High-velocity Injuries Research Articles

Peripheral immune cell dysregulation following diffuse traumatic brain injury in pigs

Traumatic brain injury (TBI) is a global health problem affecting millions of individuals annually, potentially resulting in persistent neuropathology, chronic neurological deficits, and death. However, TBI not only affects neural tissue, but also affects the peripheral immune system’s homeostasis and physiology. TBI disrupts the balanced signaling between the brain and the peripheral organs, resulting in immunodysregulation and increasing infection susceptibility. Indeed, secondary infections following TBI worsen neurological outcomes and are a major source of mortality and morbidity. Despite the compelling link between the damaged brain and peripheral immune functionality, little is known about how injury severity affects the peripheral immune system in closed-head diffuse TBI, the most common clinical presentation including all concussions. Therefore, we characterized peripheral blood mononuclear cells (PBMCs) and plasma changes over time and across injury severity using an established large-animal TBI model of closed-head, non-impact diffuse rotational acceleration in pigs. Across all timepoints and injury levels, we did not detect any changes to plasma cytokine concentrations. However, changes to the PBMCs were detectable and much more robust. We observed the concentration and physiology of circulating PBMCs changed in an injury severity-dependent manner, with most cellular changes occurring within the first 10 days following a high rotational velocity injury. Here, we report changes in the concentrations of myeloid and T cells, changes in PBMC composition, and changes in phagocytic clearance over time. Together, these data suggest that following a diffuse brain injury in a clinically relevant large-animal TBI model, the immune system exhibits perturbations that are detectable into the subacute timeframe. These findings invite future investigations into therapeutic interventions targeting peripheral immunity and the potential for peripheral blood cellular characterization as a diagnostic tool.

Outcomes Of Early And Delayed Intervention Of Maxillofacial Trauma

Background: Maxillofacial trauma is routinely evaluated on the basis of high and low velocity injuries, types of fractures in the literature. On the other hand, we have evaluated them on the basis of timing of surgery after trauma and their outcomes. In India RTA (Road traffic accidents) scenario is quite different from other countries. The highway traffic consists of a variety of vehicles from a cyclist, a two-wheeler, a four-wheeler to a heavy loaded truck. Animals like cows and dogs frequent the highways. Hence, we have classified the patients based on Single jaw and Panfacial fractures with or without the presence of extensive soft tissue injuries. Materials and Methods: In this retrospective record-based descriptive study, 200 patients that were treated at Sri Aurobindo Hospital between January 2023 to July 2024 for maxillofacial trauma were reviewed. Of which 176 patients were surgically operated, averaging 30 years of age and ranging from 12-70 years. For the purpose of our study these 176 patients were categorized into two groups, first of single jaw fractures(108 patients) and second of Panfacial fractures (68 patients). Single Jaw fractures were further divided as mandibular (84 patients); maxilla & zygomaticomaxillary complex fractures (24 patients). These were further evaluated and categorized as those patients who were treated within 72 hours (Early) and after 72 hours (Delayed) following injury. All patients of both the groups were treated with open reduction and internal fixation. Individual complications that of soft tissue dehiscence, plate/bone exposure, bone graft rejection, oroantral/palatal fistula, non-union of fractured segments, infections were analyzed. These complications were again assessed on the basis of their timing; those occurring within 72 hours and those after 72 hours. Results: When each type of complication was compared and evaluated, there was significantly more complication noted among delayed group than in early group. Conclusion: The restoration of the aesthetics and functionality of the face, post-trauma is a critical and an arduous task. As the anatomical complexity of the face must be addressed, timely intervention to achieve optimal functional and aesthetic outcomes is pertinent. Thus, the treatment should be done at the earliest when feasible

Evolving Strategies for the Management of Carotid Artery Injuries due to Penetrating Trauma

