Specific Injury Patterns Research Articles

Placental pathology in women with HIV

Recognizing the importance of placental features and their unique functions can provide insight into maternal health, the uterine environment during the course of pregnancy, birth outcomes and neonatal health. In the context of HIV and antiretroviral therapy (ART), there have been great strides in the prevention of mother to child transmission of HIV. However, there is still paucity of data on the impact of HIV/ART exposure on placental pathology and studies available only examine specific patterns of placental injury, further justifying the need for a more defined and comprehensive approach to the differential diagnoses of HIV/ART-exposed placentae. The purpose of this review is to consolidate findings from individual studies that have been reported on patterns of placental injury in the context of HIV/ART exposure. In both the pre- and post-ART eras HIV and/or ART has been associated with placental injury including maternal vascular malperfusion as well as acute and chronic inflammation. These patterns of injury are further associated with adverse birth outcomes including preterm birth and current evidence suggests an association between poor placental function and compromised fetal development. With the ever increasing number of pregnant women with HIV on ART, there is a compelling need for full incorporation of placental diagnoses into obstetric disease classification. It is also important to take into account key elements of maternal clinical history. Lastly, there is a need to standardize the reporting of placental pathology in order to glean additional insight into the elucidation of HIV/ART associated placental injury.

Comparing trauma mortality of injured patients in India and the USA: a risk-adjusted analysis

ObjectivesComparisons of risk-adjusted trauma mortality between high-income countries and low and middle-income countries (LMICs) can be used to identify specific patient populations and injury patterns for targeted interventions. Due to...

Measuring quality of pre-hospital traumatic shock care-development and validation of an instrument for resource-limited settings.

Background and AimsImproving the quality of pre‐hospital traumatic shock care, especially in low‐ and middle‐income countries, is particularly relevant to reducing the large global burden of disease from injury. What clinical interventions represent high‐quality care is an actively evolving field and often dependent on the specific injury pattern. A key component of improving the quality of care is having a consistent way to assess and measure the quality of shock care in the pre‐hospital setting. The objective of this study was to develop and validate a chart abstraction instrument to measure the quality of trauma care in a resource‐limited, pre‐hospital emergency care setting.MethodsTraumatic shock was selected as the tracer condition. The pre‐hospital quality of traumatic shock care (QTSC) instrument was developed and validated in three phases. A content development phase utilized a rapid literature review and expert consensus to yield the contents of the draft instrument. In the instrument validation phase, the QTSC instrument was created and underwent end user and content validation. A pilot‐testing phase collected user feedback and performance characteristics to iteratively refine draft versions into a final instrument. Accuracy and inter‐ and intra‐rater agreement were calculated.ResultsThe final QTSC instrument contains 10 domains of quality, each with specific criteria that determine how the domain is measured and the level of quality of care rendered. The instrument is over 90% accurate and has good inter‐ and intra‐rater reliability when used by trained pre‐hospital provider users in South Africa. Pre‐hospital provider user feedback indicates the tool is easy to learn and quick to use.ConclusionWe created and validated a novel chart abstraction instrument that can reliably and accurately measure the quality of pre‐hospital traumatic shock care. We provide a systematic methodology for developing and validating a quality of care tool for resource‐limited care settings.

Interobserver Reliability for Identifying Specific Patterns of Placental Injury as Defined by the Amsterdam Classification.

Placental pathology is an essential tool for understanding neonatal illness. The recent Amsterdam international consensus has standardized criteria and terminology, providing harmonized data for research and clinical care. To evaluate the interobserver reliability of these criteria between pathologists at different levels of experience using digitally scanned slides from placentas in a birth population including a large proportion of normal deliveries. This was a secondary analysis of selected placentas from a large case-control study of placental lesions associated with neonatal encephalopathy. Histologic slides from 80 placentas were digitally scanned and blindly evaluated by 6 pathologists. Interobserver reliability was assessed by positive and negative agreement, Fleiss κ, and interrater correlation coefficients. Overall agreement on the diagnosis, grading, and staging of acute chorioamnionitis and villitis of unknown etiology was moderate to good for all observers and good to excellent for a subset of 4 observers. Agreement on the diagnosis and subtyping of fetal vascular malperfusion was poor to fair for all observers and fair to moderate for the subset of 4 pathologists. Agreement on accelerated villous maturation was poor. This study critically evaluates interobserver reliability for lesions defined by the Amsterdam consensus using scanned images with a low frequency of pathologic lesions. Although reliability was good to excellent for inflammatory lesions, lower reliability for vascular lesions emphasizes the need to more explicitly define the specific histologic features and boundaries for these patterns.

Blunt Cerebrovascular Injuries

Blunt cerebrovascular injuries (BCVIs) are increasingly recognized in trauma patients, with 1 to 3% of all blunt trauma patients being diagnosed with a carotid artery injury or a vertebral artery injury. Specific injury patterns are associated with BCVI and serve as the trigger for injury screening in asymptomatic patients. Multislice (> 64-slice) computed tomographic angiography is the routine imaging test performed to identify BCVI. Once an injury is identified, antithrombotic treatment almost universally prevents BCVI-related stroke. Endovascular therapy for BCVI is reserved for those patients who are markedly symptomatic or have an enlarging pseudoaneurysm on repeat imaging. Key Words: blunt cerebrovascular injuries, blunt trauma, carotid artery injury, stroke, vertebral artery injury

Blunt Cerebrovascular Injuries

Blunt cerebrovascular injuries (BCVIs) are increasingly recognized in trauma patients, with 1 to 3% of all blunt trauma patients being diagnosed with a carotid artery injury or a vertebral artery injury. Specific injury patterns are associated with BCVI and serve as the trigger for injury screening in asymptomatic patients. Multislice (> 64-slice) computed tomographic angiography is the routine imaging test performed to identify BCVI. Once an injury is identified, antithrombotic treatment almost universally prevents BCVI-related stroke. Endovascular therapy for BCVI is reserved for those patients who are markedly symptomatic or have an enlarging pseudoaneurysm on repeat imaging. Key Words: blunt cerebrovascular injuries, blunt trauma, carotid artery injury, stroke, vertebral artery injury

Incidence of Fat Embolism Syndrome in Femur Fractures and Its Associated Risk Factors over Time—A Systematic Review

Background: Fat embolism (FE) continues to be mentioned as a substantial complication following acute femur fractures. The aim of this systematic review was to test the hypotheses that the incidence of fat embolism syndrome (FES) has decreased since its description and that specific injury patterns predispose to its development. Materials and Methods: Data Sources: MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases were searched for articles from 1 January 1960 to 31 December 2019. Study Selection: Original articles that provide information on the rate of FES, associated femoral injury patterns, and therapeutic and diagnostic recommendations were included. Data Extraction: Two authors independently extracted data using a predesigned form. Statistics: Three different periods were separated based on the diagnostic and treatment changes: Group 1: 1 January 1960–12 December 1979, Group 2: 1 January 1980–1 December 1999, and Group 3: 1 January 2000–31 December 2019, chi-square test, χ2 test for group comparisons of categorical variables, p-value < 0.05. Results: Fifteen articles were included (n = 3095 patients). The incidence of FES decreased over time (Group 1: 7.9%, Group 2: 4.8%, and Group 3: 1.7% (p < 0.001)). FES rate according to injury pattern: unilateral high-energy fractures (2.9%) had a significantly lower FES rate than pathological fractures (3.3%) and bilateral high-energy fractures (4.6%) (p < 0.001). Conclusions: There has been a significant decrease in the incidence of FES over time. The injury pattern impacts the frequency of FES. The diagnostic and therapeutic approach to FES remains highly heterogenic to this day.

New concept: “TARN friendly trauma reporting” (what radiologists say really does matter)

To establish if detailed review of trauma reports with reference to coding manual improved accuracy of ISS and to establish if demonstrated changes in coding affected performance and tariff payment. A study was undertaken which gathered data from 6 months across the five trusts with information on imaging undertaken, mechanism of injury (MOI), Injury Severity Score (ISS), and injury descriptors was included. Patients with ISS near to a best practice tariff boundary of 9 and 16 (5-8 and 11-15) then had their imaging reviewed by the Radiology Department with direct reference to the ISS coding manual. Injuries were then re-coded and ISS recalculated. Over the 6-month period, 1,693 patients were admitted to the database from the five hospitals. One hundred and sixty-nine (9.9%) patients met the inclusion criteria for review. Thirty-five (20.7%) had a change in abbreviated (region specific) injury code, with 30 a change in the resultant ISS. Three had a decrease in ISS and 27 increased ISS with all 27 moving across an ISS best practice tariff and three moving across two payment tariff boundaries. With re-coding, there was a potential £15,000 of lost revenue from the major trauma centre (MTC) alone. Reporting with reference to ISS description improves the accuracy of ISS significantly. Radiologists improving the descriptions of specific injury patterns and adopting 'Trauma Audit and Research Network friendly' reporting strategies may improve data accuracy, performance, and payment of best practice tariffs to hospitals.

