the conclusion is only applicable to simple single layer closureswith normal approximation.

e NOVEL COMPUTED TOMOGRAPHY SCAN SCOR-ING PREDICTS THE NEED FOR INTERVENTION AF-TER SPLENIC INJURY. Thompson B, Munera F, Cohn S, etal. J Trauma 2006;60:1083–6.

This study attempted to reliably predict the need for clinicalintervention in patients with acute blunt splenic trauma basedon findings from abdominal computed tomgraphy (CT). Thestudy was divided into two phases. In Phase 1, 20 hemody-namically stable patients with blunt injury to the spleen had CTscans of the abdomen/pelvis reviewed by experienced traumaradiologists to determine which number of findings correlatedwith the need for intervention (surgical or angiographic). Threespecific findings were noted: 1) laceration/devascularizationinvolving 50% or greater of the splenic parenchyma; 2) a blushof contrast greater than 1 cm in diameter; and 3) a largehemoperitoneum. The interventions took place based on clini-cal instability, requirement of ongoing transfusions, or thedevelopment of worsening abdominal symptoms. In Phase 2,the CT findings were then validated retrospectively in 56 pa-tients by having the trauma radiologists read the scans andgrade them positive or negative based on the scale determinedin the previous phase, while being blinded to the retrospectiveclinic course of patients in Phase 2. The positive or negativefindings in Phase 2 were then compared to the need for inter-vention based on the aforementioned clinical criterion. In Phase2 it was found that the tested radiological findings had anegative predictive value of 100%, with a positive predictivevalue of 85% and an accuracy of 93%. Sensitivity was 100%,but specificity was 88% because 4 of 56 had positive CT scans(3 large hemoperitoneums and 1 splenic laceration � 50%) anddid not require intervention based on clinical criteria (instabil-ity, transfusions, abdominal symptoms). Of the three findings,hemoperitoneum seemed to be the most sensitive indicator forintervention when evaluated in combination and individually. Itwas concluded that these CT scan grading criteria seem toreliably predict the need for early intervention, and the pro-posed scale was better than the traditional American Associa-tion for the Surgery of Trauma (AAST) grading scale.

[Yadavinder Sooch, MD,Denver Health Medical Center, Denver, CO]

Comments: Although this study yielded four false positives,it proves to have potential. It did not, however, account forinterrater reliability in interpreting scans, which is a severelimitation. Also, the size of the validation group was too small,making confidence intervals wide.

e WHOLE BODY IMAGING IN BLUNT MULTISYS-TEM TRAUMA PATIENTS WITHOUT OBVIOUSSIGNS OF INJURY. Salim A, Sangthong B, Martin M, et al.Arch Surg 2006;141:468–75.

This prospective observational study from Los AngelesCounty and the University of Southern California Medical

Center was conducted from January 2004 through June 2005.The purpose was to investigate the utility of whole-body com-puted tomography (CT) imaging in patients who were hemo-dynamically stable and had no obvious signs of chest or ab-dominal injury but suffered high mechanisms of injury. Eachpatient underwent a CT of the head, cervical spine, and chest,abdomen, and pelvis. One thousand patients were includedduring this time period. The inclusion criteria were: 1) novisible evidence of chest or abdominal injury; 2) hemodynamicstability; 3) normal abdominal examination results in neurolog-ically intact patients or unevaluable abdominal examinationresults secondary to a depressed level of consciousness; and 4)significant mechanism of injury. The latter criteria is defined as:1) motor vehicle collision at greater than 35 mph, 2) fallsgreater than 15 feet, 3) automobile hitting pedestrian withpedestrian thrown more than 10 feet, and 4) assaulted with adepressed level of consciousness.

