Extremity Trauma Research Articles

Comprehensive Validation of the German Version of the LIMB-Q.

Lower extremity trauma significantly impacts patients' lives, requiring a nuanced approach to evaluate outcomes beyond clinical measures. The LIMB-Q, a patient-reported outcome measure (PROM), assesses the multifaceted impacts of lower extremity trauma, including physical and emotional dimensions, from the patient's perspective. This study validates the German version of the LIMB-Q. We relied on the translation of the LIMB-Q that had followed the International Society for Pharmacoeconomics and Outcomes Research best practice guidelines. Sixty patients who had undergone reconstructive surgery or amputation of the lower limb completed the LIMB-Q, Lower Extremity Functional Scale (LEFS), and Short Form Health Survey (SF-36). Internal consistency of the German LIMB-Q was determined by Cronbach's alpha, and reliability was assessed using the intraclass correlation coefficient. Construct validity was analyzed using Pearson correlation coefficients between the LIMB-Q, LEFS, and SF-36. Validation involved 60 patients. Internal consistency in a test-retest subset of 5 patients was good to excellent (α: 0.891 to 0.965). The intraclass correlation coefficient for these scales ranged from 0.821 to 1. The LIMB-Q domains significantly correlated with the corresponding domains of the SF-36 and LEFS, confirming excellent construct validity. The German version of the LIMB-Q is conceptually equivalent to the original English version. It is a reliable and valid PROM for assessing physical and psychological impairments in patients who have undergone lower extremity reconstructive surgery or amputation.

Perioperative Blood Transfusion in Traumatic Limb Salvage.

Background Limb salvage following traumatic lower extremity (LE) injury often necessitates blood transfusion for adequate tissue perfusion. Appropriate transfusion decision-making via a risk-benefit analysis could maximize the opportunity for flap survival. This study aims to examine the impact of perioperative blood transfusion on postoperative complications in traumatic LE reconstruction. Methods A retrospective review was conducted at a level 1 trauma center on patients who underwent LE reconstruction between January 2007-October 2023. Patient demographics, comorbidities, perioperative blood transfusions, flap characteristics, and postoperative complications were recorded. Outcomes investigated included postoperative amputation rates, infection, partial flap necrosis, and flap loss. Univariate analysis and multivariable logistic regression were performed to examine the impact of patient factors on flap necrosis. Results In total, 234 flaps met inclusion criteria. Of these, 149 cases (63.7%) received no transfusion during their hospital stay (Tf-) and 85 cases (36.3%) received at least one unit of packed red blood cells intraoperatively through 48 hours following flap placement (Tf+). Overall flap survival rates were similar across both cohorts (Tf+: 92.9% vs Tf-: 96.6%, p=0.198). The Tf+ cohort had significantly higher rates of partial flap necrosis (12.9% vs. 2.0.%, p<0.001), amputation (6.0% vs 0.7%, p=0.015), and postoperative hardware infection (10.6% vs 2.7%, p=0.011) relative to the Tf- cohort. Multivariable logistic regression demonstrated that transfusion status was independently associated with a 5.1 fold increased risk of flap necrosis (p=0.033). Conclusion Transfusions administered intraoperatively through the acute postoperative period were associated with a significantly increased likelihood of flap necrosis. Surgeons should consider a conservative transfusion protocol to optimize flap viability in patients with traumatic LE injuries.

Financial Toxicity Among Patients With Traumatic Finger Amputation: A Retrospective Study.

Patients face increasing financial toxicity (FT), defined as emotional distress due to the cost of medical treatment. However, little is known regarding FT in the context of upper extremity trauma. We surveyed patients who sustained traumatic finger amputation (October 21, 2011-January 1, 2021). We collected patient-reported financial distress using the Comprehensive Score for Financial Toxicity (COST-11), where a lower score indicates worse FT. We also collected data of patients' perceptions regarding the costs of their treatment. We used linear regression to assess patient-level characteristics associated with FT as measured by the COST-11 score. Of the 191 eligible patients, 46 patients completed the survey (response rate of 24%). A total of 41 respondents (89%) received an initial treatment of revision amputation, with the remaining patients receiving a semi-occlusive dressing. Patients with commercial insurance had significantly lower COST-11 scores (ie, worse FT) than patients with Medicare (β = 7.5, 95% CI: 0.5 to 14.5) and Worker's Compensation (β = 8.7, 95% CI: 1.8 to 15.6). Patients who were single/never married had significantly worse FT (β = -11.3, 95% CI: -18.7 to -3.9). Approximately 35% (n = 16) reported that the costs were higher than expected. More than a third of patients (39%) reported decreasing spending on basic items, such as food, at least once since surgery. Patients face FT when obtaining surgery following traumatic finger amputation. Variation in the FT is associated with type of insurance and marriage status, highlighting how underinsurance and social support likely affect the overall economic well-being of patients.

