SOME unusual examples of intraperitoneal bleeding which have been encountered recently have stimulated the authors to review all patients with this condition in the Oxford group of hospitals over the last six years (1951)(1952)(1953)(1954)(1955)(1956), a total of 129 cases. We have excluded from consideration conditions merely producing blood-stained extravasations of fluid, (for example, acute pancreatitis and mesenteric thrombosis), and included only those patients where an extensive collection of frank blood was found either at operation or post-mortem. The aetiology and mortality of these cases, together with the accuracy of me-operative or me-autopsy diagnosis, is shownOf the uatients in this series 87 (68 ver cent) had bleeding d gynaecological origin' (ruptured ectopic pregnancies or ruptured follicular cysts) and 30 cases (23 per cent) followed trauma to spleen, liver, or both these organs. There were also 4 ruptured aortic aneurysms leaking into the peritoneal cavity and 2 severe post-operative haemorrhages. The 6 remaining examples, all of unusual origin, will be considered in detail later. As regards accuracy of diagnosis, it was evident in nearly all cases that an intra-abdominal disaster had occurred. The exceptions occurred in the 8 patients dying after splenic and/or hepatic trauma. All these were admitted with overwhelming and rapidly fatal head injuries, the abdominal lesions being found incidentally at autopsy, often accompanied by multiple injuries elsewhere.The common gynaecological emergencies and the traumatic haemorrhages uncomplicated by head injuries were correctly diagnosed pre-operatively in the majority of cases (87 per cent), as can be seen from Table I. Of 74 patients where this information was available, the general practitioners had reached a correct diagnosis in 50 per cent of cases, and had invariably recognized the urgency of the condition with which they were called upon to deal.The single fatality in the cases of gynaecological origin was unusual and of interest. She was a girl of 17 with known thrombocytopenic purpura who had had a splenectomy 5 years previously, but whose bleeding tendency had persisted. She died shortly after reaching hospital and autopsy revealed a massive haemoperitoneum due to haemorrhage from a ruptured follicular cyst.There was only I death among the 22 patients with traumatic haemoperitoneum uncomplicated by head injury. In this case the principal cause of haemorrhage was a tear of the middle colic vessels, but, as well as this, there were lacerations of liver, colon, duodenum, and kidney.All 4 patients with intraperitoneal rupture of aortic aneurysms were undiagnosed and all died. Of the 2 post-operative haemorrhages, one followed a pancreatectomy for carcinoma and was fatal, the other followed appendicectomy and the patient recovered after re-exploration and blood transfusion.The rare cases, not surprisingly, were all incorrectly diagnosed before surgery or autopsy and the mortality in this group was high, there being only I survivor in the 6 patien...
H eterotopic ossification (HO) is the formation of normal or lamellar bone in soft tissue locations where bone does not normally exist. Many acquired causes exist, including postsurgical, central nervous system injury, musculoskeletal injury, burns, vasculopathies, and arthropathies including hemarthrosis. Genetic and developmental causes also exist, including fibrodysplasia ossificans progressiva and progressive osseous heteroplasia. 1 Posttraumatic HO can occur in any site but most commonly forms in soft tissues surrounding the hip after total hip arthroplasty or open reduction and internal fixation of acetabular fractures, with an incidence between 18% and 90%. 2 Approximately 20% to 25% of patients with spinal cord injury and 10% to 20% of patients with brain injury develop HO and again, the hip is the most common location, followed by the knee and other joints. 3 Clinical and physiologic evidence suggests that patients with both severe brain injury and extremity fracture are at increased risk for developing HO. 4 -6 Children develop less HO after central nervous system injury than adults do but are at a higher risk after burns. HO frequently resolves spontaneously in children. 7,8 Overall, men are at a higher risk of developing HO and develop a larger amount of bone. 2 Male patients with spinal cord injury are twice as likely to develop HO compared with female patients. 9 Race has not been correlated with HO. Genetic predisposition has not been defined for injury-related HO.HO rarely develops in the abdomen or in abdominal scars. The few cases of abdominal HO that have been reported are primarily in general surgery patients after laparotomy. 10 -12 The exact cause of HO development in the abdomen is not well understood but is thought to relate to the migration of liberated osteoblasts from known or presumed occult bony injury, typically to the pelvis or xiphoid process. 11 Early diagnosis of HO within 3 to 5 days after injury often allows for medical treatment with a combination of nonsteroidal anti-inflammatory medications (NSAIDs), specifically indomethacin or naproxen, in conjunction with gentle physical therapy to prevent progression. 13,14 Recent studies have shown that radiation followed by physical therapy is also effective in early treatment of HO and prevention of further HO. 15,16 In cases of clinically significant or painful HO, surgical excision followed by radiation therapy or NSAIDs is the treatment of choice. 14 We report the case of a 29-year-old man who developed HO in his rectus sheath, abdomen, iliac, sub-xiphoid, and elbow after multiple injuries sustained in a motor vehicle crash. CASE REPORTA 29-year-old Hispanic man was involved in a motor vehicle crash. He sustained multiple injuries including blunt abdominal trauma with blow-out perforations of the small intestine, a right iliac wing fracture, a traumatic inguinal hernia, a skull fracture, a right medial condyle humerus fracture, and bilateral rib fractures. He underwent a damage control laparotomy at the time of admission and was...
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