Level-1 Trauma Center Research Articles

Clinical and Radiographic results of a Retrograde Nail - Washer Combination Versus Lateral Locked Plating for Distal Femur Fractures.

The objective of this study was to report outcomes of the Retrograde Femoral Nail-Advanced with Lateral Attachment Washer (RFNA-LAW) (Synthes; Paoli, PA) compared to laterally locked plates (LLP) when treating AO/OTA type 33 distal femoral fractures. Design: Retrospective chart review. Single, academic, Level-1 Trauma Center. All adult patients who had fixation of an AO/OTA type 33 distal femoral fracture with the RFNA-LAW combination or LLP from 2018-2023 with follow-up to union or a minimum of one year. immediately post-operatively and at final follow-up. The main outcome measure was union. Secondary outcomes included implant failure, infection, and alignment immediately post-operatively and at final follow-up. Patients were followed for a minimum of 1-year or to skeletal healing. Forty-eight patients (19 female) with a mean age of 56 years (range 19-94 years) were in the RFNA-LAW group. Fifty-three patients (29 female) with a mean age of 66 years (24-91 years) were in the LLP group. There were no significant differences when comparing Body Mass Index, diabetes, smoking status, mechanism of injury, or fracture classification between groups (p>0.05). There was no difference in immediate, post-operative alignment (p = 0.49). When comparing aLDFA measurements at final follow-up, there was significantly more malalignment in the LLP group (p = 0.005). There were 8 implant failures (15%) in the LLP group compared to 1 in the RFNA-LAW group (2%) (p = 0.02). There were 14 reoperations (26%) in the LLP group compared to 4 (8%) in the RFNA-LAW group (p = 0.02). The Retrograde Nail Advanced - Lateral Attachment Washer combination demonstrated a high union rate when treating complex fractures of the distal femur. When compared to lateral locked plating, this implant combination demonstrated significantly lower rates of nonunion and reoperation. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Management of Femoral and Tibial Shaft Fractures in Chronic Spinal Cord Injury Patients.

To compare outcomes and complications between non-operative and operative management of femur and tibia fractures in patients with paraplegia or quadriplegia from chronic spinal cord injury (SCI). Design: Retrospective cohort study. Three Level-1 Trauma centers. All adult patients with paraplegia or quadriplegia due to a chronic SCI with operative or nonoperative treatment of a femoral or tibial shaft fracture from 01/01/2009 through 12/31/2019 were included. Outcomes collected included range of motion, pain, return to baseline activity, extent of malunion and treatment complications (infection, pressure ulcers, nonunion, DVT/PE, stroke, amputation, death). Comparison between operative and nonoperative treatment were made for each outcome. Fifty-nine patients with acute lower extremity fracture in the setting of chronic SCI fulfilled inclusion criteria with a median age of 46 years in the operative group and 47 years in the non-operative group. Twelve patients (70.6%) in the nonoperative group were male with 32 (76.2%) male patients in the operative group. Forty-six patients (78%) presented as low energy trauma. Differences were seen between operative and non-operative management for pressure ulcers (19% vs 52.9%, p=0.009) and mean VAS pain score at first follow-up (1.19 vs 3.3, p=0.03). No difference was seen for rates of infection, nonunion, DVT/PE, stroke, amputation, death, return to baseline activity, and range of motion. Tibial and femoral shaft fractures commonly resulted from low energy mechanisms in patients with chronic SCI. Operative treatment seemed to decrease morbidity in these patients via lowered rates of pressure ulcers and decreased pain compared to non-operative management. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary nailing of proximal humerus fractures does not achieve superior functional results to non-operative treatment in the long term.

Non-operative treatment (NOT) of proximal humerus fractures (PHF) has regained significance due to recent evidence. Additionally, positive outcomes of plate osteosynthesis and fracture arthroplasty prompt a reassessment of the role of intramedullary nailing (IMN). While favorable short and medium-term results have been documented following IMN, little is known regarding functional outcomes and quality of life in the long-term. Data from 180 patients with dislocated PHF of Neer types III, IV and V, treated at our level-I trauma center between 2004 and 2014 using IMN or NOT therapy, were scanned. Patients were re-evaluated after a minimum of 5 years to assess functional outcomes (age- and sex-adapted Constant Score, QuickDASH), quality of life (SF12), and complications or reoperations. Out of the initially identified 180 patients, 51 were unavailable for follow-up (FU) and 71 had deceased during the FU period. Functional outcomes and quality of life was, therefore, assessed in 58 patients (30 IMN, 28 NOT) with an average age at injury of 68 years after a mean FU time of 10.3 ± 3.4 years. Epidemiological patient characteristics did not exhibit significant differences between the two groups (p > .05). The functional outcome assessed by age- and sex-adapted Constant Score (NOT: 74 ± 28; IMN: 68 ± 24; p = .438), QuickDASH (NOT: 25 ± 27; IMN: 31 ± 23; p = .374) or quality of life using the SF12 (p > .05) revealed no significant disparities in long-term outcomes between the treatment groups. 10 of 30 patients in the IMN group underwent surgical revision to address complications, exceeding mere implant removal. Conversely, no patient in the NOT group underwent a revision surgery during the FU period. In the long-term, functional and quality of life-related outcomes of IMN did not diverge significantly from those of NOT, while causing a higher incidence of follow-up interventions.

Exploring patient and system factors impacting undertriage of injured patients meeting national field triage guideline criteria.

Trauma systems save lives by coordinating timely and effective responses to injury. However, trauma system effectiveness varies geographically, with worse outcomes observed in rural settings. Prior data suggest that undertriage may play a role in this disparity. Our aim was to explore potential driving factors for decision making among clinicians for undertriaged trauma patients. We performed a retrospective analysis of the National Emergency Medical Services Information System database among patients who met physiologic or anatomic national field triage guideline criteria for transport to the highest level of trauma center. Undertriage was defined as transport to a non-level I/II trauma center. Multivariable logistic regression was used to determine demographic, injury, and system characteristics associated with undertriage. Undertriaged patients were then categorized into "recognized" and "unrecognized" groups using the documented reason for transport destination to identify underlying factors associated with undertriage. A total of 36,094 patients were analyzed. Patients in urban areas were more likely to be transported to a destination based on protocol rather than the closest available facility. As expected, patients injured in urban regions were less likely to be undertriaged than their suburban (adjusted odds ratio [aOR], 2.69; 95% confidence interval [95% CI], 2.21-3.31), rural (aOR, 2.71; 95% CI, 2.28-3.21), and wilderness counterparts (aOR, 3.99; 95% CI, 2.93-5.45). The strongest predictor of undertriage was patient/family choice (aOR, 6.29; 5.28-7.50), followed by closest facility (aOR, 5.49; 95% CI, 4.91-6.13) as the reason for hospital selection. Nonurban settings had over twice the odds of recognizing the presence of triage criteria among undertriaged patients (p < 0.05). Patients with injuries in nonurban settings and those with less apparent causes of severe injury are more likely to experience undertriage. By analyzing how prehospital clinicians choose transport destinations, we identified patient and system factors associated with undertriage. Targeting these at-risk demographics and contributing factors may help alleviate regional disparities in undertriage. Diagnostic; Level IV.

The combined talus and sustentaculum fracture: A case series

BackgroundThe sustentaculum tali is a biomechanically important stabilizer of the hindfoot and contributes to articular congruency of the subtalar joint. Sustentaculum injury associated with a talus fracture has been described infrequently and treatment of this combined injury varies. The purpose of this study was to describe and evaluate the outcomes of the combined talus and sustentaculum fracture. MethodsRetrospective chart and radiographic review was performed on all talus fractures (n = 436) requiring operative fixation over a 21-year period at a single Level-1 trauma center. All talus fractures with sustentaculum fractures were included. Statistical analysis was performed using Chi-squared and Fishers exact tests where appropriate. ResultsSustentaculum fractures occurred in 6.2 % (n = 27) of patients with talus fractures. Average follow-up was 14 months; 18.5 % were open fractures, 88.8 % were from high-energy mechanisms, and 44.4 % were polytraumas. Diagnosis of the sustentaculum fracture was missed on presenting radiographs in 69.2 % (n = 18). The most common associated talus fracture was a talar neck fracture (40.7 %) and the majority (73.7 %) were Hawkins II. Overall, 40.7 % (n = 11) of the sustentaculum fractures were treated with independent fixation and 7.4 % (n = 2) were treated with acute subtalar arthrodesis. Subtalar post-traumatic osteoarthritis (PTOA) at final follow-up was seen in 23.1 % of combined injuries. Independent sustentaculum fixation did not influence the rate of PTOA or re-operation (p = 0.92, p = 0.91, respectively). ConclusionTalar fractures have an associated sustentaculum fracture in approximately 6 % of cases, especially with Hawkins II fracture-dislocations. Over two-thirds of the associated sustentaculum fractures were missed on presenting radiographs, reiterating the need for heightened awareness and consideration of advanced imaging for all talus fractures. The rate of PTOA following these combined injuries at mean follow-up of 24 months does not exceed established rates after isolated talus fractures. Further research is required to determine the optimal management of the sustentaculum in these combined injuries. Level of evidenceIV

Lack of standardisation in the management of complex tibial plateau fractures: a multicentre experience.

