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Two cases of accidental asphyxia caused by lap-shoulder seat belts are reported. Lethal neck injuries from shoulder seat belts are uncommon, and episodes of asphyxiation are even rarer. Positioning of the shoulder belt over the neck, short stature, and incapacitation from other injuries were predisposing factors to upper airway compromise in these cases.
A mathematical simulation was performed to study the potential of head and neck injury to an unbelted driver restrained by an airbag. The baseline study represented a 50th percentile male dummy driving in a compact car with the steering wheel perpendicular to the floor. The vehicle was moving at 48 km/hour at the time of impact. Model predictions were compared with sled test results. The data agreed reasonably well. A parametric study was performed to study the effect of changing the steering wheel angle and the size of the airbag. It was found that when the standard 20 degrees angle steering wheel was used, neck joint torques were decreased by 22 percent while the resultant head acceleration increased 41 percent from the base line study. When the vertical dimension of the airbag was reduced by 10 percent, neck joint torques were increased by 14 percent, while head acceleration showed a slight decrease of 9 percent.
OBJECTIVE: To identify potential and modifiable risk factors for tinnitus in a population of older adults. STUDY DESIGN: Cross-sectional study. Detailed questionnaires were interviewer-administered in a representative sample of 2015 persons aged 55+ yr, living in an area west of Sydney, Australia. Air- and bone-conduction audiometric thresholds were measured from 250 to 8000 Hz and from 500 to 4000 Hz, respectively. TEOAE and SOAE were measured for both ears. RESULTS: After adjusting for multiple variables in a Cox proportional hazards model, factors that significantly increased the risk of tinnitus were poorer hearing and cochlear function, self-reported work-related noise exposure, and history of middle ear or sinus infections, severe neck injury or migraine. CONCLUSION: Interventions aimed at reducing age-related hearing loss, particularly by reducing excessive work-related noise exposure, and the effective, timely treatment of ear-related infections, may all decrease the risk of tinnitus.
A computational head-neck model was developed to test the hypothesis that increases in friction between the head and impact surface will increase head and neck injury risk during near-axial impact. The model consisted of rigid vertebrae interconnected by assemblies of nonlinear springs and dashpots, and a finite element shell model of the skull. For frictionless impact surfaces, the model reproduced the kinematics and kinetics observed in near-axial impacts to cadaveric head-neck specimens. Increases in the coefficient of friction between the head and impact surface over a range from 0.0 to 1.0 resulted in increases of up to 40, 113, 9.8, and 43% in peak post-buckled resultant neck forces, peak moment at the occiput-C1 joint, peak resultant head accelerations, and HIC values, respectively. The most dramatic increases in injury-predicting quantities occurred for COF increases from 0.0 to 0.2, while further COF increases above 0.5 generally produced only nominal changes. These data suggest that safety equipment and impact environments which minimize the friction between the head and impact surface may reduce the risk of head and neck injury in near-vertex head impact.
This study group comprises 73 patients who underwent emergency room resuscitative thoracotomy for cardiac arrest following penetrating chest and neck injuries. Overall, 12 patients (16.4%) were successfully resuscitated but only five (6.8%) left the hospital alive without neurologic defects. None of the 18 cases with no vital signs at all (no cardiac activity, no respiratory efforts, nonreactive pupils) on admission survived. Only one out of the 19 cases with no cardiac activity and with fixed pupils but present respiratory efforts survived (5.3%). Of 14 patients with cardiac arrest but with respiratory efforts and reactive pupils, three survived (21.4%). We suggest that patients with no vital signs on admission to the hospital should not be subjected to resuscitative thoracotomy.
