Major Trauma Centre Research Articles

Traumatic native hip dislocation in the absence of acetabular or femoral fracture in adults: a retrospective study reporting clinical and radiological outcomes from a major trauma centre in the United Kingdom.

Posterior native hip dislocations (NHD) are high-energy injuries. Thompson-Epstein Type I dislocations describe those without significant associated femoral or acetabular fracture. The aim of this study was to compare the clinical and radiological outcomes of patients with Type I NHDs. We also evaluate the association between radiological indicators of femoroacetabular impingement (FAI) and NHD. A retrospective study from January 2012 to May 2021 compared skeletally mature patients (⩾16 years) with Type I posterior NHD to age and gender-matched controls with Type II-V posterior NHD. Patient demographics, mechanism of injury, complications and patient-reported outcome measures (PROMs) are presented. Post reduction radiographs and computed tomography were used to assess for FAI. Univariate analyses were performed to evaluate radiological outcomes. 13 patients (77% male) with Type I posterior NHD were compared to a control group of 40 patients (80% male) with Type II-V posterior NHD. 11 patients in the study group and 14 in the control group experienced isolated injuries (p = 0.01). Post-reduction complications were similar. The study group had significantly lower post-injury osteoarthritis incidence (n = 0) compared to controls (n = 18, p = 0.0083). Patients reported a mean Oxford Hip Score of 43.5 ± 2.2 and EQ-5D-VAS score of 87.1 ± 7.4, with 6 patients indicating minimal symptoms across all EQ-5D-5L domains. Radiological femoroacetabular impingement (FAI) was prevalent in both groups, especially among males. Patients who underwent emergent closed reduction of Type I NHD demonstrated good short to medium term outcomes. Our radiological findings suggest a high prevalence of FAI. Future work should aim to quantify longer term outcomes following this injury. We call for further comparative studies of patients who suffer NHD with and without fractures to aid our understanding of risk factors. Given the rarity of this injury, multicentre efforts will be required to capture large numbers of patients.

214 Moving Forward - Exercise Promotion At A Major Trauma Centre

214 Moving Forward - Exercise Promotion At A Major Trauma Centre

Observational Study of the Clinical Impact of E-scooter Injuries at a Major Trauma Centre.

Background Due to the increased use of e-scooters in the UK, associated injuries have increased, and its cost has increased as well. Worldwide data on injuries related to e-scooter use are relatively limited, owing to the short duration since their first introduction to the public. Aim There has been an increase in using e-scooters as a method of transport recently. It was noticed that the severity and frequency of its injuries are increasing as well. This study focuses on the frequency of e-scooter-associated injuries, especially open fractures, and to evaluate its burden on the health system. Methods Data on e-scooter injuries were extracted from our trauma database from November 2017 to July 2022. Patients' notes and images were reviewed. Outcome measures were the type of injuries: site of bony fractures, closed vs. open fracture (using Anderson and Gustilo classification), number of operations, complications, and length of hospital stay. Results The number of patients enrolled was 104. The mean age was 34.3 years, and 78.8% (n = 82) were male. The main mechanism of injury was riding (91%, n = 95) vs. hitting by an e-scooter (9%, n = 9). Injured patients were more likely not to wear helmets (82% of total injured patients). Patients with bony injuries were 65.4% (n = 68), with 22.1% (n = 15) of them being open fractures. The most common bony injuries were lower limb-only fractures at 45.6% (n = 31), then upper limb-only injuries at 39.7% (n = 27). Combined upper and lower limb cases were 8.8% (n = 6), and pelvic injuries were 5.9% (n = 4). Head and neck injuries composed 23.1% (n = 24) of the reported injuries, including intracranial haemorrhages (9.6%, n = 10), extensive traumatic brain injury (3.8%, n = 4), haematoma/lacerations (3.8%, n = 4), cervical spine fractures (1.9%, n = 2), and skull fractures (1.9%, n = 2). The mean duration of hospital stay was 8.6 days, and 9.6% (n = 10) of patients needed intensive therapy unit(ITU) admission. The number of patients presented as trauma calls was 55.8% (n = 58). Patients who needed surgical intervention either under orthopaedics or other specialties were 52.9% (n = 55) and 21.2% (n = 22) of total patients had complications either due to surgical intervention or a long hospital stay. Conclusion E-scooter riding can lead to serious injuries that can end with limb- or life-threatening conditions. The most common demographic characteristics were adults in their early 30s. There should be more emphasis on wearing protective gear like wrist and elbow guards in addition to helmets. Future prospective studies with larger cohorts across multiple regions and hospitals are necessary to truly characterize the nature and cost of e-scooter injuries.

