Level-1 Trauma Center Research Articles

Predictors of Episode-of-Care Costs for Ankle Fractures

Ankle fractures are one of the most resource-consuming traumatic orthopedic injuries. Few studies have successfully evaluated the episode-of-care costs (EOCC) of common traumatic orthopedic injuries. The objective of this study was to determine the EOCC associated with the surgical management of ankle fractures. A retrospective cohort study of 105 consecutive patients who underwent open reduction internal fixation of an isolated ankle fracture at a Canadian Level-1 trauma center was conducted. Episode-of-care costs were generated using an activity-based costing framework. The median global episode-of-care cost for ankle fracture surgeries performed at the studied institution was $3,487 CAD [IQR 880] ($2,685 USD [IQR 616]). Patients aged 60 to 90 years had a significantly higher median EOCC than younger patients (p = .01). Supination-adduction injuries had a significantly higher median EOCC than other injury patterns (p = .01). The median EOCC for patients who underwent surgery within 10 days of their injury ($3,347 CAD [582], $2,577 USD [448]) was significantly lower than the cost for patients who had their surgery delayed 10 days or more after the injury ($3,634 CAD [776], $2,798 USD [598]) (p = .03). Patient sex, anesthesia type, ASA score and surgeon's fellowship training did not affect the EOCC. This study provides valuable data on predictors of EOCC in the surgical management of ankle fractures. Delaying simple ankle fracture cases due to operating time constraints can increase the total cost and burden of these fractures on the healthcare system. In addition, this study provides a framework for future episode-of-care cost analysis studies in orthopedic surgery.

A Quality Improvement Initiative to Minimize Unnecessary Chest X-Ray Utilization in Pediatric Asthma Exacerbations.

Current national guidelines recommend against chest X-rays (CXRs) for patients with acute asthma exacerbation (AAE). The overuse of CXRs in AAE has become a concern, prompting the need for a quality improvement (QI) project to decrease CXR usage through guideline-based interventions. We aimed to reduce the percentage of CXRs not adhering to national guidelines obtained for pediatric patients presenting to the Emergency Department (ED) with AAE by 50% within 12 months of project initiation. We conducted this study at a New York City urban level-2 trauma center. The team was composed of members from the ED and pediatric departments. Electronic medical records of children aged 2 to 18 years presenting with AAE were evaluated. Monthly data on CXR utilization encompassing instances where the ordered CXR did not adhere to guidelines was collected before and after implementing interventions. The interventions included provider education, visual reminders, printed cards, grand-round presentations, and electronic medical records modifications. The study encompassed 887 eligible patients with isolated AAE. Baseline data revealed a mean preintervention CXR noncompliance rate of 37.5% among children presenting to the ED with AAE. The interventions resulted in a notable decrease in unnecessary CXR utilization, reaching 16.7%, a reduction sustained throughout subsequent months. This QI project successfully reduced unnecessary CXR utilization in pediatric AAE. A multi-faceted approach involving education, visual aids, and electronic reminders aligned clinical practice with evidence-based guidelines. This QI initiative is a potential template for other healthcare institutions seeking to curtail unnecessary CXR usage in pediatric AAE.

Outcomes of Distal Third Femur Fractures in Patients 18 Years and Older: A Pilot Study.

