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Objective: Many centers advocate use of triple-contrast (IV, oral, and rectal) CT for assessing hemodynamically stable patients with penetrating abdominopelvic trauma. Enteric contrast material has several disadvantages, leading our practice to pursue use of single-contrast (IV) CT. We conducted a retrospective review of electronic medical records at our institution to assess the accuracy of single-contrast CT for diagnosing bowel injuries in cases of penetrating abdominopelvic trauma., Materials and Methods: We retrospectively reviewed patients who presented to our emergency department between January 1, 2004, and March 1, 2014, with penetrating abdominopelvic trauma, underwent an abdominopelvic CT, and had surgery performed thereafter. We reviewed pertinent emergency department records for details regarding the site of injury, the number of injuries per patient, and the type of weapon used. We correlated CT reports with operative notes for presence and sites of bowel injury., Results: A total of 274 patients (median age, 27 years old) met our inclusion criteria; 77% had sustained gunshot wounds (GSWs). CT showed bowel injury in 173 cases; surgery revealed bowel injury in 162 cases. CT had 142 true-positive, 31 false-positive, 81 true-negative, and 20 false-negative cases, resulting in sensitivity of 88%, specificity of 72%, positive predictive value of 82%, and negative predictive value of 80% for detecting bowel injuries. CT had the highest sensitivity and specificity in patients with multiple GSWs (94% and 79%, respectively) and those with injuries to the stomach and rectum., Conclusion: Single-contrast CT can show bowel injuries in patients with penetrating abdominopelvic trauma with accuracy comparable with that reported for triple-contrast CT.

Although penetrating neck trauma (PNT) is uncommon, it is associated with the significant morbidity and mortality. The management of PNT has changed significantly over the past 50 years. A radiological assessment now is a vital part of the management with a traditional surgical exploration. A 22 years old male was assaulted by a screwdriver and sustained multiple penetrating neck injuries. A contrast CT scan revealed a focal pseudoaneurysm in the left common carotid artery bulb. There was no active bleeding or any other vascular injuries and the patient remained haemodynamically stable. In view of these findings, he was initially managed conservatively without an open surgical exploration. However, the patient was noted to have an acute drop in his hemoglobin count overnight post injury and the catheter directed angiography showed active bleeding from the pseudoaneurysm. Surgical exploration 40 hours following the initial injury revealed a penetrating injury through both arterial walls of the left carotid bulb which was repaired with a great saphenous vein patch. A percutaneous drain was inserted in the carotid triangle and a course of intravenous antibiotics for five days was commenced. The patient recovered well with no complications and remained asymptomatic at five months followup., (Copyright © 2018 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. All rights reserved.)

Bows and arrows are used more for recreation, sport and hunting in the Western world and tend not to be as popular a weapon as firearms or knives. Yet there are still injuries and fatalities caused by these low-velocity weapons due to their availability to the public and that a licence is not required to own them. This study aimed to highlight the penetration capabilities of aluminium arrows into soft tissue and bones in the presence of clothing. Further from that, how the type and fit of clothing as well as arrowhead type contribute to penetration capacity. In this study ballistic gelatine blocks (non-clothed and loose fit or tight fit clothed) were shot using a 24lb weight draw recurve bow and aluminium arrows accompanied by four different arrowheads (bullet, judo, blunt and broadhead). The penetration capability of aluminium arrows was examined, and the depth of penetration was found to be dependent on the type of arrowhead used as well as by the type and fit or lack thereof of the clothing covering the block. Loose fit clothing reduced penetration with half of the samples, reducing penetration capacity by percentages between 0% and 98.33%, at a range of 10m. While the remaining half of the samples covered with tight clothing led to reductions in penetration of between 14.06% and 94.12%. The damage to the clothing and the gelatine (puncturing, cutting and tearing) was affected by the shape of the arrowhead, with the least damaged caused by the blunt arrowheads and the most by the broadhead arrows. Clothing fibres were also at times found within the projectile tract within the gelatine showing potential for subsequent infection of an individual with an arrow wound. Ribs, femur bones and spinal columns encased in some of the gelatine blocks all showed varying levels of damage, with the most and obvious damage being exhibited by the ribs and spinal column. The information gleaned from the damage to clothing, gelatine blocks and bones could potentially be useful for forensic investigators, for example, when a body has been discovered with no weapons or gunshot residue present., (Copyright © 2017 The Chartered Society of Forensic Sciences. Published by Elsevier B.V. All rights reserved.)

Objectives: To review a large series of dogs referred for treatment of traumatic impalement injuries to the thorax and/or abdomen and to report aetiologies, injury characteristics, management and long-term outcomes., Materials and Methods: Previously collected data on dogs that were surgically treated for impalement injuries to the trunk at six veterinary specialist referral institutions in the UK over an 11-year period were reviewed. Data included patient signalment, physiological variables, injury-specific variables, diagnostic imaging reports, surgical procedures undertaken, duration of hospitalisation, antibiotic use, complications and outcomes. Data were reported with summary statistics., Results: Fifty-four dogs were included. Impalement occurred most frequently on wooden objects (n=34), and the thoracic cavity was most commonly penetrated (n=37). Computed tomography was sensitive and specific to identifying wooden material in 64% and 88% of cases (n=11), respectively. Thoracotomy was performed in 56%, coeliotomy in 20% and a foreign body or its fragments were retrieved during surgery in 37% of the cases. Complications occurred in 19 dogs (35%), and of these, 68% were minor and 32% major. The survival rate for thoracotomy cases was 93% (n=30). Overall long-term survival was 90%., Clinical Significance: Despite the often dramatic presentation of impalement injuries, the majority of patients treated in the specialist referral setting can achieve excellent outcomes. These injuries require thorough diagnostic imaging and interpretation before adequate surgical exploration and management, augmented by anaesthesia and critical care during the peri- and postoperative periods; therefore stable patients should be referred to centres able to provide this type of care., (© 2017 British Small Animal Veterinary Association.)