Penetrating carotid injuries, although less common than other forms of vascular trauma, carry a significant risk of morbidity and mortality, with the potential for severe central neurologic deficits and death rates ranging from 10% to 50%. Penetrating trauma to the carotid arteries occurs in up to 20% of all trauma neck cases and when these injuries are not promptly diagnosed and treated, the consequences can be dire. Penetrating carotid injuries are often the result of violence, such as knife wounds or low-velocity firearm injuries, particularly in urban settings. In contrast, in military or combat environments, high-velocity firearm injuries are more common, and these are typically more severe and life-threatening. The urgency in managing carotid injuries lies in the need to quickly restore and maintain cerebral blood flow, prevent stroke, and manage hemorrhage, all while navigating the complex and delicate structures of the neck and concomitant injuries. In this manuscript, we will explore the anatomic considerations, clinical presentation, and evolving strategies for the surgical and endovascular management of penetrating carotid trauma. The focus will be on how modern diagnostic tools and treatment approaches, particularly the shift from traditional zone-based management to a more flexible "no-zone" approach, have improved outcomes for patients with these potentially fatal injuries.

A proposed stratification system to address the heterogeneity of Subdural Hematoma Outcome reporting in the literature

A major challenge within the academic literature on SDHs has been inconsistent outcomes reported across studies. Historically, patients have been categorized by the blood-product age identified on imaging (i.e., acute, subacute, or chronic). However, this schematic has likely played a central role in producing the heterogeneity encountered in the literature. In this investigation, a total of 494 patients that underwent SDH evacuation at a tertiary medical center between November 2013-December 2021 were retrospectively identified. Mechanism of injury was reviewed by the authors and categorized as either positive or negative for a high-velocity impact (HVI) injury. Any head strike injury leading to the formation of a SDH while traveling at a velocity beyond that of normal locomotion or daily activities was categorized as an HVI. Patients were subsequently stratified by those with an acute SDHs after a high-velocity impact (aSDHHVI), those with an acute SDH without a high-velocity impact injury (aSDHWO), and those with any combination of subacute or chronic blood products (mixed-SDH [mSDH]). Nine percent (n = 44) of patients experienced an aSDHHVI, 23% (n = 113) aSDHWO, and 68% (n = 337) mSDH. Between these groups, highly distinct patient populations were identified using several metrics for comparison. Most notably, aSDHHVI had a significantly worse neurological status at discharge (50% vs. 23% aSDHWO vs. 8% mSDH; p < 0.001) and mortality (25% vs. 8% aSDHWO vs. 4% mSDH; p < 0.001). Controlling for gender, midline shift (mm), and anticoagulation use in the acute SDH population, multivariable logistic regression revealed a 6.85x odds ratio (p < 0.001) for poor outcomes in those with a positive history for a high-velocity impact injury. As such, the distribution of patients that suffer an HVI related acute SDH versus those that do not can significantly affect the outcomes reported. Adoption of this stratification system will help address the heterogeneity of SDH reporting in the literature while still closely aligning with conventional reporting.

Vertebral Artery Injury in Cervical Spine Fracture Dislocation: An Observational Study in a Tertiary Care Center.

The incidence of traumatic vertebral artery injury (VAI) associated with cervical spine trauma varies widely in published trauma series. The primary aim of this study was to determine the incidence of traumatic VAIin patients who suffered cervical spine injuries by means of routine magnetic resonance imaging, and the secondary objective was to identify any associations with injury mechanism, level ofinjury, and neurologic injury severity. Materials and methods: A retrospective review was conducted on 96 patients who suffered cervical spine fracture dislocation with or without an associated spinal cord injury (SCI) in Indian Spinal Injuries Center (ISIC), New Delhi, Indiafrom January 2013 to April 2023. Cervical magnetic resonance imaging (MRI) was used to diagnose VAI. Patient's age, sex, cervical injury level, mechanism of injury, neurologic level of injury, association with foraminal fracture, facet dislocation,and clinical sequelae of vertebral artery injury were analyzed. In this study, of 96 patients who met the inclusion criteria, 18 patients (18.75%) had VAI on the MRI study. Thirteen (72.22%) of the eighteen patients had right-sided injuries, four (22.22%) had left-sided injuries, and one (5.55%) had bilateral injuries. There was an associated SCI in every VAI patient. VAI was significantly more common in patients who had ASIA A (61%, n = 11) and ASIA B (22%, n = 4)injuries, and no VAI was noted in neurologically intact patients (p<0.001). The incidence of VAI was higher in the flexion distraction type of injury (n = 12, 66%).The most commonly involved cervical spine injury level was C5-C6 (27%, n = 5), followed by 22% (n = 4) at C4-C5 and C6-C7 levels. About 27.8% (n = 5) of VAI was associated with foraminal fractures, and 72% (n = 13) of VAI was associated with facet dislocations, of which 44% (n = 8) were bifacetal and 28% (n = 5) were unifacetal dislocations. On clinical symptoms, only one (5.56%) patient had a headache, and 17 (94.4%) had no clinical features due to VAI. The incidence of traumatic vertebral artery disease is not very uncommon and requires careful and meticulous screening and management. Otherwise, complications like pseudoaneurysm, neurologic deficit, late-onset hemorrhage, infarction, and death can happen. Mostly, it is associated with high-velocity injuries and neurological injuries. MRI can be used as a good screening tool, which can be aided by a CT angiogram or digital subtraction angiographyfor confirmation. Proper pre-operative evaluation of vascular injury in cervical spine fracture dislocation is very important for patient counseling, patient management, and surgical planning.

