Journal of Trauma and Injury

Case Reports

Fatal fat embolism syndrome in a young trauma patient with a stable initial presentation: time to define predictive criteria? A case report: Nebojsa Brezic, Strahinja Gligorevic, Tatjana Atanasijevic, Vladimir Zivkovic, Bojan Jovanovic; Received October 23, 2024 Accepted February 6, 2025 Published online April 21, 2025; DOI: https://doi.org/10.20408/jti.2024.0072 [Epub ahead of print]

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Abstract PDF: Fat embolism syndrome (FES) is a rare but serious complication most commonly associated with trauma, particularly long bone fractures. However, symptomatic FES remains a significant diagnostic and therapeutic challenge. We present the case of a 20-year-old man who, after sustaining multiple long bone fractures in a motorcycle accident and initially appearing stable, experienced a rapid and fatal progression of FES. This case underscores the unpredictable course of FES even in young, previously healthy individuals and highlights the critical need for early recognition and intervention. It also emphasizes the importance of identifying risk factors that may predict severe outcomes and mortality.; Summary

Traumatic globe avulsion secondary to a penetrating orbital injury from a bicycle handlebar: a case report: Nishanth S. Iyengar, Edward Xie, Patricia Pahk, Nariman S. Boyle; Received October 23, 2024 Accepted January 5, 2025 Published online April 1, 2025; DOI: https://doi.org/10.20408/jti.2024.0070 [Epub ahead of print]

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Abstract PDF: A 60-year-old man presented with total avulsion of the right globe following a penetrating injury to the right orbit from a metal bicycle handlebar. There was no light perception in the right eye on presentation. External examination revealed a full-thickness, canalicular-involving, horizontal right upper eyelid laceration through which the luxated globe and other orbital contents extruded. The globe was intact. The patient underwent urgent surgical exploration. In the operating room the optic nerve and all extraocular muscles were found to be completely transected from the globe. The globe was enucleated, and the eyelid laceration was repaired with bicanalicular stent placement.; Summary

Editorial

The remarkable growth and international recognition of the Journal of Trauma and Injury: Gil Jae Lee; J Trauma Inj. 2025;38(1):1-2. Published online March 31, 2025; DOI: https://doi.org/10.20408/jti.2025.0058

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Original Articles

Patients with intentional punch injuries in the emergency department: a retrospective cohort study: İbrahim Toker, Ömer Salt, Taner Şahin, Mükerrem Altuntaş, İrfan Gökçek, Murat Eşlik, İbrahim Tüysüz, Baycan Kuş, Muhammed İslam Özer; J Trauma Inj. 2025;38(1):32-37. Published online March 31, 2025; DOI: https://doi.org/10.20408/jti.2025.0022

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Abstract PDF: Purpose
Hand and wrist injuries represent some of the most common traumatic conditions encountered in the emergency department (ED). Our study aimed to elucidate the demographic and clinical characteristics of patients sustaining intentional punch injuries.
Methods
This single-center retrospective study involved patients aged 16 years and older who presented to the ED with intentional punch injuries in 2023.
Results
A total of 405 patients were included in the study. The median patient age was 30 years (interquartile range, 22–40 years), and 363 (89.6%) were male. Among the patients, a total of 389 fractures were identified in 362 patients (89.4%). Metacarpal bone fractures were the most common, with 372 fractures (95.6%). The fifth metacarpal was the most frequently injured (67.4%), followed by the fourth (10.0%) and third (7.7%) metacarpals. Although the most common base fracture occurred in the first metacarpal, shaft fractures were most prevalent in the second, third, fourth, and fifth metacarpals. Overall, 259 patients (71.5%) had nondisplaced fractures. Additionally, 31 patients (7.7%) had previously been admitted to the ED for punching, 17 (4.2%) had prior ED visits for trauma resulting in a fracture, and 63 (15.6%) reported a history of psychiatric drug use.
Conclusions
Young men represent the majority of intentional punch injury patients. The fifth metacarpal and its shaft fractures were most commonly observed. A history of prior ED visits for punching or trauma, as well as psychiatric medication use, may serve as potential risk factors.; Summary