Background and Aims: Computed tomography angiography has become central to the diagnostic algorithm for penetrating neck injury, but despite its widespread use the literature to support this adoption is limited. We reviewed our experience with computed tomography angiography for the identification of vascular trauma in hemodynamically stable patients with penetrating neck injury at a major trauma center in South Africa., Materials and Methods: A prospectively kept trauma registry capturing data in real time was retrospectively reviewed. All patients with penetrating neck injury investigated with computed tomography angiography as the initial vascular investigation during a 47-month period were included., Results: A total of 380 patients were included. Indications for computed tomography angiography were as follows: hard signs (13), soft signs (201), no signs but proximity/zone I or III wounds (141), and undefined signs of vascular injury (25). Of the 380 scans, 7 (1.8%) were indeterminate, 299 (78.7%) negative, and 74 (19.5%) positive for a vascular injury (54 arterial and 20 isolated venous injury). Eight were false positive and 4 false negative. The sensitivity, specificity, positive, and negative predictive values for detecting arterial injury were 93.9%, 97.5%, 85.2%, and 99.1%, respectively. Overall, the yield for demonstrating "true arterial injury" was 12.1% (46/380); hard signs: 76.9% (10/13), soft signs: 16.4% (33/201), and no signs: 2.1% (3/141) which all were secondary to gunshot wounds). Only 8.4% (32/380) required intervention for arterial injury and none for isolated venous injury (hard signs: 62.0%, soft signs: 11.4%, and no signs: 0.7%). No serious complications resulted from computed tomography angiography., Conclusion: Computed tomography angiography is a safe and effective imaging modality for the investigation of vascular trauma post penetrating neck injury. Asymptomatic patients with stab wounds do not need to be imaged regardless of proximity concerns. Symptomatic stable patients including a subgroup with hard signs should be imaged rather than explored. Computed tomography angiography provides an interventional road map and can identify injuries amenable to endovascular or conservative management.

Background and Objective: Wound healing involves a complex and dynamic biological process in response to tissue injury. Monitoring of the cascade of cellular events is useful for wound management and treatment. The aim of this study is to demonstrate the potential of multifunctional polarization-sensitive optical coherence tomography (PS-OCT) to longitudinally monitor the self-healing process in a murine cutaneous wound model., Materials and Methods: A multi-functional PS-OCT system based on swept source OCT configuration (1,310 nm central wavelength) was designed to obtain simultaneously microstructural, blood perfusion, and birefringent information of a biological tissue in vivo. A 1-mm-diameter wound was generated in a mouse pinna with a complete biopsy punch. Afterwards, the self-healing process of the injured tissue was observed every week over 6-week period using the multifunctional system to measure changes in the tissue birefringence. Further OCT angiography (OCTA) was used in post data processing to obtain blood perfusion information over the injured tissue., Results: Three complementary images indicating the changes in anatomical, vascular, and birefringent information of tissue around wound were simultaneously provided from a 3-dimensional (3-D) PS-OCT data set during the wound repair over 1 month. Specifically, inflammatory and proliferative phases of wound healing were characterized by thickened epidermal tissue (from OCT images) and angiogenesis (from OCT angiography images) around wound. Also, it was observed that the regenerating tissues had highly realigned birefringent structures (from PS-OCT images)., Conclusion: This preliminary study suggests that the proposed multi-functional imaging modality has a great potential to improve the understanding of wound healing through non-invasive, serial monitoring of vascular and tissue responses to injury. Lasers Surg. Med. 50:213-221, 2018. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Background: Carotid-cavernous fistula (CCF) is a shunt between the carotid artery and the cavernous sinus. Traumatic CCFs are diagnosed in 0.2% of head traumas being only 4.6% of the pediatric population. Classified by Barrow in 1985, type A CCF is the most frequent, occurring in 75% of cases. Type A is characterized by direct and high-flow CCF that generally can occur as a result of traumatic injury or rupture of an intracavernous aneurysm., Case Presentation: The subject was an 8-year-old boy with penetrating trauma to his left eye. During the initial evaluation, a computed tomography (CT) scan was unremarkable, and after relief of symptoms, the patient was discharged. Seven days later, he developed grade I proptosis, conjunctival chemosis, ophthalmoplegia (III, IV, and VI cranial nerve palsies), and left-sided ptosis and mydriasis. Arteriography confirmed a post-traumatic CCF, and the patient was treated with an endovascular detachable balloon., Conclusion: CCF should be suspected in craniofacial traumas with ocular symptoms. The presence of a skull base fracture on CT is a poor predictor of CCF associated with head trauma. Early diagnosis and treatment can prevent permanent neurological deficits and unfavorable outcomes.

Introduction: Combat-related thoracic trauma is a significant contributor to morbidity and mortality of the casualties from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Penetrating, blunt, and blast injuries were the most common mechanisms of trauma. Imaging plays a key role in the management of combat-related thoracic trauma casualties. This review discusses the imaging manifestations of thoracic injuries from penetrating trauma, emphasizing epidemiology and diagnostic clues seen during OEF and OIF., Materials and Methods: The assessment of radiologic findings in patients who suffer from combat-related thoracic trauma is the basis of this review article. The imaging modalities for this study include multi-detector computed tomography and chest radiography., Results: High-velocity penetrating projectile injuries appear as hemorrhage and re-expansion pulmonary edema from the temporary cavity and a linear, blood-filled track from the permanent cavity. In cases where the projectile passes totally through the body, entrance wounds at the skin surface and tracks through the subcutaneous tissues may be the only indications of penetrating trauma. When assessing vascular injury, special attention should be paid to the right hilum in contrast-enhanced multi-detector computed tomography, as contrast is concentrated in the superior vena cava and superior cavoatrial junction may obscure small fragments. Additionally, CT angiography may show vessel disruption or extravasation of contrast distal to normal vessel location in addition to intraluminal filling defects and pseudo-aneurysms. Tension pneumopericardium may rarely complicate penetrating or blunt chest trauma. On imaging, distension of the pericardial sack by pneumopericardium and compression of the heart support the diagnosis of tension. On multi-detector computed tomography in the acute trauma setting, fluid in the pleural space should be considered hemothorax, particularly when Hounsfield units are above 35. Acutely, extravasated blood will have similar attenuation to the thoracic vasculature, whereas clotted blood will have higher values of 50-90 Hounsfield units., Conclusion: Combat-related thoracic trauma continues to be a significant contributor to the morbidity and mortality of those injured during OEF and OIF. This review of the imaging manifestations of penetrating thoracic injury during OEF and OIF focuses on key diagnostic findings for clinicians caring for combat casualties. The distinct injury pattern and atypical imaging manifestations of penetrating trauma are important to recognize early due to the acuity of this patient population and the influence of accurate diagnosis on clinical management.