Management of High-velocity Firearms Injury in Counterinsurgency Area: A Single-Center Study

Abstract Background: High-velocity firearms injuries in counterinsurgency (CI) areas are different from civilian injuries in terms of mechanism of injury, pathophysiology, management, and outcome. Hostile environments and difficult terrain are the main roadblocks in providing quality first aid and timely evacuation, which leads to compromised outcomes. This study was designed to analyze the epidemiology, management modalities, and complications of firearm injuries referred to a trauma care center in a counterinsurgency (CI) area. Methodology: This is a single-center prospective observational study over 3 years at a trauma care hospital in the Union Territory of Kashmir in India. All patients with firearm injuries sustained during CI operations were part of the study cohort. Patient profile, evacuation modalities, time elapsed since injury, and treatment modalities, including complications, were analyzed. Results: Four hundred and eighty patients were admitted over 3 years. The mean time elapsed in reaching the hospital was 7 h. Gunshot injury was the most common mechanism in 58% of the patients. 21.3% were priority I, 45.0% were priority II, whereas 33.7% were priority III. One hundred and fifty-four patients required definitive operative management. Lower extremity was the most common site. Sixty (12.5%) had penetrating abdominal trauma and 27 (5.6%) had vascular injury. Six patients succumbed to death postoperative due to various reasons. Conclusions: High-velocity firearms injury is a common cause of morbidity and mortality in military combat operations. This study highlights the challenges faced in managing high-velocity firearm injuries in such a large cohort of injured patients.

A 56-Year-Old Man with an Unusual Projectile Trajectory of Gunshot Wound at Head and Neck Region: A Rare Case Report

Background: Gunshot injuries to the neck are linked to a substantial risk of high mortality and morbidity due to the presence of critical vascular and vital structures. However, there are rare instances where a bullet trajectory through the neck region avoids damaging these vital structures. In this context, we report a specific case involving a 56-year-old male who presented to the emergency department with a gunshot wound to the right maxilla through the left anterior neck region.&#x0D; Case presentation: During the examination, a hematoma was observed in the left neck without an apparent entrance wound. The occurrence of a bullet injury to the neck without affecting any vital structures is exceptionally uncommon. Effectively managing patients with high-velocity penetrating injuries to the head and neck entails prioritizing tasks such as securing the airway, controlling hemorrhage, and promptly addressing any residual traumatic deformities for optimal outcomes. The presented case involves a gunshot injury to the head and neck, and a comprehensive review of the literature is provided.&#x0D; Conclusion: Gunshot injuries to the head and neck are complex and serious, demanding swift and thorough medical attention. The case emphasizes the significance of post-surgery monitoring for potential complications, contributing valuable insights to the ongoing discourse on managing such injuries.