Clinical profile, management, and outcome of pediatric neurotrauma: a multicentric observational study: Sanat Kumar Khanna, Anil Kumar, Anand Kumar Katiyar, Kundan Mishra; J Trauma Inj. 2025;38(1):22-31. Published online March 31, 2025; DOI: https://doi.org/10.20408/jti.2024.0080

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Abstract PDF: Purpose
Pediatric neurotrauma (pNT) includes pediatric traumatic brain injury and spinal cord injury. The incidence and distribution of pNT by age and sex remain understudied, with several gaps in both epidemiological and clinical data. This study aimed to estimate the epidemiological parameters, clinical presentations, surgical interventions, and outcomes in our patient population with pNT.
Methods
A multicentric, ambispective study was conducted at five tertiary care pediatric neurosurgical centers in Northern India from January 2011 to December 2022. The study included children under 16 years of age admitted with a history of head injury. Data on demographics, radiological findings, management, and outcomes were recorded.
Results
A total of 2,250 children were admitted; 77.5% were male and 22.5% were female. The most common age group was 6 months to 2 years (37.3%). The primary mechanism of injury was fall from height (64.6%), followed by road traffic accidents (26.1%). Overall, 84.6% of children had mild head injury, 14.2% moderate, and 1.2% severe. The most common abnormality on computed tomography brain was contusion (9.2%). Surgical interventions were required in only 0.8% of children. A favorable outcome, as measured by Glasgow Outcome Scale, was achieved in 99.2% of patients, and the mortality rate was 0.1%.
Conclusions
Our findings indicate that pNT is most common in children aged 6 months to 2 years and predominantly affects boys. The most frequent cause was a fall from height, and the majority of patients sustained mild head injuries requiring only observation, which led to excellent outcomes. Surgical intervention was necessary in only a few cases, and mortality was rare. This study highlights the epidemiological pattern of pNT in our population and delineates various causes of such trauma.; Summary

Review Article

Infection prevention and treatment following dog bites: a systematic review of randomized controlled trials: Yongsik Yoon, Dukho Kim, Dongwuk Lee, Hyeongyu Min, Junhyuk Choi; J Trauma Inj. 2025;38(1):3-13. Published online March 31, 2025; DOI: https://doi.org/10.20408/jti.2024.0069

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Abstract PDF Supplementary Material: Purpose
Dog bites pose a significant global public health challenge, with outcomes that range from minor injuries to fatalities. Despite their prevalence, no consensus has been established regarding the most effective prevention and treatment strategies. This systematic review aimed to consolidate and evaluate randomized controlled trials (RCTs) examining the effectiveness of interventions in preventing and treating dog bites.
Methods
A comprehensive search was conducted across the CINAHL, Embase, MEDLINE, Web of Science, and PubMed databases for RCTs published within the last 10 years. Studies were included if they focused on interventions to prevent or treat dog bites. Primary outcomes included the infection rate and recovery time of dog bites, the effectiveness of interventions in preventing or reducing bite severity, and associated health outcomes. The risk of bias was assessed using the Cochrane Collaboration tool.
Results
Five RCTs met the eligibility criteria, with a total of 1,148 participants. These studies examined various interventions, including medical techniques (medical glue, negative pressure wound therapy, and hyperbaric oxygen therapy), wound management strategies (primary suturing versus non-suturing), and educational interventions. A meta-analysis of four studies revealed no significant difference in infection rates between the intervention and control groups (risk ratio, 0.69; 95% confidence interval [CI], 0.27–1.77; I2=62%; P=0.44). However, the interventions examined in each study demonstrated shorter recovery times (mean difference, 11.25 days; 95% CI, 8.44–14.07 days; I2=99%; P<0.001).
Conclusions
Although the included studies suggest potential benefits of certain interventions in treating dog bites, particularly in reducing recovery time, the evidence regarding infection prevention remains inconclusive. The limited number of high-quality RCTs in this field highlights the need for further research to establish evidence-based guidelines for dog bite prevention and treatment.; Summary

Original Article

Changes in the clinical features and demographics of donors after brain death, before and after the establishment of a regional trauma center: 20 years of experience at a single center in Korea: Myung Jin Jang, Sang Tae Choi, Gil Jae Lee, Doo Jin Kim, Won Suk Lee; J Trauma Inj. 2025;38(1):14-21. Published online March 31, 2025; DOI: https://doi.org/10.20408/jti.2024.0068