Relationship between GPS-based community mobility data and orthopedic trauma admissions during the COVID-19 pandemic in Austria: amulticenter analysis.

The main objective of this study was to examine the relationship between mobility patterns during the coronavirus disease 2019 (COVID-19) pandemic and orthopedic trauma patients in Austria. Utilizing global positioning system (GPS)-based mobility data, the attempt was to assess both the impact of COVID-19 lockdowns on reducing orthopedic trauma patients and the degree of compliance to the imposed movement restrictions. This retrospective analysis included all patients (283,501) treated at 3 major levelI trauma centers in Austria. Analyzed time periods were 1 January 2019 to 8 February 2021. Freely available GPS-based mobility data from Google and Apple Inc. was gathered. Amoderate to strong correlation between the cumulative average outpatients and the assessed mobility index was observed for all cities (Google: r = 0.70 p < 0.001, 95% confidence interval, CI: 0.67-0.73; Apple: r = 0.64 p < 0.001, 95% CI: 0.61-0.67). Asignificant linear regression equation was found for Vienna (adjusted r2 = 0.48; F(1, 350) = 328,05; p < 0.01). During the first lockdown there was adrastic decline in mobility (up to -75.36%) and in numbers of orthopedic trauma outpatients (up to -64%, from 153 patients/day 2019 to 55patients/day 2020) in comparison to the prepandemic era. The decline diminished as time passed. Analyses of GPS-based mobility patterns show acorrelation with trauma patient numbers. These findings can be used to develop prediction models, leading to better resource planning and public health policy, enhancing patient care and cost-effectiveness, especially in the event of future pandemics. Furthermore, the results suggest that compliance to mobility restrictions decreased over time during the COVID-19 pandemic, resulting in increased mobility and trauma patients.

Utilizing injury severity score, Glasgow coma scale, and revised trauma score for trauma-related in-hospital mortality and ICU admission prediction; originated from 7-year results of a nationwide multicenter registry

Objective: During the past few decades, many scoring systems have been developed to evaluate the severity of injury and predict the outcome in trauma patients. This study aimed to assess the capacity of three common trauma scoring systems: injury severity score (ISS), Glasgow coma scale (GCS), and revised trauma score (RTS) in predicting in-hospital mortality and ICU admission in patients with traumatic injury. Methods: This is a multicenter study of the hospital-based national trauma registry of Iran (NTRI), an ongoing registry-based trauma database. This study included trauma cases from 12 major trauma centers throughout the country admitted between July 2016 and November 2023. The inclusion criteria were all patients admitted to the emergency department due to trauma, hospitalized for at least 24 hours, deceased within the first 24 hours of admission, and patients transferred from the intensive care unit (ICU)s of other hospitals. Results: A total of 50,458 traumatic patients, with 38,740 (76.9%) being male, were included in this study. After adjustment for confounders, head, face, and neck injuries were associated with the highest odds of death (OR: 7.51, P-value&lt;0.001), whereas abdominal injuries were associated with the highest odds of ICU admission (OR: 4.58, P-value&lt;0.001). Each Unit increase in RTS score was accompanied by a 61% decrease in odds of death (OR: 0.39, P-value&lt;0.001). The area under the ROC curve for predicting in-hospital mortality was 0.81 (0.79 to 0.82) in ISS, 0.78 (0.77 to 0.80) in GCS, and 0.75 (0.73 to 0.76) in RTS. There was a significant difference between RTS and GCS, as well as RTS and ISS for in-hospital mortality prediction (P-values&lt; 0.001). The area under the ROC curve for the prediction of ICU admission was 0.75 (0.74 to 0.75) in ISS, 0.63 (0.62 to 0.63) in GCS, and 0.62 (0.61 to 0.63) in RTS. There was a statistically significant difference between ISS and GCS, as well as ISS and RTS, for ICU admission prediction (P-value&lt;0.001). Conclusion: ISS is the best predictor of in-hospital mortality and ICU admission, compared to GCS and RTS.