Objective: to evaluate the role of abdominal computed tomography in the management of penetrating abdominal trauma., Methods: we conducted a historical cohort study of patients treated for penetrating trauma in the anterior abdomen, dorsum or thoracoabdominal transition, that were submitted to a computed tomography carried out on admission. We evaluated the location of the wound and the presence of tomographic findings, and the management of these patients as for nonoperative treatment or laparotomy. We calculated the sensitivity and specificity of computed tomography according to the evolution of the nonoperative treatment or the surgical findings., Results: we selected 61 patients, 31 with trauma to the anterior abdomen and 30 to the dorsum or thoracoabdominal transition. The mortality rate was 6.5% (n=4), all in the late postoperative period. Eleven patients with trauma to the anterior abdomen were submitted to nonoperative treatment, and 20, to laparotomy. Of the 30 patients with trauma to the dorsum or thoracoabdominal transition, 23 underwent nonoperative treatment and seven, laparotomy. There were three nonoperative treatment failures. In penetrating trauma of the anterior abdomen, the sensitivity of computed tomography was 94.1% and the negative predictive value was 93.3%. In dorsal or thoracoabdominal transition lesions, the sensitivity was 90% and the negative predictive value was 95.5%. In both groups, the specificity and the positive predictive value were 100%., Conclusion: the accuracy of computed tomography was adequate to guide the management of stable patients who could be treated conservatively, avoiding mandatory surgery in 34 patients and reducing the morbidity and mortality of non-therapeutic laparotomies.

Bone marrow aspiration and trephine biopsy are considered safe procedures. Some serious but rare adverse events directly attributable to these procedures have been related in a few reports in the literature. We report a rare case of ascending aortic injury following a sternal trephine biopsy.

Abdominal injuries are potentially life-threatening and occur in 20-25% of all polytraumatized patients. Blunt trauma is the main mechanism. The liver and spleen are most commonly injured and much less often the intestines. The clinical evaluation proves equivocal in many cases; therefore, the gold standard is computed tomography (CT), which has been increasingly used even in hemodynamically weakly stable or sometimes even unstable patients because it promptly provides precise diagnostic findings, which present the basis for successful therapy. Hemodynamically unstable patients always need an exploratory laparotomy (EL). An EL should also be carried out with a positive focused assessment with sonography for trauma (FAST) or CT for severe parenchymal lesions, hollow organ lesions, intraperitoneal bladder lesions, peritonitis and organ evisceration, impalement injuries and lesions of the abdominal fascia. Hemodynamically stable patients without signs of peritonitis and a lack of such findings can often be treated conservatively irrespective of the extent of an injury. Angiography (and if needed embolization) can additionally be diagnostically and therapeutically utilized.

Background: The endovascular management of arterial injuries has resulted in reduced operating time, blood loss, hospital mortality, lower incidence of sepsis, and decrease in mortality rates. For penetrating trauma, however, the benefits of endovascular therapy are questionable., Patients and Methods: Data were obtained by retrospective analysis of electronic medical records. All patients with vascular trauma seeking care at our institution from January 2010 to December 2015 were reviewed. A total of 223 vascular trauma patients were enrolled. Of these, 18 patients (8 %) were treated with endovascular techniques. The data related to clinical presentation, patient characteristics, technical aspects of the treatment, and follow-up were analysed., Results: The mean patient age was 35.4 ± 17.8 years, 94 % were male. The mean injury severity score was 10.4 ± 2.5. The most commonly observed trauma mechanism was a gunshot in 10 cases (55 %), followed by lesions provoked by arterial catheter misplacement in five cases (27 %), and stab wounds in three cases (16.6 %). The main injury site was the subclavian artery, accounting for eight cases (44 %), followed by the superficial femoral artery and the tibiofibular trunk in two cases, respectively (18 %). The anterior tibial, fibular artery, axillary, common carotid, superior mesenteric, and profunda femoris were each affected once. Arteriovenous fistula was detected in nine cases (50 %), pseudoaneurysms in nine cases (50 %), and short occlusion in two cases (11 %). The mean follow-up duration was 753 days. The primary patency rate was 92.3 and 61.5 % after one and two years, respectively. The survival rate was 94.4 % after one and two years. Infection of the stents or limb amputations were not identified at follow-up., Conclusions: The endovascular treatment of penetrating arterial injuries with covered stents is feasible. However, the criteria used to choose the best method must be individualized.

Introduction: Development of a posttraumatic herniation of brain parenchyma through the orbit is a rare complication of orbital roof fracture. Mostly, the injury is due to a direct impact to the frontal region resulting in orbital roof fracture with dural defect and herniation of cerebrospinal fluid or brain parenchyma. These patients present with acute or gradually progressive proptosis with impending risk of loss of vision and mandate surgical decompression of optic nerve with watertight closure of the dural defect. Bony reconstruction may be required to achieve normal contour of the orbit., Materials and Methods: We encountered an interesting pediatric patient who presented to us with altered sensorium and progressive proptosis 3 days after a penetrating trauma to his left orbit by falling on the handle of a bicycle. The plain computerized tomography of the head (NCCT) showed a left orbital roof defect with herniation of brain matter into the orbit displacing the globe inferolaterally. A craniotomy was performed and watertight closure of the dural rent was achieved with use of autologous bone to cover the defect., Conclusions: The child improved gradually, and at 6 months follow-up, he had good cosmetic outcome with improvement of vision.

Purpose: The rise of computed tomography (CT) use in trauma has become the subject of concern given the harms of CT including radiation, cost, over diagnosis and identification of incidental lesions. We developed a novel metric, the Negative CT Score, (∑ CT- ) which quantifies how often CT imaging identifies important injuries. Our objective was to describe the pattern of CT utilization in trauma at an urban academic level one trauma center using this novel metric., Methods: This was a retrospective study of intermediate level trauma patients who received CT imaging over a 1-year study period at an urban level one trauma center. We applied the Negative CT Score, (∑ CT- ) to quantify the results of CT imaging. ∑ CT- is computed by subtracting the number of non-extremity body regions (maximum four: head, neck, chest, abdomen) with an important positive CT finding (defined by a priori criteria) from the total number of non-extremity body regions scanned., Results: Of the 552 cases reviewed during the study period, 410 (74.3%) were male and the mean age was 40.3 years [SD ± 21.2]. Four hundred eighty-six patients (88.0%) suffered blunt trauma; 66 (12.0%) suffered penetrating trauma. The average injury severity score for admitted patients was seven. Four hundred ninety-five cases had at least one CT performed. The average number of regions per patient that received CT imaging was 2.36 (SD ± 1.3), and the average ∑ CT- was 2.10 (SD ± 1.2). Three hundred and sixty-seven (74.3%) patients had no important findings on CT imaging., Conclusions: In a consecutive series of 552 intermediate trauma patients at our urban trauma center, 2.36 body regions were scanned per patient; of these, 2.10 regions revealed no important CT findings. We hope that these results and the Negative CT Score can be used to identify trends, variations in practice, and outliers within and across departments so that CT utilization can be optimized.

