Trauma

Major trauma affects more than 20 000 people per annum in the UK. Some three quarters of these patients will experience moderate-to-severe pain either as a direct result of their injuries or during the course of their management. Acute pain is associated with activation of the stress response. Poorly treated pain can also result in considerable psychological stress, which can impact on ongoing treatment and rehabilitation post-injury. Additionally, pain may persist to become chronic pain — up to two-thirds of major trauma victims report ongoing pain severe enough to affect quality of life for several years after injury. Delivery of effective analgesia has been shown to reduce the adverse effects on outcome associated with undertreated pain.

Tibial plateau fractures are uncommon injuries of the proximal tibia which vary in severity from minimally displaced stable injuries to high energy complex fractures with significant articular and metaphyseal comminution and severe associated soft tissue injuries. Following initial assessment and appropriate investigation a number of management options are available to the treating surgeon. We discuss the presentation, initial management and investigation as well as outlining the various treatment options with an emphasis on operative treatment. We further discuss the common complications and outcomes following tibial plateau fracture.

Background: Each year, traumatic injury accounts for large number of patient admissions and deaths in the US. Injuries have tremendous public health implications, and controlling and treating traumatised patients is an essential part of any health delivery system. Nonetheless, traumatised patients whose terminal hospitalisation ends in the intensive care unit (ICU) are a particular demographic group that has not been well studied.

Methods: Here, we review demographic trends, critical care unit utilisation and outcomes for trauma patients. Based on the available data, we discuss issues related to specific patient groups (such as the elderly), management of end-of-life patients in the ICU, views of medical professionals relative to end-of-life care and costs associated and with care of terminally ill patients. In this context, we also review and discuss recent data on withdrawal of life-sustaining therapies for trauma patients.

Conclusions: We conclude that it is difficult for physicians, patients and their families to recognise when care should focus on comfort rather than aggressive interventions that prolong dying. This is particularly difficult in situations of trauma, where unexpected injury causes profound disability. Nonetheless, the challenges pertain to trauma patients as they do to all critically ill patients, where providing an ethical and dignified death can be as heroic as aggressive measures to save life. More studies are needed to determine how we can best meet the needs of terminally ill trauma patients and their families.

Pneumomediastinum (PM) is an uncommon finding after blunt trauma to the neck or chest. Motor vehicle collisions are the most common cause in adults, while falls are the most common in children. The majority of traumatic PM results from medial tracking of air from a concomitant pneumothorax. The Macklin effect, of air tracking medially along peribronchial sheaths from alveolar rupture, is responsible for most other cases. Chest pain is the most common symptom, and crepitus the most common sign. The majority of PM will resolve spontaneously, and requires no specific intervention. Only 1—6% of cases result from rupture of the larynx, trachea, bronchi or oesophagus. Hoarseness, dyspnea, persistent lung collapse or air leak should increase suspicion for aerodigestive injury. Computed tomography (CT) can help differentiate benign etiology from those that require surgical correction. High suspicion for aerodigestive injury based on clinical and/or CT findings should prompt diagnostic bronchoscopy and/or oesophagram.

Stress fractures are common overuse type injuries, caused by repetitive stresses applied to bone leading to a change within the normal physiological balance and altering key structural properties. These injuries have been well documented within certain groups of the population, as well as related to certain activity types, and pose significant diagnostic and treatment challenges. Complication of stress fractures can vary dependant of the anatomical site and the prognosis of an injury can have wide ranging effects, dependant of lifestyle choices and occupation of the patient. This piece endeavours to outline the most current and evidentiary concepts pertaining to important aspects of stress fractures, from pathophysiology through to prognosis.

A priority for all trauma patients is rapid assessment and appropriate, prompt and effective management of the airway. Adequate ventilation and tissue oxygenation can prevent hypoxic injury, particularly within the central nervous system. Failure to secure the airway soon enough is a major cause of preventable death following significant injury (Ivatury and Guilford, 2008). Many controversial issues surround the management of the trauma airway including the effect of early tracheal intubation on morbidity and mortality, the variation in failed intubation rates for paramedics compared with physicians, and the use of manual in-line stabilisation and cricoid pressure during tracheal intubation. Studies have attempted to address these and other questions related to airway management in trauma patients. Unfortunately, many variables within the studies make interpretation of the results difficult. This review aims to summarise the key issues in relation to all of these controversies.

The spleen and liver are two organs commonly injured in various forms of abdominal trauma. Their relative size, relatively fixed positions, and abundant vascular supply make them prone both to injury and potential sources of catastrophic haemorrhage. With the evolution of computed tomography (CT), there has been a paradigm shift in the management of such injuries from operative to non-operative means. Advances in imaging techniques have also enabled clinicians to observe such patients for development of complications, and when appropriate, utilise the repertoire of interventional radiology techniques available. This review aims to summarise the epidemiology of splenic and hepatic trauma, the mechanisms of trauma and the classifications used in describing these injuries. The role of commonly used imaging modalities, namely ultrasound and CT, both in the acute setting and in observation of these patients for delayed complications is described, and finally a brief description of the current management strategies of such injuries is given.

Sir Archibald McIndoe is undoubtedly one of the greatest surgeons of the twentieth century. He is widely regarded as being one of the founding fathers of plastic surgery. Throughout his early career McIndoe had shown signs of his potential by winning numerous prizes and being awarded various scholarships. During the Second World War McIndoe was appointed civilian consultant plastic surgeon to the Royal Air Force, at the East Grinstead hospital. Here he worked with RAF servicemen who had suffered horrific burns. McIndoe not only pioneered new techniques for treating and reconstructing these servicemen’s injuries, he also developed new methods for reducing the risk and preventing them from happening to other servicemen. McIndoe was renowned not only for his technical brilliance and innovations in plastic surgery but also for the huge dedication he made towards his patient’s rehabilitation and return to society. McIndoe was able to inspire the staff at the East Grinstead hospital to help him achieve this goal by emphasising the importance of teamwork and total patient care. For his outstanding work McIndoe received numerous accolades at home and abroad and was knighted in 1947.