Orthoplastics Management of Open Lower Limb Fractures at a Major Trauma Centre: Audit of Adherence to BOAST4 Guidelines

IntroductionThe British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guide the optimal management of open lower limb fractures. Adherence of the newly established Orthoplastic service at the Major Trauma Centre covering the Southeast of England was audited in relation to these standards. Materials and methodsAudit standards were produced. Data were collected using hospital records and the Trauma Audit and Research Network database. All open lower limb fractures managed between August 2020-August 2022 were included. Data collected included patient and injury demographics, and information related to initial and definitive management. ResultsOverall, 133 patients were identified, 70 men and 63 women, with an average age of 58 years. Women had a higher average age (69 years) and ASA grade (71% ASA 3 or higher). Low-energy injuries occurred in 69% of women compared to 78% of high-energy injuries in men (p<0.001). Among them, 108 (81%) were debrided within 24 h. The average time to first debridement was 18.78 h, and 95 (75%) were definitively closed within 72 h, 76 with primary closure, 7 with split-thickness skin graft, 7 with local flap and 36 with free flap. Overall, the post-operative infection rate was 13% with 94% of these fractures definitively closed within 72 h. ConclusionMost open lower limb fractures occurred in older women with higher ASA grade, from low-energy mechanisms. Most injuries were definitively managed as per the BOAST guidelines, but further efforts are required to improve the adherence to initial debridement targets, including training, appropriate resource allocation and implementation of procedures and proformas to guide injury management and improve documentation.

Mid to Long-Term Outcomes of Grade III-B Open Tibial Fractures Definitively Managed With a Circular Frame: A 13-Year Prospective Database Study at a Major Trauma Center.

The aim of this study was to report experience of a major trauma center utilizing circular frames as definitive fixation in patients sustaining Gustilo-Anderson 3B open tibial fractures. A prospectively maintained database was retrospectively interrogated. Single major trauma center in the United Kingdom. All patients over the age of 16 sustaining an open tibial fracture with initial debridement performed at the study center. All patients also received orthoplastic care for a soft tissue defect (via skeletal deformation or a soft tissue cover procedure) and subsequent definitive management using an Ilizarov ring fixator. Patients who received primary debridement at another center, had preexisting infection, sustained a periarticular fracture, or those who did not afford a minimum of 12-month follow-up were excluded. Case notes and radiographs were reviewed to collate patient demographics and injury factors. The primary outcome of interest was deep infection rate with secondary outcomes including time to union and secondary interventions. Two hundred twenty-five patients met inclusion criteria. Mean age was 43.2 year old, with 72% males, 34% smokers, and 3% diabetics. Total duration of frame management averaged 6.4 months (SD 7.7). Eight (3.5%) patients developed a deep infection and 41 (20%) exhibited signs of a pin site infection. Seventy-nine (35.1%) patients had a secondary intervention, of which 8 comprised debridement of deep infection, 29 bony procedures, 8 soft tissue operations, 30 frame adjustments, and 4 patients requiring a combination of soft tissue and bony procedures. Bony union was achieved in 221 cases (98.2%), 195 (86.7%) achieved union in a single frame without the need for secondary intervention, 26 required frame adjustments to achieve union. Autologous bone grafts were used in 10 cases. Orthoplastic care including circular frame fixation for Gustilo-Anderson-3B fractures of the tibia resulted in a low rate of deep infection (3.5%) and achieved excellent union rates (98.2%). Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Change from semi-rigid to soft collars for prehospital management of trauma patients: An observational study.

