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 seriesof 3,154 abdominal injuries, associated (extra-abdominal) wounds of significantseverity occurred in 1,089 cases (47.0 percent). Two hundred and sixty-two ofthese were fatal (table 12).
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 |
| 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 numbered1,551, 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 pelviswas the most frequent site of fracture (table 14).
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 |
| 1,403 | 100.0 |
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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 |
| 380 | 27.1 | 57.7 |
1See table 13.
MULTIPLICITY FACTOR
The importance which had been attributed to the multiplicity factor in thegeneral evaluation of the severity of abdominal injuries (p. 105) suggested ananalysis of associated injuries from this point of view (tables 15 to 17inclusive). The results were entirely dissimilar. There was no progressive risein the case fatality rates (such as practically always had been observed withincreases in the multiplicity factor in abdominal injuries) as the number ofassociated injuries increased. This might perhaps have been expected, in view ofthe different severity of abdominal wounds and associated wounds. The strikinglyhigh 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 thegroup of patients with four or more associated injuries, multiplicity ratherthan severity apparently being the dominant factor in this category. In the 121cases which make up this group, multiplicity was so extreme that tabulation wasnot attempted. There were, however, only 27 deaths, 22.3 percent, approximatelythe same as for the entire series of 1,089 casualties with associated wounds.
Although detailed analysis did not bear out the clinicalimpression that the presence of severe extra-abdominal wounds materiallyincreased the case fatality rate in abdominal wounds, a comparison of theinjuries categorized according to the visceral multiplicity factor (fig. 23)indicated that the rate in each category was definitely increased when thefactor of associated wounds was superimposed. Case fatality rates computed onthis basis are almost parallel.
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TABLE 15.-Case fatality rates in 527abdominal 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 |
| 527 | 115 | 21.8 |
TABLE 16.-Case fatality rates in299 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 |
| 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 washighest among patients with abdominal wounds of least severity (that is, of lowmultiplicity).
2. The frequency of associated injuries of least severity washighest among patients with abdominal wounds of greatest severity (that is, ofhigh multiplicity).
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TABLE 17.-Casefatality 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 |
| 142 | 56 | 39.4 |
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These two facts explain why associated wounds in a series ofabdominal injuries such as this exerted an apparently minor influence on theoverall case fatality rate. The casualties who sustained simultaneously severeabdominal wounds and severe extra-abdominal wounds seldom reached the surgeonalive. Those who survived had severe abdominal wounds associated with mildextra-abdominal wounds or vice versa.
The case fatality rate for casualties with abdominal injuriesand associated wounds but without visceral injuries was 7.2 percent (fig. 23),which was lower than for any other category of patients with extra-abdominalinjuries. On the other hand, in 19 of the 22 fatal cases in this group, theassociated extra-abdominal injuries were severe. The rate among casualties withabdominal injuries but without visceral injuries or associated injuries was 3.8percent. There seems no doubt that in these combined injuries the fatalitieswere chiefly a reflection of the severity of the extra-abdominal wounds ratherthan of the risk of exploratory laparotomy in the absence of visceral damage (p.95).
