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Chapter 8

Contents

Associated (Extra-Abdominal) Wounds (1,089 Casualties)

Leigh K. Haynes, M. D., and Floyd D. Taylor, M. D.

In addition to the 839 thoracoabdominal wounds in this series of 3,154 abdominal injuries, associated (extra-abdominal) wounds of significant severity occurred in 1,089 cases (47.0 percent). Two hundred and sixty-two of these were fatal (table 12).

TABLE 12.-Percent of casualties with and without associated wounds in 2,315 abdominal injuries, with case fatality rates1

Abdominal wounds

Cases

Frequency

Deaths

Case fatality rate

Percent

Without associated wounds

1,226

53.0

272

22.2

With associated wounds

1,089

47.0

262

24.1

Total

2,315

100.0

534

23.1


1All thoracoabdominal wounds in the series are excluded from these calculations.

The associated wounds in these 1,089 casualties numbered 1,551, but data suitable for analysis were available for only 1,403 (table 13). Fractures were the most frequent type of associated injury, and the bony pelvis was the most frequent site of fracture (table 14).

TABLE 13.-Distribution according to type of 1,403 individualassociated wounds in 1,089 casualties with abdominal injuries

Type of wound

Number of wounds

Proportion

Percent

Fracture (compound)

659

47.0

Soft tissue

531

37.8

Thoracic

101

7.2

Spinal cord

40

2.9

Maxillofacial and neck

20

1.4

Major vascular

18

1.3

Major amputation

18

1.3

Peripheral nerve

10

.7

Brain

6

.4

Total

1,403

100.0


114

TABLE 14.-Distribution of major fractures (pelvis, femur, and humerus) in 1,403 associated injuries including 659 fractures1

Fracture

Cases

Proportion of-

1,403 associated injuries

659 fractures

Percent

Percent

Pelvis

238

17.0

36.1

Femur only

57

4.1

8.7

Femur and 1 other major bone

33

2.3

5.0

Humerus only

31

2.2

4.7

Humerus and 1 other major bone

21

1.5

3.2

Total

380

27.1

57.7


1See table 13.

MULTIPLICITY FACTOR

The importance which had been attributed to the multiplicity factor in the general evaluation of the severity of abdominal injuries (p. 105) suggested an analysis of associated injuries from this point of view (tables 15 to 17 inclusive). The results were entirely dissimilar. There was no progressive rise in the case fatality rates (such as practically always had been observed with increases in the multiplicity factor in abdominal injuries) as the number of associated injuries increased. This might perhaps have been expected, in view of the different severity of abdominal wounds and associated wounds. The strikingly high case fatality rate of 39.4 percent in casualties with 3 associated wounds (table 17) could not be explained. Severe associated wounds were unusual in the group of patients with four or more associated injuries, multiplicity rather than severity apparently being the dominant factor in this category. In the 121 cases which make up this group, multiplicity was so extreme that tabulation was not attempted. There were, however, only 27 deaths, 22.3 percent, approximately the same as for the entire series of 1,089 casualties with associated wounds.

Although detailed analysis did not bear out the clinical impression that the presence of severe extra-abdominal wounds materially increased the case fatality rate in abdominal wounds, a comparison of the injuries categorized according to the visceral multiplicity factor (fig. 23) indicated that the rate in each category was definitely increased when the factor of associated wounds was superimposed. Case fatality rates computed on this basis are almost parallel.


115

TABLE 15.-Case fatality rates in 527 abdominal injuries complicated by 1 associated injury

Type of associated injury

Cases

Deaths

Case fatality rate

Fracture

236

40

16.9

Soft tissue

182

37

20.3

Thoracic

42

14

33.3

Spinal cord

28

14

50.0

Maxillofacial and neck

13

3

23.1

Major vascular

5

2

40.0

Major amputation

9

3

33.3

Peripheral nerve

6

0

0

Brain

6

2

33.3

Total

527

115

21.8

 

TABLE 16.-Case fatality rates in 299 abdominal injuries complicated by 2 associated injuries

Type of associated injury

Cases

Deaths

Case fatality rate

Two fractures

92

21

22.8

Fracture and soft tissue

72

13

18.1

Fracture and thoracic

19

5

26.3

Fracture and major vascular

5

1

20.0

Fracture and spinal cord

5

2

40.0

Fracture and amputation

6

0

0

Two soft tissue

37

8

21.6

Soft tissue and thoracic

14

2

14.3

Soft tissue and spinal cord

6

1

16.7

Soft tissue and major vascular

8

1

12.5

Other combinations

35

10

28.6

Total

299

64

21.4


When associated wounds were classified, on the basis of all available data, according to whether they were moderate or severe (a difficult and admittedly arbitrary classification), two facts became evident (fig. 24):

1. The frequency of associated injuries of great severity was highest among patients with abdominal wounds of least severity (that is, of low multiplicity).

2. The frequency of associated injuries of least severity was highest among patients with abdominal wounds of greatest severity (that is, of high multiplicity).


116

TABLE 17.-Case fatality rates in 142 abdominal injuries complicated by 3 associated injuries

Type of associated injuries

Cases

Deaths

Case fatality rate

Three fractures

10

1

10.0

Fracture and two soft tissue

54

13

24.1

Fracture, soft tissue, and thoracic

8

7

87.5

Fracture, soft tissue, and spinal cord

1

0

0

Fracture, soft tissue, and peripheral nerve

4

1

25.0

Fracture, soft tissue, and maxillofacial

3

1

33.3

Fracture, thoracic, and maxillofacial

4

2

50.0

Two fractures and thoracic

14

9

64.3

Three soft tissue

15

9

60.0

Two soft tissue and amputation

3

1

33.3

Other combinations

26

12

46.2

Total

142

56

39.4


FIGURE 23.-Influence of multiplicity factor and presence of associated injuries in 3,154 abdominal injuries.


117

These two facts explain why associated wounds in a series of abdominal injuries such as this exerted an apparently minor influence on the overall case fatality rate. The casualties who sustained simultaneously severe abdominal wounds and severe extra-abdominal wounds seldom reached the surgeon alive. Those who survived had severe abdominal wounds associated with mild extra-abdominal wounds or vice versa.

The case fatality rate for casualties with abdominal injuries and associated wounds but without visceral injuries was 7.2 percent (fig. 23), which was lower than for any other category of patients with extra-abdominal injuries. On the other hand, in 19 of the 22 fatal cases in this group, the associated extra-abdominal injuries were severe. The rate among casualties with abdominal injuries but without visceral injuries or associated injuries was 3.8 percent. There seems no doubt that in these combined injuries the fatalities were chiefly a reflection of the severity of the extra-abdominal wounds rather than of the risk of exploratory laparotomy in the absence of visceral damage (p. 95).

FIGURE 24.-Influence of multiplicity factor and gravity of associated injuries in 3,154 abdominal injuries.

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