In recent years, the trauma mechanisms and fracture types in tibial plateau fractures (TPF) have changed. At the same time, treatment strategies have expanded with the establishment of new classification systems, extension of diagnostics and surgical strategies. Evidence-based recommendations for treatment strategies are rare. The aim of this study is to assess the extent of standardization in the treatment of complex TPF. For the study, specialists in trauma surgery/orthopaedics were presented thin-slice CT data sets of three complex TPFs including 3D reconstructions. A standardized questionnaire on fracture morphology and planned treatment strategy was then completed. A total of 23 surgeons from 7 hospitals (Trauma center levels I-III) were included. All three fractures were most frequently classified as Schatzker type V (fracture I: 52.2%, II: 56.5%, III: 60%). Averaged over all three fractures, 55% of the respondents chose the same patient positioning. The combination of a posteromedial and anterolateral approach was the most frequently chosen approach at 42.7%. Double plating was favored for the surgical treatment of all fractures (70.7%). Preoperative MRI, extended approaches and intraoperative fraturoscopy were significantly more common in level I trauma centres. There are major differences in the management of complex TPF. 360° treatment is carried out in all departments regardless of the level of care, but without further standardization in terms of preoperative imaging, classification, initial treatment, approach, fixation and intraoperative imaging. There are major differences within the departments with different level of care.

Epicardial adipose tissue defined by initial polytrauma CT of mechanically ventilated trauma patients: retrospective single-center cohort study to predict short-term outcomes.

Epicardial adipose tissue (EAT) detected by computed tomography (CT) is associated with morbidity and mortality in patients with COVID-19 and other critical care patient cohorts, whereas their prognostic relevance in trauma patients remains unclear. The present study explored associations with four potential short-term outcomes in trauma patients. All consecutive trauma patients requiring emergency tracheal intubation and mechanical ventilation before initial whole-body CT imaging at a level-1 trauma center over a 12-year period (2008-2019) were reanalyzed for this study. EAT was measured semiquantitatively in initial CT and analyzed regarding associations with 24-hour and 30-day mortality using Cox proportional hazard models. In survivors, associations of EAT with intensive care unit length of stay (ICU LOS) and mechanical ventilation duration were analyzed using linear regression analyses. Four hundred fifty-five patients (74.7% male) with a median age of 49 years, and a median injury severity score (ISS) of 26 points were analyzed. In univariable analysis, EAT index was significantly associated with 24-hour and 30-day mortality (p = 0.007, and p = 0.013, respectively). After adjustment for significant predictors age, body mass index, and ISS, no significant associations were confirmed (p = 0.622, and p = 0.903, respectively). In a subanalysis of 353 survivors, EAT index was significantly associated with ICU LOS and mechanical ventilation duration in univariable analyses (p = 0.031, and p = 0.014, respectively), but not in multivariable analyses (p = 0.81 and p = 0.46, respectively). EAT index was associated with short-term outcomes in severely injured trauma patients, which not remained significant in multivariable analysis, suggesting that its prognostic capability is limited.

Easy and safe: A new surgical fixation -technique for acute and chronic anterior instabilities of the sternoclavicular joint: technique and results

Instabilities of the SC joint are a rare injury, accounting for only 3% of all injuries of the shoulder-girdle. While acute posterior dislocations are an emergency and require immediate surgical intervention, anterior instabilities (first and second degree according to Allman) can mostly be treated conservatively. Chronic and highly instable acute anterior instabilities often imposes a significant limitation on the lives of affected patients. Currently, there is no established therapeutic algorithm in place. This retrospective case series with prospective collection of data was performed at a level-I trauma centre. Patients treated surgically for anterior SC joint instabilities between January 2013 and December 2019 and with a minimum follow-up of 24 months were included. The injuries comprised of six acute anterior dislocations treated with tape-cerclage in a "figure-of-8" configuration; twelve patients with chronic anterior SC instabilities were treated with autologous tendon grafts. For one highly unstable chronic anterior instability in addition to the tendon graft synthetic suture material was applied. The clinical evaluation consisted of a physical examination and a standardized questionnaire, which included subjective and objective shoulder scores. Out of 24, 19 patients (79%) with an average age of 32 years ± 15 were available for follow-up. 63% of the patients were male. After a mean follow-up of 57 months, the mean age- and sex-adapted Constant-Murley Shoulder Score (CS) of acute anterior luxations amounted to 90 points ± 20, Nottingham Clavicle Score (NCS) to 81 points ± 22 and DASH Score to 11 points ± 18. Chronic anterior instabilities had a mean CS of 90 points ± 12, NCS of 83 points ± 17 and DASH Score of 4 points ± 5. The study shows a complication rate of 10%. Two patients underwent revision surgery. To conlude, monocortical SCJ fixation in a "figure-of-8" fashion presents a low risk for complication and a low revision rate and can achieve equally good functional outcome after the treatment of highly unstable acute and chronic anterior SCJ instabilities than other published techniques. Our approach presents less risk to the neurovascular structures of the mediastinum than other published techniques requiring bicortical drilling, therefore making the technique more accessible to hospitals without a cardiothoracic surgical background.