Functional Outcome of Locking Compression Plate in Distal Femur Fractures

Introduction: Distal femur fracture is common in young people with high velocity injury. Management of distal femur fractures is a therapeutic challenge in orthopedics practice due to its extensive soft tissue injuries, bone loss, comminution, articular extension, instability.Open reduction with internal fixation replaces previous trend of closed conservative management and external fixation. Distal femoral locking compression plate (DF-LCP) requires both locking and compression screw fixation of the femur shaft. DF-LCP has been rapidly adopted as an alternative to intramedullary nails, blade plates and non-locking condylar screw.Materials and Methods: Prospective interventional study was done in department of orthopedics at National Medical College and Teaching Hospital, Birgunj for one year among 45 patients of age more than 18 years with post traumatic closed or open GA Type I, II distal femur fractures, AO Muller type A and C fractures. Ethical approval was obtained from institutional review committee and proper informed consent was taken. Type of implant used was DF-LCP.NEER’S scoring system was used for functional outcome.Results: Out of 45 patients, 42 patients with distal femur fracture were treated by DF-LCP.Three patients lostduring follow up hence removed from study. Out of 42 patients, mean age of the patients was 36.62 years. Most of them 31, (73.8%) were male. Predominant fracture was on right side 29 (69%).The study finding showed that 30 (71.4%) sustained injury due to road traffic accidents. Most of the patients 18 (42.9%) had type A2 fracture according to AO Muller distal femur fracture classification. Complications like surgical site infection observed in 3 cases. 100% union rate achieved with an average union time of 17.26 weeks. On evaluation according to Neer’s criteria mean score was 82.1 (Range: 48-96). Out of 42 patients 24 (57%) had excellent, 14 (33%) had good, 3 (7.2%) had fair and 1 (2.4%) had poor result.Conclusion: The study concluded DF-LCP is effective treatment for distal femur fracture. It provides stable construct for fracture union with excellent functional outcome.

Maxillofacial Surgery inUkraine During a War: Challenges andPerspectives-A National Survey.

The invasion of Ukraine by Russian troops on February 24, 2022, and the beginning of the full-scale war had huge humanitarian consequences. The major challenges facing the Ukrainian health care system included the disruption of medical infrastructure and logistics, the termination of the supply of expendable materials, significant migration, and a dramatic increase in high-velocity blast and gunshot injuries among combatants and civilians.The aim of the present study was to analyze the challenges and solutions in patient care faced by the Ukrainian system of maxillofacial surgery during the war in different regions of the country. A cross-sectional study was designed and implemented as an online survey to collect national data concerning maxillofacial surgeons' experiences and professional activities. The study was initiated and supported by Bogomolets National Medical University (Kyiv, Ukraine), the Ukrainian representative of AO CMF (Arbeitsgemeinschaft für Osteosynthesefragen Craniomaxillofacial Surgery) and the University of Helsinki (Finland).The questionnaire was developed by specialists in maxillofacial surgery and sociologists and contained 65 close-ended questions. Surgeons who had not worked in this specialty in inpatient departments of hospitals since at least the beginning of the full-scale war were excluded from the study. We received and analyzed 97 responses that met the abovementioned criteria. The geography of respondents covered all the regions and the main cities of Ukraine, expect for the occupied territories. After a year of warfare, the percentage of surgeons who treated patients with blast and gunshot injuries increased from 43.4% to 86.6%. This percentage was higher in military hospitals and in regions located in the vicinity of the front line. We found that, during the war, 78.6% of respondents performed osteosynthesis in cases of high-velocity multifragmented facial bone fractures (in such cases, 58.3% of them strictly followed AO CMF recommendations, while 41.7% performed the fixation based on available hardware, existing technical possibilities and their own preferences). We found that 70.2% of respondents had the opportunity to apply Computer-Aided Design/Computer-Aided Manufacture technology and patient-specific implants for the treatment of gunshot injuries, 38.1% reported that their hospitals were able to perform microsurgical reconstructions for facial defects, 79.4% of respondents reported that their departments received humanitarian aid and support from volunteer organizations (either Ukrainian or international), which significantly facilitated the treatment process. According to this nationwide survey of Ukrainian maxillofacial surgeons during a year of the full-scale war, 86.6% of respondents were involved in the treatment of gunshot and ballistic injuries in civilians and combatants. The main problems reported by the respondents were (1) a lack of experience and knowledge related to the treatment of severe wounds, especially by secondary reconstruction, and (2) a deficit of resources (equipment, materials, and medications) under conditions of disrupted logistics and changes in the numbers and nosological distribution of patients. There were the opportunity to transfer the patients to European clinics (29.9%), online consultations (45.4%), collaboration with foreign surgeons who come to Ukraine asvolunteers (32%).

