Anti-high-mobility group box-1 (HMGB1) mediates the apoptosis of alveolar epithelial cells (AEC) by receptor of advanced glycation end-products (RAGE)/c-Jun N-terminal kinase (JNK) pathway in the rats of crush injuries

Objectives The lung injury is often secondary to severe trauma. In the model of crush syndrome, there may be secondary lung injury. We hypothesize that high-mobility group box 1 (HMGB1), released from muscle tissue, mediates the apoptosis of alveolar epithelial cells (AEC) via HMGB1/Receptor of advanced glycation end-products (RAGE)/c-Jun N-terminal kinase (JNK) pathway. The study aimed to investigate how HMGB1 mediated the apoptosis of AEC in the rat model. Methods Seventy-five SD male rats were randomly divided into five groups: CS, CS + vehicle, CS + Ethyl pyruvate (EP), CS + FPS-ZM1 group, and CS + SP600125 groups. When the rats CS model were completed after 24 h, the rats were sacrificed. We collected the serum and the whole lung tissues. Inflammatory cytokines were measured in serum samples. Western blot and RT-qPCR were used to quantify the protein and mRNA. Lastly, apoptotic cells were detected by TUNEL. We used SPSS 25.0 for statistical analyses. Results Nine rats died during the experiments. Dead rats were excluded from further analysis. Compared to the CS group, levels of HMGB1 and inflammatory cytokines in serum were downregulated in CS + EP, CS + FPS-ZM1, and CS + SP600125 groups. Western blot and RT-qPCR analysis revealed a significant downregulation of HMGB1, RAGE, and phosphorylated-JNK in CS + EP, CS + FPS-ZM1, and CS + SP600125 groups, compared with the CS groups, excluding total-JNK mRNA. Apoptosis of AEC was used TUNEL to assess. We found the TUNEL-positive cells were downregulated in CS + EP, CS + FPS-ZM1, and CS + SP600125 groups. Conclusion The remote lung injury begins early after crush injuries. The HMGB1/RAGE/JNK signaling axis is an attractive target to abrogate the apoptosis of AEC after crush injuries.

Does the Nail Bed Regenerate?

Background: The regenerative potential of the nail bed after trauma remains controversial. Methods: We performed a retrospective review of 51 patients who underwent nail bed reconstruction with 2 techniques (direct flow island flap or a Tranquilli-Leali “Atasoy” flap) due to trauma involving the nail bed complex. These 2 flaps were used to support the loss of distal substance and to allow the regeneration of the nail bed. Outcomes were analyzed for at least 18 months. There were 34 men (66.7%), and the average age was 16.1 years. Most patients (56.9%) had crush injuries. The little (16) and index (14) fingers were the most affected. Twenty-seven were children (range: 4-11) with an average age of 7.4 ± 1.9 years. The middle finger was the most affected (29.2%). Results: The outcomes were good to excellent in 41 operated patients (80.4%). Hook nail was absent in 84.3% of the patients. Most patients (98%) did not develop necrosis. Children had an excellent/good outcome rate of 85.2%, while in adults, the rate was 75% of cases ( P = .485). Conclusion: The direct flow island flap is superior in terms of outcome, regardless of age, sex, affected finger, dominant hand, type of trauma, and injury zone. In cases where there was a correct reconstruction of the hyponychium, there was regeneration of the nail bed.

Forearm Amputations and Crush Injuries, Different Scenarios and Treatments: Educational Corner

The article's abstract is not available.

Factors associated with early and late digital revascularization and replantation failure: A retrospective cohort study

Factors associated with failure of digital revascularization and replantation procedures have been well characterized, but studies have not investigated failures occurring beyond the early postoperative period. A single-centre retrospective chart review included 284 patients (434 digits) who underwent digital revascularization or replantation. Patient-, injury- and surgery-related characteristics were compared among successful procedures, digits that failed while in hospital (early failure), and initially viable digits that failed after hospital discharge (late failure). Overall, 202 patients had successful procedures (71%). There were 51 early failures (18%) and 31 late failures (11%). Crush injuries and vein grafting were associated with early failure only. Complete amputations and leeching were strongly associated with both early and late failure. This study revealed that a substantial proportion of initially viable digits fail after discharge from hospital. Patients with signs of venous congestion may benefit from longer observation periods in hospital to avoid late failure. Level of evidence: IV