Background: Computed tomography angiography has become routine in the management of penetrating trauma to the extremity. Our objective was to evaluate the efficacy of physical examination findings compared with computed tomography angiography for detection of clinically significant vascular injuries associated with penetrating trauma to the extremity., Methods: This was a retrospective chart review of patients presenting to a single level 1 trauma center from January 2013-June 2016. Patients with penetrating trauma to the extremity and no hard signs of vascular injury were included. Physical examination and computed tomography angiography findings were analyzed, with particular focus given to missed injuries., Results: We identified 393 patients with penetrating trauma to the extremity without hard signs of vascular injury. Computed tomography angiography was performed in 114 patients (29%). Four patients with distal pulses documented on their initial trauma surveys were found to have vascular injuries on computed tomography angiography, although 3 of these injuries were identified on repeat physical examination. One additional patient had a delayed presentation of a pseudoaneurysm. No mortality or limb loss resulted from these injuries. Total hospital charges for computed tomography angiography amounted to over $700,000., Conclusion: Patients with penetrating trauma to the extremity and no hard signs of vascular injury do not require computed tomography angiography for identification of clinically relevant vascular injuries that require emergent operative repair. Serial physical examination appears to provide accurate detection of vascular injury requiring procedural intervention., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: In hypotensive patients with thoracoabdominal penetrating injuries, trauma surgeons often face a considerable dilemma, which cavities and when to explore. We hypothesized that the Focused Assessment with Sonography for Trauma (FAST) would be accurate enough to determine the need and sequence of cavity exploration., Methods: We conducted a 4-year retrospective study at a level 1 trauma center with high penetrating trauma volume. Patients with potential multi-cavity thoracoabdominal injuries were selected based on the location and number of external wounds. Findings in the operation or on computed tomography were used as references to evaluate the sensitivity, specificity, positive predictive value and negative predictive value of pericardial and abdominal FAST., Results: A total of 2851 patients with penetrating injury were admitted from 2012 to 2015. Of those, 103 patients (3.6%) met our inclusion criteria (stab wounds 56.3%, gunshot wounds 43.7%). Median age: 32, male gender: 89.3%, median injury severity score: 17, in-hospital mortality rate: 11.7%. Thirty-seven patients (35.9%) required surgical exploration of more than one cavity. Although the pericardial FAST was falsely negative in only one case with large left hemothorax, all cardiac injuries were treated without delay (12/13, 92.3% sensitivity). Sensitivity and specificity of the abdominal FAST was 68.5 and 93.9%, respectively., Conclusions: In hypotensive patients following penetrating thoracoabdominal injuries, the pericardial FAST was highly sensitive and could reliably determine the need to explore the pericardium. While positive findings of abdominal FAST warrant an exploratory laparotomy, negative abdominal FAST does not exclude the abdominal cavity as a bleeding source.

Background: The most recent management guidelines advocate computed tomography angiography (CTA) for any suspected vascular or aero-digestive injuries in all zones and give zone II injuries special consideration. We hypothesized that physical examination can safely guide CTA use in a "no zone" approach., Methods: An 8-year retrospective analysis of all adult trauma patients with penetrating neck trauma (PNT) was performed. We included all patients in whom the platysma was violated. Patients were classified into three groups as follows: hard signs, soft signs, and asymptomatic. CTA use, positive CTA (contrast extravasation, dissection, or intimal flap) and operative details were reported. Primary outcomes were positive CTA and therapeutic neck exploration (TNE) (defined by repair of major vascular or aero-digestive injuries)., Results: A total of 337 patients with PNT met the inclusion criteria. Eighty-two patients had hard signs and all of them went to the operating room, of which 59 (72%) had TNE. One hundred fifty-six patients had soft signs, of which CTA was performed in 121 (78%), with positive findings in 12 (10%) patients. The remaining 35 (22%) underwent initial neck exploration, of which 14 (40%) were therapeutic yielding a high rate of negative exploration. Ninty-nine patients were asymptomatic, of which CTA was performed in 79 (80%), with positive findings in 3 (4%), however, none of these patients required TNE. On sub analysis based on symptoms, there was no difference in the rate of TNE between the neck zones in patients with hard signs (P = 0.23) or soft signs (P = 0.51). Regardless of the zone of injury, asymptomatic patients did not require a TNE., Conclusions: Physical examination regardless of the zone of injury should be the primary guide to CTA or TNE in patients with PNT. Following traditional zone-based guidelines can result in unnecessary negative explorations in patients with soft signs and may need rethinking., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: High-grade traumatic pancreatic injuries are associated with significant morbidity and mortality. Non-resection management is associated with fewer complications in pediatric patients. The present study evaluates outcomes following resection versus non-resection management of severe pancreatic injury caused by penetrating trauma., Methods: A retrospective study of the Trauma Quality Improvement Program (TQIP) database was performed from 1/2010 to 12/2014. Patients with AAST Organ Injury Scale pancreatic grade III and IV injuries caused by penetrating trauma were included in the study. Demographics, vital signs on admission, Abbreviated Injury Scale per body region, Injury Severity Score, transfusion and therapeutic modality were obtained. Mortality, length of stay (LOS), pseudocyst, pancreatitis, sepsis, thromboembolism, renal failure, ARDS and unplanned ICU admission or re-operation were stratified according to injury grade and treatment modality. Patients were stratified into those who did/did not undergo pancreatic resection., Results: A total of 4,098 patients had a pancreatic injury of which 15.9% (n=653) had a grade III and 6.7% (n=274) a grade IV pancreatic injury. There were no differences in patient demographics or overall injury severity between the resected and non-resected cohorts within each pancreatic injury grade. Forty-two percent of grade III and 38.0% of grade IV injuries underwent pancreatic resection. The total LOS was longer in the resection arm irrespective of pancreatic injury severity. There was no significant difference in morbidity between cohorts. Similarly, mortality was not significantly different between the two management approaches for grade III: 15.1% (95% CI 11.0-19.9) vs. 18.4% (95% CI 14.6-22.6), p=0.32 and grade IV: 24.0% (95% CI: 16.2-33.4) vs. 27.1% (95% CI: 20.5-34.4), p=0.68., Conclusion: Resection for treatment of grade III and IV pancreatic injury is not associated with a significant decrease in mortality but is associated with an increase in hospital LOS., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Periorbital necrotizing fasciitis (PONF) is a rare condition of the face. PONF can lead to blindness, functional and esthetic sequelae, multiple-organ failure, and death. The aim of this report is to raise the awareness of this severe condition in maxillofacial surgeons. This report describes the case of a 30-year-old woman who presented with a bilateral palpebral edema and pain 3 days after a jugal wound was sutured. Necrosis of the skin of the left palpebral unit was extending rapidly. The patient had signs of sepsis. Surgical debridement was performed promptly and intravenous broad-spectrum empiric antibiotics were administered. The patient recovered slowly with no complication other than a residual skin defect of the 2 eyelids that was later corrected by full-thickness skin grafting. Special attention should be paid to signs of preseptal cellulitis because it can, in some cases, rapidly develop into PONF. Early diagnosis and treatment are the keys to a favorable outcome., (Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Foreign body ingestion is a common presentation in the emergency room. However, the complication such as penetrating renal trauma due to sharp objects ingestion is relatively rare. We herein describe an unusual case of penetrating renal trauma in the absence of any other urinary symptoms. A 53-year-old man who had a history of iron wire ingestion went to our hospital, on examination, he only had slight abdominal tenderness due to swallowing a ball pen and 1 cap nut 1 day before, radiological imaging showed penetrating renal trauma, the blood test showed his renal function is normal. Surgical strategies were recommended to remove the pen and the iron wire simultaneously, nonetheless the patient eventually agreed to only receive surgical removal of the swallowed ball pen and cap nut, meanwhile leave the kidney untreated. During 30 months follow-up by phone and regular outpatient examination, he recovered unevenly and had no special complaint. Such cases remind us that chronic penetrating renal trauma due to foreign object ingestion may have no obvious symptoms. It is easily to be neglected. We should try to minimize the possibility of missed lesions by adhering to a meticulous examination technique.