Of the 1000 patients enrolled, 592 were enrolled based onmechanism of injury. In other words, these patients were evalu-able and had a normal level of consciousness. CT of the headwas abnormal in 3.5% of the patients. CT of the cervical spinewas abnormal in 5.1%. CT of the chest was abnormal in 19.6%.CT of the abdomen and pelvis was abnormal in 7.1%. Further-more, the authors report that the overall treatment was changedin 18.9% of the patients. Such changes include early dischargefrom the Emergency Department, release to other services,admission for serial examinations, performance of additionaldiagnostic studies or interventions, and immediate operativeintervention.

Despite the cost and radiation exposure associated with CTscanning, the authors conclude that the use of the “pan scan”based on mechanism of injury is justified in the awake andevaluable patient.

[Gerardo Ortiz, MD,Denver Health Medical Center, Denver, CO]

Comment: Despite the advancement of medical imaging,injuries may still be missed by CT scanning. It is important toinclude every aspect of the patient’s evaluation in the finaldecision-making process, and not rely solely on the results ofthe imaging studies.

e PROSPECTIVE STUDY TO EVALUATE THE IN-FLUENCE OF FAST ON TRAUMA PATIENT MAN-AGEMENT. Ollerton JE, Sugrue M, Balogh Z, et al. J Trauma2006;60:785–91.

This prospective study included all trauma team activationpatients admitted to Liverpool Hospital in New South Wales,Australia during a 7-month period in 2003. The purpose of thestudy was to determine how the Focused Abdominal Sonogra-phy for Trauma (FAST) examination affected the managementplans of trauma patients. Of the 419 patients included in thestudy, 194 (46%) received a FAST examination. Each patientin this group had a documented plan before and after the FASTexamination was performed. This examination was performedby 1 of 8 certified operators (4 Trauma Surgeons, 3 EmergencyPhysicians, and 1 Intensive Care Unit trainee). Each scan was

The Journal of Emergency Medicine 343

independently assessed and scored for adequacy according tospecific set criteria. Of the 194 FAST examinations performedduring the study, 7 were true positives, 169 were true negatives,4 were false negatives, and 14 were considered indeterminateby the set criteria for adequacy. The authors report that achange in management as a result of FAST examination find-ings was identified in 59 (33%) cases. Such management alter-ations included preventing laparotomy in 1 patient, computedtomography (CT) of the abdomen in 23 patients, and diagnosticperitoneal lavages (DPL) in 15 patients. They also noted areduction in CT requests from 47% to 34% and a reduction inDPL requests from 9% to 1%. Furthermore, the authors re-ported a sensitivity of 64% and a specificity of 100% fordetecting free intra-peritoneal fluid. The sensitivity was slightlyhigher (70%) with an equivalent specificity (100%) when blunttorso trauma was considered in isolation. These results led theauthors to conclude that the FAST examination plays a key rolein trauma, changing subsequent management in an appreciablenumber of patients.

[Gerardo Ortiz, MD,Denver Health Medical Center, Denver, CO]

Comment: Although the FAST examination has become astandard approach to the initial assessment of the trauma pa-tient in the Emergency Department, it is important to rememberthat a negative FAST does not exclude significant abdominal orthoracic injury. The study is limited by the abilities of theoperator and the amount of fluid present at the time of theexamination. It is, however, a safe and valuable adjunct totrauma care.

e TREATMENT OF PRIMARILY LIGAMENTOUSLIS-FRANC JOINT INJURIES: PRIMARY ARTHRODE-SIS COMPARED WITH OPEN REDUCTION AND IN-TERNAL FIXATION. Ly TV, Coetzee JC. J Bone Joint Surg2006;88:514–20.