Rhabdomyolysis After Prolonged Tourniquet Application Is Associated with Reversible Acute Kidney Injury (AKI) in Rats.

Extremity trauma, including ischemia (e.g., prolonged tourniquet application or crush), is common among battlefield injuries. Injured muscle releases toxins leading to rhabdomyolysis and, potentially, acute kidney injury (AKI). The goal of this study was to characterize sequelae of ischemic extremity injury over 72 h, focusing on time courses of rhabdomyolysis and AKI. Male Sprague Dawley rats were placed into two groups. Ischemic injury was produced in anesthetized rats using bilateral tourniquets (TK; n = 10) for 5 h; control (CON; n = 9) rats were treated identically without TK application. Indicators of rhabdomyolysis and renal function were measured in conscious rats 1 day preinjury (baseline, BL) and then at 1.5, 24, 48, and 72 h post-TK release. Prolonged TK application produced necrosis in both muscle and bone marrow but not in kidney. The wet/dry weights indicated edema in injured limbs at 72 h (4.1 (0.5) (TK) vs. 2.9 (0.1) (CON); p < 0.001). TK rats exhibited a 100-fold increase in creatine kinase activity compared to CON at 1.5 h (20,040 (7265) U/L vs. 195 (86) U/L (mean (SD); p < 0.0001). TK decreased the mean glomerular filtration rate (GFR; p < 0.001) at 1.5 h, but these values recovered by 24 h in concert with elevated urinary flow and alkalinization. Prolonged ischemic extremity injury therefore produced severe rhabdomyolysis without irreversible renal damage.

Avoiding “a piece of paper on the wall that everyone ignores”: A qualitative study on the barriers for implementing open fracture guidelines

BackgroundOrtho-plastic evidence-based clinical guidelines for open fractures have demonstrated to standardise care and improve outcomes for patients admitted following lower extremity trauma. Despite its benefits, very few countries have introduced such guidance. The aim of this study was to explore the attitudes, barriers and limitations to the development and implementation of guidelines for lower limb open fractures MethodsTwelve renowned orthopaedic and plastic surgeons, based in countries with no guidelines at present, underwent semi-structured interviews. A qualitative appraisal was conducted using reflexive thematic analysis methodology. Systematic coding led to the development and refinement of themes to address the research question. ResultsIndividualistic decision-making, reliance on multidisciplinary interpersonal relationships, and the presence of immobile determinants of open fracture care emerged as three themes that define how patients are currently managed in settings with no guidelines in place. Although guidelines can potentially improve care by presenting evidence-based recommendations, introducing audit practices, establishing pathways for multidisciplinary collaboration, and enhancing effective leadership; if barriers to the implementation are not considered, they may end up as a “piece of paper on the wall that everyone ignores” ConclusionsThis study is the first to explore the challenges of introducing ortho-plastic guidelines for open extremity trauma. The themes presented describe the status quo in settings with no such protocols in place, establishing the foundation for future initiatives aiming to provide a practical strategy to aid the development and introduction of clinical guidelines for open lower limb fractures.

The MangLE score: A novel simple tool to identify patients who are unlikely to require amputation following severe lower extremity injury.