The selection of the most optimal fixation method for fractures of the distal femur, whether intramedullary nail (NL), lateral locking plate (PL), or nail/plate (NP) is not always clear. This study retrospectively evaluates surgical patients with distal femur fractures and introduces a pilot study using cluster analysis to identify the most optimal fracture fixation method for a given fracture type. This is a retrospective cohort study of patients 18 years and older with an isolated distal femur fracture who presented to our Level-1 trauma center between January 1, 2012, and December 31, 2022, and obtained NL, PL, or NP implants. Patients with polytrauma and those without at least six months of follow-up were excluded. A chart review was used to obtain demographics, fracture classification, fixation method, and postoperative complications. A cluster analysis was performed. The following factors were used to determine a successful outcome: ambulatory status pre-injury and 6-12 months postoperatively, infection, non-union, mortality, and implant failure. A total of 169 patients met inclusion criteria. No statistically significant association between the fracture classification and fixation type with overall outcome was found. However, patients treated with an NP (n = 14) had a success rate of 92.9% vs only a 68.1% success rate in those treated with a PL (n = 116) (p = 0.106). The most notable findings in the cluster analysis (15 total clusters) included transverse extraarticular fractures demonstrating 100% success if treated with NP (n = 6), 50% success with NL (n=2), and 78.57% success with PL fixation (n=14). NP constructs in complete articular fractures demonstrated success in 100% of patients (n = 5), whereas 77.78% of patients treated with NL (n = 9) and 61.36% of those treated with PL (n = 44). Plate fixation was the predominant fixation method used for distal third femur fractures regardless of fracture classification.However, NP constructs trended towards improved success rates, especially in complete intraarticular and transverse extraarticular fractures, suggesting the potential benefit of additional fixation with these fractures. Cluster analysis provided a heuristic way of creating patient profiles in patients with distal third femur fractures. However, a larger cohort study is needed to corroborate these findings to ultimately develop a clinical decision-making tool that also accounts for patient specific characteristics.

Abdominal wall reconstruction (AWR) for post-trauma laparotomy ventral hernia and follow-up assessment of functional quality of life (QOL): experience of a level-1 trauma centre in India.

The aim of this study was to examine the postoperative outcomes and follow-up QOL of patients after AWR at a level-1 trauma centre in India. The study cohort included AWR patients treated between January 2011 and July 2022. The Activities Assessment Scale (AAS) was used to measure QOL, and the Ventral Hernia Recurrence Inventory (VHRI) was used to determine the occurrence of recurrence. In patients suspected of having recurrence, thorough clinical examination and relevant imaging were performed to confirm or rule out recurrence. Out of 89 patients, 35 patients whose complete perioperative and follow-up data were available were enrolled. The mean age of the patients was 28 (SD, 9) years. The mean defect size was 14. 9 (SD, 7) cm. The mean time from laparotomy to AWR surgery was 21months. During the postoperative course, 37% of patients developed complications, such as SSI and seroma. The mean follow-up time was 53 (SD, 43) months. Upon comparing procedures involving the mesh placed in the sublay position with procedures involving the mesh placed in other positions, no statistically significant difference in the recurrence rate (one in each group, p = 0.99), surgical complication rate (33% v/s 66%, p = 0.6), or mean AAS QOL score (94.7 v/s 98, p = 0.4) was observed. The specificity of the VHRI for diagnosing recurrence was 79%. Overall, the recurrence rate was low in these patients despite the presence of large hernia defects. Long-term QOL was not affected by the specific procedure used. Timely planning and execution are more important than the specific repair approach for post-trauma laparotomy ventral hernia.

Impact of lower level trauma center proliferation on patient outcomes

BackgroundIn attempt to increase trauma system coverage, our state added 21 level 3 (L3TC) and level 4 trauma centers (L4TC) to the existing 7 level 1 trauma centers from 2008 to 2012. This study examined the impact of adding these lower-level trauma centers (LLTC) on patient outcomes. MethodsPatients in the state trauma registry age ≥ 15 from 2007 to 2012 were queried for demographic, injury, and outcome variables. These were compared between 2007 (PRE) and 2008–2012 (POST) cohorts. Multivariate logistic regression was performed to assess independent predictors of mortality. Subgroup analyses were performed for Injury Severity Score (ISS) ≥15, age ≥ 65, and trauma mechanisms. Results143,919 adults were evaluated. POST had significantly more female, geriatric, and blunt traumas (all p < 0.001). ISS was similar. Interfacility transfers increased by 10.2 %. Overall mortality decreased by 0.6 % (p < 0.001). Multivariate logistic regression analysis showed that being in POST was not associated with survival (OR: 1.07, CI: 0.96–1.18, p = 0.227). Subgroup analyses showed small reductions in mortality, except for geriatric patients. After adjusting for covariates, POST was not associated with survival in any subgroup, and trended toward being a predictor for death in penetrating traumas (OR: 1.23; 1.00–1.53, p = 0.059). ConclusionsUnregulated proliferation of LLTCs was associated with increased interfacility transfers without significant increase in trauma patients treated. LLTC proliferation was not an independent protector against mortality in the overall cohort and may worsen mortality for penetrating trauma patients. Rather than simply increasing the number of LLTCs within a region, perhaps more planned approaches are needed. Key messageThis is, to our knowledge, the first work to study the effect of rapid lower level trauma center proliferation on patient outcomes. The findings of our analysis have implications for strategic planning of future trauma systems.

