Journal of Trauma and Injury

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; Received December 10, 2024 Accepted January 2, 2025 Published online March 25, 2025; DOI: https://doi.org/10.20408/jti.2024.0093 [Epub ahead of print]

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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: a case report: 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

Liver laceration as a post-cardiopulmonary resuscitation complication in a person with breast implants: a case report: Min-Jeong Cho; J Trauma Inj. 2024;37(4):300-303. Published online December 16, 2024; DOI: https://doi.org/10.20408/jti.2024.0077

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Abstract PDF: Cardiac compression is the most crucial component of successful cardiopulmonary resuscitation (CPR). However, CPR procedure poses a risk of complications, even when CPR providers perform cardiac compressions as recommended. Reports indicate that solid organ injuries, including liver injuries, occur with an incidence of about 0.6% to 3%. In this particular case, a 25-year-old woman was found hanged in her apartment. She was transported to a nearby hospital where CPR was administered for approximately 30 minutes until she was resuscitated. Subsequently, an abdomen-pelvis computed tomography scan revealed a liver injury. The location of the liver injury, between the sternum and spine, suggested it was a compression injury caused by CPR. There was no evidence of extravasation or active bleeding; thus, conservative management was chosen for the liver injury. By hospital day 4, the patient's pupil reflex had completely disappeared. Electroencephalography showed generalized attenuation, indicating severe global brain damage. Liver injury is a relatively rare post-CPR complication, with an incidence of 0.6% according to a retrospective analysis of a cardiac arrest registry. The liver is partially situated between the sternum and spine. The end of the sternum is shaped like an inverted triangle, resembling a sword. Therefore, if the CPR provider's hands are placed too low or excessive pressure is applied, the sternum can injure the left liver. Blood loss from liver injuries could potentially hinder the successful resuscitation of patients. In this case, had there been no blood loss from the liver injury, the patient might have maintained better cerebral perfusion and function.; Summary

Delayed and recurrent surgical site infection from resorbed bone fragment after autologous cranioplasty: a case report: Jin Hoo Seok, Hae Won Roh, Jong Hyun Kim; J Trauma Inj. 2024;37(4):304-308. Published online December 16, 2024; DOI: https://doi.org/10.20408/jti.2024.0052

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Abstract PDF: Decompressive craniectomy is one of the most common procedures for managing severe traumatic brain injury. Cranioplasty plays a vital role in restoring the integrity of the skull and preventing complications that may arise after a decompressive craniectomy. This case report presents a 24-year-old woman who underwent cranioplasty with a cryopreserved autologous bone flap. Initially successful, the procedure was later complicated by a delayed surgical site infection and methicillin-resistant Staphylococcus aureus osteomyelitis, ultimately resulting in complete resorption of the bone flap. The report discusses the consequences of autologous bone flap resorption and surgical site infection, highlighting the critical need for effective sterilization and proper bone storage techniques. This case emphasizes the necessity of exploring alternative strategies to improve cranioplasty outcomes and minimize the risk of infection.; Summary

Minimally invasive surgery for concomitant pericardial and diaphragmatic rupture after blunt trauma: a case report: Ranti Kenny Maila, Kenny Nyiko Mongwe, Mirza Mohamod Zahir Uddin Bhuiyan; Received July 9, 2024 Accepted October 1, 2024 Published online December 16, 2024; DOI: https://doi.org/10.20408/jti.2024.0045 [Epub ahead of print]

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Abstract PDF: Pericardial rupture with cardiac herniation is a rare injury that occurs following blunt trauma. It is even more unusual to find a pericardial tear associated with diaphragmatic injury after such trauma. Diagnosing this condition through radiologic imaging is challenging. A 51-year-old man was admitted to the emergency department after a wall collapsed on him. He reported overall body discomfort, breathlessness, chest pain, and abdominal discomfort. A plain x-ray revealed haziness in the left thoracic cavity and elevation of the left hemidiaphragm with collapse of the left lung. Additionally, a gastric shadow was seen within the left hemithorax, accompanied by a mediastinal shift to the right. An x-ray of the pelvis displayed fractures at the right sacroiliac joint, left superior pubic ramus, left inferior pubic ramus, and left anterior acetabular with displacement. A computed tomography scan indicated herniation of the stomach, splenic flexure, and spleen, but there was no clear evidence of pericardial laceration. The patient underwent emergency exploratory laparoscopy and thoracoscopy. During the laparoscopy, a significant defect was found in the left hemidiaphragm, along with a pericardial rupture that had led to cardiac herniation and visceral herniation of the stomach, splenic flexure, and spleen through the diaphragmatic tear. The abdominal visceral organs were repositioned into the abdomen, and the diaphragm was repaired. The heart was repositioned, and the pericardial defect was closed using thoracoscopic techniques. Pericardial rupture can be effectively managed using minimally invasive surgery.; Summary