There are no validated and sensitive models that can guide the decision regarding amputation in patients with mangled lower extremities. We sought to describe a simple scoring model, the Mangled Lower Extremity (MangLE) score, which can predict those who are highly unlikely to need an amputation as a means to direct resources to this cohort. This is a retrospective study using the 2013-2021 American College of Surgeons Trauma Quality Improvement Program data set. Adult patients with a mangled lower extremity, defined as a crush injury or a fracture of the femur or tibia combined with severe soft tissue injury, arterial injury, or nerve injury, were included. Patients who suffered a traumatic lower extremity amputation, underwent amputation within 24 hours of admission, or who died within 24 hours of admission were excluded. Patients were divided into those who did/did not undergo amputation during their hospital stay. Demographics, injury mechanism, Injury Severity Score, and Abbreviated Injury Scale score, initial vital signs, and comorbid conditions were abstracted. A logistic regression model was constructed and the top five most important variables were used to create the score. The study includes 107,620 patients, of whom 2,711 (2.5%) underwent amputation. The five variables with the highest predictive value for amputation were arterial injury, lower-extremity Abbreviated Injury Scale score of ≥3, crush injury, blunt mechanism, and shock index. The lowest possible MangLE score was 0, and the highest was 15. The model demonstrated an excellent predictive ability for lower extremity amputation in both the development and validation data set with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval, 0.80-0.82) and 0.82 (95% confidence interval, 0.81-0.84), respectively. The negative predictive value for a score of <8 is 99%. The MangLE score is able to identify patients who are unlikely to require amputation. Resources for limb salvage can be directed to this cohort. Prospective and Epidemiologic; Level IV.

Mortality association with extremity trauma and transferring patients for higher level of care.

Rising healthcare costs and reduced Medicaid reimbursements pose lasting challenges for trauma centers. Various studies have highlighted the adverse effect of these cost-related circumstances on trauma center survival and the need for local hospitals to transfer patients to tertiary and quaternary care centers. Our study seeks to assess the relationship between patient transfer status to a higher-level health center and its association with mortality. A total of 19417 patients were identified, of which 15317 patients presented directly to the higher level health center, and 3830 patients who transferred from 49 different outside hospitals within a 500-mile radius. Data collection was collected from the receiving higher level of care hospital trauma registry. IBM SPSS version 23 was used to analyze the data. A 1:1 propensity-matched analysis based on age, sex, and injury severity score yielded 3566 patients that presented directly to ARMC and 3566 patients who were transferred to ARMC for a higher level of care. Amongst various factors we considered mechanism of injury, response levels, arrival methods, and transfusion of blood products. The univariate analysis of the propensity-matched analysis demonstrated 88% blunt injury in the nontransferred group and 82% in the transferred group (P<0.001). Overall, hospital mortality was 3% in nontransferred patients versus 4% in the transferred group (P<0.001). A multivariate logistic regression demonstrated mortality is more likely in patients with higher injury severity scores [odd ratio (OD) 2.351 (1.029-1.082), P<0.001] and lack of packed red blood cell (pRBC) transfusions received within first 4h [OD 6.852 (3.525-13.318), P=0.001]. The transfer of trauma patients with extremity injuries to level 1 trauma centers has significant implications on patient outcomes. In our retrospective observational cohort study, the authors noted increased mortality among patients with higher injury severity scores, penetrating injuries, pRBC administration within the first 4h of hospitalization, and among patient transfers.

Polytrauma in a Jet Pilot After Low-Altitude Ejection Without Parachute Deployment

BACKGROUND: Ejection seats are designed to be a lifesaving device for aircrew in emergencies. Modern ejection seats are widely prevalent in fighter and bomber aircraft and are occasionally associated with acceleration injury from axial loading (Gz) during the catapult phase of ejection, limb flail injury due to windblast, or parachute landing fall, especially if the ejection is outside of the seat’s performance envelope. CASE REPORT: We present the first known case in the medical literature of a military pilot who survived a low-altitude, high-angulation (&gt;90° of bank angle) ejection where the pilot’s ejection seat parachute did not deploy due to contact with the ground before completion of the ejection sequence. The patient’s initial exam upon arrival at a trauma center was significant for a Glasgow Coma Scale of 3T, with evidence of cranial and extremity trauma. The patient presented with respiratory acidosis and required upsizing of his endotracheal tube placed in the field. The patient’s injury list included bilateral subdural and subarachnoid hemorrhages, a Hangman’s fracture, spinal burst fractures, and extensive extremity fractures. After a prolonged hospital stay, the patient was discharged to rehabilitation. The patient made a functional and neurological recovery, including return to independent completion of his activities of daily living. DISCUSSION: This case provides evidence of favorable outcome after a low-altitude, high-angulation ejection without parachute deployment. This case details the medical and traumatic pathology medical personnel should expect from an ejection that occurs outside of the seat’s performance envelope. Zivkovic MM, Inman BL, Figlewicz MR, Burchett JA, Nowadly CD. Polytrauma in a jet pilot after low-altitude ejection without parachute deployment. Aerosp Med Hum Perform. 2024; 95(11):862–866.

