25, 50 and 75 years ago

With the trend towards conservation in splenic trauma, the ability to identify a group of patients for whom we can safely offer conservative treatment becomes an important factor. Data were reviewed from the trauma register at the Auckland Hospital, Auckland, New Zealand, in an attempt to isolate any predictive factors that may allow more appropriate allocation of treatment modalities in the future. Methods of treatment were determined and the success or failure of conservative management noted. Differences in the demographics, Injury Severity Score (ISS) and computed tomographic (CT) findings were particularly sought. Over a period of 111 weeks 48 patients were admitted with splenic injuries. Fifteen (31.2%) had immediate splenectomy, 27 (56.2%) were initially treated non-operatively and six (10.1%) died pre-operatively. Of the non-operative group eight (29.6%) failed this management at an average of 4.125 days into their hospital stay. No differences were found in age, mechanism, gender or ISS between the failed and successfully treated group. Using the Buntain classification of CT-graded splenic injury, 13 (87%) who had successful non-operative treatment had a grade II or III compared with six (86%) who failed this management being grade IV. Although these results did not reach statistical significance, by coupling the trends seen together with other work, CT grading of splenic injury is a predictive indicator and does appear to have a role in the early allocation of patients to appropriate treatment plans. There are numerous studies about morbidity and mortality, technical complications and in-hospital factors after proximal femoral fracture surgery in the elderly. Although experienced clinicians are often able to make an accurate prediction, little information is available about the factors that allow early determination of whether a patient may return to the community. The present study aimed to provide that information and, hence, allow better use of health resources. At Westmead Hospital a prospective study was conducted of 304 patients with a proximal femoral fracture who were previously residing at home. A number of different factors were analysed using statistical methods to determine their effect on outcome, which was defined simply in terms of whether the patient was able to return to the community or whether they needed institutional care. Factors that had an adverse influence on return to the community were: a low activities of daily living (ADL) score on admission; increasing age; dementia; the use of regional analgesia; and the occurrence of postoperative complications. Other factors such as gender, fracture type, delay to surgery and length of stay were not significant. Consideration of the ADL score, age and mental state at the time of admission to hospital is all that is needed to determine return to the community. This is helpful to the patient and their family, and allows an early and appropriate referral pattern to either community services or a nursing home. Rupture of the spleen frequently results from high-speed trauma. The most common mode of presentation is as immediate splenic haemorrhage, which is usually easily recognized and treated by immediate splenectomy. Presentation is delayed in one-third of cases, and these may be very difficult to diagnose, especially if the intrasplenic or peri-splenic haematoma has not yet ruptured into the general peritoneal cavity. In this last group the latent period is variable, shock is absent, and abdominal tenderness may be confined to the epigastrium. The diagnosis may be aided by plain skiagrams of the abdomen, which may show suggestive signs such as fractures of the left lower ribs or displacement of the stomach or colon, but even these features may be indefinite, and it may be necessary to consider performing a laparotomy on an ill patient. Four cases are presented and discussed to illustrate the value of angiography in clinching a suspected diagnosis of delayed traumatic rupture of the spleen. Such confirmation was obtained in two patients and early splenectomy was performed. The possibility of splenic rupture was excluded in the third patient, and an operation was thus avoided. In the fourth, an angiographic abnormality consistent with local rupture was shown at surgical exploration to be due to an artefact. In the past, emphasis has been placed on the clinician's ability to assess the size of an abdominal aortic aneurysm, this in turn determining whether or not a patient would undergo elective aortic surgery. When calcification is present within the aneurysm wall, it too can be a useful method of assessing aneurysm size. However, in our series this was of value in only 25% of the cases studied. Such a small percentage may be related to the fact that many of the aneurysms in this series were of small size. Aortography can provide much useful information but it does carry definite risks, and aneurysm size is often not determined accurately. Ultrasonic aortography (echography) has been shown to be of use in assessing abdominal aortic size, and our small series confirms the usefulness of this procedure. We believe that clinical assessment alone is inaccurate and that additional information about abdominal aortic aneurysm size may be obtained by using plain abdominal radiology, echography, and in selected cases, aortography. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians.