Tertiary Trauma Center Research Articles

Incidence of thoracic trauma in tertiary level trauma centre, Northeast India

Incidence of thoracic trauma in tertiary level trauma centre, Northeast India

Epidemiology of missed orthopaedic injuries in adult trauma patients at a rural tertiary trauma centre

Introduction: Missed injuries is defined as an injury found after the initial complete patient assessment and diagnostic studies that was directly related to the traumatic event and was identified after first 24 hours following admission. Missed injuries increase the risk of death, result in significant long-term disability, are a common reason for litigation and embarrassment to the surgeon and institution. Materials and Methods: This is a prospective study of 671 admissions in Orthopaedics indoor patients of Adichunchanagiri Institute of Medical Sciences for the period of 10 months from 1st January 2016 to 31st October 2016. The patient notes and radiology reports was reviewed daily while each patient was an inpatient up to the end-point of discharge from hospital. Results: 18 patients out of 671 patients were identified with delayed diagnoses of the injury. Incidence rate of missed injury was 2.68%. The different parameters that were considered for this study are sex of patient, age, mechanism of injury, whether patient was under the influence of alcohol, GCS

Role of Provisional Fixation of Fracture Fragments By Steinmann-Pin and Technical Tips in Proximal Femoral Nailing for Intertrochanteric Fracture

Proximal Femoral Nailing (PFN) in Intertrochanteric Fractures (IF) is becoming the choice of implant due to better biomechanics and prevention of varus collapse associated with Dynamic Hip Screw (DHS). Technical difficulties and implant related complications are yet to be addressed. To understand the technical difficulties involved in PFN and role of provisional fixation of fracture by Steinmann-pin. In this study, 55 patients presented to a tertiary trauma center in India with trochanteric fractures from April 2010 to March 2012 were included and treated with PFN. All patients were followed-up for two years and final outcome assessment included shortening, neck shaft angle and Harris Hip Score was done. In all except one, neck shaft angle greater than 130° was achieved and also maintained in the final follow up (Mean 131.1°). All fractures were united with mean shortening of 3.6 mm and average Harris Hip Score of 91 after two years. There were five complications which included one shortening, two varus collapses, one backed out screws and one reverse Z effect. Though PFN is technically challenging, with proper technique, gives excellent results with negligible varus collapse even in unstable fractures. Three most important technical aspects are achieving good non-varus reduction, inserting nail correctly and accurate placement of lag screws. The technique of provisional fixation of fracture fragments by Steinmann-pin significantly helps in achieving these and reduces the risk of implant failure.

Use of bioresorbable implants for orbital fracture reconstruction

PurposeBioresorbable implants offer several advantages over permanent implants and serve as a useful alternative in the reconstruction of orbital fractures. Our aim of the study was to evaluate the clinical...

Fibrinogen in the initial resuscitation of severe trauma (FiiRST): a randomized feasibility trial

BackgroundDecreased plasma fibrinogen concentration shortly after injury is associated with higher blood transfusion needs and mortality. In North America and the UK, cryoprecipitate transfusion is the standard-of-care for fibrinogen supplementation during acute haemorrhage, which often occurs late during trauma resuscitation. Alternatively, fibrinogen concentrate (FC) can be beneficial in trauma resuscitation. However, the feasibility of its early infusion, efficacy and safety remain undetermined. The objective of this trial was to evaluate the feasibility, effect on clinical and laboratory outcomes and complications of early infusion of FC in trauma. MethodsFifty hypotensive (systolic arterial pressure ≤100 mm Hg) adult patients requiring blood transfusion were randomly assigned to either 6 g of FC or placebo, between Oct 2014 and Nov 2015 at a tertiary trauma centre. The primary outcome, feasibility, was assessed by the proportion of patients receiving the intervention (FC or placebo) within one h of hospital arrival. Plasma fibrinogen concentration was measured, and 28-day mortality and incidence of thromboembolic events were assessed. ResultsOverall, 96% (43/45) [95% CI 86–99%] of patients received the intervention within one h; 95% and 96% in the FC and placebo groups, respectively (P=1.00). Plasma fibrinogen concentrations remained higher in the FC group up to 12 h after admission with the largest difference at three h (2.9 mg dL − 1 vs. 1.8 mg dL − 1; P<0.01). The 28-day mortality and thromboembolic complications were similar between groups. ConclusionsEarly infusion of FC is feasible and increases plasma fibrinogen concentration during trauma resuscitation. Larger trials are justified.