Investigating the Association Between Pre-Flap Negative Pressure Wound Therapy and Surgical Outcomes in Extremity Free Flap Reconstruction: A Systematic Review.

While prior studies have recommended immediate flap coverage within 72 hours of injury for soft tissue reconstruction for traumatic extremity injuries, recent evidence in the setting of advanced wound care techniques de-emphasizes the need for immediate coverage. Negative-pressure wound therapy (NPWT) has been an essential tool for extending the time to definitive soft tissue coverage. This study sought to elucidate the impact of preoperative NPWT use on the success of microsurgical reconstruction. A literature search was conducted using the following databases from their inception up to February 2023: PubMed, OVID Databases (Embase and Cochrane Library), Web of Science, and Scopus. Of 301 identified articles, 161 were assessed and 24 were included. Cases were divided based on whether NPWT was used preoperatively or not. Timing to definitive coverage, injury details, and basic demographics were recorded. Rates of flap failure, infection, bone nonunion, reoperation, and complications were compared between groups. A total of 1,027 patients and 1,047 flaps were included, of which 894 (85.39%) received pre-flap NPWT. The average time to definitive coverage for the NPWT and non-NPWT groups was 16 and 18 days, respectively. The NPWT group experienced lower postoperative complication rates than the non-NPWT group in all reported complications except for deep infections. Compared to the non-NPWT group, the NPWT group experienced lower rates of any flap failure (3.69% vs. 9.80%) and partial flap failure (2.24% vs. 6.54%). Preoperative NPWT was associated with reduced postoperative complications, most importantly flap failure rates. This merits further investigation into the decision-making process for traumatic extremity reconstruction. Future prospective studies adopting standardized protocols with longer follow-up are required to better understand the potentially beneficial role of preoperative NPWT use in soft tissue reconstruction.

Comparison of Patient-Reported Outcomes after Local Flap Coverage versus Amputation for Complex Lower Extremity Trauma

Abstract Background There is a paucity of patient-reported outcomes (PROs) data in lower extremity salvage. Limb salvage can often be achieved with the use of local muscle flaps or fasciocutaneous flaps. The purpose of this study was to compare PROs of patients who underwent lower extremity salvage using local fasciocutaneous flaps or muscle flaps to lower extremity amputation. Materials and Methods The outcomes of 61 patients that underwent lower extremity local flap reconstruction (n = 33) or amputation (n = 28) between 2014 and 2020 were recorded. Chart reviews were performed to collect perioperative data. Patients were contacted via telephone for participation in the survey portion of our study. PROs were recorded utilizing both the Lower Extremity Functional Scale (LEFS) and the 36-Item Short-Form Health Survey (SF-36). Results Surveys were completed by 61 patients (response rate 59.2%). The mean time of survey after flap reconstruction or amputation was 2.7 ± 1.4 years. Recent trauma (within 90 days) was the most common indication for local flap coverage (n = 23). LEFS score and SF-36 physical functioning scores were significantly lower in patients who underwent muscle flaps compared with fasciocutaneous flaps (p = 0.021 and p = 0.022). Muscle flap patients had similar LEFS and SF-36 scores to amputation patients, while fasciocutaneous flap patients had significantly higher LEFS (p = 0.01), SF-36 physical functioning (p = 0.031), physical role functioning (p = 0.031), and emotional role functioning (p = 0.047) scores than amputation patients. Conclusion Patients who underwent local fasciocutaneous flaps for limb salvage reported higher PRO scores than those undergoing amputation, while patients undergoing muscle flaps reported outcomes similar to those undergoing amputation. PROs for muscle flap patients were significantly lower than those of fasciocutaneous flap patients. These data suggest that while fasciocutaneous and muscle flaps are both useful limb salvage procedures, fasciocutaneous flaps may confer advantages that result in improved patient-perceived outcomes. Further study is needed to better characterize outcomes in limb salvage.