Treatment of Large Femoral and Tibial Bone Defects With Plate-Assisted Bone Segment Transport.

The purposes of this study were to assess clinical and radiographic outcomes following plate-assisted bone segment transport (PABST) in large bone defects of the lower extremities. Retrospective study of prospectively collected data. Level-1 trauma center located in Germany. Patients who underwent PABST and were at least 1 year postoperatively were included. Demographic data were collected. Radiographic apparent bone gap (RABG), time to consolidation, time to full weight-bearing, and consolidation index were calculated. Numeric rating scale, lower extremity functional scale (LEFS), and complications were assessed. Fifteen patients [13 male; mean age 51 years (range, 20-75)] underwent PABST and had follow-up at a mean of 29.1 months. The tibia was affected in 8 and the femur in 7 patients. Preoperative RABG was 60 mm [interquartile range (IQR): 40-125], and bone defects were caused by septic nonunions in 73% of patients. Fourteen patients (93%) demonstrated consolidated transport callus at 7.3 months [95% confidence interval (95% CI), 6-8.5], and 9 patients (60%) demonstrated complete consolidation of both docking site and transport callus at 11.5 months (95% CI, 7.3-15.3). Postoperative RABG was 0.1 mm (IQR: 0-0.8), and consolidation index was 1.9 months/cm (95% CI, 1.3-2.5). All patients achieved full weight-bearing at 8.7 months (IQR: 6.5-10.3). LEFS was 42 (95% CI, 34-50), and numeric rating scale was 3 (95% CI, 2-4). Patients treated for tibial defects had a significantly higher consolidation rate compared with patients treated for femoral defects ( P = 0.040). PABST demonstrated high consolidation of transport callus with few complications. Although full weight-bearing was achieved in all patients, complete consolidation of the docking site was only present in 60% of cases. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A survey of low titer O whole blood use within the trauma quality improvement program registry.

The use of low titer O whole blood (LTOWB) has expanded although it remains unclear how many civilian trauma centers are using LTOWB. We analyzed data on civilian LTOWB recipients in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database 2020-2021. Unique facility keys were used to determine the number of centers that used LTOWB in that period. A total of 16,603 patients received LTOWB in the TQIP database between 2020 and 2021; 6600 in 2020, and 10,003 in 2021. The total number of facilities that reported LTOWB use went from 287/779 (37%) in 2020 to 302/795 (38%) in 2021. Between 2020 and 2021, among all level 1-3 designated trauma facilities that report to TQIP LTOWB use increased at level-1 centers (118 to 129), and level-2 centers (81 to 86), but decreased in level-3 facilities (9 to 4). Among pediatric and dual pediatric-adult designated hospitals there was a decrease in the number of pediatric level-1 centers (29 to 28) capable of administering LTOWB. Among centers with either single or dual level-1 trauma center designation with adult centers, the number that administered LTOWB to injured pediatric patients also decreased from 17 to 10, respectively. There was an increase in the number of facilities transfusing LTOWB between 2020 and 2021. The use of LTOWB is underutilized in children at centers that have it available. These findings inform the expansion of LTOWB use in trauma.

