Aortic rupture in high-speed skiing crashes

BACKGROUND: New equipment and techniques in winter sports, such as carving skis and snowboards, have brought up new trauma patterns into the spectrum of leisure trauma. The injuries resemble high-energy trauma known from road crashes. The aim of the present study was to assess the incidence of acute traumatic descending aortic rupture in recreational skiing-crashes. MATERIAL: Between January 1995 and December 2004, 22 patients were admitted to our hospital for aortic rupture. Four patients had skiing crashes (18.2%). Mean age was 31 years, all patients were male. In two cases, aortic rupture was associated with fractures of the upper and lower extremities. One patient additionally had a cerebral contusion with an initial Glasgow Coma Scale score of 13. In two patients, isolated aortic rupture was diagnosed. RESULTS: Two patients were treated by graft interposition, and one by endograft. One patient arrived under mechanical resuscitation without blood pressure. He died at admission. He had been observed for 5 hours in another hospital, complaining of severe intrascapular back pain, before transport to our trauma unit for unknown bleeding. In the other three cases, treatment was successful. CONCLUSION: Rescue services and paramedics should be aware of this new type of injury. Acute aortic rupture has to be considered as possible injury in high velocity skiing crashes.

Traumatic free wall and ventricular septal rupture - 'hybrid' management in a child

A 8-year-old boy showed a traumatic ventricular septal rupture following a blunt chest trauma, and was scheduled for elective catheter closure. Two weeks later, a follow-up echocardiogram revealed a pseudoaneurysm of the anterior wall of the left ventricle. Because of the apical location of the VSD, it was decided to proceed with transcatheter occlusion. After successful VSD closure, the patient was taken to the operation room for surgical repair of the left ventricular pseudoaneurysm. Symptoms and signs seen in patients with ventricular pseudoaneurysms appear to be discrete and variable, and a high clinical index of suspicion with a very close echocardiographic follow-up is strongly recommended after occurrence of a blunt cardiac trauma. The combined 'hybrid' approach of transcatheter closure of the intraventricular rupture followed by surgical closure of the pseudoaneurysm allows for a less invasive and efficient management of this rare combination of post-traumatic ventricular free wall and septal rupture in a child.

Reduction of airspace after lung resection through controlled paralysis of the diaphragm

OBJECTIVES: Residual airspace following thoracic resections is a common clinical problem. Persistent air leak, prolonged drainage time, and reduced hemostasis extend hospital stay and morbidity. We report a trial of pharmacologic-induced diaphragmatic paralysis through continuous paraphrenic injection of lidocaine to reduced residual airspace. The objectives were confirmation of diaphragmatic paralysis and possible procedure related complications. METHODS: Six eligible patients undergoing resectional surgery (lobectomy or bilobectomy) were included. Inclusion criteria consisted of: postoperative predicted FEV1 greater than 1300 ml, right-sided resection, absence of parenchymal lung disease, no class III antiarrhythmic therapy, absence of hypersensitivity reactions to lidocaine, no signs of infection, and informed consent. Upon completion of resection an epidural catheter was attached in the periphrenic tissue on the proximal pericardial surface, externalized through a separate parasternal incision, and connected to a perfusing system injecting lidocaine 1% at a rate of 3 ml/h (30 mg/h). Postoperative ICU surveillance for 24h and daily measurement of vital signs, drainage output, and bedside spirometry were performed. Within 48 h fluoroscopic confirmation of diaphragmatic paralysis was obtained. The catheter removal coincided with the chest tube removal when no procedural related complications occurred. RESULTS: None of the patients reported respiratory impairment. Diaphragmatic paralysis was documented in all patients. Upon removal of catheter or discontinuation of lidocaine prompt return of diaphragmatic motility was noticed. Two patients showed postoperative hemodynamic irrelevant atrial fibrillation. CONCLUSION: Postoperative paraphrenic catheter administration of lidocaine to ensure reversible diaphragmatic paralysis is safe and reproducible. Further studies have to assess a benefit in terms of reduction in morbidity, drainage time, and hospital stay, and determine the patients who will profit.

Mice with a targeted disruption of the Fgfrl1 gene die at birth due to alterations in the diaphragm

FGFRL1 is a recently discovered member of the fibroblast growth factor receptor family that is lacking the intracellular tyrosine kinase domain. To elucidate the function of the novel receptor, we created mice with a targeted disruption of the Fgfrl1 gene. These mice develop normally until term, but die within a few minutes after birth due to respiratory failure. The respiratory problems are explained by a significant reduction in the size of the diaphragm muscle, which is not sufficient to inflate the lungs after birth. The remaining portion of the diaphragm muscle appears to be well developed and innervated. It consists of differentiated myofibers with nuclei at the periphery. Fast and slow muscle fibers occur in normal proportions. The myogenic regulatory factors MyoD, Myf5, myogenin and Mrf4 and the myocyte enhancer factors Mef2A, Mef2B, Mef2C and Mef2D are expressed at normal levels. Experiments with a cell culture model involving C2C12 myoblasts show that Fgfrl1 is expressed during the late stages of myotube formation. Other skeletal muscles do not appear to be affected in the Fgfrl1 deficient mice. Thus, Fgfrl1 plays a critical role in the development of the diaphragm.

