Introduction:
Rare traumatic injuries are uncommon and occur primarily from accidents or unexpected events. Though infrequent, these require special attention to obtain better patient outcomes. The initial stabilization should involve managing the airway, circulation, breathing, fluid resuscitation, and early transport to the trauma center by road or helicopter emergency medical service (HEMS). The management should also identify life-threatening injuries and treat them. Therefore, the total outcome for trauma patients depends on the multidisciplinary approach of the healthcare teams.
What Are Rare Traumatic Injuries and Their Initial Stabilization?
Rare traumatic injuries are not commonly encountered in everyday life, and these can manifest in different forms. Some rare traumatic injuries are:
1. Bilateral Simultaneous Rupture of the Achilles Tendon: This condition refers to the rupture of both Achilles tendons (a strong fibrous tendon that connects the muscle that is present behind the leg to the heel bone). This can occur due to excess strain, long-term use of steroids, conditions like tendinopathy (inflammation and degeneration of tendon), or use of antibiotics such as fluoroquinolones (rare cause). It can cause severe pain, swelling, a palpable gap, and difficulty in walking.
Initial Stabilization: This includes assessing the severity of the injury by evaluating the range of motion and the presence of a palpable gap. The lower extremity should be immobilized with the help of a cast or splint. Analgesics should be administered to control pain and inflammation. Surgical treatment includes repair of the tendon, and in case of severe damage, a graft can be placed, followed by rehabilitation and physical therapy.
2. The Floating Metatarsal: Also called a Lisfranc injury, which involves injury to the midfoot. This causes fracture or dislocation of the tarsometatarsal (TMT) joints, which are present in the middle of the foot. This can occur due to direct trauma, twisting forces, or falling from a height. It can cause pain, swelling, and instability in the mid area of the foot.
Initial Stabilization: This includes a thorough physical examination, evaluation of foot alignment, presence of swelling, and range of motion. The affected foot is immobilized using a cast or a splint. The injured foot is elevated to reduce swelling, and ice packs can be used to reduce inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) are given to manage the pain. Surgical management includes open reduction and internal fixation (ORIF) followed by physical therapy.
3. Marjolin's Ulcer: It is a type of malignancy that occurs in a chronic scar, burn scar, wound, or previous radiation therapy. This occurs from chronic inflammation and repeated damage to the area. This ulcer is non-healing, with irregular borders, and is associated with pain, foul odor, bleeding, and discharge. It can also infiltrate the surrounding tissues.
Initial Stabilization: This includes the evaluation of the ulcer's depth, location, size, and other symptoms. A biopsy (a small piece of infected tissue is removed to study) should be done to identify the stage of cancer. The wound is cleaned, and a dressing should be given to promote healing. Antibiotic therapy is given to control the infection. Systemic evaluation should be done to evaluate the extent of cancer infiltration. Surgical treatment includes wide local excision in which the ulcer, along with healthy tissue, is removed, followed by flap reconstruction, and in case of lymph node involvement, dissection should be performed.
4. Nonpenetrating Traumatic Injury of the Heart: This refers to the injury that occurs without any direct penetration. Some types include myocardial contusion (impact on the heart), cardiac rupture, valvular injuries (narrowing or leakage in the blood vessels), and coronary artery injury. Symptoms include chest pain, shortness of breath, low blood pressure, irregular heartbeat, fatigue, and altered mental status.
Initial Stabilization: This includes stabilizing the patient's airway, breathing, and circulation. In case of cardiac arrest, cardiopulmonary resuscitation (CPR) should be done, which involves assisted ventilation and chest compressions. Adequate oxygenation should be maintained by giving supplemental oxygen. Fluid resuscitation through the intravenous route should be done, and in case of hemorrhagic shock (heavy blood loss), blood products should be administered. Continuous cardiac monitoring should be done, and other associated injuries should be evaluated. The patient should be transferred to the cardiac center for further surgical interventions.
5. Traumatic Asphyxia: It is also called Perthes syndrome or crush asphyxia, where there is severe compression to the chest or abdomen. The common symptoms include severe facial cyanosis (bluish discoloration of the skin), distended neck veins, small red spots, swelling in the chest region, and difficulty in breathing.