The real time to surgery: Limited delay after medical optimization does not impact hip fracture surgery outcomes

IntroductionCurrent U.S./Canadian guidelines recommend hip fracture surgery within 48 h of injury to decrease morbidity/mortality. Multiple studies have identified medical optimization as the key component of time to surgery, but have inherent bias as patients with multiple co-morbidities often take longer to optimize. This study aimed to evaluate time from medical optimization to surgery (TMOS) to determine if “real surgical delay” is associated with: 1) mortality and 2) complications for geriatric hip fracture patients. MethodsA retrospective chart review of geriatric hip fractures treated from 2015–2018 at a single, level-1 trauma center was conducted. Univariate logistic regression was performed to identify association between TMOS and post-operative complication rates. For mortality, the Wilcoxon test was used to compare TMOS for patients discharged following surgery to those who were not. ResultsA total of 884 hip fractures were treated operatively, with median TMOS 16.2 h (5.0–22.5, 1st-3rd quartiles). Univariate logistic regression models did not identify an association between TMOS and complication rates. For patients successfully discharged, median TMOS was 16.2 h (5.0–22.3, 1st-3rd quartiles). For the cohort of patients not successfully discharged, median TMOS was 19.1 h (10.1–25.9, 1st-3rd quartiles, p = 0.16). Conclusion“Real surgical delay”, or TMOS is not associated with increased complications or with inpatient mortality for geriatric hip fracture patients. With few exceptions, our institution adhered to the 48-hour time window from injury to hip surgery. We maintain the belief timely surgery following optimization plays a crucial role in the geriatric hip fracture patient outcomes.

Prehospital care and interfacility transfer of trauma patients before reaching the emergency of a level-1 trauma care center.

Management of trauma patients includes prevention, prehospital care, appropriate resuscitation at a hospital, definitive treatment, and rehabilitation. Timely and adequate care for a trauma patient is paramount, which can dramatically impact survival. This study was planned to assess the proportion of patients who failed to receive adequate prehospital care before reaching our institute. A retrospective study was conducted in the trauma and emergency department of a level-1 trauma center in eastern India from February to April 2022. The demographic profile, vital parameters, injury, mode of transport, travel duration, referring hospital, and any interventions as per airway/breathing/circulation/hypothermia were collected. The records of a hundred-two patients who were brought to the trauma and emergency department in the study period were reviewed. Road traffic accident involving two wheelers was the leading cause of injury. Eighty-three percent of the patients were referred from other health centers, of which 49 were referred from district headquarters hospitals. Only three patients out of 14 had been provided with an oropharyngeal airway for whom endotracheal intubation was indicated. Only one among the 41 patients needing Philadelphia collar actually received. Sixteen patients were provided supplemental oxygen out of the 35 for whom it was indicated. Out of 68 patients in whom intravenous cannulation and fluid administration were indicated, only 35 patients had received it. Out of 31 patients with fractures, none were provided immobilization. The care of the trauma patients with respect to airway, breathing, circulation, and fracture immobilization was found to be grossly inadequate, emphasizing the need of structured and protocol based prehospital trauma care.

Effect of Increasing Blood Pressure on Brain Tissue Oxygenation in Adults After Severe Traumatic Brain Injury.

To examine if increasing blood pressure improves brain tissue oxygenation (PbtO 2 ) in adults with severe traumatic brain injury (TBI). Retrospective review of prospectively collected data. Level-I trauma center teaching hospital. Included patients greater than or equal to 18 years of age and with severe (admission Glasgow Coma Scale [GCS] score < 9) TBI who had advanced neuromonitoring (intracranial blood pressure [ICP], PbtO 2 , and cerebral autoregulation testing). The exposure was mean arterial pressure (MAP) augmentation with a vasopressor, and the primary outcome was a PbtO 2 response. Cerebral hypoxia was defined as PbtO 2 less than 20 mm Hg (low). MAP challenge test results conducted between ICU admission days 1-3 from 93 patients (median age 31; interquartile range [IQR], 24-44 yr), 69.9% male, White ( n = 69, 74.2%), median head abbreviated injury score 5 (IQR 4-5), and median admission GCS 3 (IQR 3-5) were examined. Across all 93 tests, a MAP increase of 25.7% resulted in a 34.2% cerebral perfusion pressure (CPP) increase and 16.3% PbtO 2 increase (no MAP or CPP correlation with PbtO 2 [both R2 = 0.00]). MAP augmentation increased ICP when cerebral autoregulation was impaired (8.9% vs. 3.8%, p = 0.06). MAP augmentation resulted in four PbtO 2 responses (normal and maintained [group 1: 58.5%], normal and deteriorated [group 2: 2.2%; average 45.2% PbtO 2 decrease], low and improved [group 3: 12.8%; average 44% PbtO 2 increase], and low and not improved [group 4: 25.8%]). The average end-tidal carbon dioxide (ETCO 2 ) increase of 5.9% was associated with group 2 when cerebral autoregulation was impaired ( p = 0.02). MAP augmentation after severe TBI resulted in four distinct PbtO 2 response patterns, including PbtO 2 improvement and cerebral hypoxia. Traditionally considered clinical factors were not significant, but cerebral autoregulation status and ICP responses may have moderated MAP and ETCO 2 effects on PbtO 2 response. Further study is needed to examine the role of MAP augmentation as a strategy to improve PbtO 2 in some patients.