Clinical presentation of a traumatic cervical spine disc rupture in alpine sports: a case report

ABSTRACT: Isolated non-skeletal injuries of the cervical spine are rare and frequently missed. Different evaluation algorithms for C-spine injuries, such as the Canadian C-spine Rule have been proposed, however with strong emphasis on excluding osseous lesions. Discoligamentary injuries may be masked by unique clinical situations presenting to the emergency physician. We report on the case of a 28-year-old patient being admitted to our emergency department after a snowboarding accident, with an assumed hyperflexion injury of the cervical spine. During the initial clinical encounter the only clinical finding the patient demonstrated, was a burning sensation in the palms bilaterally. No neck pain could be elicited and the patient was not intoxicated and did not have distracting injuries. Since the patient described a fall prevention attempt with both arms, a peripheral nerve contusion was considered as a differential diagnosis. However, a high level of suspicion and the use of sophisticated imaging (MRI and CT) of the cervical spine, ultimately led to the diagnosis of a traumatic disc rupture at the C5/6 level. The patient was subsequently treated with a ventral microdiscectomy with cage interposition and ventral plate stabilization at the C5/C6 level and could be discharged home with clearly improving symptoms and without further complications.This case underlines how clinical presentation and extent of injury can differ and it furthermore points out, that injuries contracted during alpine snow sports need to be considered high velocity injuries, thus putting the patient at risk for cervical spine trauma. In these patients, especially when presenting with an unclear neurologic pattern, the emergency doctor needs to be alert and may have to interpret rigid guidelines according to the situation. The importance of correctly using CT and MRI according to both - standardized protocols and the patient's clinical presentation - is crucial for exclusion of C-spine trauma.

The feasibility of non-viral gene transfer to the diaphragm in vivo

Gene transfer using electroporation is an essential method for the study of developmental biology, especially to understand the internal control of degeneration and apoptosis of the muscle cells that occurs earlier and quicker than the usual degeneration process occurring by aging. Such experimental studies may have a role in developing new strategies for treating patients suffering from inherited primary myopathies such as Duchenne muscular dystrophy (DMD). The present study was designed to evaluate the feasibility of electroporation mediated transfer of reporter genes to the diaphragm in vivo. This is the first report of gene transfer of naked plasmid DNA into the diaphragm muscle in vivo using electroporation. Our results showed that in vivo gene transfer of naked plasmid DNA into the diaphragm muscle using electroporation is feasible.

Atraumatic splenic rupture in amyloidosis

BACKGROUND: Splenic involvement in amyloidosis is rather frequent (5-10%). An atraumatic rupture of the affected spleen is however an extremely rare event. We report on a patient with undiagnosed amyloidosis who underwent emergency splenectomy for atraumatic splenic rupture. METHODS: Review of the literature and identification of 31 patients, including our own case report, with atraumatic splenic rupture in amyloidosis. Analysis of the clinical presentation, the surgical management, the nomenclature and definition of predisposing factors of splenic rupture. RESULTS: We identified 15 women and 16 men (mean age 53.3 +/- 12.4 years; median 52, range: 27-82 years) with an atraumatic splenic rupture. Easy skin bruisability and factor X deficiency were detected in four (13%) and five patients (16%), respectively. The diagnosis of splenic rupture was made either by computed tomography (n = 12), ultrasound (n = 5), exploratory laparotomy (n = 9) or autopsy (n = 4). All patients underwent surgery (n = 27) or autopsy (n = 4). Amyloidosis was previously diagnosed in nine patients (29%). In the remaining 22 patients (71%), the atraumatic splenic rupture represented the initial manifestation of amyloidosis. Twenty-five patients (81%) suffered from primary (AL) and four patients (13%) from secondary amyloidosis (AA). In two patients, the type of amyloidosis was not specified. A moderate splenomegaly was a common feature (68%) and the characteristic intraoperative finding was an extended subcapsular hematoma with a limited parenchymal laceration (65%). In five patients with known amyloidosis, the atraumatic splenic rupture was closely associated with autologous stem-cell transplantation (ASCT) (16%). Three patients were suffering from multiple myeloma (10%). A biopsy-proven amyloidotic liver involvement was present in 14 patients (45%), which lead to atraumatic liver rupture in two patients. The splenic rupture related 30-day mortality was 26% (8/31). CONCLUSIONS: Atraumatic splenic rupture in amyloidosis is associated with a high 30-day mortality. It occurs predominantly in patients with previously undiagnosed amyloidosis. A moderate splenomegaly, coagulation abnormalities (easy skin bruisability, factor X deficiency) and treatment of amyloidosis with ASCT are considered predisposing factors for an atraumatic splenic rupture.