Role of the Surgical Pathologist in Diagnosis of Drug-induced Liver Injury: Recognizing Specific Patterns of Drug Injury.

Eighteen histologic patterns of drug-induced liver injury (DILI) are described, most of which are also seen in other commonly occurring acute and chronic liver diseases. However, certain patterns such as sinusoidal obstruction syndrome/veno-occlusive disease, "bland" cholestasis and cholestatic hepatitis are more often caused by drugs than other competing etiologies. Amiodarone, acetaminophen, anabolic androgenic steroids and estrogens, result in histologic patterns that are virtually diagnostic of the respective drug. Recognition of a DILI or drug specific injury pattern enables the clinician to focus on eliciting an appropriate history to identify the offending agent, which may otherwise be rare and not immediately apparent. Although drugs can mimic any and every liver disease, the mimicry is often imperfect. Unusual features that do not completely fit the clinicopathologic paradigm of the mimicked liver disease are clues to diagnosis of DILI. When mimicking a liver disease, drugs tend to hasten or accelerate the natural progression of the disease. Novel immunomodulatory drugs for inflammatory disorders and cancer may cause unintended effects on the immune system, resulting in immune-related side effects. The role of the pathologist in diagnosis of DILI is to recognize known patterns of DILI, and either confirm a diagnosis when clinically suspected, or alert the clinician to the possibility of DILI when it is not suspected. The latter is particularly vital in contemporary practice, which is witnessing an accelerated pace of drug development, and a surge in consumption of nutritional supplements and herbal compounds by an increasingly health conscious society.

Geometrical and Mechanical Characterization of the Abdominal Fold of Obese Post Mortem Human Subjects for Use in Human Body Modelling.

Obese vehicle occupants sustain specific injury patterns in case of accidents in which the interaction between the seat belt and the abdomen may play a role. This study aimed to collect geometrical characteristics and to investigate the mechanical responses of the abdomen of obese subjects. Four Post Mortem Human Subjects (PMHS) with BMI ranging from 31 to 46 kg/m2 were collected. CT-scans performed in the seated position revealed that the antero-posterior depth of the abdominal fold (from the inguinal region to the most anterior point of the abdominal surface) was much greater (170 mm max., 127 mm average) than the thickness of subcutaneous adipose tissues (85 max., 38 mm in average). Each PMHS was subjected to three infra-injurious antero-posterior belt pulls in a seated posture with a lap belt positioned (C1) superior to the umbilicus, (C2) inferior to the umbilicus, (C3) inside the abdominal fold between the abdomen and the thigh. During the C1 and C2 tests, the belt moved cranially, and the abdominal fold opened widely especially in C2. Forces remained below 1800 N, for maximum applied displacements ranging from 89 to 151 mm for C1 and C2, and 37 to 66 mm for C3. Finally, sled tests were conducted on two PMHS seated on a semi-rigid seat and restrained by a three-point belt equipped with pretensioners and a 3.5 kN force limitation at the shoulder. The first PMHS (BMI 39 kg/m2) was tested at 49 km/h (39 g peak) and sustained severe injuries (AIS 4 pelvis dislocation, AIS 3 bilateral femur fractures) attributed to the combined loading of the seat and lap belt force (about 11 kN and 7 kN, respectively). The second PMHS (BMI 46 kg/m2) was subjected to a 29 km/h test (8 g plateau) and sustained no injury. The lap belt slid inside the abdominal fold in the first case and deformed the lower abdomen in the second, providing limited restraint forces during that interaction and leading to a large body excursion for the first test. The results highlight the possible relevance of the abdominal fold at the abdomen thigh junction to model and study the restraint conditions of obese occupants using Human Body Models (HBM).