Parallax and Distortion in Fluoroscopy Units.

Parallax is an imaging phenomenon where an object appears to be at different positions when viewed from different angles. Distortion can occur secondary to internal fluoroscopic, or external environmental, factors. Fluoroscopy is a vital tool to assist surgeons intraoperatively. However, parallax and distortion can lead to inaccuracy, potentially leading to incorrect surgical decisions. The purpose of this study was to investigate the prevalence of parallax/distortion in large fluoroscopy units at a level-1 trauma center. Two types of C-arm models were evaluated, including (1) round image intensifiers, and (2) flat plate detectors (FPD). A square plexiglass grid with embedded wire at ½-in intervals was created, with a round metal washer secured centrally. The grid was placed 16 in from the image intensifier. A metal ball bearing (BB) was secured to the center of the x-ray tube. Fluoroscopic images were obtained until the BB and washer were "center-center." A straight blade served as a fiducial marker to ensure there was no off-axis angulation. Standard anterior-posterior and lateral views were obtained. External factors were considered, tested, and limited. Images were printed and the patterns of parallax/distortion were identified. All 11/11 (100%) of fluoroscopy units had some degree of parallax and/or distortion. We noted 3 different patterns, including sigmoidal, converging, and diverging. The FPD units had less apparent distortion overall; however, two-thirds (66%) were off-axis in the x- and y-axes in relation to the fiducial marker. All fluoroscopy units had varying degrees and patterns of parallax/distortion. We noted less overall distortion in FPDs. However, some of these units may produce images that are off-axis. This research has important implications for improving the accuracy of intraoperative fluoroscopy. Musculoskeletal surgeons should understand the limitations of fluoroscopy and how to combat parallax distortion to improve surgical outcomes and reduce patient morbidity. Level V.

Initial Imaging of Pregnant Patients in the Trauma Bay—Discussion and Review of Presentations at a Level-1 Trauma Centre

Trauma is the leading non-obstetric cause of maternal and fetal mortality and affects an estimated 5–7% of all pregnancies. Pregnant women, thankfully, are a small subset of patients presenting in the trauma bay, but they do have distinctive physiologic and anatomic changes. These increase the risk of certain traumatic injuries, and the gravid uterus can both be the primary site of injury and mask other injuries. The primary focus of the initial management of the pregnant trauma patient should be that of maternal stabilization and treatment since it directly affects the fetal outcome. Diagnostic imaging plays a pivotal role in initial traumatic injury assessment and should not deviate from normal routine in the pregnant patient. Radiographs and focused assessment with sonography in the trauma bay will direct the use of contrast-enhanced computed tomography (CT), which remains the cornerstone to evaluate the potential presence of further management-altering injuries. A thorough understanding of its risks and benefits is paramount, especially in the pregnant patient. However, like any other trauma patient, if evaluation for injury with CT is indicated, it should not be denied to a pregnant trauma patient due to fear of radiation exposure.

Immediate plate fixation of open tibial plafond fractures does not elevate risk of infection.