The Clinical Value of Intraoperative Mobile Computed Tomography in Managing High-Risk Surgical Patients with Traumatic Brain Injury–A Single Tertiary Trauma Center Experience

A subset of surgically treated patients with traumatic brain injury (TBI) cannot be stabilized by initial surgery. Mobile computed tomography (CT) provides real-time information for diagnosis in these TBI surgically high-risk (TBI-SHR) patients. The objective of this study was to analyze a 5-year series of TBI-SHR patients to evaluate the impact of intraoperative mobile CT (imCT) on prognosis. Of 1017 surgically treated patients with TBI retrospectively reviewed over a 5-year period (2009-2013), 59 patients required second operations within 72 hours of their initial surgery because of progressive or delayed hematomas (TBI-SHR group). Their clinical, radiographic, and intraoperative findings were compared among 19 patients who received imCT versus 40 patients who received fixed-unit CT. Our TBI-SHR group accounted for 5.8% of all surgically treated patients with TBI. The use of imCT led to a change in surgical plan in 56% of patients with TBI intraoperatively. Younger patients (≤55 years; P < 0.05) with multifocal hemorrhage on preoperative CT (P= 0.033) and with an intraoperative unexpected event such as intraoperative intracranial pressure >20 mm Hg or acute brain swelling after adequate decompression (P= 0.003 and 0.004, respectively) significantly benefited from imCT in the TBI-SHR group. imCT also provided a quicker diagnosis (P< 0.001), led to a trend toward shorter intensive care unit stays (P= 0.077), and was associated with better neurologic outcomes at discharge days (P= 0.044). The use of imCT is associated with better neurologic outcomes at discharge days compared with the use of fixed-unit CT in TBI-SHR patients.

323 Virtual Reality Simulation Can Help Prepare Emergency Physicians for REBOA

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is emerging as a bridge to hemostasis in patients with exsanguinating hemorrhage below the diaphragm, as well as a means to increase cerebral and coronary perfusion in patients arriving in arrest. This procedure is currently used in a small number of tertiary trauma centers by acute care surgeons (ACS) in the United States, and internationally by emergency medicine (EM) providers both in the ED and in the field. Virtual Reality Simulation (VRS) is a well-established means of endovascular skills training for REBOA. We hypothesize that EM providers can learn the concepts and skill required for REBOA using VRS. EM trainees in ACGME-approved critical care fellowships at one institution received didactic and instructional sessions on REBOA. The subjects performed the procedure 6 times. Subjects were excluded if they had taken a similar endovascular training course or had performed the procedure in the clinical setting. Performance metrics were measured on a Likert scale, and included procedural time; accurate placement of guide wire, sheath, and balloon; correct sequence of steps; economy of motion; and safe use of endovascular tools. A pre- and post-course test and questionnaire were completed by each subject. Analysis included simple linear regression and the Student’s t test. A p-value below 0.05 was considered statistically significant. Ten subjects, with a mean PGY level of 4.6 years (SD±0.5) participated in the study. No correlation with task times was observed with any confounder studied including previous endovascular training or experience, number of central and arterial lines placed recently, or number of intra-aortic balloon pumps placed in training. Procedural task times improved from a mean of 218±19 to 106±15 seconds with a mean difference of 112 seconds, indicating the task time improvement from Trial 1 to Trial 6 was significantly different from 0 (p < 0.001). There was significant improvement in comprehension and knowledge between the pre-test and post-test, as their average performance improved from 74.3 ± 13.6% to 96.4 ± 5.0% (p<0.001). Significant improvements in procedural time and knowledge can be achieved by emergency physicians based on VRS. Advances in technology will decrease the tools and steps required for REBOA, and ultimately decrease the time to occlusion for all providers. Despite these encouraging results and regardless of advances in equipment, successful REBOA utilization will be contingent on patient selection and common femoral artery access which may not be possible without operative exposure. These areas should become a focus of further training.