Reperfusion injury or cytokine storm? Utilizing plasmapheresis in severe trauma-induced multiorgan failure: a case report: Gun Woo Kim, Suyeong Hwang, Kyoung Hoon Lim, Sung Hoon Cho; J Trauma Inj. 2024;37(4):295-299. Published online December 4, 2024; DOI: https://doi.org/10.20408/jti.2024.0051

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Abstract PDF: Reperfusion injury can cause tissue damage due to ischemia, with severe cases potentially resulting in multiorgan failure. Cytokine storm, a life-threatening systemic inflammatory state characterized by elevated levels of circulating cytokines and hyperactive immune cells, can also lead to tissue damage and multiorgan failure. Reperfusion injury and cytokine storm sometimes exhibit similar clinical features, necessitating specific treatment in severe cases. A 31-year-old man sustained a stab wound to his left knee. Computed tomography angiography and surgical exploration revealed a transection of the left popliteal artery and vein. Both vessels were revascularized via end-to-end anastomosis approximately 3 hours after the injury. On postoperative day 2, marked increases were observed in levels of aspartate aminotransferase (8,600 U/L), alanine transaminase (6,690 U/L), creatine phosphokinase (26,817 U/L), and lactate dehydrogenase (7,398 U/L) levels. Elevated levels of interleukin 6 (178 pg/mL) and ferritin (41,079 ng/mL) were also noted. Given the possibility of either reperfusion injury or cytokine storm, plasmapheresis was initiated. Following two rounds of plasmapheresis, the patient’s condition rapidly improved, and he was discharged without complications. Reperfusion injury can arise when a target blood vessel is revascularized, particularly during severe stages of ischemia. Cytokine storm represents a life-threatening systemic inflammatory state characterized by high levels of circulating cytokines and overactive immune cells. Both reperfusion injury and cytokine storm can cause systemic inflammation and multiorgan failure. These two conditions may exhibit similar clinical features, necessitating supportive care primarily to prevent organ dysfunction. However, plasmapheresis may represent an effective treatment option in cases of severe progression.; Summary

Treatment of placental abruption following blunt abdominal trauma: a case report: Jinjoo Kim, Seokyung Kim, Dongwook Kwak, Donghwan Choi; Received July 23, 2024 Accepted October 7, 2024 Published online December 4, 2024; DOI: https://doi.org/10.20408/jti.2024.0050 [Epub ahead of print]

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Abstract PDF: Trauma during pregnancy poses a potentially tragic risk to both the fetus and mother, making its management particularly challenging. Here, we present the case of a 35-year-old woman at 34 weeks and 2 days gestation who was in a motor vehicle accident and subsequently suffered placental abruption and underwent an emergency cesarean section. We also present a review of traumatic placental abruption and its epidemiology. On arrival at the trauma bay, the patient showed no significant abdominal findings other than a seat belt sign. However, 2 hours after admission, the patient developed abdominal pain and vaginal bleeding. Ultrasonography revealed no clear evidence of placental abruption. This case demonstrates the necessity of close maternal and fetal monitoring with cooperation between the trauma and obstetric teams. Even in the absence of typical symptoms such as abdominal pain on initial presentation, a high-energy mechanism of injury should be suspected.; Summary

Heterodigital flap as a solution for a thumb defect: a case report: Bontor Daniel Sinaga, Dwi Purnomo Setyo Budi, Mochamad Sadabaskara; Received July 19, 2024 Accepted October 1, 2024 Published online November 18, 2024; DOI: https://doi.org/10.20408/jti.2024.0049 [Epub ahead of print]

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Abstract PDF: Thumb traumatic injuries are incredibly common in hand injuries. The thumb is essential to hand function in order to do daily tasks like gripping, holding, opposing, circumducting, and movements. As a result, compared to injuries to other fingers, a thumb injury significantly impairs hand function. Traumas can cause soft tissue loss linked to vascular injuries that require revascularization. Replantation is the surgical treatment most frequently suggested to patients who have had their thumbs amputated in an attempt to restore function and attractiveness. There are alternative reconstructive techniques, such as skin grafting or local, distal, and free flaps, when replantation of the severed segment is not feasible. Reconstruction techniques vary depending on where the amputation occurred and include transfer site reconstruction and homodigital and heterodigital flaps. We reported a case of a woman who has a right traumatic thumb injury due to blender accident. Primary suturing and debridement were done to save the thumb. But after several days, the thumb was necrotic and not viable. Heterodigital island flap from the right middle finger was chosen. Radial forearm skin was grafted to cover the middle finger defect. This gave satisfactory results. Wound healing was quite good, but there were signs of scar tissue growth after several months of follow-up. The function and mobility of the thumb and hand were also achieved well through the QuickDASH (quick Disability of the Arm, Shoulder and Hand) score. Heterodigital flap provides satisfactory results both aesthetically and functionally in traumatic thumb injury cases.; Summary

