Volume 1, Issue 2

Background: Traumatic injuries to the hand, including crush injuries, avulsions, devascularizations, and complex fractures with soft tissue compromise, present significant surgical challenges due to compromised tissue perfusion, edema, and high risk of infection and necrosis. Hyperbaric Oxygen Therapy (HBOT), which involves breathing 100% oxygen at pressures greater than one atmosphere absolute (ATA), is an adjunctive treatment proposed to enhance wound healing in such complex scenarios by maximizing tissue oxygenation. Objective: This study aimed to evaluate the clinical efficacy and outcomes of adjunctive HBOT in the management of acute traumatic hand injuries requiring surgical intervention. Methods: A prospective, randomized controlled trial was conducted involving 80 patients with severe traumatic hand injuries (Gustilo Anderson type IIIB/C open fractures, severe crush injuries with devitalized tissue, or replantation/revascularization cases). Patients were randomly assigned to the Standard Care Group (n=40), receiving surgical management (debridement, fixation, vascular repair, flap coverage as needed) and conventional post operative care, or the HBOT Group (n=40), receiving standard surgical care plus an adjunctive HBOT protocol (2.4 ATA for 90 minutes, twice daily for 5 days, then once daily for a total of 20 30 sessions). Primary outcomes included wound healing rate, time to complete wound closure/graft take, flap survival rate, and infection rate. Secondary outcomes encompassed functional recovery (Total Active Motion   TAM, grip strength), analgesic requirement, and length of hospital stay. Results: The HBOT group demonstrated statistically superior outcomes. The incidence of major post operative complications (flap/graft failure, deep infection, osteomyelitis) was significantly lower (15% vs. 37.5% in the control group, p<0.05). Time to complete wound closure or successful graft/flap take was reduced by an average of 4.2 days (p<0.01). Flap survival rates were 94% in the HBOT group compared to 82% in controls (p<0.05). Functionally, the HBOT group showed significantly greater TAM recovery at 3 month follow up (p<0.01) and required fewer opioid analgesics in the first post operative week (p<0.05). Conclusion: Adjunctive HBOT significantly improves wound healing, reduces complication rates, and enhances functional recovery in patients with severe traumatic hand injuries. It serves as a valuable adjuvant to meticulous surgical technique by modulating the ischemic reperfusion injury, controlling edema, and augmenting neovascularization, thereby optimizing conditions for tissue survival and repair.

Background: Penetrating neck trauma (PNT) represents a surgical emergency due to the potential for life threatening vascular and aerodigestive injuries. Traditional management relies on physical examination, advanced imaging (e.g., CT angiography), and mandatory surgical exploration in selected cases. Video assisted thoracoscopic surgery (VATS), while established in elective thoracic surgery, has been proposed as a potential tool for rapid assessment in the emergency department (ED) or trauma bay setting for injuries with suspected intrathoracic extension. However, its utility, feasibility, and impact on outcomes in the acute management of PNT remain poorly defined and potentially limited. Objective: This study aimed to critically evaluate the role, diagnostic yield, and therapeutic impact of emergency department thoracoscopy (ED VATS) in the management of hemodynamically stable patients with penetrating neck trauma, and to compare outcomes with a standard management protocol. Methods: A retrospective cohort study was conducted at a Level I trauma center over a 5 year period. Patients with PNT (zones I III) who were hemodynamically stable on presentation were included. Two groups were compared: 1) The ED VATS Group: patients who underwent thoracoscopy in the ED or trauma resuscitation room for suspected intrathoracic injury (e.g., based on wound trajectory, chest X ray findings, or ultrasound). 2) The Standard Management Group: patients managed per protocol with a combination of physical exam, multi detector computed tomography angiography (MDCTA), endoscopic evaluation, and observation or operative exploration as indicated. Primary outcomes were diagnostic accuracy of ED VATS for thoracic injuries, rates of negative/non therapeutic procedures, time to definitive management, and in hospital complications. Results: Of 347 patients with PNT, 28 (8.1%) underwent ED VATS, while 319 were managed with the standard protocol. The diagnostic yield of ED VATS for a clinically significant intrathoracic injury (requiring intervention) was only 39.3% (11/28). In 17 patients (60.7%), ED VATS was non diagnostic or identified minor injuries not requiring intervention. The median time from ED arrival to incision for ED VATS was 42 minutes, but 9 patients (32.1%) in this group subsequently required a formal operative intervention (thoracotomy or neck exploration) based on VATS findings or clinical progression, effectively adding a procedural step. Compared to the standard group, the ED VATS group had no significant difference in mortality (3.6% vs. 2.5%, p=0.6) or major complication rates (14.3% vs. 11.9%, p=0.7), but had a significantly higher rate of minor complications related to the procedure (e.g., port site issues, prolonged air leak) (21.4% vs. 3.1%, p<0.001). MDCTA demonstrated a sensitivity of 98% and specificity of 95% for detecting injuries requiring intervention. Conclusion: In hemodynamically stable patients with penetrating neck trauma, emergency department thoracoscopy has a limited and highly selective role. It carries a high rate of non therapeutic procedures, adds minimal therapeutic benefit over modern imaging guided selective management, and introduces procedure specific morbidity. Its use should be restricted to rare, specific scenarios where immediate thoracic visualization is deemed critical and CT is contraindicated or unavailable, rather than as a routine diagnostic tool. Standardized protocols utilizing clinical examination and MDCTA remain the cornerstone of safe and effective management.