Systematic review of atraumatic splenic rupture

BACKGROUND: Atraumatic splenic rupture (ASR) is an ill defined clinicopathological entity. METHODS: The aim was to characterize aetiological and risk factors for ASR-related mortality in order to aid disease classification and treatment. A systematic literature review (1980-2008) was undertaken and logistic regression analysis employed. RESULTS: Some 632 publications reporting 845 patients were identified. The spleen was normal in 7.0 per cent (atraumatic-idiopathic rupture). One, two or three aetiological factors were found in 84.1, 8.2 and 0.7 per cent respectively (atraumatic-pathological rupture). Six major aetiological groups were defined: neoplastic (30.3 per cent), infectious (27.3 per cent), inflammatory, non-infectious (20.0 per cent), drug- and treatment-related (9.2 per cent) and mechanical (6.8 per cent) disorders, and normal spleen (6.4 per cent). Treatment comprised total splenectomy (84.1 per cent), organ-preserving surgery (1.2 per cent) or conservative measures (14.7 per cent). The ASR-related mortality rate was 12.2 per cent. Splenomegaly (P = 0.040), age above 40 years (P = 0.007) and neoplastic disorders (P = 0.008) were associated with increased ASR-related mortality on multivariable analysis. CONCLUSION: The condition can be classified simply into atraumatic-idiopathic (7.0 per cent) and atraumatic-pathological (93.0 per cent) splenic rupture. Splenomegaly, advanced age and neoplastic disorders are associated with increased ASR-related mortality.

Right ventricular rupture after lateral thoracotomy for removal of rib-associated telangiectatic osteosarcoma in a dog

OBJECTIVE: To describe a case of a focal right ventricular rupture following removal of a rib-associated telangiectatic osteosarcoma (TOS) in a dog. CASE SUMMARY: A 2-year-old spayed female mixed-breed dog, weighing 20 kg, was presented in compensated hypovolemic shock due to active bleeding into the thoracic cavity. The dog was stabilized with appropriate fluid administration. Subsequent computed tomographic examination revealed a large mineralized mass originating from the body of a rib and displacing the heart. Two days after surgical removal of this mass, focal right ventricular rupture occurred and the dog died. The mass was later identified as a TOS. NEW OR UNIQUE INFORMATION PROVIDED: Although hemothorax secondary to TOS has been described previously, this report describes for the first time, spontaneous focal right ventricular rupture as a rare complication of thoracotomy and rib resection for the removal of a rib-associated, intrathoracic TOS.

Type II DeBakey dissection with complete aortic rupture visualized by unenhanced postmortem imaging

We present postmortem computed tomography (pmCT) as well as postmortem magnetic resonance (pmMR) imaging findings in a case of type II DeBakey aortic dissection with a complete rupture of the ascending aorta compared to the findings obtained at forensic autopsy. PmCT only allowed a presumptive diagnosis of aortic dissection based on an anterior mediastinal enlargement. However, at pmMR the dissection including the aortic rupture was clearly visible. Visualization was realized in an unenhanced manner without the need for postmortem angiography.

Nitric oxide metabolite production in the cranial cruciate ligament, synovial membrane, and articular cartilage of dogs with cranial cruciate ligament rupture

OBJECTIVE To measure concentrations of nitric oxide metabolites (nitrite-nitrate [NOt]) in cartilage, synovial membrane, and cranial cruciate ligament (CCL) in dogs and evaluate associations with osteoarthritis in dogs with CCL rupture. ANIMALS 46 dogs with CCL rupture and 54 control dogs without joint disease. PROCEDURE Tissue specimens for histologic examination and explant culture were harvested during surgery in the CCL group or immediately after euthanasia in the control group; NOt concentrations were measured in supernatant of explant cultures and compared among dogs with various degrees of osteoarthritis and between dogs with and without CCL rupture. RESULTS Osteoarthritic cartilage had significantly higher NOt concentration (1,171.6 nmol/g) than did healthy cartilage (491.0 nmol/g); NOt concentration was associated with severity of macroscopic and microscopic lesions. Synovial membrane NOt concentration did not differ between dogs with and without CCL rupture. Ruptured CCL produced less NOt than did intact ligaments. In control dogs, NOt concentrations were similar for intact ligaments (568.1 nmol/g) and articular cartilage (491.0 nmol/g). Synthesis of NOt was inhibited substantially by coincubation with inhibitors. CONCLUSIONS AND CLINICAL RELEVANCE Results suggest that NOt in canine joint tissues originates from the inducible nitric oxide synthase pathway. Nitric oxide metabolite production in cartilage was greater in dogs with osteoarthritis than in healthy dogs and was associated with lesion severity, suggesting that nitric oxide inhibitors may be considered as a treatment for osteoarthritis. The CCL produces substantial concentrations of NOt; the importance of this finding is unknown.