Protection of the cervical spine is recommended following multisystem injury. In 2021, Ambulance Victoria changed clinical practice guidelines to apply soft collars instead of semi-rigid collars for suspected cervical spine injury. The aim of this study was to describe associated changes in imaging practices and diagnoses of pressure sores, hospital acquired pneumonia, and spinal cord injury. A retrospective pre- and postintervention study was conducted including all consecutive patients that presented to an adult major trauma center in Melbourne, Australia with a cervical collar placed by emergency medical services over two 3-month periods. There were 1762 patients included. A computed tomography (CT) of the cervical spine was performed in 795 (88.4%) patients in the semi-rigid collar period and 810 (93.8%) in the soft collar period (p=0.001). Soft collars were associated with higher rates of clearance of the cervical spine in the emergency department (ED) (odds ratio [OR] 4.14; 95% confidence interval [CI]: 3.36-5.09). There were no differences in diagnosis of pressure sores (0.11%vs. 0.23%, p=0.97) or hospital acquired pneumonia (2.0%vs. 2.7%; p=0.44) or cervical spinal cord injury (0.45%vs. 0.81%; p=0.50). Following a change from prehospital semi-rigid collars to soft collars, more patients were investigated with a CT scan and more frequent clearance of the cervical spine occurred in the ED. There were no differences in the rates of spinal cord injuries, pressure sores or hospital acquired pneumonia, but the study was underpowered to detect significant differences. The practice of soft collars for prehospital care of patients with suspected neck injury requires ongoing surveillance.

Multidisciplinary management of orthopaedic trauma - are we adhering to the guidelines?

A multidisciplinary team (MDT) approach to polytrauma patients minimises morbidity and mortality. This project assesses the extent to which British Orthopaedic Association Standards for Trauma guidelines for the management of the frail Orthopaedic patient are currently being met. A retrospective analysis was performed of all Trauma and Orthopaedic patients in multiple medical institutions over a 2-week capture period from 1 March 2022 until 14 March 2022 inclusive. Data collected included age, sex, injury, length of stay and dates of speciality input. A total of 1,050 patients were included from 27 hospitals. The median age was 80 years, with 560 (53.3%) of all fractures being neck of femur fractures. Of the 1,050 patients, 870 (82.9%) were managed operatively. The median number of different speciality involvements was 3; 645 (61.4%) had an orthogeriatric (OG) review. In major trauma centres (MTC), 93.3% had OG input, compared with 66.3% in non-MTC. The speciality with the greatest input was Radiology, with Plastics having the lowest input. A standardised MDT approach is needed to optimise care and recovery in orthopaedic trauma patients. The difference in results regarding speciality involvement is substantial and needs to be addressed to minimise disparities in care received by this vulnerable cohort of patients.

Penetrating trauma on the rise- nine-year trends of severe trauma in Sweden.

Sweden has an established trauma system involving national trauma criteria and the Swedish trauma registry (SweTrau), since over a decade. Meanwhile, the injury panorama has evolved, with an increase in gang-related violence in the Swedish community. In this study, we aimed to investigate long-term trends in mortality, management and trauma type in two major Swedish trauma centers over a nine-year period. All trauma patients with a New Injury Score (NISS) > 15 or a Trauma Alert (TA) call during 2013-2021 were identified in the participating centers' SweTrau registries. Data were analysed regarding mortality, proportion of emergency interventions, intensive care unit (ICU) admissions, mechanism of injury and type of trauma (penetrating or blunt). To assess trends, Chi-Squared test for trend and JoinPoint regression method were used. A total of 10,587 patients were included in the study. Mortality remained unchanged over time in patients with NISS > 15 (10.0-10.9%, p = 0.963) but increased in patients with a TA and NISS < 15 (1.3-2.7%, p = 0.005). For NISS > 15, the proportion undergoing emergency interventions was stable (53.9%-48.8%, p = 0.297) while ICU admissions declined (62.1%-45.7%, p < 0.001). Penetrating trauma increased (12.4-19.6%, p < 0.001), including knife (10.0-15.7%, p < 0.001) and gunshot wounds (2.3-3.8%, p < 0.001), whereas accidents involving motorcycles (8.8%-7.0%, p = 0.004) and pedestrians (5.3%-2.2%, p < 0.001) decreased. Assaults (both penetrating and blunt) increased from 14.7 to 21.4% (p < 0.001). In this trend analysis at two major Swedish trauma centers during 2013-2021, penetrating trauma increased with over 50% while traffic injuries decreased. The rise in mortality in patients with a TA and NISS < 15 is concerning and requires further evaluation, as do the reduction in ICU admissions.