Penetrating injuries can result in acute or subacute arterial injuries of the solid organs or extremities. Although most penetrating injuries are managed conservatively, some patients require endovascular or surgical treatment. Often, the best method for management is controversial and the level of urgency for clinical decision-making is high. Once the decision has been made to intervene, the operator must also determine the best embolization material and technique to use. Not unfrequently, these decisions are made during the course of the procedure. There are numerous embolization agents, each of which serves a very specific purpose, depending on the clinical scenario. Within this article, we will review endovascular treatment indications, contraindications, and endovascular techniques for the treatment of penetrating trauma of the solid organs or extremities., (Copyright © 2017. Published by Elsevier Inc.)

Trauma centers must prepare to manage high-velocity injuries resulting from a mass casualty incidents as global terrorism becomes a greater concern and an increasing risk. The most recent conflicts in Iraq and Afghanistan have significantly improved understanding of battlefield trauma and how to appropriately address these injures. This article applies combat surgery experience to civilian situations, outlines the physiology and kinetics of high-velocity injuries, and reviews applicable triage and management strategies., (Published by Elsevier Inc.)

We report the case of a 55-year-old man who successfully underwent resection of a recurrence of ulcerative colitis(UC)- associated colon cancer located in the pancreatic body and left kidney. The patient had undergone an emergency laparotomy (total proctocolectomy with stapled ileal-pouch anal anastomosis)for the treatment of a descending colon cancer with retroperitoneal penetration associated with UC at the age of 50 years. At that time, histological examinations revealed a mucinous carcinoma that was classified as Stage II colon cancer. Three years after the patient's initial operation, a CT scan revealed a small mass located between the pancreatic tail and the left kidney. However, the accumulation of FDG was not observed during a positron emission tomography(PET)examination, resulting in close observation. As the size of the tumor and the levels of serum carcinoembryonic antigen and carbohydrate antigen 19-9 gradually increased, recurrence was highly suspected. A distal pancreatectomy and left nephrectomy were performed. Pathological examination showed findings concurrent with a local recurrence of colon cancer. Special histological types, such as mucinous carcinoma, often occur in some colitic cancers. For the postoperative surveillance of patients with colitic cancer, it should be noted that the sensitivity of FDG/PET is lower for mucinous carcinoma of the colon than it is for more common colon cancers.

In patients with penetrating neck injuries with clinical soft injury signs, and patients with hard signs of injury who do not require immediate surgery, CT angiography of the neck is the preferred imaging procedure to evaluate extent of injury. Other modalities, such as radiography and fluoroscopy, catheter-based angiography, ultrasound, and MR angiography have their place in the evaluation of the patient, depending on the specific clinical situation and question at hand. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Foot foreign body granulomas can mimic malignancies, especially when the history and unusual location pose a diagnostic dilemma. We report the case of a 33-year-old male with delayed-onset progressive swelling over the foot dorsum after a sharp injury through the plantar aspect of the foot. The unusual presentation and radiolucency warranted further radiologic evaluation, which revealed a benign foot swelling. An excision biopsy and histopathologic examination revealed a rubber body granuloma. No recurrence of the granuloma was noted during the 11-month follow-up period after removal of the offending agent. The nature of the injury, immunologic response to the rubber fragment, and lack of infection led to the delayed presentation at an unusual site, mimicking malignancy. Rubber body granuloma has rarely been reported in published studies. A high index of suspicion of retained radiolucent fragments and astute radiologic evaluation with magnetic resonance imaging are required for management of sharp injuries occurring through footwear. We reviewed the approach for evaluating such cases of foot swelling that can mimic malignancies., (Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: None declared. Patient consent: Obtained.

Purpose: To explore the effect of admission physical examination findings, anamnesis, and computed tomography on dural penetration and prognosis in patients with cranial gunshot wound (CGW)., Methods: In this study, the medical data of 56 subjects who were admitted to the Emergency Department of Dicle University Hospital with CGWs between January 2011 and December 2013 were retrospectively reviewed. The effects of type of incident (suicidal vs non-suicidal), pupil diameter and light reflex, hemodynamic status, type (bullet or pellet), velocity, trajectory of foreign material, trauma scores, and imaging findings on dural penetration and mortality were explored., Results: The mean age of the study population was 24.8 ± 13.50 years. Thirty (53.6 %) patients had penetrating injuries and 26 (46.4 %) had non-penetrating injuries; 9 (16.1 %) patients died and 47 (83.9 %) survived. Suicidal injury, pupil diameter and light reflex, bullet as foreign material, and high velocity and lateral trajectory of foreign material significantly affected dural penetration and mortality (p < 0.05). In addition, dural penetration, bilobar, multilobar, or bihemispheric involvement of brain parenchyma, presence of intracranial hemorrhage, subarachnoid hemorrhage, ventricular hemorrhage, fracture, shift, edema, and trauma scores significantly affected mortality (p < 0.05)., Conclusions: In CGWs, dural penetration and prognosis can be predicted by physical examination findings and patient characteristics on initial admission.