STUDY DESIGN: A case of accident-induced late complaint of odontoid nonunion is reported. OBJECTIVES: To report a rare case of accident-induced late complaint of odontoid nonunion and to discuss operative techniques of stabilization. SUMMARY OF BACKGROUND DATA: The literature is reviewed. METHODS.: A 60-year-old man sustained a neck injury with incomplete transverse lesion after a traffic accident. A loosening of odontoid nonunion with displacement 40 years after primary trauma was noted. RESULTS: Surgical treatment of the odontoid nonunion was undertaken to perform anterior screw fixation and additional posterior C1-C2 arthrodesis according to Gallie or Brooks. The patient wore a cervical brace for 6 weeks and underwent physiotherapy. Neurologic deficit decreased after surgery. CONCLUSION: This is the first reported case of accident-induced loosening of odontoid nonunion. Anterior screw fixation and posterior C1-C2 arthrodesis achieved stable fixation.
A review of 83 patients with penetrating neck wounds was performed to assess the relative merits of operation versus observation. Fifty patients (60 percent) underwent immediate surgery, 28 of whom (56 percent) had no significant neck injury. There were no deaths and only two complications (4 percent). Thirty-three patients (40 percent) were treated with initial observation, one of whom required subsequent surgery. In the latter group, there were also no deaths and two complications (6 percent). Length of hospital stay did not differ between patients with negative findings on exploration and those observed. When clinical signs as indications for surgery were present, management was more often correct than when signs were absent (82 and 52 percent, respectively), but the presence or absence of signs correctly predicted injury or lack of injury in over 80 percent of the patients. These data demonstrate the safety and efficacy of selective observation of patients with penetrating neck trauma, and confirm that clinical signs are a reliable indicator of significant injury.
Thirty-four cases of emergency cricothyroidotomy performed formed from September 1984 through January 1988 are reviewed. Thirty-one of the cases were required out of 2,200 acute-trauma patients. The indication for cricothyroidotomy was inability to establish an airway by intubation usually in a situation of possible neck injury or severe facial trauma. Fourteen of the patients died as a result of their injuries, 13 of these in the first several hours after injury. The 20 surviving patients are studied in two groups: eleven patients whose cricothyroidotomy remained in place until decannulation (group I) and nine patients who underwent tracheostomy subsequent to cricothyroidotomy (group II). Clinical follow-up included physical examination in all survivors and endoscopic evaluation in twelve patients. Three minor complications were discovered in each of the two groups and two major complications were noted in group II. The major complications included a case of tracheal stomal stenosis requiring tracheal resection and a case of partially obstructing tracheal granulation tissue requiring endoscopic resection. This study supports the use of emergency cricothyroidotomy in situations in which intubation is not successful or thought to be safe. Data is also presented that suggests that tracheostomy subsequent to emergency cricothyroidotomy does not necessarily reduce airway-related morbidity in these patients.
A 69 year-old male was admitted to our clinic with the chief complaint of hoarseness and difficulty in swallowing. These symptoms occurred about 5 months after penetrating neck injury. Neurological examination revealed right ninth to twelfth cranial nerves palsy and Horner's syndrome. Plain skull X-P demonstrated two broken pieces of glass below the right mastoid processus. The right carotid angiogram showed a 45 x 25 mm aneurysm originated from the right internal carotid artery just below the carotid canal. As the first operation, gradual occlusion of right internal carotid artery combined with the right STA-MCA anastomosis was performed. But two days after complete occlusion, left hemiparesis and pseudobulbar palsy appeared. Two months after such episode, aneurysm and the pieces of glass were removed. He discharged on foot with the improvement of the symptoms of lower cranial nerves. Villaret's syndrome caused by the traumatic aneurysm of extracranial internal carotid artery is rare. This case seems to be the first report in Japan.