Identifying the key characteristics, trends, and seasonality of pedestrian traffic injury at a major trauma center in Saudi Arabia: a registry-based retrospective cohort study, 2017–2022

BackgroundPedestrian traffic injuries are a rising public health concern worldwide. In rapidly urbanizing countries like Saudi Arabia, these injuries account for a considerable proportion of trauma cases and represent a challenge for healthcare systems. The study aims to analyze the key characteristics, seasonality, and outcomes of pedestrian traffic injuries in Riyadh, Saudi Arabia.MethodsThis study was a retrospective cohort analysis of all pedestrian traffic injuries presented to King Saud Medical City, Riyadh, and included in the Saudi Trauma Registry (STAR) database between August 1, 2017, and December 31, 2022. The analysis of metric and nominal variables was reported as mean (standard deviation, SD) or median (interquartile range, IQR) and frequencies (%), respectively. A logistic regression analysis was performed to examine the influence of patients’ pre-hospital vitals and key characteristics on arrival at the ED on the need for mechanical ventilation and in-hospital mortality.ResultsDuring the study period, 1062 pedestrian-injured patients were included in the analysis, mostly males (89.45%) with a mean (SD) age of 33.44 (17.92) years. One-third (35.88%) of the patients were Saudi nationals. Two-thirds (67.04%) of the injuries occurred from 6 p.m. until 6 a.m. Compared to other years, a smaller % of injury events (13.28%) were noticed during the COVID-19 pandemic (2020). Half (50.19%) of the patients were transported to the emergency department by the Red Crescent ambulance, and 19.68% required intubation and mechanical ventilation. Most of the patients (87.85%) were discharged home after completion of treatment, and our cohort had a 4.89% overall mortality. The logistic regression analysis showed the influence of patients’ pre-hospital vitals and key characteristics on arrival at the ED on the need for mechanical ventilation (Chi2 = 161.95, p < 0.001) and in-hospital mortality (Chi2 = 63.78, p < 0.001) as a whole significant.ConclusionThis study details the demographic, temporal, and clinical trends of pedestrian traffic injuries at a major Saudi trauma center. Identifying high-risk individuals and injury timing is crucial for resource allocation, targeting road safety interventions like public awareness campaigns and regulatory reforms, and improving prehospital care and patient outcomes.

Implementation of major trauma app: usability and data completeness

Background The current UK standard for major trauma patients is to record notes in a paper trauma booklet. Through an innovative collaboration between a major trauma centre and a digital transformation industry partner, a TraumaApp was developed. Electronic notes have been shown to have fewer errors, granular data collection and enable time stamped contemporaneous record keeping. Implementation of digital clinical records presents a challenge within the context of trauma multidisciplinary trauma resuscitation. Data can be easily accessible and shared for quality improvement, audit and research purposes. This study compared paper and electronic notes for completeness and for acceptability data following the implementation of the TraumaApp.MethodsTrauma team members who performed scribe function attended training for the newly launched TraumaApp. Two staff members acted as scribe, using either the paper trauma booklet or TraumaApp, and attended major trauma calls. A framework for comparison of paper and electronic notes was created and used for a retrospective review of major trauma patients’ notes. Statistical analysis was performed using a two-tailed t-test. Staff using the TraumaApp completed a System Usability Score questionnaire.ResultsThere was a total of 37 data points for collection per case. The mean numbers collected were paper notes 24.1 of 37 (65.1%) and electronic notes, 25.7 of 37 (69.5%). There was no statistical significance between the completeness of paper and electronic notes. The mean System Usability Score was 68.4.DiscussionRecording accurate patient information during a major trauma call can be challenging and the role of the scribe to accurately record events is critical for immediate and future care. There was no statistically significant difference in completeness of paper and electronic notes, however the mean System Usability Score was 68.4, which is greater than the internationally validated standard of acceptable usability.ConclusionIt is feasible to introduce digital data collection tools enabling accurate record keeping during trauma resuscitation and improve information sharing between clinicians.