Background: Patients with penetrating trauma who cannot be stabilized undergo operative intervention without preoperative imaging. In such cases, postoperative imaging may reveal additional injuries not identified during the initial operative exploration. The purpose of this study is to explore the utility of postoperative CT imaging in the setting of penetrating trauma., Methods: This was a retrospective analysis of patients with penetrating trauma treated at an urban Level 1 trauma center between 2010 and 2015. Patients were included if they underwent an emergent laparotomy without preoperative imaging. Patients were excluded if they had prior imaging or concomitant blunt injury. For the purposes of this study, occult injury was defined as a CT scan finding not mentioned in the first operative report. Descriptive statistics were used to compare patient characteristics who had received imaging immediately postoperatively with those who had not., Results: During the 5-year study period, 328 patients who had a laparotomy for penetrating trauma over the study period, 225 patients met the inclusion criteria. Seventy-three (32%) patients underwent CT scanning immediately postoperatively with occult injuries identified in 38 (52%) patients. The most frequent occult injuries were orthopedic (20 of 43) and genitourinary (9 of 43). Importantly, 10 (26%) of the 38 patients required an intervention for these occult injuries. Those selected for immediate postoperative imaging were more likely to have sustained gunshot wounds and were significantly more severely injured (higher Injury Severity Score and longer length of hospital stay) when compared to patients who did not receive immediate imaging., Conclusion: We recommend the use of immediate postoperative CT after emergent laparotomy especially when there is a high index of suspicion for spine or genitourinary injuries and in patients who have sustained ballistic penetrating injuries., Level of Evidence: Therapeutic/care management, level IV; diagnostic tests or criteria, level IV.

Introduction: Traumatic diaphragmatic injuries (TDIs) are clinically challenging. We aimed to review TDIs treated at a tertiary trauma centre over a 12-year period., Methods: This was a single-centre retrospective review of adult patients with TDIs treated between 1 January 2003 and 31 December 2014. Primary outcomes were mortality rates and Injury Severity Scores (ISS) associated with each TDI subtype. Secondary outcomes included proportions of TDIs diagnosed radiologically, operatively or during autopsy. We compared the TDI subtypes with respect to mechanism of injury, mortality rates and median ISS. Data was analysed using descriptive statistics., Results: Among 46 patients studied, the TDI subtypes noted were acute diaphragmatic herniation (n = 14, 30.4%), tears (n = 22, 47.8%) and contusions (n = 10, 21.7%). Patients with these TDI subtypes had a mortality rate of 35.7%-100%, while the ISS ranges for survivors and deaths were 22.0-34.0 (interquartile range [IQR] 6.5-23.0) and 53.5-66.0 (IQR 16.0-28.5), respectively. TDIs were identified via chest radiography (n = 2/33, 6.1%) and computed tomography (n = 6/13, 46.2%). All survivors (n = 21) and deaths (n = 25) underwent open surgery or autopsy, respectively, which confirmed TDIs. Blunt traumas and penetrating traumas were more frequently associated with acute herniation/contusions and tears, respectively. There were statistically significant differences among the TDI subtypes in their mechanism of injury, mortality rate and median ISS of survivors., Conclusion: TDIs showed varying injury patterns with blunt versus penetrating mechanisms of injury, and were associated with significant mortality rates. Preoperative imaging had limited diagnostic use., (Copyright: © Singapore Medical Association)

An 84-year-old man sustained a motorcycle accident resulting in a left elbow laceration. Orthopaedics was consulted to rule out traumatic arthrotomy. Radiographs and CT of the left elbow showed no acute osseous abnormalities and no evidence of traumatic arthrotomy. The wound was irrigated, dressed and splinted. On follow-up, the patient reported that he had been given clindamycin on a return visit to the emergency department for increased drainage. On inspection, the patient's wound was found sutured and draining purulent fluid. The patient persistently had no pain on axial loading or range of motion since his injury and no evidence of intra-articular air on initial CT. However, given the mechanism of injury, irrigation and debridement (I&D) in the operating room was immediately performed revealing purulent joint fluid and a traumatic arthrotomy. I&D was carried out for the second time in the joint. After an extended hospital stay and antibiotics, the infection resolved., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Intracranial injury resultant from a chopstick penetrating the oral cavity is often fatal in children, and only 5 clinical cases have been reported. If the depth of penetration is indeterminable, due to the chopstick being removed or the remaining piece not being located, then injury management is challenging; here, we report such a case. A 26-month-old girl fell over with a plastic chopstick in her mouth. The chopstick was removed immediately and without breakage by her father. He noted that around 3 cm of the pointed end had pierced the palate. CT revealed air bubbles in the retropharyngeal space but no abnormality in the cranium. Subsequent complications included bacterial meningitis and right hemiparesis but neither MRI nor any alternative imaging modality could aid in locating the intracranial lesion that induced the weakness. Neurological findings suggested injury of the right lateral corticospinal tract at the lower end of the medulla oblongata. An axial T2-weighted MRI showed a 30-mm high signal path of penetration from the posterior nasopharyngeal wall to the dura at the craniocervical junction. When the route is extended 36 mm intracranially from the wound orifice, the path makes superficial contact with the right lateral portion of the medulla oblongata, which corresponds with the lateral corticospinal tract. We therefore hypothesize that this was the lesion location but that it was too small to be detected using MRI.