The Challenge of Managing Patients Suffering from TBI: The Utility of Multiparametric MRI

Traumatic brain injury (TBI) is a complex phenomenon affecting multiple areas of the brain in multiple ways. Both right and left hemispheres are affected as well as supratentorial and infratentorial compartments. These multifocal injuries are caused by many factors including acute mechanical injury, focal intracranial hemorrhage, blunt and rotational forces, epidural and subdural hematoma, hypoxemia, hypotension, edema, axonal damage, neuronal death, gliosis and blood brain barrier disruption. Clinicians and patients benefit by precise information about the neuroanatomical areas that are affected macroscopically, microscopically and biochemically in an individual patient.Standard imaging studies are frequently negative or grossly underestimate the severity of TBI and may exacerbate and prolong patient suffering with an imaging result of "no significant abnormality". Specifically, sophisticated imaging tools have been developed which reveal significant damage to the brain structure including atrophy, MRI spectroscopy showing variations in neuronal metabolite N-acetyl-aspartate, elevations of membrane related Choline, and the glial metabolite myo-inositol is often observed to be increased post injury. In addition, susceptibility weighted imaging (SWI) has been shown to be more reliable for detecting microbleeds versus calcifications.We have selected two TBI patients with diffuse traumatic brain injury.The first patient is a 43-year-old male who suffered severe traumatic brain injury from a motorcycle accident in 2016. Following the accident, the patient was diagnosed with seizures, major depression, and intermittent explosive disorder.He has attempted suicide and has neurobehavioraldisinhibition including severe anger, agitation and irritability.He denies psychiatric history prior to TBI and has negative family history.Following the TBI, he became physically aggressive and assaultive in public with minimal provocation.He denies symptoms of thought disorder and mania. He is negative for symptoms ofcognitive decline or encephalopathy.The second patient is a 49-year-old male who suffered at least 3 concussive blasts in the Army and a parachute injury.Following the last accident, the patient was diagnosed with major depressive disorder, panic disorder, PTSD and generalized anxiety disorder.He denies any psychiatric history prior to TBI including negative family history of psychiatric illness. In addition, he now suffers from nervousness, irritability, anger, emotional lability and concurrent concentration issues, problems completing tasks and alterations in memory.Both patients underwent 1.5T multiparametric MRI using standard T2, FLAIR, DWI and T1 sequences, and specialized sequences including susceptibility weighted (SWAN/SWI), 3D FLAIR, single voxel MRI spectroscopy (MRS), diffusion tensor imaging (DTI), arterial spin labeling perfusion (ASL) and volumetric MRI (NeuroQuant).Importantly, this exam can be performed in 30-45 minutes and requires no injections other than gadolinium in some patients. We will discuss the insights derived from the MRI which detail the injured areas, validate the severity of the brain damage, and provide insight into the psychological, motivational and physical disabilities that afflict these patients. It is our expectation that this kind of imaging study will grow in value as we link specific patterns of injury to specific symptoms and syndromes resulting in more targeted therapies in the future.

High incidence of superficial and deep medial collateral ligament injuries in \u2018isolated\u2019 anterior cruciate ligament ruptures: a long overlooked injury

PurposeIn anterior cruciate ligament (ACL) injuries, concomitant damage to peripheral soft tissues is associated with increased rotatory instability of the knee. The purpose of this study was to investigate the incidence and patterns of medial collateral ligament complex injuries in patients with clinically ‘isolated’ ACL ruptures.MethodsPatients who underwent ACL reconstruction for complete ‘presumed isolated’ ACL rupture between 2015 and 2019 were retrospectively included in this study. Patient’s characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the grade and location of injuries to the superficial MCL (sMCL), dMCL and the posterior oblique ligament (POL) recorded. All patients were clinically assessed under anaesthesia with standard ligament laxity tests.ResultsHundred patients with a mean age of 22.3 ± 4.9 years were included. The incidence of concomitant MCL complex injuries was 67%. sMCL injuries occurred in 62%, dMCL in 31% and POL in 11% with various injury patterns. A dMCL injury was significantly associated with MRI grade II sMCL injuries, medial meniscus ‘ramp’ lesions seen at surgery and bone oedema at the medial femoral condyle (MFC) adjacent to the dMCL attachment site (p < 0.01). Logistic regression analysis identified younger age (OR 1.2, p < 0.05), simultaneous sMCL injury (OR 6.75, p < 0.01) and the presence of bone oedema at the MFC adjacent to the dMCL attachment site (OR 5.54, p < 0.01) as predictive factors for a dMCL injury.ConclusionThe incidence of combined ACL and medial ligament complex injuries is high. Lesions of the dMCL were associated with ramp lesions, MFC bone oedema close to the dMCL attachment, and sMCL injury. Missed AMRI is a risk factor for ACL graft failure from overload and, hence, oedema in the MCL (especially dMCL) demands careful assessment for AMRI, even in the knee lacking excess valgus laxity. This study provides information about specific MCL injury patterns including the dMCL in ACL ruptures and will allow surgeons to initiate individualised treatment.Level of evidenceIII.

