Journal of Trauma and Injury

Review Article

Biomechanics of stabbing knife attack for trauma surgeons in Korea: a narrative review: Kun Hwang, Chan Yong Park; J Trauma Inj. 2024;37(1):1-5. Published online January 15, 2024; DOI: https://doi.org/10.20408/jti.2023.0057

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Abstract PDF: The aim of this paper was to review the biomechanics of knife injuries, including those that occur during stabbing rampages. In knife stab attacks, axial force and energy were found to be 1,885 N and 69 J, respectively. The mean velocity of a stabbing motion has been reported to range from 5 to 10 m/sec, with knife motions occurring between 0.62 and 1.07 seconds. This speed appears to surpass the defensive capabilities of unarmed, ordinarily trained law enforcement officers. Therefore, it is advisable to maintain a minimum distance of more than an arm's length from an individual visibly armed with a knife. In training for knife defense, particularly in preparation for close-quarter knife attacks, this timing should be kept in mind. Self-inflicted stab wounds exhibited a higher proportion of wounds to the neck and abdomen than assault wounds. Injuries from assault wounds presented a higher Injury Severity Score, but more procedures were performed on self-inflicted stab wounds. Wound characteristics are not different between nonsuicidal self-injury and suicidal self-wrist cutting injuries. Consequently, trauma surgeons cannot determine a patient's suicidal intent based solely on the characteristics of the wound. In Korea, percent of usage of lethal weapon is increasing. In violence as well as murders, the most frequently used weapon is knife. In the crimes using knife, 4.8% of victims are killed. Therefore, the provision of prehospital care by an emergency medical technician is crucial.; Summary

Case Reports

Isolated penetrating gluteal stab injury with uncontrolled bleeding in Türkiye: a case report: Ali Metehan Celep, Görkem Yiğit, Ayla Ece Çelikten, Kudret Atakan Tekin, Ufuk Türkmen; J Trauma Inj. 2023;36(4):454-457. Published online August 8, 2023; DOI: https://doi.org/10.20408/jti.2023.0010

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Abstract PDF: Arterial injuries in the gluteal region caused by a knife are rare but serious, with mortality rates of up to 25%. This case report presents the management of a young male patient admitted to the emergency department in hypovolemic shock, with uncontrollable bleeding from an isolated penetrating gluteal injury. Additionally, the details of the surgical approach employed are discussed.; Summary

Percutaneous screw fixation and external stabilization as definitive surgical intervention for a pelvic ring injury combined with an acetabular fracture in the acute phase of polytrauma in Korea: a case report: Hohyoung Lee, Myung-Rae Cho, Suk-Kyoon Song, Euisun Yoon, Sungho Lee; J Trauma Inj. 2023;36(3):298-303. Published online July 13, 2023; DOI: https://doi.org/10.20408/jti.2023.0002

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Abstract PDF: Unstable pelvic ring injuries are potentially life-threatening and associated with high mortality and complication rates in polytrauma patients. The most common cause of death in patients with pelvic ring injuries is massive bleeding. With resuscitation, external fixation can be performed as a temporary stabilization procedure for hemostasis in unstable pelvic fractures. Internal fixation following temporary external fixation of the pelvic ring yields superior and more reliable stabilization. However, a time-consuming extended approach to open reduction and internal fixation of the pelvic ring is frequently precluded by an unacceptable physiologic condition and/or concomitant injuries in patients with multiple injuries. Conservative treatment may lead to pelvic ring deformity, which is associated with various functional disabilities such as limb length discrepancy, gait disturbance, and sitting intolerance. Therefore, if the patient is not expected to be suitable for additional surgery due to a poor expected physiologic condition, definitive external fixation in combination with various percutaneous screw fixations to restore the pelvic ring should be considered in the acute phase. Herein, we report a case of unstable pelvic ring injury successfully treated with definitive external fixation and percutaneous screw fixation in the acute phase in a severely injured polytrauma patient.; Summary

Thoraco-laparotomy approach to salvage a life-threatening cardiac box stab injury to the infecrior vena cava in Malaysia: a case report: Ida Arinah Mahadi, Jih Huei Tan, Jin Zhe Teh, Yuzaidi Mohamad, Imran Alwi Rizal; J Trauma Inj. 2023;36(3):286-289. Published online May 19, 2023; DOI: https://doi.org/10.20408/jti.2022.0071