Older adults in major trauma centre psychology provision

Older adults in major trauma centre psychology provision

Impact of mistriages in on-scene injury assessment on trauma network and patient safety

An accurate on-scene assessment of a trauma patient’s injury by emergency medical service providers is critical to determining the right hospital for prompt care delivery. However, literature and anecdotal evidence from trauma professionals in the Midwestern U.S. suggest that mistriages (i.e., an error in assessing a severely injured patient as having non-severe injuries, and vice versa) often occur in practice. Due to a lack of approaches that consider such mistriages while designing the trauma network, we propose a stochastic nested multi-level, multi-transportation capacitated facility location model, which explicitly considers mistriages in injury assessment, to maximize patient safety by determining the number and locations of major trauma centers (MTCs). Assessment-related mistriages are modeled using a Bernoulli random variable for each of the two injury groups, moderate (ISS 9–15) and severe (ISS>15). We propose a Simheuristic approach that integrates Monte Carlo Simulation with a genetic algorithm. We convert infeasible solutions into feasible ones during offspring generation and maintain a superior population pool to balance quality against computational time. Our findings based on a realistic data set suggest that assessment-related mistriages in the ISS>15 group can substantially decrease patient safety and may lead to a clustering of MTCs, while mistriages in the ISS 9–15 group tend to have a dispersed distribution of MTCs in the resulting network. Our case study using actual 2019 data from a midwestern state of the U.S. resulted in an over 20% reduction in the mistriages, further providing evidence for incorporating injury assessment-related mistriages in trauma network design.

What affects implementation of the UK major trauma rehabilitation prescription? A survey informed by the behaviour change wheel

ObjectiveMajor trauma 'Rehabilitation Prescriptions' aim to facilitate continuity of care and describe patient needs following discharge from UK Major Trauma Centre (MTCs), however research suggests rehabilitation prescriptions are not being implemented as intended. We aimed to identify factors influencing completion and use of rehabilitation prescriptions using the Behaviour Change Wheel (BCW) and Theoretical Domains Framework (TDF). DesignOnline survey informed by the TDF and BCW. SettingUK trauma rehabilitation pathway. PopulationRehabilitation and trauma service providers involved in completing and/or using rehabilitation prescriptions (n = 78). AnalysisMean scores were calculated for TDF behavioural domains, identifying facilitators (score ≥5) and barriers (≤3.5) to rehabilitation prescription implementation. Thematic analysis of free text data informed by the BCW/TDF identified further facilitators and barriers, plus potential behaviour change strategies. ResultsMost respondents worked in UK MTCs (n = 63) and were physiotherapists (n = 34), trauma rehabilitation coordinators (n = 16) or occupational therapists (n = 15). ‘Social/professional role and identity’, 'knowledge’ and ‘emotion’ (the highest-scoring TDF domains) were facilitators to implementing rehabilitation prescriptions. Qualitative data identified barriers to rehabilitation prescription completion, including ‘seen as tick-box exercise’,‘not a priority’, lack of resources (IT and workforce), poor inter-service communication, limited knowledge/training. Facilitators included therapist buy-in, standardised training, easy inter-service rehabilitation prescription transfer, usefulness for sharing patient needs. ConclusionsAlthough rehabilitation prescriptions are valued by some service providers, their effectiveness is hindered by negative attitudes, limited knowledge and poor communication. Uncertainties exist about whether rehabilitation prescriptions achieve their goals, particularly in documenting patient needs, engaging patients in rehabilitation, and informing onward referrals following MTC discharge. Improving IT systems, empowering patients, redirecting funding, and providing training might improve their usage. Further research should explore service provider and patient perspectives, and prospective long-term follow-up on outcomes of rehabilitation prescription recommendations.