Increasing BMI is associated with higher mortality, worsening outcomes and highly specific injury patterns following trauma: A multi-institutional analysis of 191,274 patients.

As the prevalence of obesity has increased, trauma centers are faced with managing this expanding demographics' unique care requirements. Research on the effects of body mass index (BMI) in trauma patients remains conflicting. This study aims to evaluate the impact of BMI on patterns of injury and patient outcomes following trauma. Patients from 87 hospitals' trauma registries were selected. Those missing height, weight, disposition, or who died in the emergency department were excluded. The BMI categories were calculated from admission height and weight and verified against the electronic medical records. Patients were grouped by the National Institutes of Health-defined obesity class and compared by rate of mortality and in-hospital complications. Logistic regression was used to estimate associations, adjusting for age, gender, race, Injury Severity Score, and number of comorbidities. There were 191,274 patients, 53% male; mean age was 60.4 years, mean Glasgow Coma Scale score 14.4, mean Injury Severity Score of 8.8, and 40.4% normal weight. Increased BMI was associated with an injury pattern of increased rates of extremity fractures (humerus, femur, tibia/fibula) and decreased rates of hip fractures and head injuries. Compared with the normal weight group, patients were more likely to die if they were Underweight (adjusted odds ratio [AOR], 1.18; 95% confidence interval [CI], 1.01-1.38), obese class II (AOR, 1.24; 95% CI, 1.07-1.45), or obese class III (AOR, 1.55; 95% CI, 1.29-1.87). Obese class III was associated with higher odds of a National Trauma Data Standard complication (AOR, 1.20; 95% CI, 1.11-1.30). In this large multicenter study, increasing BMI and lower than normal BMI were strongly associated with higher mortality. Increasing BMI was also associated with longer length of stay, increased complications, and unique injury patterns. These untoward outcomes, coupled with a distinct injury pattern, warrant care guidelines specific to trauma patients with higher BMI, as well as those with BMI lower than normal. Epidemiological, Level III.

Anterior glenohumeral instability: Current review with technical pearls and pitfalls of arthroscopic soft-tissue stabilization.

The glenohumeral joint (GHJ) allows for a wide range of motion, but is also particularly vulnerable to episodes of instability. Anterior GHJ instability is especially frequent among young, athletic populations during contact sporting events. Many first time dislocators can be managed non-operatively with a period of immobilization and rehabilitation, however certain patient populations are at higher risk for recurrent instability and may require surgical intervention for adequate stabilization. Determination of the optimal treatment strategy should be made on a case-by-case basis while weighing both patient specific factors and injury patterns (i.e., bone loss). The purpose of this review is to describe the relevant anatomical stabilizers of the GHJ, risk factors for recurrent instability including bony lesions, indications for arthroscopic vs open surgical management, clinical history and physical examination techniques, imaging modalities, and pearls/pitfalls of arthroscopic soft-tissue stabilization for anterior glenohumeral instability.

Injuries and time loss in elite judo athletes: a Korean prospective cohort study.

Few epidemiological studies have investigated pain and time loss due to sports injury. We analyzed the specific patterns of injury among Korean elite judo athletes and examined the effects of pain on time loss. We also assessed the association between the type of injury and time loss. We prospectively collected data on elite judo athletes at the Korean Training Center for the year 2019. The athletes were assessed by sports medicine doctors, and data were stratified according to sex, weight class, and injury location. We used χ2 tests to compare groups. Injury rates were expressed as Poisson rates with 95% confidence intervals. One-way analysis of variance was used to investigate the pain scores and time losses due to sports injury. The study included 232 athletes whose 606 injuries (annual average, 2.61 injuries/athlete) were recorded. Female athletes had higher injury rates than male athletes. Overall, most injuries occurred in the lower extremities (38.12%), followed by the upper extremities (36.80%), trunk (17.66%), and head and neck area (7.43%). Injury severity significantly differed according to the body regions in the weight classes. The pain score and time loss differed significantly according to the type of injury. When the pain score increased by 1, the time loss increased by approximately 1.47 days. Among all weight classes, female athletes had a higher injury rate than male athletes. The pain score and time loss varied depending on the type of injury, with pain score being associated with time loss.

