An Often Easily Missed Injury in the Presence of Orthopaedic Trauma: A Case Series of Derived Injury.

Derived disaster is a common concept in emergencies such as earthquakes. With the progress of society, the incidence of fractures caused by high-energy trauma has increased year by year. After the first injury, the possibility of derived injury caused by the original injury also increases rapidly. Orthopaedic surgeons, especially trauma orthopaedic surgeons, lack sufficient understanding and recognition of this kind of injury. The purpose of this article is to present a case series of an often missed injury pattern that is associated with an original injury. The diagnosis of derived injury may go unrecognized in a considerable number of cases and delayed treatment decreases the success rate of soft tissue repairing; therefore, a high index of suspicion and a proper early diagnosis is of paramount importance. We also describe the current surgical management used by the authors, and propose the concept of "derived injury", studying its clinical significance in traumatic orthopaedics.

Introduction

Derived injury refers to an injury directly caused by a primary injury that has already occurred to the body. According to its performance and nature, derived injury is divided into three types: (i) occult derived injury; (ii) obvious derived injury; and (iii) interventional derived injury. Once orthopaedic trauma occurs, derived injury inevitably follows. Occult derived injury occurs straight after the initial injury due to the carrying of weight or rolling over or changing of body position or other situation, resulting in a fracture that causes injuries such as attrition, stab and puncture to the surrounding tissue and organ (include nerves, blood vessels, ligaments, muscles, tendons, and organs)1, 2. This kind of injury does not show obvious clinical symptoms and signs, and is therefore called occult derived injury. Obvious derived injury refers to the injury of important organs, blood vessels, and nerves caused by the original injury after the original injury, with obvious clinical symptoms and signs. It can be divided into two types: acute derived injury and delayed derived injury. The former points to derived injury that happens a short time after injury. For example, spinal fracture patients do not have neurological symptoms originally after injury, but because of carrying their weight or rolling over to change body position or other situations in the process of transfer to the hospital, the fracture that compresses the spinal cord brings about neurological symptom3, 4. The latter is that the vascular adventitia did not suffer injury with the fracture, but stabbed the vascular adventitia in the process of the carrying their body weight, limb traction or reduction of fracture5, 6, 7. For weeks or months after pseudoaneurysm formation, the clinical manifestations of the derived injury appear. Interventional derived injury is a man‐made injury, which is caused by saving the life of or treating disease in the patient8, 9, 10. At present, some doctors did not treat all kinds of invasive intervention treatment as derived injury, which led to the failure to take effective preventive measures for its occurrence, sometimes even including interventional derived injury that endangers a patient's life.

The main purpose of this study is to reduce the number of derived injuries and reduce the severity of derived injuries. We present a case series three types of derived injury that were caused by violence.

Case Presentation and Surgical Management

Case One

A 38‐year‐old man suddenly developed pain in his pelvis after being hit by a truck. The initial assessment revealed visible subcutaneous ecchymosis in the hypogastrium and obvious scrotal swelling (Fig. 1). Plain radiography (Fig. 2) and computed tomography (Fig. 3) showed a Type C pelvic fracture according to the AO Foundation and Orthopaedic Trauma Association classification. After the patient's general condition was improved by the standardized advanced trauma life support protocol, he underwent urethral realignment, bladder colostomy, and drainage of the scrotal incision. The patient was stable postoperatively. He was placed in temporary skeletal traction of the tibial tubercle and admitted to our hospital for the second surgery to address his pelvic fracture with internal fixation.

Figure 1

There was visible subcutaneous ecchymosis in the hypogastrium and obvious scrotal swelling on examination in the emergency room.

Figure 2

Plain radiography shows a typical pelvic fracture.

Figure 3

Computed tomography shows anterior dislocation of the sacroiliac joint.

He was transferred to the operating room and then he was manually moved from the bed to the operative table. General anesthesia was performed. After sterilization and draping, his blood pressure decreased suddenly and rapidly, with the lowest pressure of 50/30 mm Hg. Angiography revealed no apparent pelvic vascular damage (Fig. 4). He was then given an emergency blood transfusion and simultaneous volume expansion therapy. Physical examination revealed abdominal distension, abdominal tenderness, and rebound tenderness. Emergency laparotomy revealed a large amount of uncoagulated blood (about 4000 mL) and 1800 g of blood clots (Fig. 5). Careful probing uncovered branches of a ruptured external iliac vein (Fig. 6), which was quickly repaired with 1.0 sutures (Ethicon, Johnson & Johnson, Tokyo, Japan). The patient's blood pressure then stabilized.

Figure 4

Angiography reveals no apparent pelvic vascular damage.

Figure 5

Large amount of uncoagulated blood (about 4000 mL) and remnants of clotted blood were found during the operation.

Figure 6

Branch of the ruptured external iliac vein was found (arrow).

