Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

Patients as young as 45 with more than 4 rib fractures are at increased risk for adverse outcomes. Efforts to improve outcomes in rib fracture patients should focus not only on elderly patients, but on those as young as 45 years. Based on these data, we established a rib fracture clinical pathway focusing on patients 45 years and older with more than 4 rib fractures.

ATV accidents with severe injuries have increased dramatically at our trauma center and include increased numbers of older riders. Riders over age 50 are generally not identified as a subset of the population vulnerable to such incidents. Preventive efforts should include older riders.

Penetrating brain injury resulting from nail-gun use is a well-characterized entity, one that is increasing in frequency as nail guns become more powerful and more readily available to the public. We present a case and offer management strategies for a 50-year-old male with two intracranial penetrating nail gun injuries. Nail gun brain injuries are commonly intentionally self-inflicted. Suicide should be considered when straight nails cause wounds to the chest, head, or abdomen. The primary preoperative concern is formation of a traumatic pseudoaneurism, which prompts both preoperative and follow-up cerebral angiography. Surgery for combined intracranial and extracranial injury may require the collaborative expertise of colleagues from the fields of ophthalmology, otolaryngology, and oral maxillofacial surgery. A rational management strategy should permit these patients to be discharged with no additional injury.

A patient with an axillary artery gunshot wound pseudoaneurysm was evaluated and managed with computed tomographic angiogram and endovascular stent graft. Vascular injuries resulting from penetrating trauma or interventional vascular procedures are relatively uncommon. Subclavian and axillary arterial injuries may be associated with substantial morbidity and mortality if not managed expeditiously. The inaccessibility of these arteries makes stent graft treatment particularly attractive. The stable patient with a pseudoaneurysm or an arteriovenous fistula seems to be the ideal candidate to treat in this way. As computed tomography (CT) technology has evolved, CT angiography has become an integral part of the initial assessment of proximal extremity vascular injuries.