Neurotrauma in the Syrian War: Analysis of 41,143 cases from July 2013-July 2015

Introduction Despite nearly a decade of conflict, little is known about trauma and injuries resulting from the Syrian war. Methods Secondary analysis was conducted of an administrative dataset of patient presentations to a network of 95 war-affected hospitals in Syria from July 2013 - July 2015. Logistic regression was performed to identify factors associated with mortality of neurotrauma patients. Results Of 193,618 overall trauma presentations, 41,143 were for neurotrauma (37,410 head trauma, 1,407 spinal trauma and 3,133 peripheral nervous system). There were 31,359 males (76.2%) and 9,784 females (23.8%). Males aged 19-30 years (10,113; 24.6%) were the largest single demographic group. Presumed non-combatants including females, elders and children under 13 years (16,214; 39.4%) were the largest group of patients overall. There were 16,881 (41.0%) presentations with blunt injuries (blunt/crush injuries) and 21,307 (51.8%) patients with penetrating injuries (shrapnel, cut, gunshot). A total of 36,589 patients (89.6%) were treated and discharged from the hospital, 2,100 (5.1%) were transferred to another facility, 2,050 patients (5.0%) died in-hospital, 26 remained in the hospital (0.1%), 108 (0.3%) had unknown disposition. The median length of hospital stay was 1 day. There were 4,034 (9.7%) neurosurgical procedures documented. Patients with combined neurotrauma and general trauma suffered 30 times higher mortality than neurotrauma alone (aOR: 30.4; 95%CI: 20.8-44.2, p<0.0001). Conclusion The Syrian War resulted in large volumes of neurotrauma patients. Presumed non-combatants comprised 39.4% of patients who survived to treatment at a facility. Further study is needed on long-term needs of neurotrauma victims of the Syrian war.

Hands

This chapter contains practice questions based on a broad range of orthopaedic topics that may be encountered within the ‘Hand & Paediatrics’ station of the FRCS (Trauma & Orthopaedics) viva examination. The topics covered include a combination of common trauma and elective conditions. Trauma topics include: scaphoid fractures, fight-bite, perilunate dislocations, crush injuries, ligament injuries, and hamate fractures. Elective topics include: Dupuytren’s disease, rheumatoid hands, ganglion cysts, Kienböck’s disease, and de Quervain’s syndrome. Some basic hand anatomy is also touched upon in this chapter.

Neurotrauma in the Syrian War: Analysis of 41,143 cases from July 2013-July 2015

Introduction: Despite nearly a decade of conflict, little is known about trauma and injuries resulting from the Syrian war.Methods: Secondary analysis was conducted of an administrative dataset of patient presentations to a network of 95 war-affected hospitals in Syria from July 2013 - July 2015. Logistic regression was performed to identify factors associated with mortality of neurotrauma patients. Results: Of 193,618 overall trauma presentations, 41,143 were for neurotrauma (37,410 head trauma, 1,407 spinal trauma and 3,133 peripheral nervous system). There were 31,359 males (76.2%) and 9,784 females (23.8%). Males aged 19-30 years (10,113; 24.6%) were the largest single demographic group. Presumed non-combatants including females, elders and children under 13 years (16,214; 39.4%) were the largest group of patients overall. There were 16,881 (41.0%) presentations with blunt injuries (blunt/crush injuries) and 21,307 (51.8%) patients with penetrating injuries (shrapnel, cut, gunshot). A total of 36,589 patients (89.6%) were treated and discharged from the hospital, 2,100 (5.1%) were transferred to another facility, 2,050 patients (5.0%) died in-hospital, 26 remained in the hospital (0.1%), 108 (0.3%) had unknown disposition. The median length of hospital stay was 1 day. There were 4,034 (9.7%) neurosurgical procedures documented. Patients with combined neurotrauma and general trauma suffered 30 times higher mortality than neurotrauma alone (aOR: 30.4; 95%CI: 20.8-44.2, p<0.0001).Conclusion: The Syrian War resulted in large volumes of neurotrauma patients. Presumed non-combatants comprised 39.4% of patients who survived to treatment at a facility. Further study is needed on long-term needs of neurotrauma victims of the Syrian war.