Orbitoethmoidal foreign body through traumatic penetrating orbital injury

Foreign bodies in the nasal cavity, paranasal sinuses, and orbit are commonly related to high-velocity maxillofacial injuries. Cases of foreign bodies in paranasal sinuses are very rare. They may present with non-specific symptoms which make them easily neglected during history taking and clinical assessment. High clinical suspicion and radiological assessments are essential in patients with high-velocity insult to rule out the possibility of impalement injury. The course of management is determined by the location and type of foreign body. We share a rare case of metallic foreign bodies in the orbitoethmoidal region which took a combined surgical and conservative course of treatment involving a multidisciplinary team.

SURGICAL MANAGEMENT OF UNSTABLE SACRAL FRACTURES

Sacral fractures are often underdiagnosed, but are frequent in the setting of pelvic ring injuries. They are mostly caused by high velocity injuries or they can be pathological in aetiology. We sought to assess the clinical outcomes of the surgically treated unstable sacral fractures, with or without neurological deficits. unstable sacral fractures were included in the study.Single centre, prospectively collected data, retrospective review of patients who sustained vertically unstable fractures of the sacrum who underwent surgical fixation. out of a total of 432 patients with pelvis and acetabulum injuries. fifty six patients met the inclusion criteria. 18 patients had sustained zone one injuries. 14 patients had zone 2 injuries and 10 patients had zone 3 injurie. Operative fixation was performed percutaneously using cannulated screws in 18 patients.. Open fixation of the sacrum using the anterior approach in 6 patients. Posterior approach was indicates in all 10 of the zone 3 injuries of the sacrum. While in 4 patients, combined approaches were used. 3 patients had decompression and spinopelvic fixation.Neurological deficits were present in 16% of the patients. 2 patients presented with neurgenic bladder. Of the 4 patients who had neurological fall out, 3 resolved with posterior decompression and posterior fixation. All 4 neurological deficits were due to taction or compression of the nerve roots. No hardware failures or non unions observed.The rate of neurological deficit was related more to the degree of pelvic ring instability than to a particular fracture pattern. Low rates of complications and successful surgical treatment of sacral fractures is achiavable. Timeous accurate diagnosis mandatory

Multiligament instabilities of the knee in sports injuries : An update of the Hamburg concept

Knee dislocation (KD) is arare but severe injury of the knee joint, with ahigh rate of concomitant neurovascular injuries. The severity of the ligamentous injury, which is classified according to the Schenck classification, the mechanism of injury, concomitant injuries and individual factors determine the treatment strategy in KD. Furthermore, aclear differentiation between high-velocity (HV) and low-velocity (LV) injuries is necessary. Generally, surgical treatment within 7-10days should be aspired. Herein, the one-stage hybrid treatment using augmented ligament sutures (ligament bracing) in combination with primary ligament reconstruction (posterolateral and ACL) leads to very good functional results in the mid-term. Ultra-low-velocity (ULV) dislocations and those with concomitant peroneal lesions require amodified approach, due to alimited prognosis. During rehabilitation, the individual progress must be closely monitored and follow an early functional approach. In approximately 20% of all cases, early arthroscopic arthrolysis shows ahigh success rate.

Association of age with death and withdrawal of life-sustaining therapy after severe traumatic brain injury.

Compared to younger age, older age (≥ 65 yr) is associated with worse outcomes after severe traumatic brain injury (TBI). We sought to describe the association of older age with in-hospital death and aggressiveness of intervention. We conducted a retrospective cohort study of adult (age ≥ 16 yr) patients with severe TBI admitted to a single academic tertiary care neurotrauma centre between January 2014 and December 2015. We collected data through chart review as well as from our institutional administrative database. We provided descriptive statistics and used multivariable logistic regression to evaluate the independent association of age with the primary outcome, in-hospital death. The secondary outcome was early withdrawal of life-sustaining therapy. There were 126 adult patients (median age 67 yr [Q1-Q3, 33-80 yr]) with severe TBI during the study period who met our eligibility criteria. The most common mechanism was high-velocity blunt injury (55 patients [43.6%]). The median Marshall score was 4 (Q1-Q3, 2-6), and the median Injury Severity Score was 26 (Q1-Q3, 25-35). After controlling for confounders including clinical frailty, pre-existing comorbidity, injury severity, Marshall score and neurologic examination at admission, we observed that older patients were more likely than younger patients to die in hospital (odds ratio 5.10, 95% confidence interval 1.65-15.78). Older patients were also more likely to experience early withdrawal of life-sustaining therapy and less likely to receive invasive interventions. After controlling for confounding factors relevant to older patients, we observed that age was an important and independent predictor of in-hospital death and early withdrawal of life-sustaining therapy. The mechanism by which age influences clinical decision-making independent of global and neurologic injury severity, clinical frailty and comorbidities remains unclear.