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Abstract PDF Supplementary Material: Torso stab injuries near the cardiac box may present unique challenges due to difficulties in hemorrhage control. For a stab injury to the heart, the repair is straightforwardly performed via median sternotomy. In contrast, injuries to the inferior vena cava are challenging to repair, especially when they are close to the diaphragm, and the bleeding can be torrential. Herein, we describe a case of a self-inflicted stab wound within the "cardiac box." The trajectory of the stab injuries went below the diaphragm and injured the infradiaphragmatic inferior vena cava. Successful emergent repair via the thoraco-laparotomy approach revived the young man. In this report, we revisit and discuss previous large series of patients with this rare vena cava injury.; Summary

Original Article

National utilization of rib fracture fixation in the geriatric population in the United States: Jennifer M. Brewer, Leah Aakjar, Kelsey Sullivan, Vijay Jayaraman, Manuel Moutinho, Elan Jeremitsky, Andrew R. Doben; J Trauma Inj. 2022;35(3):173-180. Published online May 31, 2022; DOI: https://doi.org/10.20408/jti.2021.0076

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Abstract PDF

Purpose
The use of surgical stabilization of rib fractures (SSRF) has steadily increased over the past decade. Recent literature suggests that a larger population may benefit from SSRF, and that the geriatric population—as the highest-risk population—may receive the greatest improvement from these interventions. We sought to determine the overall utilization of SSRF in the United States.
Methods
The National Trauma Database was analyzed between 2016 and 2017. The inclusion criteria were all patients ≥65 years old with rib fractures. We further stratified these patients according to age (65–79 vs. ≥80 years old), the presence of coding for flail chest, three or more rib fractures, and intervention (surgical vs. nonoperative management). The main outcomes were surgical interventions, mortality, pneumonia, length of stay, intensive care unit length of stay, ventilator use, and tracheostomy.
Results
Overall, 93,638 patients were identified. SSRF was performed in 992 patients. Patients who underwent SSRF had improved mortality in the 65 to 79 age group, regardless of the number of ribs fractured. We identified 92,637 patients in the age group of 65 to 79 years old who did not undergo SSRF. This represents an additional 20,000 patients annually who may benefit from SSRF.
Conclusions
By conservative standards and the well-established Eastern Association for the Surgery of Trauma clinical practice guidelines, SSRF is underutilized. Our data suggest that SSRF may be very beneficial for the geriatric population, specifically those aged 65 to 79 years with any rib fractures. We hypothesize that roughly 20,000 additional cases will meet the inclusion criteria for SSRF each year. It is therefore imperative that we train acute care surgeons in this skill set.

Summary

Citations

Citations to this article as recorded by

Incidence of adult rib fracture injuries and changing hospitalization practice patterns: a 10-year analysis
Sergio M. Navarro, Rafat H. Solaiman, Jilun Zhang, Ilitch Diaz-Gutierrez, Christopher Tignanelli, James V. Harmon
European Journal of Trauma and Emergency Surgery.2024;[Epub] CrossRef

Case Reports

Hemorrhagic Shock in a Patient with a Morel-Lavallée Lesion Combined with Active Arterial Bleeding without Fracture: Eic Ju Lim, Jong-Keon Oh, Jae-Woo Cho, Seungyeob Sakong, Jun-Min Cho; J Trauma Inj. 2021;34(1):61-65. Published online November 30, 2020; DOI: https://doi.org/10.20408/jti.2020.0013

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Abstract PDF: A Morel-Lavallée lesion is a closed degloving injury caused by traumatic separation of the skin and subcutaneous tissue from the underlying fascia. However, since physicians tend to focus on treating the bone fracture, hemodynamic instability accompanying a Morel-Lavallée lesion can sometimes be overlooked. We report the case of a hemodynamically unstable 73-year-old man who had a Morel-Lavallée lesion of the thigh, but no femur fracture. Angiography showed active bleeding from the muscular branch of the right deep femoral artery, which was then successfully embolized.; Summary