Comparison of Maxillofacial Fractures Between Pedestrians and Passengers in Road Traffic Accidents

Road traffic accidents remain as the most common cause of maxillofacial injuries in developed countries. To the best of our knowledge, comparative analysis of fracture localizations and injury types of injured pedestrians and passengers is seldom performed. Thus, this study aimed to compare maxillofacial injuries between pedestrians and passengers injured in road traffic accidents in terms of demographic characteristics of the patients, localization of fractures, and treatment. The study population was composed of patients who underwent surgery for maxillofacial fractures resulting from road traffic accidents. They were divided into the pedestrian group and passenger group. Demographic data, fracture sites, and treatment methods were investigated retrospectively. Most of the patients were 20 to 30years of age. Isolated mandible fractures occurred in 55.71% of the pedestrian group and 43.78% of the passenger group. Panfacial fractures were observed in 5.71% (n=8) of the patients in the pedestrian group compared with 14.28% (n=21) in the passenger group. Based on the injury pattern and mechanism of in-vehicle accidents, fractures tend to be located in the middle and upper facial bones rather than in the mandible. Thus, careful management in triage is important, as each group has specific injury patterns. Patients with panfacial fractures require meticulous management because they are at risk for high-energy injury and comorbidities.

Clinical examination of partial ruptures of the anterior cruciate ligament: A retrospective case–control study

BackgroundAnterior drawer test, Lachman test including evaluation of the endpoint, and pivot shift test have been commonly applied clinically in diagnosing anterior cruciate ligament (ACL) injury but how they function in the appraisal of partial ACL tears is less known. The aims of this study were to examine the diagnostic values of the commonly used knee function tests on patients in detecting ACL injury including partial injury patterns, to assess each of the test's predictive values on the specific ACL injury pattern, and to assess if using multiple tests collectively for the diagnosis of the injury could improve diagnostic accuracy. MethodsWe evaluated 36 consecutive patients who underwent ACL single bundle augmentation surgery. Those patients were matched by gender and age to 36 patients with a complete rupture of the ACL. Data was obtained from the patients' records. The rupture pattern was confirmed by arthroscopy. An examination under anesthesia was routinely performed by two surgeons who were blinded to the rupture pattern prior to surgery. ResultsCollectively using both Lachman test and pivot shift test increases ability to distinguish between partial tears and complete ruptures. When comparing partial PL tears and complete ruptures the pivot shift test is more important than the Lachman test. In diagnosing a complete rupture, the evaluation of the endpoint during the Lachman test is more sensitive than the evaluation of the anterior tibial translation during the Lachman test. ConclusionBased on the findings of this study, a diagnostic algorithm has been implemented and is presented in this manuscript.

Posterolateral Fractures of the Tibial Plateau Revisited: A Simplified Treatment Algorithm.

High-energy fractures of the proximal tibia with extensive fragmentation of the posterolateral (PL) quadrant of the tibial plateau are challenging to manage. Herein, we present a review of the literature on the patterns and options of approach and fixation of the PL fragment of the tibial plateau to optimize the treatment of this specific injury pattern. We searched PubMed (1980-May 2020) to identify and summarize the most relevant articles evaluating both the morphology and treatment recommendations, including the choice of approach and fixation strategy, for the PL tibial plateau fracture. We found PL fragment can present in several patterns as a pure split, split depression, contained pure depression, and noncontained depression (rim crush), which are mostly determined by the position of the knee and the force magnitude applied during the course of the accident. Based on previous concepts described by Schatzker and Kfuri, we suggest a simplified treatment algorithm highlighting the two concepts (buttressing and containment) used for plating the PL tibial plateau fragments. Based on the available current evidence, we propose an algorithm for these two morphological types of PL tibial plateau fracture. Shear-type fractures need buttressing (the "rule of thumb"), whereas noncontained peripheral rim-type fractures need peripheral repair and containment. Contained pure depression fractures are not frequent and need percutaneous-assisted elevation and subchondral rafting, either controlled by fluoroscopy or arthroscopically. It is believed that such an approach would simplify their assessment and preoperative planning and would assist the clinicians to appreciate and manage more consistently these complex injuries.