To determine if immediate plate fixation of open tibial plafond fractures has a negative effect on soft tissue complications and increases the risk of deep infection. This was a single-institution retrospective cohort study performed at level-1 trauma center. All patients with open OTA/AO 43C plafond fractures treated over 20-year period with follow-up until fracture union or development of deep infection. Ninety-nine of 333 identified patents met the inclusion criteria. The intervention was operative treatment of open tibial plafond fractures. The main outcome measurements were return to operating room for deep infection, nonunion, and below knee amputation. The overall rate of complications was 52%. Gender, body mass index, tobacco use, diabetes, ASA classification, time to OR from injury, wound location, and associated fibula fracture were not associated with deep infection. There was a significant difference in Gustilo-Anderson fracture grade among infected versus non-infected (P = 0.04). There was no significant difference in postoperative infection rates between patients treated with external fixation, external fixation and limited plate fixation, and plate fixation alone during initial surgery (P = 0.64). It is well established that open pilon fractures have a high incidence for postoperative infection and development of complications such as nonunion. As these injuries have poor clinical outcomes, any additional measures to prevent infection and soft tissue complications should be utilized. In appropriately selected cases, both immediate plate fixation and immediate limited plate fixation with external fixation at the time of I&D do not appear to elevate risk of deep infection. Therapeutic Level III.

Clinical outcomes and end-of-life treatment in 596 patients with isolated traumatic brain injury: a retrospective comparison of two Dutch level-I trauma centers

PurposeWith an increasingly older population and rise in incidence of traumatic brain injury (TBI), end-of-life decisions have become frequent. This study investigated the rate of withdrawal of life sustaining treatment (WLST) and compared treatment outcomes in patients with isolated TBI in two Dutch level-I trauma centers.MethodsFrom 2011 to 2016, a retrospective cohort study of patients aged ≥ 18 years with isolated moderate-to-severe TBI (Abbreviated Injury Scale (AIS) head ≥ 3) was conducted at the University Medical Center Rotterdam (UMC-R) and the University Medical Center Utrecht (UMC-U). Demographics, radiologic injury characteristics, clinical outcomes, and functional outcomes at 3–6 months post-discharge were collected.ResultsThe study population included 596 patients (UMC-R: n = 326; UMC-U: n = 270). There were no statistical differences in age, gender, mechanism of injury, and radiologic parameters between both institutes. UMC-R patients had a higher AIShead (UMC-R: 5 [4–5] vs. UMC-U: 4 [4–5], p < 0.001). There was no difference in the prehospital Glasgow Coma Scale (GCS). However, UMC-R patients had lower GCSs in the Emergency Department and used more prehospital sedation. Total in-hospital mortality was 29% (n = 170), of which 71% (n = 123) occurred after WLST. Two percent (n = 10) remained in unresponsive wakefulness syndrome (UWS) state during follow-up.DiscussionThis study demonstrated a high WLST rate among deceased patients with isolated TBI. Demographics and outcomes were similar for both centers even though AIShead was significantly higher in UMC-R patients. Possibly, prehospital sedation might have influenced AIS coding. Few patients persisted in UWS. Further research is needed on WLST patients in a broader spectrum of ethics, culture, and complex medical profiles, as it is a growing practice in modern critical care.Level of evidenceLevel III, retrospective cohort study.

DOES FRAILTY IMPACT FAILURE-TO-RESCUE IN GERIATRIC TRAUMA PATIENTS?

Failure-to-rescue (FTR), defined as death following a major complication, is a metric of trauma quality. The impact of patient frailty on FTR has not been fully investigated, especially in geriatric trauma patients. This study hypothesized that frailty increased the risk of FTR in geriatric patients with severe injury. A retrospective cohort study was conducted using the TQIP database between 2015 and 2019, including geriatric patients with trauma (age ≥ 65 years) and an Injury Severity Score (ISS) > 15, who survived ≥48 h post-admission. Frailty was assessed using the modified 5-item frailty index (mFI). Patients were categorized into frail (mFI ≥ 2) and non-frail (mFI < 2) groups. Logistic regression analysis and a generalized additive model (GAM) were used to examine the association between FTR and patient frailty after controlling for age, sex, type of injury, trauma center level, ISS, and vital signs on admission. Among 52,312 geriatric trauma patients, 34.6% were frail (mean mFI: frail: 2.3 vs. non-frail: 0.9, p < 0.001). Frail patients were older (age 77 vs. 74 years, p < 0.001), had a lower ISS (19 vs. 21, p < 0.001), and had a higher incidence of FTR compared to non-frail patients (8.7% vs. 8.0%, p = 0.006). Logistic regression analysis revealed that frailty was an independent predictor of FTR (odds ratio [CI]: 1.32 [1.23-1.44], p < 0.001). The GAM plots showed a linear increase in FTR incidence with increasing mFI after adjusting for confounders. This study demonstrated that frailty independently contributes to an increased risk of FTR in geriatric trauma patients. The impact of patient frailty should be considered when using FTR to measure the quality of trauma care. Level IV, therapeutic/care management.