Combination of Anterior and Posterior Subcutaneous Internal Fixation for Unstable Pelvic Ring Injuries: The “Hula Hoop Technique”: Daniel Balbachevsky, Robinson Esteves Pires, Rodrigo Guerra Sabongi, The?philo Asfora Lins, Geiser de Souza Carvalho, H?lio Jorge Alvachian Fernandes, Fernando Baldy dos Reis; J Trauma Inj. 2019;32(1):51-59. Published online March 31, 2019; DOI: https://doi.org/10.20408/jti.2018.003

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Abstract PDF: Unstable pelvic ring lesions are usually treated with internal fixation. In patients presenting clinical instability or soft tissue complication risk, external fixation is a safe treatment option. However, pin tract infection, insufficient biomechanical properties, difficulty sitting and changing decubitus are important drawbacks related to the treatment. The present study reports the association of anterior and posterior subcutaneous internal fixation by applying spine-designed implants on the pelvic ring disruption: supra-acetabular pedicle screws with an interconnecting rod (Infix), plus posterior transiliac fixation with the same system, which the authors have named the “Hula Hoop Technique”.; Summary

Original Articles

Clinical Analysis of the Patients with Isolated Low-Velocity Penetrating Neck Injury: Junepill Seok, Hyun Min Cho; J Trauma Inj. 2018;31(1):1-5. Published online April 30, 2018; DOI: https://doi.org/10.20408/jti.2018.31.1.1

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Abstract PDF: Purpose
Although there has been substantial progress for the treatment of thoracic trauma, the mortality of the penetrating neck injury is still high, has been reported about 10?15%. However, there has not been a report which is reflecting Korean medical present. We retrospectively analyzed the penetrating neck injury patients based on the Korean Trauma Data Base.
Methods
Between December 2013 and June 2017 at the trauma center of the Pusan National University Hospital, Busan, Korea, total of 36 patients with isolated low-velocity penetrating neck injuries were included. We analyzed the patients’ age, gender, injury mechanism and causes by medical chart review.
Results
Among total of 36 patients, 26 (72.2%) were male and 10 (27.8%) were female. Homicidal neck injuries were most common, followed by accidental and suicidal injuries (47% vs. 33% vs. 19%, respectively). All penetrating injuries in our study were low-velocity trauma such as following: knife (n=16, 44.4%); glass or glass bottle (n=11, 30.6%); scissors (n=4, 11.1%); grinder (n=2, 5.6%); and three (8.3%) of miscellaneous injuries. Twenty-seven (75.0%) patients underwent emergency surgery, and only one (2.8%) patient underwent elective surgery. Eleven (30.6) patients were diagnosed with superficial injuries, including six patients who had conservative treatment. Twelve (33.3%) patients had arterial injuries and 10 (27.8%) patients had venous injuries. The patients who had deep injuries showed significant difference against the patient with superficial injury (98.0 vs. 129.1, p=0.008).
Conclusions
Low velocity penetrating injury confined to the neck is able to be successfully treated with prompt surgical management. Regardless of the conditions which are evaluated at emergency department, all penetrating neck injury patients should be regarded as urgent surgical candidates.; Summary

Treatment of Thoracolumbar and Lumbar Unstable Burst Fractures by Using Combined and Posterior Surgery: Jong Ki Shin, Tae Sik Goh, Seung Min Son, Jung Sub Lee; J Trauma Inj. 2016;29(1):14-21. Published online March 31, 2016; DOI: https://doi.org/10.20408/jti.2016.29.1.14

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Abstract PDF

PURPOSE
The purpose of this research was to analyze the results of the combined and posterior approaches for treating thoracolumbar and lumbar burst fractures and to find an adequate method of treatment.
METHODS
We retrospectively analyzed the cases of 46 patients with unstable thoracolumbar and lumbar burst fractures who had been surgically treated. All cases were divided into two groups based on the operation method used. Eleven patients had undergone the combined approach, while 35 patients had undergone the posterior approach. Radiological and clinical evaluations were performed before surgery, after surgery, and at the final follow-up.
RESULTS
The stenotic ratios of the area occupied by the retropulsed bony fragments to the estimated area of the original spinal canal were 68.2% and 45.6% for the combined and the posterior approaches, respectively. No significant differences in the neurological improvement or the corrected state of the sagittal index were noted, but the patients who had been treated with the combined approach group had better results than those who had been treated with the posterior approach group in terms of correction and maintenance of the sagittal index. The average kyphosis corrections at the final follow-up were 15.3 degrees for the patients in the combined approach group and 10.0 degrees for those in the posterior approach group. Surgical time and estimated blood loss were all significantly higher for patients in the combined approach group.
CONCLUSION
The combined and the posterior approaches showed similar results in the improvements of the neurologic state and the corrected state of the sagittal index. However, use of the combined approach is recommended for patients with severe kyphosis and with severe canal encroachment.