Emergency treatment of pelvic ring injuries: state of the art.

High energy pelvic injuries sustain significant mortality rates, due to acute exsanguination and severe associated injuries. Managing the hemodynamically unstable trauma patient with a bleeding pelvic fracture still forms a major challenge in acute trauma care. Various approaches have been applied through the last decades. At present the concept of Damage Control Resuscitation (DCR) is universally accepted and applied in major trauma centers internationally. DCR combines hemostatic blood transfusions to restore blood volume and physiologic stability, reduced crystalloid fluid administration, permissive hypotension, and immediate hemorrhage control by operative or angiographic means. Different detailed algorithms and orders of hemostatic procedures exist, without clear consensus or guidelines, depending on local traditions and institutional setups. Fracture reduction and immediate stabilization with a binder constitute the basis for angiography and embolization (AE) or pelvic packing (PP) in the hemodynamically unstable patient. AE is time consuming and may not be available 24/7, whereas PP offers a quick and technically easy procedure well suited for the patient in extremis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has also been described as a valuable adjunct in hemostatic non-responders, but merely constitute a bridge to surgical or angiographic hemostasis and its definitive role in DCR is not yet clearly established. A swift algorithmic approach to the hemodynamically unstable pelvic injury patient is required to achieve optimum results. The present paper summarizes the available literature on the acute management of the bleeding pelvic trauma patient, with emphasis on initial assessment and damage control resuscitation including surgical and angiographic hemostatic procedures. Furthermore, initial treatment of open fractures and associated injuries to the nervous and genitourinary system is outlined.

Efficiency and safety of microvascular anastomotic coupler for wrist revascularization in traumatic injuries

IntroductionEffective vascular anastomosis is crucial for successful hand surgery, particularly in traumatic injuries where rapid restoration of blood flow is essential. The Synovis microvascular anastomotic coupler system presents a novel approach by potentially offering faster and more reliable outcomes than traditional suturing methods. This study was conducted to assess the effectiveness and safety of the Synovis coupler for microvascular anastomoses in the wrist, evaluating anastomosis time, patency rates, and complication rates. MethodsThis retrospective study examined 25 microvascular anastomoses (22 arteries and 3 veins) in 24 patients at a major trauma center. The primary outcomes measured were anastomosis time and vascular patency, which were assessed immediately post-operation and at subsequent follow-ups. ResultsThe average time required for anastomosis using the coupler was 7.3 min. Immediate post-operative vascular patency was 100%, with a long-term patency rate of 88%. Complications included arterial narrowing at the coupler site in 3 arteries, and complete occlusion in 3 arteries, accounting for a 12% long-term complication rate. ConclusionAlthough the Synovis coupler demonstrated a significant reduction in anastomosis time and high patency rates, our data suggest that its effectiveness is more pronounced in venous anastomoses. The higher complication rates in arterial anastomoses warrant cautious use in these cases. Further research, including prospective randomized controlled trials, is needed to validate these findings and optimize patient selection criteria for using couplers in microvascular surgery.

Surgical Management of Complex Ankle Fractures in Patients with Diabetes: A National Retrospective Multicentre Study.