OBJECTIVE: To compare two neck strength training modalities. BACKGROUND: Neck injury in pilots flying high performance aircraft is a concern in aviation medicine. Strength training may be an effective means to strengthen the neck and decrease injury risk. METHODS: The cohort consisted of 32 age-height-weight matched participants, divided into two experimental groups; the Multi-Cervical Unit (MCU) and Thera-Band tubing groups (THER), and a control (CTRL) group. Ten weeks of training were undertaken and pre-and post isometric strength testing for all groups was performed on the MCU. Comparisons between the three groups were made using a Kruskal-Wallis test and effect sizes between the MCU and the THER groups and the THER and CTRL groups were also calculated. RESULTS: The MCU group displayed the greatest increase in isometric strength (flexion 64.4%, extension 62.9%, left lateral flexion 53.3%, right lateral flexion 49.1%) and differences were only statistically significant (p<0.05) when compared to the CTRL group. Increases in neck strength for the THER group were lower than that shown in the MCU group (flexion 42.0%, extension 29.9%, left lateral flexion 26.7%, right lateral flexion 24.1%). Moderate to large effect sizes were found between the MCU and THER as well as the THER and CTRL groups. CONCLUSIONS: This study demonstrated that the MCU was the most effective training modality to increase isometric cervical muscle strength. Thera-Band tubing did however, produce moderate gains in isometric neck strength.
Isolated hypoglossal nerve palsy is rare, but occasionally it appears as the initial or solitary sign of an intracranial or extracranial space-occupying lesion, a head and neck injury, or a vascular abnormality of the internal carotid artery. Therefore it should be considered in differential diagnosis. We report two cases of isolated unilateral hypoglossal nerve palsy. In Case 1 the cause of the palsy appeared to be hypoglossal nerve neurilemmoma within the hypoglossal canal, whereas in Case 2 the cause could not be identified. Neither patient complained of any disability other than slight dysarthria. The tongue deviated toward the healthy side at rest and toward the affected side on protrusion. Hemiatrophy of the tongue with fatty displacement was demonstrated by means of T1-weighted magnetic resonance imaging. Dentists who might at times see patients with isolated hypoglossal nerve palsy should be aware of the significance of its oral manifestation, and they should be able to perform differential diagnosis of patients with the condition who appear for treatment.
BACKGROUND: The purpose of the study was to compare the outcome of severely injured patients who were transported directly to a Level I, tertiary trauma center with those who were transferred after being first transported to less specialized hospitals. METHODS: The data were based on all patients treated at three tertiary trauma centers in Quebec between April 1, 1993, and December 31, 1995. There were 1,608 patients (37%) transferred and 2,756 patients (63%) transported directly. RESULTS: The mean age of the patients was approximately 45 years, and more than 60% were males. The predominant mechanisms of injury were falls and motor vehicle crashes. The transfer and direct transport groups were similar with respect to age, gender, and mechanism of injury. Body regions injured were also similar with the exception of head or neck injuries (transfer, 56%; direct, 28%; p < 0.0001). The mean Injury Severity Score was 14, the mean Pre-Hospital Index score was 5.5, and the mean Revised Trauma Score was 7.5. The two groups were similar with respect to these injury severity measures. The primary outcome of interest was mortality described as overall death rate, death rate in the emergency room, and death rate after admission. Other outcomes studied were hospital length of stay and duration of treatment in an intensive care unit. When compared with the direct transport group, transferred patients were at increased risk for overall mortality (transfer, 8.9%; direct, 4.8%; odds ratio, 1.96; 95% confidence interval (CI) = 1.53-2.50), emergency room mortality (transfer, 3.4%; direct, 1.2%; odds ratio, 2.96; 95% CI = 1.90-4.6), and mortality after admission (transfer, 5.5%; direct, 3.6%; odds ratio, 1.57; 95% CI = 1.17-2.11). All of these differences were statistically significant (p < 0.003). Stratified and multiple logistic regression analysis did not alter these results and failed to identify a patient subgroup for which transfer was associated with a reduced risk of mortality. After adjusting for patient age, Injury Severity Score, and presence of injuries to the head or neck and extremities, transferred patients stayed significantly longer in the hospital and the intensive care unit as indicated by the mean length of stay (transfer, 16.0 days; direct, 13.2 days; p = 0.02) and the mean intensive care unit stay (transfer, 2.0 days; direct, 0.95 days; p = 0.001). CONCLUSION: The results of this study have shown that transportation of severely injured patients from the scene directly to Level I trauma centers is associated with a reduction in mortality and morbidity. Further studies are required for the evaluation of transport protocols for rural trauma. Economic and cost-effectiveness considerations of patient triage are also essential.