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Abstract PDF: Purpose
Organ transplantation is considered the definitive treatment for end-stage organ disease. However, the scarcity of donor organs compared to the number of patients awaiting transplants is a major barrier. This study aimed to assess the impact of a regional trauma center on organ procurement and to provide a basis for future collaboration between regional trauma centers and transplant centers.
Methods
This retrospective study analyzed organ donors after brain death over a 20-year period from January 1, 2003, to December 31, 2022. It compared patients before and after the establishment of the regional trauma center, as well as trauma and nontrauma patients. The study investigated general patient characteristics and the number and types of donated organs.
Results
The average age of patients significantly increased from 37.75 years before the trauma center was established to 46.72 years after (t=–4.32, P<0.001). The organ acquisition rate significantly increased from 3.03 before to 3.47 after (t=–2.96, P=0.003). Suicide (t=6.52, P=0.011) and cardiopulmonary resuscitation cases were more common among nontrauma patients than among trauma patients (t=8.34, P=0.004). However, the organ acquisition rate was significantly higher among trauma patients than among nontrauma patients (3.53 vs. 3.21; t=2.04, P=0.004).
Conclusions
This study identified changes in the characteristics and donor organs of patients diagnosed with brain death after the establishment of a regional trauma center. Given the increase in the proportion of trauma patients and the rate of organ acquisition per capita post-establishment, efforts should be made to encourage organ donation from patients diagnosed with brain death through close collaboration between regional trauma centers and organ transplant centers.; Summary

Case Reports

The SPAIRE (saving piriformis and internus, repair of externus) posterolateral approach in bipolar hemiarthroplasty for femoral neck fractures: a case report: Nazim Sifi, Sorin Suba; Received December 16, 2024 Accepted January 12, 2025 Published online March 25, 2025; DOI: https://doi.org/10.20408/jti.2024.0099 [Epub ahead of print]

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Abstract PDF: Femoral neck fractures commonly occur in older patients and typically require surgical intervention to promptly restore mobility and minimize complications. While the anterior, lateral, and posterior approaches are frequently employed for hemiarthroplasty, each has its own benefits and drawbacks. Notably, the posterior approach has been linked to a higher risk of dislocation in some studies. The SPAIRE (saving piriformis and internus, repair of externus) technique is a modern adaptation of the traditional posterolateral approach. This less invasive, anatomically considerate method preserves the piriformis muscle tendon and the conjoint tendon of the superior gemellus, obturator internus, and inferior gemellus muscles. However, it involves sectioning the tendon of the obturator externus muscle. The technique is designed to maintain stabilizing muscular structures, decrease dislocation risk, and hasten functional recovery, including in patients with neurological conditions. This case report describes the treatment of a 79-year-old woman with a transcervical fracture of the right femoral neck. A bipolar hemiarthroplasty was performed using the SPAIRE technique. The procedure effectively preserved the functional synergistic unit of the piriformis-conjoint tendon (quadriceps coxa) and included meticulous capsular and tendinous repair. The patient's postoperative recovery was characterized by an excellent functional outcome at the 3-month follow-up. This case highlights the advantages of the SPAIRE technique in enhancing joint stability and facilitating rapid recovery, especially in geriatric patients.; Summary

Successful treatment of hemophagocytic lymphohistiocytosis in a trauma patient: a case report: Young Soo Chung, Jihoon Kim; J Trauma Inj. 2025;38(1):66-70. Published online March 25, 2025; DOI: https://doi.org/10.20408/jti.2024.0093

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Abstract PDF: Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening hyperinflammatory syndrome characterized by excessive activation of the immune system. This case report describes an unusual presentation of HLH triggered by severe trauma from a motorcycle accident, which is a departure from traditional associations with infections, malignancies, or autoimmune conditions. A 40-year-old man with multiple traumatic injuries developed persistent fever, pancytopenia, and elevated inflammatory markers following orthopedic surgery. Despite empiric antibiotic therapy, his condition deteriorated, exhibiting high fever, skin rash, hepatic dysfunction, and marked elevation of ferritin levels (32,901 ng/mL). Bone marrow biopsy confirmed the diagnosis of HLH, and treatment was initiated according to the HLH-2004 protocol, which included methylprednisolone, intravenous immunoglobulin, and immunosuppressive therapy. The patient demonstrated significant clinical improvement and was discharged after 37 days, with no recurrence observed during the follow-up period. This case underscores the need to consider HLH in trauma patients presenting with unexplained inflammatory responses and illustrates that prompt diagnosis and aggressive treatment can lead to successful outcomes.; Summary