Femoral Neck Fractures With Associated Ipsilateral Femoral Shaft Fractures in Young Adults

To analyze patients, injury patterns, and treatment of femoral neck fractures (FNFs) in young patients with FNFs associated with shaft fractures (assocFNFs) to improve clinical outcomes. The secondary goal was to compare this injury pattern to that of young patients with isolated FNFs (isolFNFs). Retrospective multicenter cohort series. Twenty-six North American level-1 trauma centers. Skeletally mature patients, <50 years old, treated with operative fixation of an FNF with or without an associated femoral shaft fracture. The main outcome measurement was treatment failure defined as nonunion, malunion, avascular necrosis, or subsequent major revision surgery. Odds ratios for these modes of treatment were also calculated. Eighty assocFNFs and 412 isolFNFs evaluated in this study were different in terms of patients, injury patterns, and treatment strategy. Patients with assocFNFs were younger (33.3 ± 8.6 vs. 37.5 ± 8.7 years old, P < 0.001), greater in mean body mass index [BMI] (29.7 vs. 26.6, P < 0.001), and more frequently displaced (95% vs. 73%, P < 0.001), "vertically oriented" Pauwels type 3, P < 0.001 (84% vs. 43%) than for isolFNFs, with all P values < 0.001. AssocFNFs were more commonly repaired with an open reduction (74% vs. 46%, P < 0.001) and fixed-angle implants (59% vs. 39%) (P < 0.001). Importantly, treatment failures were less common for assocFNFs compared with isolFNFs (20% vs. 49%, P < 0.001) with lower rates of failed fixation/nonunion and malunion (P < 0.001 and P = 0.002, respectively). Odds of treatment failure [odds ratio (OR) = 0.270, 95% confidence interval (CI), 0.15-0.48, P < 0.001], nonunion (OR = 0.240, 95% CI, 0.10-0.57, P < 0.001), and malunion (OR = 0.920, 95% CI, 0.01-0.68, P = 0.002) were also lower for assocFNFs. Excellent or good reduction was achieved in 84.2% of assocFNFs reductions and 77.1% in isolFNFs (P = 0.052). AssocFNFs treated with fixed-angle devices performed very well, with only 13.0% failing treatment compared with 51.9% in isolFNFs treated with fixed-angle constructs (P = <0.001) and 33.3% in assocFNFs treated with multiple cannulated screws (P = 0.034). This study also identified the so-called "shelf sign," a transverse ≥6-mm medial-caudal segment of the neck fracture (forming an acute angle with the vertical fracture line) in 54% of assocFNFs and only 9% of isolFNFs (P < 0.001). AssocFNFs with a shelf sign failed in only 5 of 41 (12%) cases. AssocFNFs in young patients are characterized by different patient factors, injury patterns, and treatments, than for isolFNFs, and have a relatively better prognosis despite the need for confounding treatment for the associated femoral shaft injury. Treatment failures among assocFNFs repaired with a fixed-angle device occurred at a lower rate compared with isolFNFs treated with any construct type and assocFNFs treated with multiple cannulated screws. The radiographic "shelf sign" was found as a positive prognostic sign in more than half of assocFNFs and predicted a high rate of successful treatment. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Greater Socioeconomic Deprivation is Associated with Increased Complication Rates and Lower Patient-Reported Outcomes Following Open Reduction and Internal Fixation of Humeral Shaft Fractures.