Reply: Unnecessary Interfacility Transfers for Craniomaxillofacial Trauma

Sir: We appreciate the auhors’ review of our recent study.1 The question of whether a referring provider is able to diagnose a patient’s traumatic injuries is an important one. We did not address this because it was not the goal of this study. The goal of this study was to identify the problem of secondary overtriage of facial trauma patients. The second phase of our study has been designed to evaluate national perceptions of this problem and whether the craniomaxillofacial surgical community felt there was a need for transfer guidelines. Indeed, the results of this multidisciplinary survey demonstrated that roughly 50 percent of facial trauma surgeons agreed that most emergency transfers for isolated facial trauma at their institutions were unnecessary. Eighty-seven percent of respondents thought that transfer guidelines could help decrease unnecessary transfers, and data regarding which specific injury patterns should be transferred were also collected.2 With regard to the availability of on-call facial traumatologists, the data presented by the authors’ team appear to be regional. Unfortunately, studies have shown that a large percentage of referral centers implicated in secondary overtriage of facial trauma patients have full-time facial trauma coverage.3 This was also the case in our cohort. The long-term goal of our project is not to leave the diagnosis of facial injuries to the nontrauma practitioner; in fact, it is the opposite. Our goal is to educate those practitioners and provide them with tools to diagnose injuries of lesser acuity that may not require emergency systems activation. Education is essential in this effort. The first phase is to define the problem; the second, to quantify the need; and the third, to provide a solution. The third phase of our project, which is underway, uses an assembled panel of expert craniomaxillofacial traumatologists in the fields of ear, nose, and throat; oromaxillofacial; and plastic surgery. We aim to construct transfer guidelines similar to those put forth by the American Burn Association for referral to a regional burn center. The guidelines will be written for use by all providers, including those with little facial trauma experience. Using data collected from our second study2 and consensus collected in our third stage (using the modified Delphi method), our guidelines will define exactly which facial skeletal and soft-tissue injuries should be transferred. We agree that a patient with an unclear diagnosis should be transferred to a higher level of care. It is well documented that isolated facial trauma is implicated in secondary overtriage,2–6 and we, alongside facial trauma providers from different specialties across the nation, believe that there is room to improve the management of these patients. Our goal remains to refine the transfer process for facial trauma patients while minimizing the potential untoward consequence of secondary undertriage. Unfortunately, a small percentage of secondary undertriage is a necessary tradeoff for a reduction in substantial secondary overtriage, and a proper balance of undertriage and overtriage is paramount. Such a large percentage of unnecessary transfers carry far worse ramifications to the patient and the health care system than does the rare undertriage event. We thank the authors for their thoughtful commentary. DISCLOSURE The authors have no relevant financial disclosures related to the content of this communication.

Sports Specific Injury Pattern of Sportspersons

Objective: Previous researches on sports injuries primarily focused on specific games or sports or on specific types of injuries. None of them had tried to explore the injury patterns of games and sports altogether. The current study tried to explore the injury patterns of sportspersons over 16 different types of games and sports. Materials and methods: Total of 1008 injury cases (649 male and 369 female, age 21.07±2.78 and 20.81± 3.01 years) between the academic sessions 2008 to 2017 were analysed. Injury data were extracted from the institute injury record book. Apart from age and gender, 'Body site of injury', 'Types of injury' and 'Recurring of injury' were selected as variables for the study. Descriptive statistics, bar and pie diagram were generated using crosstabs function of IBM SPSS. Results: An average 101.80±12.59 injury was reported per year. Footballers were found to be the highest injured sportsperson (19.5%). Injury percentage of male players (63.75%) was higher compared to female (36.25%) counterparts. Lower limb area (45.28%) was found to be the highest affected body site of injury followed by upper limb area (29.47%). Acute injury constituted 50.39% of overall injuries. Most injuries were non-recurring in nature (63.65%). Further different combinations of analysis revealed more insight of injury patterns of sportspersons.