The Godina Principle in the 21st Century: Free Flap Timing after Isolated Lower Extremity Trauma in a Retrospective National Cohort.

The timing of free flap reconstruction after lower extremity trauma has been a controversial debate since Marko Godina's original 72-hour recommendation. Recent advances in microsurgery warrant an evaluation of the optimal time to reconstruction. The Nationwide Readmission Database (2014-2019) was used to identify patients undergoing free flap reconstruction after lower extremity trauma. Risk-adjusted statistical methods were used to identify optimal time where risk of infectious and microsurgical complications increase and to quantify the risk associated with time delays. A total of 1,030 patients undergoing reconstruction were identified. The mean time to flap coverage was 24.3 days. Thirty-three percent were performed within 72 hours, 24% from 72 hours to 10 days, 18% from 10 to 30 days, and 24% after 30 days. Flaps performed after 10 days were associated with increased risk of surgical site infection, osteomyelitis, and other wound complications, compared with those performed within 72 hours. There was no increased risk in the period of 72 hours to 10 days. Revision amputation and microsurgical complications were not increased after 10 days. The predicted optimal cutoff was 9.5 days for microsurgical complications and 14.5 days for infectious complications. Advances in microsurgery may be responsible for extending the time in which definitive soft tissue coverage is required for wounds resulting from lower extremity trauma. Although it appears the original 72-hour time window can be safely extended, efforts should be made to refer patients to specialty limb salvage centers in a timely fashion.

Quality of Life after Open Extremity Trauma (QUINTET) study: An international, multicentric, observational, cohort study of quality of life following lower extremity open fractures

IntroductionOpen lower limb fractures are severe injuries long-lasting consequences. Limited research has been done on the impact of these on quality of life, internationally. MethodsThe Quality of Life after Open Extremity Trauma (QUINTET) study was designed as an international, multi-centre, observational, cohort study of patients admitted with open lower limb fractures. Demographic and clinical information was collected, along with repeated validated quality of life measures. Primary outcomes were SF-12 and EQ-5D-3L and secondary outcomes were soft tissue infection, deep infection, non-union and amputation. ResultsA total 92 patients were enrolled in 8 centres, based in the UK, Spain, Chile and Sudan. Mean age at presentation of 54 years, 47 years for males and 64 years for females. Males presented a higher proportion of road traffic accidents as the underlying mechanism, while for females this was the case for low-energy falls. Participant retention was 71.7% and 73.9% for the 3 and 12-months assessments, respectively. There was a substantial reduction in quality of life after open fracture, which only partially recovered at 12 months. Participants recruited in the UK presented lower quality of life scores compared with patients treated in Spain and Chile. DiscussionFor this study, international patient recruitment proved challenging, leading to most patients being recruited in the UK. Despite this limitation we found significant a statistically significant detriment in self-reported quality of life which did not recover after a year. This study highlights differences in quality-of-life outcomes from a gender and international perspective.

Damage control thoracic surgery: What you need to know.

Damage control surgery in trauma prioritizes patient stabilization through an initial temporizing surgical approach to rapidly control hemorrhage and contamination, minimizing intraoperative time to allow for resuscitation and the correction of hypothermia, coagulopathy, and acidosis in the intensive care unit. This is followed by definitive repair of injuries once physiological parameters have improved. While damage control techniques for traumatic intra-abdominal and extremity injuries are well established and frequently utilized, the same cannot be said for damage control thoracic surgery. The complexity of thoracic injuries, the intricate decision making process, the level of surgical expertise required, and potential complications make damage control thoracic surgery particularly challenging. However, advances in surgical techniques, improvements in perioperative care, and the emergence of adjuncts such as extracorporeal membrane oxygenation have significantly enhanced decision making and underscored the importance of timely and decisive intervention in damage control thoracic surgery to optimize patient outcomes. This review aims to provide a comprehensive overview of damage control thoracic surgery, detailing the principles, indications, operative techniques, perioperative management, and the integration of advanced therapies to improve outcomes in patients with severe thoracic injuries.