This study explored the hypothesis that social determinants of health (SDOH), including racial and economic differences, may impact orthopaedic trauma outcomes in patients undergoing open reduction and internal fixation (ORIF) of humeral shaft fractures. Design: Retrospective. Single, academic, tertiary Level-I trauma center. Adults with midshaft humerus fractures (AO/OTA 12) treated operatively with plate fixation from 05/2011 to 05/2021 with a minimum follow-up of nine months. Radiographic fracture healing, complication rates, and patient-reported outcomes were investigated. SDOH were assessed using the Area Deprivation Index (ADI). Demographics, complications rates, and patient-reported clinical outcomes were compared between the first and fourth ADI quartiles. 196 patients fit the study criteria. The average age of the cohort was 47 years with 50 women (51%). Comparisons of the least deprived quartile (n=49) to the most deprived quartile (n=49) yielded similar sex distribution (59% vs 43% female, p=0.15), fewer non-white patients (8% vs 51%, p<0.01), older average age (51 years vs 43 years, p=0.05), similar BMI (30.5 vs. 31.8, p=0.45), and higher Charlson Comorbidity Index (CCI) (2.2 vs.1.1, p=0.03). While nonunion rates were similar (p=0.20) between groups, the most deprived quartile had 2.3 times greater odds of post-operative complications (p=0.04). Patients in the most deprived group exhibited higher PROMIS Pain Interference (PI) scores (p<0.01) and PROMIS Depression (D) scores (p=0.01), with lower PROMIS Physical Function (PF) scores (p<0.01) at 6-month follow-up than the least depriver cohort. The most deprived cohort had three times higher odds of missing scheduled appointments within the first post-operative year (p<0.01), resulting in a significantly higher no-show rate (p<0.01) than the least deprived cohort. Regression analysis including several demographic and injury factors identified that ADI was significantly associated with the occurrence of any missed appointments (p<0.01), no-show rates (p=0.04), and experiencing one of the following post-operative complications during recovery: Nonunion, radial nerve injury, or dysfunction (p=0.03). Patients experiencing greater resource deprivation faced increased odds of complications, missed appointments, and poorer PROMIS outcomes following humeral shaft fracture fixation, emphasizing that baseline socioeconomic disparities predict unfavorable post-operative outcomes even given favorable baseline health status according to the CCI score. Level III. See Instructions for Authors for a complete description of levels of evidence.

Integrated Dual Lag Screws Have Higher Reoperation Rates for Fixation Failure Than Single Lag Component Cephalomedullary Nails: A Retrospective Study of 2,130 Patients with Intertrochanteric Femoral Fractures.

Previous studies comparing reoperation risk between integrated dual lag screw (IDL) and single lag component (SL) cephalomedullary nails (CMNs) in the treatment of intertrochanteric femoral fractures have demonstrated mixed results. The purpose of this study was to assess the rates of reoperation for fixation failure and all-cause reoperation in a large, multi-institutional cohort of patients with an intertrochanteric fracture treated with an IDL or SL CMN. We hypothesized that there would be no difference between the groups with respect to either of the reoperation rates. Adults (≥18 years old) who sustained an intertrochanteric fracture (AO/OTA 31A1 to 31A3) treated with an IDL or SL CMN between January 2014 and May 2021 at 1 of 13 Level-I trauma centers were included. Patients with <3 months of follow-up or pathologic fractures were excluded. Rates of reoperation were compared with use of the chi-square test and multivariable regression, controlling for age, gender, injury mechanism, fracture pattern, and postoperative neck-shaft angle. A total of 2,130 patients met the inclusion criteria. The median age was 78 years, and 62.5% of patients were female. The cohort consisted of 287 patients (13.5%) with an IDL CMN and 1,843 patients (86.5%) with an SL CMN. A total of 99 patients (4.6%) had a reoperation of any type, of whom 29 (1.4% of all patients) had a reoperation for fixation failure. Compared with patients with an SL CMN, those with an IDL CMN had higher rates (4.2% versus 0.9%; p < 0.001) and odds (odds ratio [OR], 4.95 [95% confidence interval (CI), 2.29 to 10.69]; p < 0.001) of reoperation for fixation failure as well as higher rates (7.3% versus 4.2%; p = 0.021) and odds (OR, 1.83 [95% CI, 1.10 to 3.06]; p = 0.021) of all-cause reoperation. Intertrochanteric femoral fractures treated with an IDL CMN were associated with low but significantly higher rates and significantly higher odds of reoperation for fixation failure and all-cause reoperation compared with those treated with an SL CMN. We suggest caution to surgeons in the use of IDL CMNs for high-risk patients and recommend using SL CMNs for most patients with intertrochanteric femoral fractures. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

A Criteria to Reduce Interhospital Transfer of Traumatic Brain Injuries in Greater East Texas.