Impact of Yoga Intervention on Functional Assessment and Quality of Life in Pelvic Injury Patients at Level-1 Trauma Center – A Randomized Control Trial

ABSTRACT Introduction: Pelvic fractures are severe injuries that are frequently accompanied by multiple system injuries and also lead to various complications. Thus, pelvic injuries bring a dramatic change in the life situation of an individual in almost all aspects of daily living and functioning and hence affect the quality of life (QoL) of the patients. Objective: The objective of the study is to determine the impact of Yoga intervention on functional assessment and QoL in pelvic injury patients. Methods: A total of 50 patients with a stable pelvic fracture will be recruited to participate in this randomized controlled study by simple random sampling. The subjects will be randomly divided into two groups. One group will receive Yoga intervention along with conventional physiotherapy, while another group will receive conventional physiotherapy only. The session will be given for a duration of up to a maximum of 1 h. The intervention will be given for 12 weeks. Their outcome measures will be assessed at 0, 4, 8, and 12 weeks, respectively. Results: Statistical significance between and within the group will be analyzed. Conclusion: This study will provide data for the efficacy of Yoga in pelvic injury in addition to physiotherapy rehabilitation.

Functional and Radiographic Outcomes of Open Proximal Femoral Fractures Caused by Gunshot Wounds in Yemen: A Prospective Cohort Study.

Open proximal femoral fractures caused by gunshot wounds are rare but devastating injuries that pose considerable challenges for prognosis and management. The aim of this study was to evaluate the functional and radiographic outcomes of patients with open proximal femoral fractures caused by gunshot wounds treated at 3 Level-I trauma centers in Yemen and to identify the factors that influence them. We prospectively enrolled 174 patients with open proximal femoral fractures caused by gunshot wounds. The fractures were classified according to the Gustilo-Anderson and OTA/AO systems. The primary outcome measures were fracture union, infection, and functional outcomes. The secondary outcome measures were the Harris hip score (HHS) and the Short Form-36 (SF-36) health survey score. We performed multivariable logistic regression modeling to identify the predictors of complications and poor functional outcomes. The overall rate of fracture union was 87%. The complication rates were 18% for infection, 13% for nonunion, 23% for reoperation, 12% for delayed union, 4% for osteonecrosis, 6% for heterotopic ossification, and 2% for amputation. The mean HHS at the final follow-up was 78.4, and the mean SF-36 score was 67.3. Open proximal femoral fractures caused by gunshot wounds are associated with high rates of complications and poor functional outcomes in Yemen. Early debridement, appropriate fixation, infection control, and adequate soft-tissue coverage are essential for achieving satisfactory results. The type of wound, the type of fracture, and the type of definitive fixation are significant predictors of the outcomes. Future studies should compare different fixation methods and evaluate the long-term outcomes and complications of these injuries. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