Resolution is not the end: The Macklin effect after chest tube removal in a trauma patient with aging and comorbidities: a case report: Faye Abdulkareem, Fayez G. Aldarsouni, Sahar Alomar, Zisis Touloumis, Hussain M. AlHassan, Ghassan Z. Al Ramahi, Tareq Alsabahi, Khaled Twier, Mohammad Alsenani, Emad Alamoudi; Received December 1, 2024 Accepted January 12, 2025 Published online March 25, 2025; DOI: https://doi.org/10.20408/jti.2024.0090 [Epub ahead of print]

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Abstract PDF: Pneumomediastinum is an uncommon complication in cases of blunt chest trauma but can signal severe underlying issues. This report discusses a 69-year-old male patient with preexisting conditions of obesity, sleep apnea, and asthma, who experienced delayed pneumomediastinum and pneumopericardium following the removal of a chest tube. This tube had been placed to address a traumatic hemopneumothorax, which had resolved. The removal of the chest tube triggered a series of events, exacerbated by the patient's chronic health conditions. The patient was managed conservatively with close monitoring and physiotherapy, which successfully resolved the condition without the need for further invasive procedures. The multifactorial nature of the Macklin effect illustrates that even routine procedures such as chest tube removal can trigger a chain reaction in susceptible patients. The choice of conservative management, rather than immediate invasive interventions, underscores the delicate balance necessary in trauma care.; Summary

Cerebral fat emboli monitoring using transcranial Doppler ultrasound and confirmation of a successful treatment response: a case report: Morgan Jude, Ryan Martin, Ivy Nguyen, Christine Cocanour, Heather Nicoletto, Keyanna Raihani, Alicia Alley, Jeffrey R. Vitt; Received October 25, 2024 Accepted January 5, 2025 Published online March 25, 2025; DOI: https://doi.org/10.20408/jti.2024.0075 [Epub ahead of print]

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Abstract PDF: Fat emboli syndrome is a rare and potentially fatal condition that most commonly manifests after traumatic long-bone fractures. Cerebral fat emboli are one of the most feared complications leading to permanent neurologic injury, though methods for optimal monitoring in high-risk patients are lacking. We present a case of a 16-year-old female patient who presented to the emergency department following a motor vehicle collision with multiple injuries, including a comminuted femoral shaft and pelvic ring fracture, as well as an acute basilar artery occlusion due to fat embolism. Continuous transcranial Doppler ultrasound (TCD) of the bilateral middle cerebral arteries was utilized for emboli detection and evaluation of right-to-left shunt. The patient was found to have a high burden of microemboli on TCD in combination with a right-to-left shunt conferring increased risk of additional neurologic injury. Following surgical fixation of her orthopedic injuries, repeated TCD assessment demonstrated no further evidence of microemboli thus demonstrating efficacious response to definitive treatment. This report highlights the utility of TCD for early monitoring and detection of cerebral emboli in patients at risk for fat emboli syndrome as well as evaluating response to intervention.; Summary

Similarities and differences between lightning and electrical injuries: two case reports: Yi Liu, Zosimo Ken L. Jimeno, Wan Azman Wan Sulaiman; Received October 18, 2024 Accepted December 23, 2024 Published online March 25, 2025; DOI: https://doi.org/10.20408/jti.2024.0067 [Epub ahead of print]

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Abstract PDF: Exposure to electrical current, whether through accidental contact in residential or industrial settings or via lightning strikes, represents a serious global health concern. Although numerous studies have been published on the differences between electrical and lightning injuries, they are often discussed together due to the similarities in their clinical presentations, management approaches, and outcomes. The question of whether electrical and lightning injuries should be studied together remains a matter of debate. Here, we present two cases: one of a lightning injury and another of an electrical injury. Our discussion aims to improve the understanding of lightning and electrical injuries as distinct entities. Vigorous resuscitative measures are recommended and given the complexity of electrical and lightning injuries and their long-term sequelae, patients should be managed in a multidisciplinary burn center. Furthermore, the knowledge and awareness of the general population must be improved to reduce the incidence of such injuries.; Summary