A Rare Case of Rhabdomyolysis in a Patient With Pembrolizumab Induced Hypothyroidism

Introduction: Although reported in previous literature, Rhabdomyolysis due to hypothyroidism,without an obvious precipitating factor, is rare. We report a case of severe hypothyroidism leading torhabdomyolysis. Case Report: A 70-year-old man with a history of progressive weakness, myalgia x1 month, statinallergy, pancreatic adenocarcinoma, metastatic melanoma, and acquired hypothyroidism afterreceiving Pembrolizumab for 6 months. He was non-adherent to the levothyroxine, prescribed 1month before hospitalization. He presented to the ED after slipping from his bed onto the floor in aseating position and being unable to get up due to his weakness. Initially, he was afebrile, hypoxic,tachypneic, tachycardic, hypotensive, lethargic, oriented x2, and had a global muscular weakness. Labs were significant for CK of 10,180 (n &lt; 166 IU/L), TSH 136.18(n 0.34-5.6 mU/L), FT4 &lt; 0.25 (n0.6-1.10 ng/dl), FT3 1.4 (n 2.5-3.9 Pg/ml), AKI, leukocytosis, abnormal electrolytes and LFTs. IV fluidsand antibiotics failed to improve the patient’s clinical status in 48 hours. He was started on IVthyroxine and stress steroids with improved weakness and overall clinical picture. Discussion: 4.6 % of people have hypothyroidism per the United States National Health andNutrition Examination Survey. Rhabdomyolysis is defined as the rapid breakdown of skeletal muscle,which may also develop due to hypothyroidism. Most patients with hypothyroidism who developrhabdomyolysis are found to have a clear precipitating risk factor, such as the use of statins orstrenuous exercise. Still, none of these risk factors were present in this case. Our patient acquiredhypothyroidism after a few months of receiving Immunotherapy. It is reported that hypothyroidismoccurs in (9% to 18%) of patients receiving Pembrolizumab. Although the patient was prescribedthyroid replacement therapy, he was not adherent to the medication for 1 month prior topresentation. Although mechanical injury is reported to cause elevated CK levels, mostrhabdomyolysis cases are related to crush injuries. We believe that the fall was probably related tohis progressive generalized weakness due to his noncompliance with medical therapy leading tomyxedema coma and rhabdomyolysis. Conclusion: Screening for hypothyroidism in patients with elevated muscle enzymes should behighly considered since an early diagnosis. Prompt treatment of hypothyroidism is essential toprevent rhabdomyolysis and its consequence.

Epidemiology of pelvic and acetabular fractures in a tertiary hospital in Singapore

Introduction: Pelvic and acetabular fractures (PAFs) usually result from high-energy, potentially life-threatening accidents. They are one of the major injuries that lead to death in patients involved in such accidents. We studied the recent epidemiology of these injuries in Singapore. Methods: This is a retrospective data analysis of all trauma patients who underwent surgery for PAFs from 2008 to 2016 in a tertiary trauma centre in Singapore. Data including patient demographics, mechanism of injury and associated injuries was collected. Results: A total of 169 patients were admitted for PAFs over the eight-year period. The majority (79.3%) were male. The mean age was 41 (range 13–79) years. Most patients (51.5%) were Chinese. The most common mechanisms of injury were road traffic accidents (53.8%), falls (33.1%) and crush injuries (13.0%). 46.2% sustained acetabular fractures, while 44.4% sustained pelvic fractures. PAFs were most commonly associated with upper and lower limb injuries, followed by spinal and thoracic injuries. Average of length of stay in hospital was 24 (range 2–375) days. Conclusion: PAF predominantly affects young working males. Compared to previously published local data, there has been a significant reduction in the incidence of PAFs, likely due to improved road and work safety. The demographics of PAFs have changed, with fewer injuries in females (20.7% vs. 33.3%), a reduction in the proportion of injuries in the Chinese (51.5% vs. 70.1%). While road traffic accidents remain the most common cause, crush injuries are now more prevalent (13.0%).