This prospective randomized clinical trial was conductedbetween March 1998 and June 2002. Forty-one patients withprimarily ligamentous Lis-Franc joint injuries were enrolled inthe study comparing two different treatment options. The firstoption was open reduction and internal fixation (ORIF), whichis the currently recommended treatment for displaced Lis-Francjoint injuries. The second option was primary arthrodesis,which is currently regarded as a salvage procedure. The studywas designed to include all primarily ligamentous injuries thatwere seen within 1 month of the injury. Exclusion criteriaincluded: 1) comminuted intra-articular fractures at the base ofthe first or second metarsals; 2) any other substantial foot,ankle, or leg injury; 3) previous surgery for the same injury; 4)insulin-dependent diabetes mellitus; 5) ipsilateral ankle fusion;6) peripheral vascular disease; 7) peripheral neuropathy; and 8)rheumatoid arthritis. Post-operative checks were performed at 2weeks, 6 weeks, 3 months, 6 months, and then annually. Patientoutcomes were determined by radiographs, a visual analog painscale (ranging from 0 to 10), clinical examination, the Ameri-can Orthopaedic Foot and Ankle Society (AOFAS) MidfootScale (ranging from 0 to 100), and a clinical questionnaire.

Twenty patients were randomized to the ORIF group, and 21patients were assigned to the primary arthrodesis group. In theORIF group, 16 patients underwent further surgery to removepainful hardware. At the time of the last follow-up, 8 patientsreported being very satisfied. Three reported being somewhatsatisfied, 3 were neutral, and 6 were dissatisfied. Furthermore,their AOFAS score averaged 57.1, and their visual analog painscale averaged 4.1. In the arthrodesis group, only 4 patientsrequired any additional surgery. During their last follow-upvisit, 16 patients reported being very satisfied and 5 reportedbeing somewhat satisfied. The AOFAS score in this groupaveraged 86.9, whereas the visual analog pain scale averaged1.2. Based on these findings, the authors conclude that patientswith primarily ligamentous Lis-Franc injuries should be treatedwith primary arthrodesis. They believe that this subset of pa-tients with Lis-Franc joint injuries have better short- and me-dium-term outcomes than those treated with ORIF.

[Gerardo Ortiz, MD,Denver Health Medical Center, Denver, CO]

Comment: Although uncommon, Lis-Franc joint injuries areimportant to detect in the Emergency Department. Such aninjury can lead to chronic pain and disability. Once detected,prompt follow-up with an orthopedic surgeon must be estab-lished to give the patient a chance at a meaningful recovery.

e ECONOMIC IMPACT OF MOTORCYCLE HEL-METS: FROM IMPACT TO DISCHARGE. Eastridge BJ,Shafi S, Minei JP, et al. J Trauma 2006;60:978–84.

This was a retrospective analysis to attempt to determine thedifference in the cost of healthcare for helmeted vs. unhelmetedmotorcycle riders involved in traffic collisions. Specifically, thestudy was undertaken to counter the claims that motorcyclehelmets do not reduce the cost of healthcare for riders. Theauthors suggest that previous cost analysis surveys are inaccu-rate in that they do not included riders that were involved incollisions and either did not get transported to the hospital, orwere discharged from the Emergency Department (ED). Theauthors hypothesize that helmeted riders are more likely to becleared at the scene or discharged from the ED, thereforeaccruing less health care costs. Prehospital motorcycle crashdata were collected from the National Highway TransportationSafety Administration (NHTSA) General Estimates System(GES) database from 1994 to 2002 with respect to helmet use,injury severity, and transport to the hospital. Hospital admis-sion rates of helmeted vs. unhelmeted riders were collectedfrom a focused literature search. Helmet use and hospitalcharge data were collected from the National Trauma DataBank (NTDB). Cost analysis was performed by linkage of thequeried databases and data from the literature. Statistical com-parisons between groups were performed using an independentsamples t-test and �2 analysis. The NHTSA GES databaseyielded 1854 (35%) unhelmeted patients and 3474 (65%) hel-meted patients from 1994 to 2002. Transport to the hospital wasrequired for 79% of unhelmeted patients and 73% of helmetedpatients (p � 0.01). Unhelmeted patients evaluated in the EDwere admitted to the hospital 40% of the time, vs. 33% of

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