlik fark edilen üç aylık erkek hastaya indirekt kasık fıtığı tanısı konuldu. Hastanın sistemik muayenesinde başka bir özellik saptanmadı. Elektif şartlarda sağ kasık transvers kesi ile girilerek indirekt fıtık kesesi bulundu. Kese kısmen fibrotik yapıdaydı ve çevreye yapışıklıkları vardı. Fıtık kesesi içerisinde redükte edilemeyen ince yapıda farklı bir doku olduğu görüldü. Kese açıldığında içerisindeki yapının uç kısmından keseye yapışık apendiks vermiformis olduğu görüldü (Şekil 2). Yapışmanın olduğu ortak duvarın elektrokoagülasyon ile disseke edilmesini takiben serbestleştirilen sağlam görünümlü apendiks karın içerisine redükte edildi. Ardından herniyoplasti yapılarak ameliyat sonlandırıldı. Hasta aynı gün sorunsuz olarak taburcu edildi. Ulus Travma Acil Cerrahi Derg, Eylül 2013, Cilt. 19, Sayı. 5


Çığşar ve ark. Amyand fıtığında apendektomi (a)

(b)

Şekil 1. (a) Boğulmuş fıtık kesesinden çıkarılan dolaşımı bozulmuş apendiks. (b) Distal ucundan kese içerisine yapışık sağlam yapıdaki apendiks.

TARTIŞMA Pediatrik hasta popülasyonunda kasık fıtıkları en sık cerrahi tedavi gerektiren hastalıktır. Literatüre bakıldığında 18 yaş altında bu hastalığın görülme sıklığı %0.8 ile %4.4 arasında değişmektedir.[3] Amyand fıtığı erkeklerde kadınlara göre daha sık görülmekte olup büyük çoğunluğu sağ kasık bölgesinde, nadiren de sol kasık bölgesinde yerleşim göstermektedir.[4] Amyand fıtığı çocuklarda, özellikle de infantil dönemde, çok seyrek görülmektedir.[6] Literatüre bakıldığında yenidoğanlarda amyand fıtığı ile ilgili çok az bildiri bulunduğundan kesin bir görülme sıklığı söylemek mümkün olmamaktadır.[6] Amyand fıtığı tedavisi, herni kesesinde bulunan apendiksin durumuna ve ek patoloji olup olmamamasına bağlı olarak, değişiklik gösterir. Kesede bulunan apendiks inflame görünümlü veya perfore olmuşsa, hastaya özel bir engel yoksa jeneralize peritonit ve sepsis riski almamak için aynı kesiden apendektomi yapılıp ardından herniyoplasti uygulanır.[5] Apendikste enflamatuvar bulgular yoksa tedavi tartışmalıdır. Enflamatuvar sürecin başlamamış olduğu Amyand fıtıkla karşılaşıldığında, ameliyata bağlı iritasyon sonucu apandisit gelişiminin engellenmesi ve ileride apandisit olma riskini ortadan kaldırmak için apendektomiyi savunan birçok yayın bulunmakla beraber,[6,7] profilaktik apandektomi yapılmasının yeterince kanıta dayanmadığı, kasık herniyoplasti gibi temiz bir cerrahiye enfeksiyon riski kattığı gerekçesiyle uygulamayan ekipler de vardır.[8,9] Amyand fıtığı çocuklarda nadir görülen bir klinik tablo olması dolayısıyla geniş seriler üzerinde yapılmış yeterli sayıda çalışma bulunmamaktadır. Dolayısıyla erişkinlerde olduğu gibi pediatrik yaş grubu hastalarda da tedavi konusunda bir fikir birliği yoktur. Birinci olguda Amyand fıtığı tanısını ameliyat öncesi yapılan USG ile, diğer olguda ise ameliyat sırasında koyduk. Tedavi şeklimize apendiksin olgudaki durumuna göre karar verdik. Ulus Travma Acil Cerrahi Derg, Eylül 2013, Cilt. 19, Sayı. 5