Radiological perspective on earthquake trauma: differences in children and adults.

February 2023 saw major earthquakes in Pazarcık and Elbistan, causing significant devastation in Turkey. Patients were transferred to hospitals in neighboring provinces, with multiple traumas-especially fractures and organ injuries-forming the main reasons for hospital admissions. This study aimed to examine earthquake-related injuries in pediatric and adult populations to understand differences. This study analyzed 1,220 adults and 590 pediatric patients with radiological imaging out of 8,704 earthquake trauma cases. Radiological images were assessed independently by two radiologists. Statistical analysis using SPSS examined relationships between variables such as age group and injury type. Results showed 40% of adults and 64% of children had normal radiological findings. Cerebral and extremity traumas were most common in pediatrics, while adults showed more extremity, thoracic, and spinal traumas. Significant differences between adult and pediatric groups were observed in cranial fractures, thoracic and lumbar vertebral fractures, hemopneumothorax, lung contusions, rib fractures, femur and talocalcaneal fractures, and compartment syndrome (p<0.001). Earthquake-related injuries may vary between children and adults. Due to children's more flexible anatomical structure, it is believed that earthquake-related injuries occur less frequently in children. In this study, head traumas were more common in children compared to adults. The rate of cranial fractures was significantly higher in children, with a higher incidence of epidural hematoma compared to adults. Spinal traumas were more frequent in adults than in children, attributed to children's greater flexibility reducing the risk of entrapment under rubble. Pediatric thoracic compliance being significantly higher than in adults often resulted in milder chest traumas. However, compartment syndrome was more common in children, with a lower rate of accompanying bone fractures compared to adults. No significant difference was observed between children and adults in maxillofacial, abdominal, and pelvic traumas. These findings provide insights for future disaster healthcare planning and management.

The role of 3D cinematic rendering in the evaluation of upper extremity trauma.

Traumatic upper extremity injuries are a common cause of emergency department visits, comprising between 10-30% of traumatic injury visits. Timely and accurate evaluation is important to prevent severe complications such as permanent deformities, ischemia, or even death. Computed tomography (CT) and CT angiography (CTA) are the favored non-invasive imaging techniques for assessing upper extremity trauma, playing a crucial role in both the treatment planning and decision-making processes for such injuries. In CT postprocessing, a novel 3D rendering method, cinematic rendering (CR), employs sophisticated lighting models that simulate the interaction of multiple photons with the volumetric dataset. This technique produces images with realistic shadows and improved surface detail, surpassing the capabilities of volume rendering (VR) or maximal intensity projection (MIP). Considering the benefits of CR, we demonstrate its use and ability to achieve photorealistic anatomic visualization in a series of 11 cases where patients presented with traumatic upper extremity injuries, including bone, vascular, and skin/soft tissue injuries, adding to diagnostic confidence and intervention planning.

Magnitude, mechanism and outcome of pediatric trauma at university of gondar comprehensive specialized hospital, 2023

IntroductionTrauma is the leading cause of mortality among children older than one year. In fact, injuries alone account for a greater number of deaths in children than all other causes combined. Among children under the age of 19, accidental injuries contribute to 65 % of all injury-related deaths. Limited research on childhood trauma in Ethiopia makes it difficult to fully understand its processes, patterns, and effects. In this research, we thoroughly examine the mechanisms, patterns, and outcomes of pediatric trauma cases at the University of Gondar Comprehensive Specialized Hospital, located in Northwest Ethiopia, in the year 2023. MethodsThis cross-sectional study was conducted on a randomly selected sample of 405 pediatric patients who visited the University of Gondar Comprehensive Specialized Hospital between January 1, 2023, and December 30, 2023. Data were extracted from each medical chart using a structured checklist. The collected data were entered into Epi-data 3.1 for cleaning and analyzed using SPSS version 25. The results were reported using tables and text. ResultsA total of 405 patients, consisting of 265 males (65.4 %) and 140 females (34.6 %), were included in this study. The patients had a mean age of 7.1 years and a standard deviation of 4.3. The majority of the patients, 303 (74 %), were under the age of 10. More than half of the trauma cases, 222 (54.8 %), occurred in children from rural areas. Fall-down accidents accounted for 187 (46.2 %) of the cases. The second most common cause of trauma was road traffic incidents with collisions, accounting for 53 (13.1 %) cases. In terms of anatomical location, face and head trauma were the most common, accounting for 165 (40.7 %) cases. This was followed by extremity trauma (upper and lower extremities) in 159 (39.3 %) cases and abdomen and pelvic trauma in 103 (25.4 %) cases. The majority of children, specifically 373 (92.1 %), were discharged with improvement. ConclusionPediatric trauma continues to be a significant issue of public health importance. It is predominantly observed in boys residing in rural areas, with fall-related injuries being the most prevalent cause. Moreover, a majority of the affected individuals experience trauma to the head and face. Therefore, it is imperative to emphasize the necessity of educating the general population about the potential risks associated with pediatric trauma, especially concerning incidents involving falls and motor vehicle collisions. Educating children about the potential hazards linked to activities like climbing trees, crossing roads, and interacting with animals is of utmost importance.