Shoulder injuries are common among athletes involved in repetitive overhead arm movements, particularly baseball pitchers and tennis players. Due to the similarities between pitching and serving, both athletes often present with similar types of shoulder injuries. However, subtle differences in neck and shoulder movements between the pitcher and tennis player may be responsible for additional mechanisms of injuries specific to tennis players. This paper outlines the similarities and differences between the pitch and serve and discusses how these differences may relate to additional neck and/or shoulder injuries specific to tennis players. In the analyses of mechanisms of injuries sustained by tennis players, such detailed analyses of movement patterns occurring during the serve may optimize a clinician's sports-specific rehabilitation protocol.
OBJECTIVE: The traumatic lesions of the trachea and the main bronchi appear to be rare, but as complications of the severe chest and neck injuries they require urgent surgical treatment. Unfortunately for the last few years the incidence of such traumas has increased. METHODS: During the last 15 years we have treated 28 patients (20 male and eight female) with traumatic lesions of the tracheobronchial tree aged from 8 to 64 years. The tracheal lesions were predominantly iatrogenic caused by difficult endotracheal intubation. The lesions of the bronchi (12 of the main and three of the lobar) were caused mainly by blunt traumas (car accidents and falling from heights). Total disruption of the right main bronchus was observed in five cases and of the left main bronchus - in seven cases. Emergency operative treatment was performed in all patients within 6 to 12 h after the incident. Cervical approach was performed in eight patients and postero-lateral thoracotomy in the other cases. RESULTS: We had one death in the early post, which was due to a severe trauma. Excellent and good results were obtained in 27 patients, which recovered well within 3 months and were followed up for periods ranging from 1 to 10 years. CONCLUSION: The traumatic lesions of the trachea and main bronchi require emergency surgical treatment. The proper choice of operative approach is largely dependent on the precise early diagnosis and on the determining of the exact location of the lesions. Operative tactics must aim at optimal preservation of the functional lung parenchyma and have to include reconstructive and plastic procedures.
Seatbelts provide substantial benefits in rollover crashes, yet occupants still receive head and neck injuries from contacting the vehicle roof interior when the roof exterior strikes the ground. Prior research has evaluated rollover restraint performance utilizing anthropomorphic test devices (dummies), but little dynamic testing has been done with human volunteers to learn how they move during rollovers. In this study, the vertical excursion of the head of restrained dummies and human subjects was measured in a vehicle being rotated about its longitudinal roll axis at roll rates from 180-to-360 deg/sec and under static inversion conditions. The vehicle's restraint design was the commonly used 3-point seatbelt with continuous loop webbing and a sliding latch plate. This paper presents an analysis of the observed occupant motion and provides a comparison of dummy and human motion under similar test conditions. Thirty-five tests (eighteen static and seventeen dynamic) were completed using two different sizes of dummies and human subjects in both near and far-side roll directions. The research indicates that far-side rollovers cause the restrained test subjects to have greater head excursion than near-side rollovers, and that static inversion testing underestimates head excursion for far-side occupants. Human vertical head excursion of up to 200 mm was found at a roll rate of 220 deg/sec. Humans exhibit greater variability in head excursion in comparison to dummies. Transfer of seatbelt webbing through the latch plate did not correlate directly with differences in head excursion.
Cervical spinal cord injury without demonstrable bony injury occurred in 141 (37%) of 384 successive neck injuries admitted to the Sheffield Spinal Injuries Unit. The condition was common in patients in the older age-groups and there were 70% of the cases who were over the age of 50 years. The commonest cause was a fall. The patients presented with varying degrees of motor paralysis with the greatest deficits in the upper limbs and lesser deficits in the lower limbs. There was a dissociation of impairment of the sensory modalities and a loss of bladder and bowel control.