Case Two

A 42‐year‐old man developed pain in his pelvis after being involved in a traffic accident. The patient was stable postoperatively after accepting conservative treatment at a local hospital. Subsequently, the patient was admitted to our hospital for treatment of the pelvic fracture. However, his right hip suddenly developed obvious swelling and progressive aggravation. Physical examination revealed the right buttock distension and tenderness (Fig. 7). The fracture line was still visible on the plain radiography (Fig. 8) at admission, and computed tomography (Fig. 9) showed a massive hematoma of the right hip. Angiography revealed superior gluteal artery damage (Fig. 10). Emergency operation was suggested by the consulting surgeons. During the operation, 400 g of blood clots and 800 mL of blood were removed from the gluteus maximus (Fig. 11). Careful probing uncovered branches of a ruptured superior gluteal artery (Fig. 12), which was quickly repaired with 1.0 sutures (Ethicon, Johnson & Johnson, Tokyo, Japan). Postoperatively, closed drainage was used for 3 days with no more than 10 mL of blood was collected by the third day. The drainage tube was removed, and the patient recovered from the derived injury. This patient's arterial injury was caused by puncture from a sharp fracture fragment during the process of transferring the patient, which is a typical derived injury. If we are more careful in transferring patients, this derived arterial injury might have been avoided.

Figure 7

There was visible hematomas in the right hip.

Figure 8

Plain radiography shows pelvic fracture.

Figure 9

Computed tomography shows a massive hematoma of the right hip.

Figure 10

Angiography reveals superior gluteal artery damage.

Figure 11

Large amount of uncoagulated blood (about 800 mL) and remnants of clotted blood were found during the operation.

Figure 12

The ruptured superior gluteal artery was found (arrow).

Case Three

A 50‐year‐old women developed pain in her left thigh and abdomen after being hit by a motorbike. The patient was diagnosed with multiple fractures of the left femur and separation of the pubic symphysis, and was stable after accepting surgical treatment. However, 3 days later, the right side of her perineum appears red, swollen and a skin ulcer about 2.5 cm × 4.0 cm (Fig. 13) appear. The patient felt very uncomfortable and the ulcer gradually healed after a 3‐week intermittent dressing change. Multiple fractures of the left femur were visible on the plain film (Fig. 14) at the time of admission, and the treatment of the tibial tuberosity traction was performed. After reduction and fixation of the pubic symphysis, the surgeon developed a treatment plan with a closed reduction intramedullary nail placement, the intraoperative reduction process was difficult, taking nearly 2 hours and requiring continuous strong traction. Good effects of reduction showed on the postoperative plain radiography (Fig. 15). The reason of perineal injury was analyzed: the perineal bar was jammed on the right perineum for a long time during the operation on the traction bed (Fig. 16).

Figure 13

Plain radiography shows multiple fractures of the left femur and separation of the pubic symphysis.

Figure 14

The right side of perineum appears red, swollen and there is a skin ulcer about 2.5 cm × 4.0 cm (arrow).

Figure 15

Postoperative plain radiography of the left femur.

Figure 16

The operation of traction bed and the perineal bar (arrow).

Discussion

There is a certain dialectical relationship between derived injury and other injuries. Derived injuries after primary injury are different from associated injuries or secondary injuries, for example, no pneumothorax occurred after the rib fracture. Under the situation of carrying weight, turning over and other factors, the fracture punctured the pulmonary vessels and bronchi, resulting in pneumothorax; this is a typical derived injury. If trauma occurs with rib fracture and pneumothorax at the same time, this is an associated injury. Secondary injury is a term used to describe the destructive and self‐propagating biological changes in cells and tissues that lead to their dysfunction or death over hours to weeks after the primary injury11, 12, for example, clotting mechanism changes after multiple fractures, leading to venous thrombosis. Multiple injuries are caused by one single cause but result in several injuries; for example, a traffic accident caused humerus and femur fractures at the same time. Subsequent injury refers to two or more injuries to a tissue or organ in a short period of time; for instance, the patient sustains a pelvis fracture after falling from a high place and was injured again by a falling object, the latter being the subsequent injury. Derived injuries are also different from iatrogenic injuries. Iatrogenic injury is tissue and organ damage in patients caused by medical error; for example, in the internal fixation of clavicle fracture, screw injury to subclavicular arteries and veins is called iatrogenic injury.

Because derived injury is inevitable, it is particularly important to prevent and control it. We should have a focus, because the process of prevention may cause irritation and interference to the surrounding soft tissues. We should make necessary treatment to the injury to minimize the derived injury, including hemostasis of the blood vessel injury, cold compress for soft tissue contusion, homeopathic treatment, and fixation of the external stent for fracture13, 14. On the basis of homeopathic treatment, the irritation and interference to soft tissues should be reduced to the minimum. Derived injuries should not only be prevented, but more importantly controlled. We should master the anatomy around the injury, and it is necessary for us to conform to the mechanical axis of the limb and the movement track of soft tissue. During the operation, not only the incision should be small, but also the soft tissue protection should be strengthened. The surgeon and assistant should cooperate with each other to minimize soft tissue injury and shorten the operation time to the minimum.

In conclusion, this paper proposes the concept of “derived injury” for the first time, in order to attract the attention of the majority of clinicians. Derived injury is inevitable – all kinds of diagnostic and therapeutic measures can lead to derived injury, but we must reduce it to a minimum. For the inevitable “interventional derived injury”, a detailed preoperative diagnosis and treatment plan should be developed to predict all possible difficulties and solutions during the operation. After the occurrence of injury, the body will mobilize everything for its own protection. If we take inappropriate or excessive intervention treatment blindly, it will lead to the body's dysfunction. Therefore, doctors should minimize the damage to the body caused by the interventional measures. As this is a new theory summarized by clinical experience, it still needs to be revised and improved through extensive clinical practice.