Background: Penetrating Extremity Trauma (PET) may result in arterial injury, a rare but limb- and life-threatening surgical emergency. Timely, accurate diagnosis is essential for potential intervention in order to prevent significant morbidity., Objectives: Using a systematic review/meta-analytic approach, we determined the utility of physical examination, Ankle-Brachial Index (ABI), and Ultrasonography (US) in the diagnosis of arterial injury in emergency department (ED) patients who have sustained PET. We applied a test-treatment threshold model to determine which evaluations may obviate CT Angiography (CTA)., Methods: We searched PubMed, Embase, and Scopus from inception to November 2016 for studies of ED patients with PET. We included studies on adult and pediatric subjects. We defined the reference standard to include CTA, catheter angiography, or surgical exploration. When low-risk patients did not undergo the reference standard, trials must have specified that patients were observed for at least 24 hours. We used the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) to evaluate bias and applicability of the included studies. We calculated positive and negative likelihood ratios (LR+ and LR-) of physical examination ("hard signs" of vascular injury), US, and ABI. Using established CTA test characteristics (sensitivity = 96.2%, specificity = 99.2%) and applying the Pauker-Kassirer method, we developed a test-treatment threshold model (testing threshold = 0.14%, treatment threshold = 72.9%)., Results: We included eight studies (n = 2,161, arterial injury prevalence = 15.5%). Studies had variable quality with most at high risk for partial and double verification bias. Some studies investigated multiple index tests: physical examination (hard signs) in three studies (n = 1,170), ABI in five studies (n = 1,040), and US in four studies (n = 173). Due to high heterogeneity (I 2  > 75%) of the results, we could not calculate LR+ or LR- for hard signs or LR+ for ABI. The weighted prevalence of arterial injury for ABI was 14.3% and LR- was 0.59 (95% confidence interval [CI] = 0.48-0.71) resulting in a posttest probability of 9% for arterial injury. Ultrasonography had weighted prevalence of 18.9%, LR+ of 35.4 (95% CI = 8.3-151), and LR- of 0.24 (95% CI = 0.08-0.72); posttest probabilities for arterial injury were 89% and 5% after positive or negative US, respectively. The posttest probability of arterial injury with positive US (89%) exceeded the CTA treatment threshold (72.9%). The posttest probabilities of arterial injury with negative US (5%) and normal ABI (9%) exceeded the CTA testing threshold (0.14%). Normal examination (no hard or soft signs) with normal ABI in combination had LR- of 0.01 (95% CI = 0.0-0.10) resulting in an arterial injury posttest probability of 0%., Conclusions: In PET patients, positive US may obviate CTA. In patients with a normal examination (no hard or soft signs) and a normal ABI, arterial injury can be ruled out. However, a normal ABI or negative US cannot independently exclude arterial injury. Due to high study heterogeneity, we cannot make recommendations when hard signs are present or absent or when ABI is abnormal. In these situations, one should use clinical judgment to determine the need for further observation, CTA or catheter angiography, or surgical exploration., (© 2017 by the Society for Academic Emergency Medicine.)

The present report illustrates a very rare case report of a foreign body granuloma of the foot associated with a 2-year period of a retained spongeous rubber foreign body after a penetrating injury. Because it appeared almost 2 years after the injury, the history of trauma was minimized, the foreign body had migrated from the plantar to the dorsal side of the foot, and the radiographic appearance resembled a malignant process, it was difficult to rule out the possibility of a malignant tumor. This case shows the weakness of magnetic resonance imaging in detecting spongeous rubber in the body. Also, a bone osteoblastic reaction to the foreign body has very rarely been noted. To the best of our knowledge, just 5 cases have been previously reported. Provided suspicion exists of previous trauma with an embedded foreign body, the differential diagnosis of a bone neoplasm should consider the possibility of a foreign body reaction. Biopsy proved to be the best diagnostic tool., (Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Tendon ruptures are common musculoskeletal injuries all around the world. Correct and timely diagnosis of tendon injuries is obviously important for improving the treatment and minimizing the community costs. Ultrasound is now being considered as one of useful modalities in this area., Objective: The preset study is going to validate the diagnostic ability of ultrasound in tendon injuries induced by penetrating extremity trauma., Methods: In this prospective, observational study, patients with penetrating extremity trauma and suspicion of tendon injuries were enrolled in our study. A team of emergency medicine (EM) residents performed ultrasound examination in these cases after attending the specific workshop and acquiring necessary skills in normal and abnormal tendon ultrasound examination. Then another team of either EM or orthopedic residents explored patients' wounds and determined intact or injured tendons under direct visual observation. The results were analyzed to validate sensitivity and specificity of ultrasound as an alternative diagnostic test., Results: Seventy-one patients were enrolled in our study and 11 patients were excluded during one year in 2014. Sixty patients, 11 with lower extremity and 49 with upper limb injuries were evaluated, among them 32 patients had extensor zone and 28 patients had flexure zone injuries. The overall sensitivity and specificity were calculated 94.4% (95% CI 72.7-99.8%) and 100% (95% 91.5-100.0%) respectively., Conclusions: Our results were similar to previous findings. Ultrasound can effectively differentiate injured from intact tendons in penetrating extremity trauma., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study is to assess the performance of CT angiography (CTA) in the evaluation of penetrating vascular trauma to the extremities in a large cohort of patients at our level I trauma center., Methods: A retrospective, IRB-approved review of consecutive CTAs for the evaluation of penetrating trauma to the extremities in 446 patients (M/F = 396:50, mean age = 27 years) from 1/1/2005 to 5/1/2015 was performed. Medical records were reviewed to correlate diagnostic imaging findings with clinical history and subsequent interventions. Image quality was quantified by measurement of CT attenuation coefficients in the major arteries of the extremities. The Fisher's exact test was used to analyze the relationships between the presence and type of vascular injury and subsequent clinical management., Results: One hundred and thirty-one (29.4 %) of 446 patients with penetrating trauma demonstrated major vascular injury on CTA, 35 (26.7 %) of whom underwent subsequent surgical repair. None of the patients without vascular injury on CTA underwent subsequent vascular intervention. Fisher's exact test demonstrated a statistically significant difference in management and requirement for vascular repair in those patients with a vascular injury on CTA when compared to those without a vascular injury (p < 0.0001). The mean attenuation values achieved in upper and lower extremity CTAs in this population exceeded 250 HU., Conclusion: Extremity CTA is found to be an accurate tool for surgical triage in patients having sustained penetrating vascular trauma.