Successful laparotomy for intra-abdominal hypertension following veno-venous extracorporeal membrane oxygenation after severe thoracoabdominal trauma: a case report: Yo Huh, Jonghwan Moon, Kyoungwon Jung, Hye-Min Sohn; Received September 21, 2024 Accepted December 31, 2024 Published online March 25, 2025; DOI: https://doi.org/10.20408/jti.2024.0060 [Epub ahead of print]

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Abstract PDF: Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is often used as a life-saving therapy for lung injuries; however, it presents challenges, including bleeding risks and potential reductions in ECMO flow. This case report details the intricate management of a 16-year-old boy who suffered severe thoracoabdominal trauma following a nine-floor fall. The patient sustained severe lung injury and damage to multiple solid organs, including liver lacerations, and was placed on VV-ECMO. When initiating ECMO, it is crucial to carefully consider anticoagulation to avoid potential bleeding complications. Therefore, despite the usual risks associated with ECMO, such as bleeding and reduced flow rates, anticoagulation was withheld due to the risk of hemorrhage from the liver injury. While on ECMO support, the patient experienced a sudden decrease in flow and blood pressure, suggesting an increase in intra-abdominal pressure. An immediate decompressive laparotomy revealed a significant hemoperitoneum, primarily caused by oozing from the liver laceration. The prompt recognition of abdominal distension and the timely decision to proceed with surgery without further imaging were key to the successful treatment. Postoperatively, the patient showed good recovery, with gradual weaning from ECMO, extubation, and eventual discharge. In conclusion, this case highlights the importance of ongoing monitoring for patients with complex trauma who are on ECMO. External factors, including elevated intra-abdominal pressure, can impair ECMO performance. Meticulous management and a multidisciplinary approach are essential in these intricate cases, which involve the nonsurgical treatment of solid organ damage accompanied by severe lung injury.; Summary

Original Article

Vitamin D levels and bone mineral density: a prospective cross-sectional analysis of young orthopedic trauma patients at a rural United States trauma center: Michael Booth, Kenneth Sabacinski, Colleen Watkins, Erin Butcho, Emilie Kramer, Lukas Meadows, Michelle A. Bramer; J Trauma Inj. 2024;37(4):276-280. Published online December 26, 2024; DOI: https://doi.org/10.20408/jti.2024.0038

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Abstract PDF: Purpose
The goal of this cross-sectional study was to investigate the prevalence of vitamin D deficiency in young orthopedic trauma patients and its impact on bone mineral density (BMD) measured through computed tomography imaging of the lumbar spine.
Methods
Conducted at a level I trauma center, this prospective cross-sectional analysis included 100 patients aged 18 to 50 years with non-fragility fractures. Vitamin D levels and Hounsfield units of the lumbar spine were recorded from computed tomography scans. Exclusion criteria included fragility fractures, lumbar surgery history, or lumbar bony/metastatic lesions. The correlation between vitamin D levels and BMD was assessed; vitamin D deficiency was defined as below 30 ng/mL.
Results
Among the participants, 75% were vitamin D–deficient, with an average vitamin D level of 25.0 ng/mL. No patients had osteoporosis based on Hounsfield units; however, 5% of patients were in the osteopenic range. In patients with normal vitamin D levels, there was an inverse correlation between vitamin D levels and BMD measured by Hounsfield units (P=0.025). Higher lumbar spine Hounsfield unit measurements correlated with lower vitamin D levels in this nondeficient population.
Conclusions
This study highlights a high prevalence of vitamin D deficiency in young orthopedic trauma patients, and it suggests a potential inverse relationship with BMD in patients with vitamin D levels >30 ng/mL. The absence of osteoporosis in our population raises questions about the influence of vitamin D on BMD in this young trauma patient demographic. Future research should explore the impact of vitamin D replacement on fracture union and investigate the interaction between vitamin D levels and bone health in the younger orthopedic trauma population.; Summary

Erratum

Erratum to “Massive traumatic abdominal wall hernia in pediatric multitrauma in Australia: a case report”: J Trauma Inj. 2024;37(4):309-309. Published online December 26, 2024; DOI: https://doi.org/10.20408/jti.2023.0023.e; Corrects: J Trauma Inj 2023;36(4):447

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