Summary

Citations

Citations to this article as recorded by

Vertebrae at the thoracolumbar junction: A quantitative assessment using CT scans
Anneli Du Plessis, Albert Van Schoor, Quenton Wessels, Patrick Murphy, Francois Van Schouwenburg, Pulenge Ihuhua, Jana Kehrmann, Magda Scholtz, Natalie Keough
Journal of Anatomy.2022; 240(6): 1179. CrossRef
Minimally invasive reduction of thoracolumbar burst fracture using monoaxial percutaneous pedicle screws: Surgical technique and report of radiological outcome
Weng Hong Chung, Wei Cheong Eu, Chee Kidd Chiu, Chris Yin Wei Chan, Mun Keong Kwan
Journal of Orthopaedic Surgery.2020; 28(1): 230949901988897. CrossRef
Differentiation and classification of thoracolumbar transitional vertebrae
Anneli M. Du Plessis, Linda M. Greyling, Benedict J. Page
Journal of Anatomy.2018; 232(5): 850. CrossRef

Case Report

Penetrating Neck Trauma: A Case of Spinal Cord Injury by Embedded Scissor: Seon Hee Kim, Sun Woo Choi, Sung Jin Park, Kwang Hee Yeo, Chang Wan Kim, Sang Bong Lee, Ho Hyun Kim, Chan Yong Park, Jae Hun Kim, Jung Joo Hwang, Hyun Min Cho; J Trauma Inj. 2015;28(2):71-74. Published online June 30, 2015; DOI: https://doi.org/10.20408/jti.2015.28.2.71

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Abstract PDF: Penetrating neck trauma involving spinal cord injury is relatively uncommon, but can be life-threatening. We report a case of 59-year-old female who presented with hypotension after stab injury self-inflicted with a scissor to her neck. Although Open removal of the scissor and control of bleeding were successfully done, penetration of spinal cord resulted in a neurologic impairment.; Summary

Original Articles

Factors Affecting Hemodynamic Instability in Patients with Pelvic Bone Fracture: Seung Min Park, Kang Hyun Lee, Han Ju Choi, Kyung Hye Park, Sang Chul Kim, Hyun Kim, Sung Oh Hwang; J Korean Soc Traumatol. 2008;21(1):22-27.

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Abstract PDF: PURPOSE
Treatment and prognosis in patients with pelvic bone fracture depend on the characteristics of the fracture and the stability of the pelvic ring. The purpose of this study is to analyze the characteristics of and the relationships between fracture patterns, injury mechanisms, clinical courses, and prognoses according to the hemodynamic pattern.
METHODS
Between January 2004 and September 2006, 89 patients under diagnosis of pelvic bone fracture were retrospectively analyzed on the basis of medical records and radiologic examinations. Patients with confirmed hemorragic shock with a systolic pressure of less than 90 mmHg were defined as the shock group. Young's classification was used to characterize fracture patterns. Factors relating to the clinical manifestation and to treatments such as transfusion and surgery were analytically compared.
RESULTS
The mean age of the patients was 48.8+/-18.7, among which 49 (55.1%) were male. The numbers of shock and non-shock patients were 35 (39.3%) and 54 (60.7%) respectively. Eighteen (51.4%) of the shock patient had injuries resulting from pedestrian accidents (p=0.008). According to Young's classification, lateral impact fractures amounted to 20 and 33, front-rear impact fractures to 9 and 20, and multiple fractures to 6 and 1 among the shock and non-shock patients, respectively (p=0.027). Thirty-nine (39) cases in non-shock injuries were conservatively managed while 18 cases in shock injuries were surgically treated. In the shock group, the liver and the kidney were often damaged, as well. Among the shock patients, the average admission period was 7.5+/-8.7 days in intensive care and 55.1+/-47.9 days in total, which were longer than the corresponding numbers of days for the non-shock patients (p<0.05). No deaths occurred in the non-shock group while 5 deaths (14.2%) occurred in the shock group (p=0.007).
CONCLUSION
The factors affecting hemodynamic instability in patients with pelvic bone fracture are injury mechanism, classification of fracture, and associated injuries.; Summary

Indications for an Immediate Laparotomy in Patients with Abdominal Stab Wounds: Hyeong Ju Kim, Seong Youn Hwang, Young Cheol Choi; J Korean Soc Traumatol. 2007;20(2):106-114.