Spatiotemporal profile of atrophy in the first year following moderate-severe traumatic brain injury.

Traumatic brain injury (TBI) triggers progressive neurodegeneration resulting in brain atrophy that continues months-to-years following injury. However, a comprehensive characterization of the spatial and temporal evolution of TBI-related brain atrophy remains incomplete. Utilizing a sensitive and unbiased morphometry analysis pipeline optimized for detecting longitudinal changes, we analyzed a sample consisting of 37 individuals with moderate-severe TBI who had primarily high-velocity and high-impact injury mechanisms. They were scanned up to three times during the first year after injury (3 months, 6 months, and 12 months post-injury) and compared with 33 demographically matched controls who were scanned once. Individuals with TBI already showed cortical thinning in frontal and temporal regions and reduced volume in the bilateral thalami at 3 months post-injury. Longitudinally, only a subset of cortical regions in the parietal and occipital lobes showed continued atrophy from 3 to 12 months post-injury. Additionally, cortical white matter volume and nearly all deep gray matter structures exhibited progressive atrophy over this period. Finally, we found that disproportionate atrophy of cortex along sulci relative to gyri, an emerging morphometric marker of chronic TBI, was present as early as 3 month post-injury. In parallel, neurocognitive functioning largely recovered during this period despite this pervasive atrophy. Our findings demonstrate msTBI results in characteristic progressive neurodegeneration patterns that are divergent across regions and scale with the severity of injury. Future clinical research using atrophy during the first year of TBI as a biomarker of neurodegeneration should consider the spatiotemporal profile of atrophy described in this study.

Manoeuvring Distal Tibial Shaft Fractures with Ender’s Nailing: Case Series

Fractures of the tibial shaft are the most common fractures to occur in the human body. Number of motor vehicle high-velocity injuries has increased in recent years. Various modalities used for treatment range from immobilization with the cast to open reduction and plating, closed reduction and nailing, and external fixator application. In our study, we have preferred fixation with multiple Ender’s nails in a series of three cases with different modes of injury. We found that closed reduction along with internal fixation with Ender’s nailing is a better modality in terms of easy technique, cost-effectiveness, small incision size, no soft-tissue damage or stripping, and complication. Ender’s nailing is an excellent alternative.

Team Approach: Treatment of Traumatic Dislocations of the Knee

Traumatic knee dislocations are complex injuries that can be associated with compromise of the neurovascular structures about the knee. Various classification systems for knee dislocations exist in the literature but should be used with caution as a prognostic tool because many knee dislocations fit into more than 1 category. Special populations of knee dislocations, such as obese patients and high-velocity mechanism injuries, require additional caution during the initial evaluation for possible vascular injuries.

Elbow Ulnar Collateral Ligament Tears: A Modified Consensus Statement

To establish consensus statements on the treatment of ulnar collateral ligament (UCL) injuries and to investigate whether consensus on these distinct topics could be reached. A modified consensus technique was conducted among 26 elbow surgeons and 3 physical therapists/athletic trainers. Strong consensus was defined as 90% to 99% agreement. Of the 19 total questions and consensus statements 4 achieved unanimous consensus, 13 achieved strong consensus, and 2 did not achieve consensus. There was unanimous agreement that the risk factors include overuse, high velocity, poor mechanics, and previous injury. There was unanimous agreement that advanced imaging in the form of either magnetic resonance imaging or magnetic resonance arthroscopy should be performed in a patient presenting with suspected/known UCL tear that plans to continue to play an overhead sport, or if the imaging study could change the management of the patient. There was unanimous agreement regarding lack of evidence for the use of orthobiologics in the treatment of UCL tears as well as the areas pitchers should focus on when attempting a course of nonoperative management. The statements that reached unanimous agreement for operative management were regarding operative indications and contraindications for UCL tears, prognostic factors that should be taken into consideration in when performing UCL surgery, how to deal with the flexor-pronator mass during UCL surgery, and use of an internal brace with UCL repairs. Statements that reached unanimous agreement for return to sport (RTS) were regarding portions of the physical examination should be considered when determining whether to allow a player to RTS; unclear how velocity, accuracy, and spin rate should be factored into the decision of when players can RTS and sports psychology testing should be used to determine whether a player is ready to RTS. V, expert opinion.