İlk olguda apendiks kese duvarlarına herhangi bir yapışıklığı olmadan kese içerisinde fakat dolaşımı bozuk ve inflame görünümdeydi. Bu olguda apendiksteki enflamatuvar sürecin ilerleyerek perforasyon olabileceğini düşündük ve aynı kesiden apandektomi yapmayı uygun bulduk. Ameliyat sonrası dönemde herhangi bir sorun yaşamadık. İkinci olguda ise apendiksin bir duvarı fıtık kesesiyle ortak olmakla beraber apendikste herhangi enflamasyon veya dolaşım bozukluğu bulguları saptamadık. Apendiksi fıtık kesesinden serbestleştirerek redükte edip karın içinde bırakmayı uygun bulduk. Bu olgumuzun da ameliyat sonrası takiplerinde herhangi bir komplikasyonla karşılaşmadık. Günümüzde apandiks, sürekli mesane kateterizasyonu gerektiren hastaların yaşam kalitesini artıran Mitrofanoff prosedürü (apendikovezikostomi) ve gaita inkontinansı olan hastalarda antegrad kontinans enema yapılmasını mümküm kılan Malone prosedüründe (apendikoçekostomi) sıkça kullanılan bir organdır.[10] Üriner sistem travmaları ardından üreter rekonstrüksiyonunda ve renal transplantasyonlarda üreter boyunu uzatmada kullanıldığı da bildirilmiştir.[11] İleride farklı rekonstrüktif cerrahilerde kullanma olasılığı nedeniyle mutlaka gerekmedikçe insidental apandektomiden kaçınılmalıdır. Sonuç olarak elektif veya acil olarak uygulanan pediatrik herniyoplasti olgularında cerrahlar Amyand fıtığı ile karşılaşabilirler. Pediatrik olgularda tüm organlar gibi apendiks de oldukça küçük olduğundan iyi disseke edilmeyen bir kasık fıtığı kesesi içinde rahatlıkla fark edilmeden bağlanabilir ve ameliyat sonrası komplikasyonlara yol açabilir. Özellikle sağ kasık herniyoplasti olgularında Amyand fıtığı olasılığı akılda tutulmalı ve küçük apendikslerin gözden kaçmasına neden olmamak için kural olduğu üzere kese mutlaka açılıp içi kontrol edilmelidir. Amyand fıtıklarında, apendektomi yapılıp yapılmamasına apendiksin komplike olup olmadığına göre karar verilmelidir. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir. 489


Çığşar ve ark. Amyand fıtığında apendektomi

KAYNAKLAR 1. Hutchinson R. Amyand’s hernia. J R Soc Med 1993;86:104-5. 2. Gurer A, Ozdogan M, Ozlem N, Yildirim A, Kulacoglu H, Aydin R. Uncommon content in groin hernia sac. Hernia 2006;10:152-5. 3. Bronsther B, Abrams MW, Elboim C. Inguinal hernias in children--a study of 1,000 cases and a review of the literature. J Am Med Womens Assoc 1972;27:522-5. 4. Meinke AK. Review article: appendicitis in groin hernias. J Gastrointest Surg 2007;11:1368-72. 5. Thomas WE, Vowles KD, Williamson RC. Appendicitis in external herniae. Ann R Coll Surg Engl 1982;64:121-2. 6. Livaditi E, Mavridis G, Christopoulos-Geroulanos G. Amyand’s hernia

in premature neonates: report of two cases. Hernia 2007;11:547-9. 7. Ofili OP. Simultaneous appendectomy and inguinal herniorrhaphy could be beneficial. Ethiop Med J 1991;29:37-8. 8. Cankorkmaz L, Ozer H, Guney C, Atalar MH, Arslan MS, Koyluoglu G. Amyand’s hernia in the children: a single center experience. Surgery 2010;147:140-3. 9. Sharma H, Gupta A, Shekhawat NS, Memon B, Memon MA. Amyand’s hernia: a report of 18 consecutive patients over a 15-year period. Hernia 2007;11:31-5. 10. Wheeler RA, Malone PS. Use of the appendix in reconstructive surgery: a case against incidental appendicectomy. Br J Surg 1991;78:1283-5. 11. Dagash H, Sen S, Chacko J, Karl S, Ghosh D, Parag P, et al. The appendix as ureteral substitute: a report of 10 cases. J Pediatr Urol 2008;4:14-9.

CASE R E P O R T - ABSTRACT

Should appendectomy be performed in Amyand’s hernia?: two case reports Emine Burcu Çığşar, M.D., Çetin Ali Karadağ, M.D., Nihat Sever, M.D., Ali İhsan Dokucu, M.D. Department of Pediatric Surgery, Şişli Etfal Training and Research Hospital, Istanbul, Turkey

The presence of appendix vermiformis in an inguinal hernia sac is called Amyand’s hernia. The disease is named after Claudius Amyand, who performed the first documented and successful appendectomy during a hernioplasty in 1975. Finding an appendix within an inguinal hernia is reported at a rate of 0.51%-1% in the adult population, whereas there is no reported frequency of Amyand’s hernia in children due to its rare occurrence. Here, we report two cases of Amyand’s hernia. The first is a newborn, diagnosed with strangulated Amyand’s hernia by preoperative ultrasound examination of the groin. In this case, the appendix had compromised blood supply, so we performed appendectomy during the hernioplasty. The second patient was diagnosed with Amyand’s hernia during elective hernioplasty. In this case, the appendix had no evidence of circulatory or inflammatory disorders, so we performed simple hernioplasty and left the appendix in the abdominal cavity. In Amyand’s hernia, there are no standards in approaching the appendix. Appendectomy is not a necessity unless there are circulatory or inflammatory injuries. Key words: Amyand’s hernia, pediatric, strangulated inguinal hernia, acute appendicitis. Ulus Travma Acil Cerr Derg 2013;19(5):488-490

490

doi: 10.5505/tjtes.2013.14306

Ulus Travma Acil Cerrahi Derg, Eylül 2013, Cilt. 19, Sayı. 5


Travma 2013 5