Traumatic brain injury (TBI) due to single-level falls (SLF) are frequent and often require interhospital transfer. This retrospective cohort study aimed to assess the safety of a criteria for non-transfer among a subset of TBI patients who could be observed at their local hospital, vs mandatory transfer to a level 1 trauma center (L1TC). We conducted a 7-year review of patients with TBI due to SLF at a rural L1TC. Patients were classified as transfer/non-transfer according to the Brain Injuries in Greater East Texas (BIGTEX) criteria. The primary outcome measure was the occurrence of a critical event defined as deteriorating repeat head computed tomography (CT) scan or neurological status, neurosurgical intervention, or death. Of the 689 included patients, 63 (9.1%) were classified as non-transfer. Although there were 4 cases with a neurological change and one with a head CT change among the non-transfer group, there were no neurosurgical procedures or deaths. The Cox Proportional Hazard model showed a near 3-fold increased risk of experiencing a critical event if classified as a non-transfer. The multivariable regression model showed patients with an Abbreviated Injury Scale (AIS) of 3 was twice as likely to experience a critical event, with an AIS of 4, three times, and 3 times more likely to be classified to transfer. The BIGTEX criteria identify a subset of patients who can safely be observed at their local hospital. To confirm the safety and efficacy of this transfer criteria recommendation, a prospective study is warranted.

Limited impact of traumatic brain injury on the post-traumatic inflammatory cellular response.

Trauma triggers a systemic inflammatory cellular response due to tissue damage, potentially leading to a secondary immune deficiency. Trauma severity is quantified by the Injury Severity Score (ISS). Severe Traumatic Brain Injury (TBI) is associated with high ISSs due to high lethality, despite limited tissue damage. Therefore, ISS might overestimate the post-traumatic inflammatory cellular response. This study investigated the effect of TBI on the occurrence of different systemic neutrophil phenotypes as alternative read-out for systemic inflammation. A single-center retrospective cohort study was conducted at a level-1 trauma center. Patients aged ≥ 18 years, admitted between 01-03-2021-01-11-2022 and providing a diagnostic blood sample were included. Four groups were created: isolated TBI, isolated non-TBI, multitrauma TBI and multitrauma non-TBI. Primary outcome was occurrence of different neutrophil phenotypes determined by automated flow cytometry. Secondary outcome was infectious complications. In total, 404 patients were included. TBI and non-TBI patients demonstrated similar occurrences of different neutrophil phenotypes. However, isolated TBI patients had higher ISSs than their isolated non-TBI controls who suffered similar post-traumatic inflammatory cellular responses. Regardless of the type of injury, patients exhibiting higher systemic inflammation had a high infection risk. When TBI is involved, ISS tends to be higher compared to similar patients in the absence of TBI. However, TBI patients did not demonstrate an increased inflammatory cellular response compared to non-TBI patients. Therefore, TBI does not add much to the inflammatory cellular response in trauma patients. The degree of the inflammatory response was related to the incidence of infectious complications.

627 Epidemiology, Admissions Outcomes, and Mortality for Geriatric Trochanteric Fractures. A Major Trauma Centre Study

Abstract Aim Femur trochanteric fractures are very debilitating injuries yet are under investigated in orthopaedic literature. We study the epidemiology, hospital admission factors, and mortality for elderly patients with trochanteric fractures. Method All patients over 65 years old at a level-1 trauma-centre with a trochanteric hip fracture from January-2015 to June-2021 were included. Fractures were subdivided with AO/OTA subclassifications into intertrochanteric (31-A1,A2,A3) and subtrochanteric (32-A1,A2) sub-types. Patient demographics, preadmission mobility, time-to-surgery, length-of-surgery, surgical fixation used, inpatient rehabilitation/mobilisation, and post-operative mortality at 1,3,6 and 12 months, were collected. Patients were followed up for minimum of 2-years. Statistical significance was p&amp;lt;0.05. Results A total of 1101 patients were included. The AO/OTA classification was: 31-A1(123), 31-A2(491), 31-A3(105), 32-A1(221), 32-A2(161). Average age was 84.9, with 72.8% patients being female. Average admission-to-surgery, surgery-time, and surgery-to-discharge-time was 21.6hours, 1.2hours, and 15.5days respectively. Overall mortality was 7.2%(1-month), 15.4%(3-months), 20.4%(6-months) and 27.1%(12-months). There were no statistically significant associations of type of fracture, operative method, or surgery-within-36hours, with mortality at any scale. Post-operative mobilisation within 24-hours, with or without physiotherapist aid, was associated with lower mortality on all investigated time scales, compared to no mobilisation (p&amp;lt;0.05). Conclusions Our study presents a large and detailed cohort of patients with trochanteric fractures classified with AO/OTA, the first in the UK, and investigated the associations with inpatient admission and mortality outcomes. Our detailed analysis and high-resolution data will allow for cross region and country comparisons and inform guideline and quality improvement efforts.