Initial Stabilization: This includes evaluation of the patient's airway for any obstructions such as blood, swelling, or foreign body. In case of obstruction, manual clearing or suctioning should be done. Proper ventilation should be provided, and techniques such as mouth-to-mouth or bag-valve-mask ventilation should be used. Circulation should be assessed, which involves blood pressure and pulse. Monitoring of complications such as pulmonary edema (fluid accumulation in the lungs), organ damage, or cardiac dysfunction (a condition in which the heart's ability to pump blood is compromised) should be carried out. Supportive management, such as supplemental oxygen, management of pain, and administration of intravenous fluid, should be considered.
6. Traumatic Injuries to the Portal Vein: The portal vein is a blood vessel that carries blood from the spleen, pancreas, and gastrointestinal tract to the liver. This can cause laceration, avulsion, or formation of a blood clot in the portal vein. The symptoms include abdominal pain, abdominal distention, internal bleeding signs (low blood pressure, pale skin, and fast heart rate), jaundice (yellowing of eyes and skin), and vomiting or nausea.
Initial Stabilization: This includes an initial assessment of the patient and control of bleeding by using the clamping or packing method. Fluid resuscitation or transfusion of blood should be given to maintain the hemodynamic state. With the help of diagnostic imaging such as angiography, the extent of the injury can be studied, and surgical interventions such as repair of the injured segment, bypass surgery (creating a new route), or resection and reconstruction can be performed.
7. Scapulothoracic Dissociation: This refers to the complete or partial separation of the shoulder blade or scapula from the chest wall. This occurs from high-energy trauma. The symptoms include visible deformity where the scapula is elevated, severe pain, neurovascular symptoms such as weakness or numbness, and soft tissue injuries.
Initial Stabilization: This includes assessing the patient's condition (airway, breathing, and circulation). The affected shoulder and spine should be immobilized, and in case of bleeding, it should be controlled by applying direct pressure. Concurrent injuries (fractures and vascular injuries) should be identified and assessed. Intravenous administration of fluids and medications should be given to maintain the hemodynamic state and to control pain. The surgical approach includes repair and fixation using screws and plates, followed by rehabilitation and physical therapy.
8. Traumatic Intracranial Aneurysms: This condition refers to the bulge-out area in the blood vessel wall of the brain. This can occur from blunt trauma or a nonpenetrating injury. An unruptured aneurysm may not cause any symptoms, but a ruptured aneurysm can cause severe headaches, neck stiffness, and loss of consciousness.
Initial Stabilization: This includes the airway, breathing, circulation, disability, and exposure (ABCDE) assessment and monitoring of the vital signs. An endotracheal intubation can be used to maintain adequate oxygenation. Intravenous access is established to administer fluids. Imaging studies such as MRI (magnetic resonance imaging) or CT (computed tomography) can be taken to study the extent of injury. Pain can be controlled by using analgesic medications. Surgical interventions such as clipping (placing a small metal clip to prevent the blood flow) or coiling (tiny platinum coils are filled inside the aneurysm) can be done in case of an accessible aneurysm.
What Is the Prognosis Of Rare Traumatic Injuries?
The prognosis of rare traumatic injuries depends on several factors, such as:
- Type of the Injury: The prognosis depends on the nature of the injury; some have a favorable outcome.
- The Severity of the Injury: Any involvement of vital organs can impact the overall prognosis and can result in a poor outcome; timely and appropriate interventions can decrease associated complications.
- Patient's Overall Health and Age: Overall health and pre-existing conditions such as diabetes, hypertension, or any heart disease can impact the prognosis. Additionally, young individuals have a better prognosis because of faster healing.
- Presence of Associated Injuries and Complications: Complications such as infections or secondary injuries can impact the ability to recover.
- Rehabilitation and Follow-up Care: Rehabilitation plays an important role in recovery and regaining function.
Conclusion:
Rare traumatic injuries present unique challenges during their initial stabilization and treatment. These injuries, although infrequent, can cause severe life-threatening consequences. Therefore, prompt diagnosis, assessment, and appropriate interventions are required to improve patient outcomes and prevent further complications. Emergency healthcare providers should be vigilant and knowledgeable about the management of rare traumatic injuries to ensure the best possible care for their patients.