External fixation about the elbow: Indications and long-term outcomes

BackgroundOperative management is often required for fractures of the elbow, with treatment goals aiming to restore stability, reduction, and early range of motion. The purpose of this study was to determine risk factors for necessitating the application of an external fixator, and to compare range of motion and functional outcomes between patients who required an elbow external fixator to those who did not. HypothesisWe hypothesize that patients who require an external fixator will have worse elbow range of motion and functional outcomes when compared to those who did not. Patients and methodsThis is a retrospective study of 391 patients who presented at a Level-I trauma center between March 2011 and January 2021 for operative management of a fracture/fracture-dislocation of the distal humerus (AO/OTA 13A-C) and/or proximal ulna and/or radius (AO/OTA 21A-C). A primary analysis was performed to determine risk factors for necessitating the application of an external fixator. A secondary analysis was performed comparing elbow range-of-motion and functional outcomes between cases and controls. Results391 patients were identified; 26 required external fixation (cases) and 365 did not (controls). Significant risk factors for necessitating placement of an external fixator included large BMI (OR = 1.087, 95 % CI = 1.007–1.173, p = 0.033), elbow dislocation (OR = 7.549, 95 % CI = 2.387–23.870, p = 0.001), open wound status (OR = 9.584, 95 % CI = 2.794–32.878, p < 0.001), and additional non-contiguous orthopaedic injury (OR = 9.225, 95 % CI = 2.219–38.360, p = 0.002). Elbow ROM was poorer in the external fixator group with regards to extension (−15°), flexion (+19.4°), and pronation (+14.3°) (p < 0.05). In addition, those who did not need external fixation had better functional scores (+20.4 points MEPI) (p < 0.05). DiscussionThe use of external fixation about the elbow is associated with significantly worse initial injuries and results in poorer outcomes. These results can be used to inform the surgeon-patient discussion regarding treatment options and expected functional outcomes. Level of evidenceIII.

Lactate dehydrogenase can be used for differential diagnosis to identify patients with severe polytrauma with or without chest injury-A retrospective study.

Chest injury is an important factor regarding the prognosis of patients with polytrauma (PT), and the rapid diagnosis of chest injury is of utmost importance. Therefore, the current study focused on patients' physiology and laboratory findings to quickly identify PT patients with chest injury. Data on 64 PT patients treated at a trauma center level I between June 2020 and August 2021 were retrospectively collected. The patients were divided into a PT group without chest injury (Group A) and a PT group including chest injury (Group B). The relationship between chest injury and the patients' baseline characteristics and biochemical markers was analyzed. Heart rate, respiration rate, Sequential Organ Failure Assessment (SOFA) score, glutamate oxaloacetate aminotransferase (GOT), glutamate pyruvate transaminase (GPT), creatine kinase MB (CK-MB), leucocytes, hemoglobin (Hb), platelets, urine output, lactate, and lactate dehydrogenase (LDH) in groups A and B exhibited statistically significant differences at certain time points. Multifactorial analysis showed that blood LDH levels at admission were associated with chest injury (P = 0.039, CI 95% 1.001, 1.022). LDH may be a promising indicator for screening for the presence of chest injury in patients with severe polytrauma.

The role of test results in the emergency department in the evaluation of major torso injury patients

We studied the role of laboratory tests in the emergency department (ED) for the prediction of outcomes in major torso injury patients. We hypothesized that the laboratory test results in the ED could predict worse outcomes and be complement of the TRISS (trauma and injury severity score) which serves a popular prediction model for trauma patients. Patients with major torso trauma who were sent to a level-I trauma center between January 2016 and December 2020 were retrospectively studied. Demographic information, TRISS, and laboratory data (glucose, lactate, base deficit (BD)) were collected and analyzed. The early death (death within 24 hours from the ED arrival) and the long intensive care unit (ICU) length of stay (LOS) (over seven days) were defined as the primary and secondary outcomes. A prediction model that integrated TRISS and the laboratory test results was created and evaluated by using the receiver operating characteristic (ROC) curve with the area under the curve (AUC). In total, 827 patients were studied. The glucose (255.2 ± 109.9 vs. 192.1 ± 77.0, p &lt; 0.001) and lactate (77.2 ± 43.4 vs. 39.2 ± 26.4, p &lt; 0.001) levels were significantly higher in patients who died early. The performance of glucose, lactate and BD in identifying those major torso trauma patients who would die early demonstrated acceptable discrimination (glucose: AUC = 0.687; lactate: AUC = 0.778; BD: AUC = 0.734). Furthermore, a model that integrated the TRISS and laboratory tests showed calibration of AUC = 0.863. Moreover, the levels of BD and glucose were also independent factors of long ICU LOS. In conclusion, checking lactate, BD and blood glucose is recommended in the evaluation of major torso trauma patients. Biochemical markers are beneficial in predicting worse outcomes for patients with major torso trauma and can complement the TRISS for these patients.