Differentiation of antimicrobial toxicity and sepsis-induced disseminated intravascular coagulation in an orthopedic burn patient in India: a case report: Parampreet Singh Saini, Ankita Aggarwal, Tarunpreet Saini; Received June 27, 2024 Accepted September 19, 2024 Published online November 18, 2024; DOI: https://doi.org/10.20408/jti.2024.0040 [Epub ahead of print]

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Abstract PDF: Drug-induced thrombocytopenia, hemolytic anemia, and leukopenia are serious, and sometimes fatal, complications of common medications. These conditions are challenging to diagnose in patients with polytrauma injuries due to the presence of multiple potential etiologies. In such clinical scenarios, sepsis-induced disseminated intravascular coagulation is a more frequent diagnosis. The clinical manifestations of these conditions can be indistinguishable. We present the case of a 32-year-old man who sustained a left open grade 2 leg fracture and 18% to 20% second-degree superficial electrical flash burns on his right leg. Following primary management, skin testing for antibiotic sensitivity was performed, and prophylactic therapy with ceftriaxone, gentamycin, and metronidazole was initiated for the grossly contaminated wounds. On the second day of emergency admission, the patient developed hepatorenal dysfunction accompanied by severe thrombocytopenia (<30×103/mm3). The suspected antimicrobial agents were discontinued by the third day. Within 48 hours, the patient’s hepatorenal function markedly improved; however, the blood dyscrasia progressed to severe pancytopenia over the next few days. Despite worsening parameters, the patient’s vitals were maintained, and he exhibited no overt bleeding. On the fourth day, the patient developed opportunistic fungal bronchopneumonia, indicated by bilateral lower lobe infiltrates on chest x-ray and an elevated serum galactomannan level. He received supportive care, broad-spectrum antibiotics, and antifungal treatment, with a full recovery within 2 weeks. Antibiotic toxicity must be distinguished from other medical conditions to ensure appropriate management and a favorable prognosis.; Summary

Acute irreducible anterior shoulder dislocation due to interposition of the subscapularis muscle and the lesser tuberosity: a case report: Nazim Sifi, Ahmad Madani, Mahdi Zeghdoud; Received July 7, 2024 Accepted August 29, 2024 Published online October 21, 2024; DOI: https://doi.org/10.20408/jti.2024.0044 [Epub ahead of print]

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Abstract PDF: Efforts to reduce an anterior shoulder dislocation can fail due to numerous mechanical obstructions caused by soft tissue interposition (long head of the biceps, rotator cuff muscles, labrum, musculocutaneous nerve) and/or bony elements (displaced fragment of a greater tuberosity or glenoid fracture, bone impaction such as a Hill-Sachs lesion fixed on the glenoid rim, a bony Bankart lesion). Herein, we report the case of a 35-year-old man who sustained an anterior shoulder fracture-dislocation of his left shoulder after a fall. Despite a postreduction radiological examination that appeared misleadingly reassuring, subtle signs of persistent subluxation raised concerns. A computed tomography (CT) scan revealed subscapularis muscle entrapment along with avulsion of its bony insertion from the lesser tuberosity of the humerus, and a comminuted avulsion fracture of the greater tuberosity of the humerus. The patient underwent surgery using a deltopectoral approach. This involved releasing the entrapped subscapularis muscle and fixing the two fractured fragments. The lesser tuberosity was reduced and secured with two cannulated screws, and the comminuted fragment of the greater tuberosity was reattached using transosseous sutures. At 12-month follow-up, the patient achieved a Constant-Murley score of 85 of 100, with limitation in internal rotation at L3 but no signs of instability or new dislocation episode. This case underscores the importance of confirming shoulder reduction on at least two orthogonal views and paying close attention to the patient’s feedback about sensation in their shoulder. Additionally, it highlights the utility of CT or magnetic resonance imaging scans if doubt exists about the integrity of the reduction.; Summary

A starry night: a case report of severe liver injury due to a close-range shotgun blast in Argentina: Rodrigo Antonio Gasque, José Gabriel Cervantes, Magalí Chahdi Beltrame, Marcelo Enrique Lenz-Virreira, Emilio Gastón Quiñonez; J Trauma Inj. 2024;37(4):286-290. Published online October 21, 2024; DOI: https://doi.org/10.20408/jti.2024.0036

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Abstract PDF: This report presents the case of a 20-year-old man who sustained a severe liver injury from a close-range shotgun blast. A prompt medical intervention, including damage control exploratory laparotomy and surgical debridement, was undertaken due to the extent of liver damage. Despite challenges such as a nondirected biliary fistula and extensive liver parenchymal injury, comprehensive surgical management led to successful treatment. Postoperative complications, including biloma and fungal infection, were managed appropriately, highlighting the importance of vigilant follow-up care. The case underscores the complexity of managing severe liver trauma and emphasizes the evolving role of trauma damage control strategies and minimally invasive procedures in achieving favorable outcomes.; Summary

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