Background: Selective neck exploration and computed tomography angiography (CTA) in penetrating neck trauma have been well described in adults. However, data in the pediatric population are sparse. The extent to which these practices have been adopted in pediatric patients is unknown., Methods: Retrospective, single-center cohort study of pediatric penetrating neck trauma for the years 2001 to 2014 in a dedicated children's hospital/Level 1 pediatric trauma center. Clinical data, sensitivity and specificity of hard signs (active hemorrhage, airway compromise, expanding hematoma, crepitus, and so on) and soft signs of injury (bruit, voice change, stridor, laceration less than 2 cm, nonexpanding hematoma, and so on), and trends in imaging were examined., Results: A total of 44 patients were identified with penetrating neck trauma. The majority of these patients were male (55%) aged 8 months to 18 years and a median of 7.3 years. Sixteen patients underwent neck exploration with 13 major injuries identified in 10 patients. Nineteen patients had associated injuries. Ten patients had at least one hard sign of injury, and 16 patients had only soft signs of injury. The sensitivity and specificity of hard signs of injury were 100% (95% confidence interval [CI], 59-100%) and 94.4% (95% CI, 79-99%), respectively. Soft signs only had a sensitivity and specificity of 100% (95% CI, 39-100%) and 75.5% (95% CI, 60-86%), respectively. Positive and negative predictive values were 4.8% and 100%, respectively, for both hard and soft signs. The number of CTA studies increased over time but was not statistically significant. Forty (90%) patients were discharged home and two patients died., Conclusion: These results suggest that management of penetrating neck trauma in children includes selective neck exploration based on physical examination and the use of CTA in stable patients, similar to current adult recommendations. We did not observe evidence of missed injuries over the study period., Level of Evidence: Therapeutic/care management, level IV.

Stingray injuries are frequent, and although mostly benign, some can be life-threatening. We present the case of a 24-year-old man who suffered from a stingray attack in the Indian Ocean with a thoracic penetrating trauma, and its management., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

In the perioperative period, the emergency department or the intensive care unit accurate assessment of variable chest pain requires meticulous knowledge, diagnostic skills, and suitable usage of various diagnostic modalities. In addition, in polytrauma patients, cardiac injury including aortic dissection, pulmonary embolism, acute myocardial infarction, and pericardial effusion should be immediately revealed and treated. In these patients, arrhythmias, mainly tachycardia, cardiac murmurs, or hypotension must alert physicians to suspect cardiovascular trauma, which would potentially be life threatening. Ultrasound of the heart using transthoracic and transesophageal echocardiography are valuable diagnostic tools that can be used interchangeably in conjunction with other modalities such as the electrocardiogram and computed tomography for the diagnosis of cardiovascular abnormalities in trauma patients. Although ultrasound of the heart is often underused in the setting of trauma, it does have the advantages of being easily accessible, noninvasive, and rapid bedside assessment tool. This review article aims to analyze the potential cardiac injuries in trauma patients, and to provide an elaborate description of the role of echocardiography for their accurate diagnosis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

A 5-year-old spayed female Boston terrier mixed breed dog was presented with porcupine quill migration. The quills were difficult to detect directly using computed tomography and magnetic resonance imaging. This case highlights difficulties faced in detecting porcupine quills with current diagnostic imaging modalities and describes surgical and medical management of a patient with massive quill migration.

Marine animal injuries are rare causes of emergency room visits and vascular injuries worldwide. Penetrating injuries from marine animals risk damage to vasculature, and physicians must be alert to such possibilities. We report a 7-year-old boy with penetrating trauma and retained foreign body in the forearm from a catfish injury. Initial imaging suggested transection of the radial artery, but on exposure in a controlled setting the foreign body was found to compress the artery without any vascular injury. No vascular repair was needed after foreign body removal., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Penetrating chest wounds is less common but more deadly then blunt trauma. Majority of penetrating chest trauma can be managed conservatively with observation and simple thoracotomy. This case report highlights a bizarre occupational hazard causing a penetrating chest injury and the option of non-invasive management with the aid of computed tomography with 3D reconstruction.

Introduction: The management of severe renal trauma is disputable. Herein, we present diagnosis and treatment of patients with high-grade renal injury (grades IV and V)., Materials and Methods: The records of 31 patients with severe renal trauma who were treated between 2009 and 2014 were analyzed retrospectively. All patients' CT results were evaluated by two radiologists and assigned grades of IV or V in accordance with the American Association for the Surgery of Trauma Organ Injury Severity Scale. All hemodynamically stable renal trauma patients were treated conservatively. Patients with renal traumas of grade IV and V were evaluated statistically via the SPSS 15.0 software program. Chi-square and Mann-Whitney U tests were used to evaluate the categorical data., Results: Thirteen (42 %) of 31 patients had grade IV, and 18 (58 %) had grade V renal traumas. Twenty-seven (87 %) of the patients had suffered blunt trauma, and four (13 %) had sustained penetrating injuries. Additional organ injuries were seen in 16 patients (52 %), and 15 (48 %) had no concurrent injuries. Twenty-five patients (89 %) were monitored conservatively, three (10 %) underwent surgery, and three patients with grade V renal trauma and additional organ injuries died. There was no statistically significant difference between the grade IV and grade V groups, except in hemoglobin values and the affected kidney (P = 0.07 and P = 0.02, respectively)., Conclusions: Computerized tomography can help to grade renal injury and assess additional organ injuries quickly. Most children with high-grade renal injury can be managed conservatively. However, conservative management of renal traumas relies on a multidisciplinary approach. Additionally, surgical intervention is generally required in the face of hemodynamic instability or other concurrent organ injuries.

Background: Penetrating skull base injury (PSBI) is uncommon among head injuries, presenting unique diagnostic and therapeutic challenges. Although many cases of PSBIs have been reported, comprehensive understanding of its initial diagnosis, management, and outcome is still unavailable., Materials and Methods: A retrospective review was performed for patients treated in neurosurgical department of Changzheng Hospital for PSBIs. Presurgical three-dimensional (3D) Slicer-assisted reconstructions were conducted for each patient. Then we reviewed previous literature about all the published cases of PSBIs worldwide and discussed their common features., Results: A total of 5 patients suffering PSBIs were identified. Penetrating points as well as the surrounding neurovascular structures were clearly visualized, assisting in the presurgical planning of optimal surgical approach and avoiding unexpected vascular injury. Four patients underwent craniotomy with foreign bodies removed successfully and 1 patient received conservative treatment. All of them presented good outcomes after proper management., Conclusion: Careful physical examination and radiological evaluation are essential before operation, and angiography is recommended for those with suspected vascular injuries. 3D modeling with 3D Slicer is practicable and reliable, facilitating the diagnosis and presurgical planning. Treatment decision should be made upon the comprehensive evaluation of patient's clinicoradiological features and characteristics of foreign bodies.