Objectives: Patients with ankle fractures associated with diabetes experience more complications following standard open reduction-internal fixation (ORIF) than those without diabetes. Augmented fixation strategies, namely extended ORIF and hindfoot nails (HFNs), may offer better results and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, we aimed to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes, including early post-operative weightbearing and surgical complications. Methods: A national multicentre retrospective cohort study was conducted between January and June 2019 in 56 centres (10 major trauma centres and 46 trauma units) in the United Kingdom; 1360 patients with specifically defined complex ankle fractures were enrolled. The patients' demographics, fixation choices and surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with and without diabetes. Results: There were 316 patients in the diabetes cohort with a mean age of 63.9 yrs (vs. 49.3 yrs. in the non-diabetes cohort), and a greater frailty score > 4 (24% vs. 14% (non-diabetes cohort) (p < 0.03)); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% an HFN, compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p < 0.02), but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications compared to non-diabetes patients, even though early-weightbearing rates were greater than for standard-ORIF. Conclusions: Ankle fractures in diabetes occur in older, frailer patients, whilst lower-than-expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weightbearing without increasing complications, in keeping with modern guidelines in ankle fracture management.

682 Impact of Regionalisation of Major Trauma Services on Hip Fracture Care in England: A Comparative Study

Abstract Aim Following the establishment of Major Trauma Networks in England in 2012, there were concerns that pressures regarding resource allocation in Major Trauma Centres (MTCs) may negatively impact their care of hip fracture patients. This study aimed to compare outcomes in hip fracture care between MTCs and trauma units (TUs). Method National Hip Fracture Database data was extracted from 01/01/2015 to 31/12/2022 for all hospitals in England. Outcome measures included perioperative medical and physiotherapy assessments, time to surgery, Best Practice Tariff (BPT) compliance, discharge to original residence, and mortality. Data was pooled and weighted for MTCs and remaining hospitals (TUs). Results 487,089 patients were included from 167 hospitals (23 MTCs, 144 TUs). MTCs achieved marginally higher rates of orthogeriatrician assessment within 72 hours of admission (91.1% vs 90.4%, p&amp;lt;0.001) and mobilisation by first postoperative day (81.9% vs 79.7%, p&amp;lt;0.001). Fewer patients underwent surgery by the day after admission in MTCs (65.2% vs 69.7%, p&amp;lt;0.001). There was poorer compliance with BPT criteria in MTCs (57.3% vs 60.4%, p&amp;lt;0.001), and fewer MTC patients were discharged to their original residence (60.4% vs 63.5%, p&amp;lt;0.001). There was no difference between MTCs and TUs in 30-day mortality (6.8% vs 6.8%, p=0.825). Conclusions This study demonstrates that MTCs have greater difficulty in providing prompt surgery to hip fracture patients. However, their marginally superior perioperative care outcomes appear to compensate for this, with similar mortality rates compared to TUs. These findings suggest that the regionalisation of major trauma in England has not significantly compromised the overall care of hip fracture patients.

559 Can Poller Screws Decrease Pain Relief in Femoral Fractures?

Abstract Aim Poller screws, used alongside intramedullary (IM) nails for femoral shaft fractures, aim to expedite healing and minimize complications by enhancing fracture stability and controlling IM nail insertion. Despite their benefits, the impact of poller screws on post-operative pain is understudied. This retrospective cohort study aimed to compare opioid medication needs in femoral shaft fractures managed with IM nails with and without poller screws. Method Between January 2015 and December 2022, a retrospective analysis was conducted on femoral shaft fractures treated at a major trauma centre. Patients primarily treated with IM nails were included. Patient and operation notes, along with radiographs, identified poller screw utilization and categorized screw generation. Opioid medication data, converted to "coverage" (days) and "strength" (morphine milligrams equivalent or MME), was collected. Two-tailed independent samples T-tests compared patients treated with (n=43) and without poller screws (n=364). Results Second-generation poller screws significantly reduced opioid strength requirements in the first post-operative year (603.6 vs. 1711.6 MME, p=0.03), except the first month. However, no significant difference was observed in the number of days with opioid prescriptions throughout the first post-operative year for each poller screw generation. Conclusions This study highlights the potential of poller screws in reducing post-operative pain in femoral fractures. Future endeavors aim to use a larger patient sample, but these results signify the promise of poller screws in mitigating post-operative pain in IM-treated femoral fractures.