Minimal Clinically Important Difference (MCID) for the Short Musculoskeletal Function Assessment (SMFA) in Severe Lower Extremity Trauma: Pooled Data from 7 Multicenter, Prospective Clinical Trials.

The Short Musculoskeletal Function Assessment (SMFA) is a well validated, widely used patient-reported outcome (PRO) measure for orthopaedic patients. Despite its widespread use and acceptance, this measure does not have an agreed upon minimal clinically important difference (MCID). The purpose of the present study was to create distributional MCIDs with use of a large cohort of research participants with severe lower extremity fractures. Three distributional approaches were used to calculate MCIDs for the Dysfunction and Bother Indices of the SMFA as well as all its domains: (1) half of the standard deviation (one-half SD), (2) twice the standard error of measurement (2SEM), and (3) minimal detectable change (MDC). In addition to evaluating by patient characteristics and the timing of assessment, we reviewed these calculations across several injury groups likely to affect functional outcomes. A total of 4,298 SMFA assessments were collected from 3,185 patients who had undergone surgical treatment of traumatic injuries of the lower extremity at 60 Level-I trauma centers across 7 multicenter, prospective clinical studies. Depending on the statistical approach used, the MCID associated with the overall sample ranged from 7.7 to 10.7 for the SMFA Dysfunction Index and from 11.0 to 16.8 for the SMFA Bother Index. For the Dysfunction Index, the variability across the scores was small (<5%) within the sex and age subgroups but was modest (12% to 18%) across subgroups related to assessment timing. A defensible MCID can be found between 7 and 11 points for the Dysfunction Index and between 11 and 17 points for the Bother Index. The precise choice of MCID may depend on the preferred statistical approach and the population under study. While differences exist between MCID values based on the calculation method, values were consistent across the categories of the various subgroups presented. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors and predictors of prolonged hospital stay in the clinical course of major amputations of the upper and lower extremity a retrospective analysis of a level 1-trauma center

Risk factors and predictors of prolonged hospital stay in the clinical course of major amputations of the upper and lower extremity a retrospective analysis of a level 1-trauma center

The Efficacy of Intraosseous Access for Initial Resuscitation in Patients with Severe Trauma: A Retrospective Multicenter Study in South Korea.

Background/Objective: In patients with severe trauma, intraosseous (IO) access is an alternative when intravenous (IV) access proves challenging. However, detailed insights into its utilization patterns and effectiveness are lacking. This study aims to evaluate the use and efficacy of IO access in hemodynamically unstable patients with trauma at level-1 trauma centers in South Korea. Methods: Data from six centers over 12 months were analyzed, focusing on patients with traumatic cardiac arrest or shock. Overall, 206 patients were included in the study: 94 in the IO group and 112 in the IV group. Results: The first-attempt success rate was higher in the IO group than in the IV group (90.4% vs. 75.5%). The procedure time in the IO group was also shorter than that in the IV group. The fluid infusion rate was lower in the IO group than in the IV group; however, the use of a pressure bag with IO access significantly increased the rate, making it comparable to the IV infusion rate. Further, regarding IO access, a humeral site provided a higher infusion rate than a tibial site. Conclusions: IO access offers a viable alternative to IV access for the initial resuscitation in patients with trauma, providing advantages in terms of procedure time and first-attempt success rate. The use of a pressure bag and a humeral site for IO access afforded infusion rates comparable to those associated with IV access.