Mountain climbing is a popular recreational activity with a growing number of participants and associated fatalities. To define the characteristics of these fatal incidents and the typical autopsy findings in the victims, we reviewed the autopsy and investigative findings of all fatalities that occurred on Mount Rainier from 1977 through 1997. A total of 50 deaths occurred in 29 separate incidents. Fifty-eight percent of accident victims died as the result of a fall; another 34% died as a result of an avalanche. The incidents leading to death occurred at an average altitude of 3652 m (11,977 feet); range, 2073 to 4389 m (6800-14,400 feet). The average age of the victims was 31.2 years (range, 17-55 years), and 47 of the 50 were men (94%). Bodies were not recovered in 13 cases (26%). Autopsies were performed in 30 of the remaining 37 cases. At autopsy, the cause of death was ascribed to multiple injuries in 12 cases (40%), isolated head and neck injuries in 7 cases (23%), and chest injuries in 1 case (3%). Asphyxia and hypothermia were the cause of death in 8 cases (27%) and 2 cases (7%), respectively. The frequency of specific injuries is presented by anatomic region. The unique autopsy and investigative features of mountaineering deaths are discussed.
OBJECTIVES: This study was performed to assess the experience with penetrating esophageal injuries of an urban Level I trauma center and to attempt to correlate the time to establish a diagnosis with outcome including death, surgical intensive care unit length of stay, and esophageal-related complications. METHODS: Retrospective study over a 72-month period at a single institution comparing age, admission blood pressure, Revised Trauma Score (RTS), Injury Severity Score (ISS), mechanism and anatomic location of injury, and time interval from admission to the operating room (OR) between nonsurvivors and survivors. Patients who survived to reach the operating room were divided into two groups: those who went immediately to the operating room (no preoperative evaluation) and those who underwent diagnostic studies to identify their injuries (preoperative evaluation). Data analysis was done of the same parameters plus average number of associated injuries, complications, and intensive care unit length of stay. Statistical methods used univariate analysis (Fisher's exact test and Student's t test). RESULTS: Forty-three patients were identified with penetrating esophageal injuries and had the following characteristics: 36 males (84%) and 7 females (16%); mean RTS, 9.39; mean ISS, 28.1; mean time interval to OR, 9.8 hours. Associated injuries occurred with 42 patients (98%). The overall complication rate was 14 of 32 (44%), and the overall mortality was 11 of 43 (26%). Corrected mortality was 22%. Differences were noted between nonsurvivors and survivors in the following parameters: admission blood pressure < 90, 11 of 11 versus 3 of 29 (p < 0.001); RTS, 2.364 versus 11.406 (p < 0.001); ISS, 45 versus 21 (p < 0.001); time interval from admission to OR, 18.3 minutes versus 9.8 hours (p < 0.05). Thirty-six patients survived to reach the operating room, 18 in the no preoperative evaluation group and 17 in the preoperative evaluation group. No statistically significant differences were noted between these two groups in the following parameters: age, RTS, ISS, admission blood pressure, anatomic location of injury, number of associated injuries, or intensive care unit length of stay. Average length of time to the operating room was 16.7 hours in the preoperative evaluation group and 1.4 hours in the no preoperative evaluation group (p < 0.001). Twelve complications (all esophageal-related) occurred among seven patients in the preoperative evaluation group, and seven complications (five esophageal-related) occurred among seven patients in the no preoperative evaluation group. Because of the small sample size, this failed to reach a statistical difference (p < 0.05). CONCLUSIONS: Esophageal injuries carry a high morbidity and mortality. Although no definite conclusion can be drawn because of the small sample size, there does appear to be an increased morbidity associated with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, the rapid diagnosis and definitive repair of esophageal injury should be made a high priority.