Fractures of the Lower Extremity after E-Bike, Bicycle, and Motorcycle Accidents: A Retrospective Cohort Study of 624 Patients.

Electric bicycles (e-bikes) have gained enormous popularity in recent years, and as a result, they have successively become more involved in traffic accidents. The aim of the present study was to assess differences in severity and localization of injuries to the lower extremities after accidents with e-bikes, conventional bicycles, and motorcycles. A retrospective cohort-analysis of patients who sustained traumatic accidents with two-wheeled vehicles transferred to a level 1 trauma center in Switzerland was performed. We assessed patient demographics, injury pattern, and trauma severity (ISS), with a subgroup analysis of outcomes stratified by vehicle. In total, 624 patients (71% male) with injuries to the lower extremities after bicycle (n = 279), electric bike (n = 19), and motorcycle (n = 326) accident were included. The mean age of all assessed patients was 42.4 years (SD 15.8), with a significantly higher age in the e-bike cohort (p = 0.0001). High-velocity injuries were found significantly more often in the motorcycle and e-bike group. The motorcycle group had a significantly higher mean ISS (17.6) than the other groups (p = 0.0001). E-bike accidents produce a different injury profile to the lower extremities compared to motorcycle or bicycle accidents. Higher age, higher velocity, and different protective equipment seem to have an impact on these fracture patterns.

Ilizarov fixation: As a treatment modality of complex tibial diaphyseal fractures

Introduction: Treating difficult non-unions with the Ilizarov technique has been the gold standard method for the last few decades. Here we have used Ilizarov for treating complex tibial fractures. The temporary management of compound fractures of the tibial diaphysis is commonly done with provisional external fixators which is followed by internal fixation. Ilizarov can also be used as a definitive fixation method besides it is more superior and can be the primary and definite choice of fixation where expertise is available. Materials and Methods: This was a prospective study conducted between august 2020 to august 2021 were 30 patients participated. Patients with complex tibial shaft fractures willing for regular follow up and surgical procedure were part of this study. All 30 0articipants were assessed for fracture union radiological and clinically using ASAMI functional and radiological score. The patients were evaluated at regular intervals until fracture union is observed. Results: From total of 30 patients 90% (26 patients) of fracture healed after Ilizarov ring fixation. The frame removed on an average of 177 days from the point of original injury. The healing time of closed fractures was a mean of 164 days. The open fracture healed in a mean time of 212 days. We encountered non-union in 4 patients after primary fixation. All the 4 cases were high velocity injury, classified under 42C2 or 42C3. All the 4 cases were open fractures. Conclusion: Ilizarov ring fixation is a versatile management option for the management of complex tibial diaphyseal fracture which also helps to manage and correct limb length discrepancies, correction of deformity in sagittal and coronal plane, along with managing fracture with bone gap and bone loss.

Open Non-conjoint Bicondylar Hoffa Fracture with Ipsilateral Tibial Spine Avulsion and Disruption of Patellar Tendon – A Rare Case

Hoffa's fracture is rare high velocity injuries. Bicondylar Hoffa is a rare fracture entity with only few reported cases. We report a case of open Type 3b non-conjoint bicondylar Hoffa fracture accompanied with ipsilateral anterior tibial spine avulsion and disruption of the patellar tendon. Staged procedure was done, first procedure included wound debridement with external fixator. Second procedure involved definitive fixation of Hoffa fracture, anterior tibial spine, and patellar tendon avulsion. In our case, we have discussed the possible mechanism of injury, operative approaches, and early functional outcome. We report such a case with its possible etiological causation, surgical management, clinical outcome, and prognostic outcome.