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Abstract PDF: PURPOSE
There is little controversy that a classic indication such as hemodynamic instability or any sign of peritoneal irritation requires an immediate laparotomy in the management of abdominal stab wounds. However, omental herniation or bowel evisceration as an indication for an immediate laparotomy is controversial. The purpose of this study was to evaluate the significance of these factors as indications for an immediate laparotomy.
METHODS
The medical records of 98 consecutive abdominal stab wounds patients admitted to the Emergency Center of Masan Samsung Hospital from January 2000 to December 2006 were carefully examined retrospectively. Using multivariate logistic regression analysis, thirty-nine factors, including the classic indication and intraabdominal organ evisceration, were evaluated and were found to be associated with a need for a laparotomy. Also, the classic indication was compared with a new indication consisting of components of the classic indication and intra-abdominal organ evisceration by constructing a contingency table according to the need for a laparotomy.
RESULTS
Multivariate logistic regression analysis revealed any sign of peritoneal irritation, base deficit, and age to be significant factors associated with the need for a laparotomy (p<0.05). The sensitivity, specificity, and accuracy rates of the classic indication were 98.6%, 72.0%, and 91.8%, respectively, and those of the new indication were 93.2%, 84.0%, and 90.8%, respectively. The differences in those rates between the above two indications were not significant.
CONCLUSION
Intra-abdominal organ evisceration was not a significant factor for an immediate laparotomy. Moreover, the new indication including intra-abdominal organ evisceration was not superior to the classic indication. Therefore, in the management of abdominal stab wounds, the authors suggest that an immediate laparotomy should be performed on patients with hemodynamic instability or with any sign of peritoneal irritation.; Summary

A Clinical Analysis of Abdominal Stab Injuries: Jae Woong Han, Byung Chun Kim, Jae Pil Jung, Ji Woong Cho, Bong Hwa Chung, Kyung Suk Chung, Koo Hyun Kang; J Korean Soc Traumatol. 2006;19(2):143-149.

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Abstract PDF: PURPOSE
This study was done to evaluate the incidence, type of injury, medical consequences, mortality, and prognostic factors associated with stab wounds in patients who visited Kangnam Sacred Heart Hospital, Hallym University, Seoul, Korea.
METHODS
A retrospective analysis of the clinical data of 40 patients with abdominal stab wounds who visited Kangnam Sacred Heart Hospital, Hallym University, Seoul, Korea from January 1, 2000 to December 31, 2004.
RESULTS
1) The most prevalent age group was patients in their the twenties to fourties (77.5% of all patients), and average age of the patients was 39.3 years. The male-to-female ratio was 2.07:1. 2) The external site of stab wounds was most commonly the periumbilcal area of the abdomen (14 cases, 33.3%). 3) The most commonly injured organs were the liver and the stomach (10 cases each, 16.9%). 4) Operations were performed on all 40 patients, with 9 (22.5%) negative operation findings. 5) Death occurred in 5 cases (12.5%). 6) The trauma indices of the death group were TRISS 51.9%, RTS 3.6 points, and APACHE II 23.0 points. 7) The average transfusion amount of the death group was 13.8 pints CONCLUSION: These data suggest that the transfusion amount and the trauma index of abdominal stab injuries may be statistically significant factors for predicting mortality.; Summary

Early Surgical Stabilization of Ribs for Severe Multiple Rib Fractures: Jung Joo Hwang, Young Jin Kim, Han Young Ryu, Hyun Min Cho; J Korean Soc Traumatol. 2011;24(1):12-17.