Limb Salvage and Treatment of Posttraumatic Lymphedema in a Mangled Lower Extremity

Summary: Post traumatic lymphedema (PTL) is a known complication of extremity trauma that is detrimental to limb form and function, healing, and quality of life. In cases of complex lower extremity trauma with vascular and extensive soft tissue injury, the risk of PTL is increased. However, many trauma patients are lost to follow-up, making the risk and potential management of these patients’ lymphedema difficult to characterize. The purpose of this report is to describe the successful surgical management of PTL secondary to significant lower extremity trauma requiring complex limb salvage reconstruction. A 43-year-old woman involved in a motorcycle accident presented with a Gustilo IIIB right tibial fracture and single-vessel leg. She underwent successful limb salvage with serial debridement, bony fixation, creation of an arteriovenous loop with a contralateral saphenous vein graft, and a chimeric latissimus dorsi-serratus anterior muscle flap. At the 5-month follow-up, she presented with significant right lower extremity lymphedema. She underwent lymphovenous bypass surgery guided by preoperative indocyanine green lymphography, which resulted in a 62% improvement in functional outcome measures, eliminated her prior need for compression garments and inability to wear regular shoes, and sustained improvement at two years follow-up. This case illustrates a near circumferential traumatic defect reconstructed with a muscle flap and successful delayed lymphatic reconstruction with lymphovenous bypass in the same patient.

Investigation of treatment outcomes for severe extremity trauma in an independent orthopedic trauma center: A case series

BackgroundSevere extremity trauma is one of the most challenging injuries to treat. Limb salvage after severe extremity trauma requires rapid revascularization, accurate and appropriate bone and soft tissue reconstruction, and appropriate management to address critical complications. The purpose of this study was to report the treatment outcomes for severe extremity trauma injuries at our independent orthopedic trauma center. MethodsThis study included patients with severe extremity trauma who underwent major vascular repair or soft tissue reconstruction. Bone reconstruction method, presence or absence of revascularization, and flap type were investigated. Complications were investigated, including revascularization failure, flap failure, infection, and ultimately, whether amputation was required. Additionally, we investigated the number of surgeries performed on each patient at the time of initial hospitalization. ResultsThirty-five patients who underwent revascularization or soft tissue reconstruction were included in this study. Plate fixation was performed in 18 patients, intramedullary nail fixation in 8, screw fixation in 1, pinning in 4, and without implant fixation in 4. Revascularization was performed in six patients, and no vascular complications occurred. Pedicled and free flaps were used in 17 and 16 patients, respectively. Partial flap necrosis occurred in four patients, and arterial occlusion occurred in one. Infection occurred in 10 patients who were treated with frequent irrigation and high-concentration antibiotics local infusion therapy. None of the 35 patients required limb amputation. Mean number of surgeries was 12.5. ConclusionsThe limb of all the 35 patients with severe extremity trauma treated at our independent orthopedic trauma center were salvaged.

Lower Extremity Trauma is Associated with an Increased Rate of New Mental Disorder Diagnosis and Suicide Attempt.