Incidence of intra-abdominal injuries in hemodynamically stable blunt trauma patients with a normal computed tomography scan admitted to the emergency department

ObjectivesBlunt abdominal trauma is a common cause of emergency department admission. Computed tomography (CT) scanning is the gold standard method for identifying intra-abdominal injuries in patients experiencing blunt trauma, especially those with high-energy trauma. Although the diagnostic accuracy of this imaging technique is very high, patient admission and prolonged observation protocols are still common practices worldwide. We aimed to evaluate the incidence of intra-abdominal injury in hemodynamically stable patients with high-energy blunt trauma and a normal abdominal CT scan at a Level-1 Trauma Center in Colombia, South America, to assess the relevance of a prolonged observation period.MethodsWe performed a retrospective study of patients admitted to the emergency department for blunt trauma between 2021 and 2022. All consecutive patients with high-energy mechanisms of trauma and a normal CT scan at admission were included. Our primary outcomes were the incidence of intra-abdominal injury identified during a 24-hour observation period or hospital stay, ICU admission, and death.ResultsWe included 480 patients who met the inclusion criteria. The median age was 33 (IQR 25.5, 47), and 74.2% were male. The most common mechanisms of injury were motor vehicle accidents (64.2%), falls from height (26%), and falls from bikes (3.1%). A total of 99.2% of patients had a Revised Trauma Score of 8. Only 1 patient (0.2%) (95% CI: 0.01–1.16) presented with an abdominal injury during the observation period. No ICU admissions or deaths were reported.ConclusionThe incidence of intra-abdominal injury in patients with hemodynamically stable blunt trauma and a negative abdominal CT scan is extremely low, and prolonged observation may not be justified in these patients.

Rate of skin and nerve complications as a result of cutaneous traction with modern foam boots

IntroductionCutaneous traction is used to temporize lower extremity fractures and relies on friction between the skin and surrounding material to apply a longitudinal force. This circumferential compressive force can lead to pressure sores, skin sloughing, or compressive neuropathies. These complications have been reported in up to 11% of patients when the cutaneous traction relies on adhesive tapes, plaster, and rubber bandages being in immediate contact with the skin. The rates of these complications are not well documented when using modern foam boots. MethodsA retrospective chart review was performed on all orthopedic trauma patients who suffered pelvic or lower extremity injuries between March 1st, 2020 and April 30th, 2021 at a single Level-1 trauma center. We included all patients with femoral fractures, axially unstable pelvic ring and/or acetabular fractures, and unstable hip dislocations temporized with the use of cutaneous traction. All patients had intact skin and lower extremity nerve function prior to application. ResultsThere were 138 patients identified with 141 lower extremities. The average patient age was 50.7 (6–100) years. Mean traction weight of 9.8 (5–20) pounds. Average traction duration was 20.9 (2.3–243.5) hours. At the time of traction removal, there was 1 (0.7%) new skin wound and 0 nerve palsies. The new skin wound was a stage one heel pressure sore and did not require further treatment. ConclusionCutaneous traction with a modern foam boot was found to have a skin complication rate of 0.7% and a nerve palsy complication rate of 0% for an overall complication rate of 0.7%, which has not been previously established and is lower than historically reported complication rates of 11% when utilizing adhesive and plaster directly on skin. Foam boot Cutaneous traction may be considered a safe option for traction placement.

The Trauma Recovery Clinic: A Stepped Collaborative Care Model for Trauma Surgery Patients to Address Health Disparities.

Background: The Trauma Recovery Clinic (TRC) was developed to meet the psychiatric, psychological, and psychosocial needs of traumatically injured patients following discharge from a level-I trauma center. The objective of this study is to demonstrate the efficacy of the TRC as an application of the stepped collaborative care model in order to address health disparities.Methods: Patients with a history of inpatient treatment for a physically traumatic injury at this level-I trauma center were approached and enrolled at initial TRC outpatient appointments. Data was collected, including the PTSD Checklist-Civilian Version (PCL-C), the Patient Health Questionnaire (PHQ-9), the Attitudes towards Guns scale, and the Youth Behavior Risk Survey (questions about weapon carrying practices).Results: A total of 80 patients were included in this study. Patients expressed several social determinants of health risk factors, with 60% of the sample reporting witnessing someone being wounded or killed. Results demonstrated a significant decrease in trauma symptoms (T24 = 3.33; P = .001, d = 0.67) and depressive symptoms (T24 = 2.23, P = .02, d = 0.45) by their 6th clinic visit. Additionally, patients reported significant improvements in role limitations due to emotional problems (T25 = 1.74; P = .04; d = 0.34) and social functioning (T25 = 2.23; P = .02; d = 0.43). Interestingly, patients who reported carrying a weapon in the last 30 days reported significantly higher trauma symptoms (T64 = 3.21, P = .002) and depressive symptoms (T64 = 2.77, P = .007).Discussion: This evaluation of services at the recently implemented Trauma Recovery Clinic demonstrated that the clinic is successfully treating individuals who have experienced traumatic injuries. More specifically, the clinic services are effectively engaging a vulnerable, hard-to-reach patient population.