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Abstract PDF: PURPOSE
A rib fracture secondary to blunt thoracic trauma continues to be an important injury with significant complications. Unfortunately, there are no definite treatment guidelines for severe multiple rib fractures. The purpose of this study was to evaluate the result of early operative stabilization and to find the risk factors of surgical fixation in patients with bilateral multiple rib fractures or flail segments.
METHODS
From December 2005 to December 2008, the medical records of all patients who underwent operative stabilization of ribs for severe multiple rib fractures were reviewed. We investigated patients' demographics, preoperative comorbidities, underlying lung disease, chest trauma, other associated injuries, number of surgical rib fixation, combined operations, perioperative ventilator support, and postoperative complications to find the factors affecting the mortality after surgical treatment.
RESULTS
The mean age of the 96 patients who underwent surgical stabilization for bilateral multiple rib fractures or flail segments was 56.7 years (range: 22 to 82 years), and the male-to-female ratio was 3.6:1. Among the 96 patients, 16 patients (16.7%) underwent reoperation under general or epidural anesthesia due to remaining fracture with severe displacement. The surgical mortality of severe multiple rib fractures was 8.3% (8/96), 7 of those 8 patients (87.5%) dying from acute respiratory distress syndrome or sepsis. And the other one patient expired from acute myocardial infarction. The risk factors affecting mortality were liver cirrhosis, chronic obstructive pulmonary disease, concomitant severe head or abdominal injuries, perioperative ventilator care, postoperative bleeding or pneumonia, and tracheostomy. However, age, number of fractured ribs, lung parenchymal injury, pulmonary contusion and combined operations were not significantly related to mortality.
CONCLUSION
In the present study, surgical fixation of ribs could be carried out as a first-line therapeutic option for bilateral rib fractures or flail segments without significant complications if the risk factors associated with mortality were carefully considered. Furthermore, with a view of restoring pulmonary function, as well as chest wall configuration, early operative stabilization of the ribs is more helpful than conventional treatment for patients with severe multiple rib fractures.; Summary

A Clinical Analysis of Abdominal Stab Wounds: Jiyeon Park, Min Chung, Yeongdon Lee, Jungnam Lee, Woonki Lee, Yeonho Park, Jungheum Baek, Heunggyu Park, Keonkuk Kim, Jinmo Kang, Sangtae Choi, Wonsuk Lee, Seungyoun Park; J Korean Soc Traumatol. 2010;23(2):134-141.

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Abstract PDF: PURPOSE
A classic approach to abdominal stab wounds has been a routine laparotomy for the purpose of diagnosis or treatment. However, management protocols for abdominal stab wounds are still contentious in most trauma centers. We examined the relationship between the character of the stab wound and the injured intraabdominal organs by retrospectively analyzing the medical records of patients with abdominal stab wounds admitted to Gil hospital, and the findings for our patients are then confronted with a review of the literature. We aimed to propose proper management protocols to approach abdominal stab wounds.
METHODS
The medical records of all 80 patients sustaining abdominal stab wounds, admitted at the Department of Surgery, Gil Hospital, Gachon Medical School, from January 2004 to December 2008 were retrospectively reviewed. All the abdominal stab wounds were collated based on the site and the character of the injury, investigations performed on admission, results of investigations, operations performed and findings at the time of the operation.
RESULTS
The most prevalent age group was patients in their forties and the average age of the patients was 41 years for both genders. The stab wounds were most commonly located at the periumbilical area (16.9%), followed by the epigastric area (15.6%), and 18.2% of the patients had multiple wounds. The most commonly eviscerated organ was the omentum (9 out of 16 cases); 61.7% of non-eviscerated patients underwent a therapeutic laparotomy while 81.3% of eviscerated patients underwent a therapeutic laparotomy. The small bowel was the most commonly injured organ (22.7%, 17 out of 75 injuries). The review revealed a relatively common diaphragmatic injury in abdominal stab wound patients (8 cases, 10.5%). The average hospital stay was 11 days.
CONCLUSION
This review revealed commonly eviscerated and injured intraabdominal organs in abdominal stab wound patients and their relationship with a therapeutic laparotomy. Although the management is still controversial, the authors suggest indications for an immediate laparotomy and a protocol for managing abdominal stab wounds. Hemodynamic instability and peritoneal irritation signs are definite indicators for an immediate laparotomy, but the review revealed intraabdominal organ evisceration alone not to be a statistically significant factor. In addition, the authors suggest that abnormal CT findings can be valuable for making a decision on management of hemodynamically stable stab wound patients. Further study may clarify a role for a more selective approach to operative intervention and for a more extensive use of selective observation.; Summary

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