To evaluate the risk of developing a new mental disorder diagnosis within two years of lower extremity fracture. Design: Retrospective cohort study. National insurance claims database. Included were patients between the ages of 18 and 65 with lower extremity, pelvis and acetabular fractures without prior mental disorders as defined with ICD-9 and ICD-10 diagnosis codes. Mental disorders evaluated included alcohol use disorder, generalized anxiety disorder, bipolar disorder, major depressive disorder, drug use disorder, panic disorder, post-traumatic stress disorder, and suicide attempt.Outcome Measures and Comparisons: The individual lower extremity fracture cohorts were matched 1:4 with non-fracture controls. The specific groups of interest were pelvis fractures, acetabulum fractures, proximal femur fractures, femoral shaft fractures, distal femur fractures, patella fractures, tibia plateau fractures, tibia shaft fractures, ankle fractures, pilon fractures, calcaneus fractures, and Lisfranc fractures. Rates of mental disorders after primary lower extremity fractures within two years were compared using multivariable logistic regression. Overall, the 263,988 patient fracture group was 57.2% female with an average age of 46.6 years. Compared to controls with no fracture, patients who sustained pelvis, acetabulum, proximal femur, femoral shaft, distal femur, patella, tibia plateau, tibia shaft, pilon, calcaneus, or Lisfranc fracture had a statistically significant increased risk of being diagnosed with a queried mental disorder within two years of fracture. When comparing all fracture patients by location, those suffering from fractures proximal to the knee joint, including pelvis fractures (OR: 1.51, 95% CI: 1.39-1.64) and proximal femur fractures (OR: 1.36, 95% CI: 1.26-1.47), demonstrated greater risk of developing any of the queried mental disorders compared fractures distal to the knee, including ankle fractures (OR: 0.99, 95% CI: 0.95-1.03) and pilon fractures (OR: 1.05, 95% CI: 0.81-1.36). When comparing specific fracture patients to patients without fracture by mental disorder, patients demonstrated an increased risk of suicide attempt following fracture of the pelvis, acetabulum, femoral shaft, distal femur, and calcaneus, as well as patients suffering a Lisfranc fracture. There is an increased risk of being diagnosed with a new mental disorder following lower extremity trauma in patients without prior mental disorder diagnosis compared to matched individuals without a lower extremity fracture. Among the fractures studied, those that were more proximal, such as pelvis and proximal femur fractures, carried the greatest risk compared to more distal fracture sites, including ankle and pilon fractures. Patients who experienced certain lower extremity fractures had a significantly higher rate of suicide attempt compared to patients without fracture. Physicians should consider increased mental health screening and potential referral for mental health evaluation for patients following lower extremity trauma. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Stop the Bleed-Wait for the Ambulance or Get in the Car and Drive? A Post Hoc Analysis of an EAST Multicenter Trial.

Background: The Stop the Bleed campaign gives bystanders an active role in prehospital hemorrhage control. Whether extending bystanders' role to private vehicle transport (PVT) for urban penetrating trauma improves survival is unknown, but past research has found benefit to police and PVT. We hypothesized that for penetrating trauma in an urban environment, where prehospital procedures have been proven harmful, PVT improves outcomes compared to any EMS or advanced life support (ALS) transport.Methods: Post-hoc analysis of an EAST multicenter trial was performed on adult patients with penetrating torso/proximal extremity trauma at 25 urban trauma centers from 5/2019-5/2020. Patients were allocated to PVT and any EMS or ALS transport using nearest neighbor propensity score matching. Univariate analyses included Wilcoxon signed rank or McNemar's Test and logistic regression.Results: Of 1999 penetrating trauma patients in urban settings, 397 (19.9%) had PVT, 1433 (71.7%) ALS transport, and 169 (8.5%) basic life support (BLS) transport. Propensity matching yielded 778 patients, distributed equally into balanced groups. PVT patients were primarily male (90.5%), Black (71.2%), and sustained gunshot wounds (68.9%). ALS transport had significantly higher ED mortality (3.9% vs 1.9%, P = 0.03). There was no difference in in-hospital mortality rate, hospital LOS, or complications for all EMS or ALS only transport patients.Conclusion: Compared to PVT, ALS, which provides more prehospital procedures than BLS, provided no survival benefit for penetrating trauma patients in urban settings. Bystander education incorporating PVT for early arrival of penetrating trauma patients in urban settings to definitive care merits further investigation.