Extracorporeal Life Support in Multiple Trauma Patients with Refractory Cardiopulmonary Failure: Predictors of Procedural Suitability and Success Rate

Background: Major trauma is a leading cause of death, particularly amongst young patients. New strategies in management are needed to improve the poor outcome of severe trauma. We report our initial experience with extracorporeal life support (ECLS) as a rescue therapy in severe multiple trauma patients with refractory cardiopulmonary failure. Objectives: The purpose of this study was to identify the pre-ECLS patient characteristics predicting appropriateness ECLS treatment. Methods: From December 2008 to May 2013, 420 multiple trauma patients were treated at our tertiary level referral trauma center. Our ECLS team was alerted on 35 and applied ECLS in 20 adult trauma patients. In 16 patients with cardiopulmonary failure with refractory shock, we adopted a veno-arterial ECLS; in 4 patients with isolated refractory acute respiratory failure, we used venovenous ECLS. Results: ECLS was initiated at a mean of 324.15 ± 197.8 (110 - 950) min from initial trauma. In 4 patients, ECLS treatment failed due to an incapability to maintain adequate ECLS flow and patient perfusion. In the other 16 patients efficiently supported by ECLS, the Cardiac Index, mean arterial pressure, lactate concentration, PaO2, PaCO2, and pH showed significant improvement with normal values reached at 3.2 ± 1.5 hours. Seven (43.7%) patients in the ECLS-Success Group donated organs, 2 patients (22.2%) died due to septic multi organ failure (MOF), and 7 (77.7%) patients were discharged from the hospital. ECLS was suitable and successful in patients with a significantly lower injury severity score, lower blood lactate level, lower number of blood units given, and significantly higher pH and Hb. Conclusions: From our data, ECLS seems to be a valuable option to resuscitate severe trauma patients when conventional therapies are insufficient: it is safe, feasible and effective in providing hemodynamic support and blood gas exchange. Our data permitted us to identify strong predictors of ECLS non-suitability and success in multiple trauma patients; these might be helpful in deciding whether ECLS should be used or not. Future improvements in materials and techniques are expected to make ECLS even easier and safer to manage, leading to a further extension of its use in disastrously injured patients

Emergency thoracotomy: Experience of one year in a large tertiary trauma center

IntroductionEmergency thoracotomy (ET) can be a life-saving procedure in highly selected trauma patients, especially after penetrating chest trauma. The aim of this work was to evaluate the outcome in trauma patients who were admitted to the Alexandria Main University Hospital (AMUH) during 1 year period and underwent ET as a management and to compare our results with that documented in the literature. Patients and methodsThis is prospective clinical study included trauma patients who were admitted to AMUH during 1 year period (August 2013–August 2014) and underwent ET. Analysis of the cause of trauma, age, sex, different tools of investigations used, concomitant organ injuries, systolic blood pressure (SBP), Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Trauma Revised Injury Severity Score (TRISS) and mortality rate were performed. ResultsTwenty-two patients who had ET were included in this study (All were males, Age range: 5–45 years; median: 23.5 ± 7.83 years). Twenty patients from twenty-two were survived. Two of them had blunt trauma while 18 had penetrating injuries. The most frequent injury encountered was isolated thoracic injury (n=13). Thoracotomy was performed in 20 patients, sternotomy in two, and one patient underwent additional laparotomy. Median ISS and TRISS were 10 (Range 9–29) and 0.98 (Range 0.54–0.99), respectively. Blood transfusion ranged between 1 and 13 units with a median of 2 units of packed red blood cells. The median time from admission to operating room was 37.50 min. Pre-operative (FAST & Thoracic Ultrasound) was done in 90.9% of patients. Most common indication for thoracotomy was shock (SBP < 90). The mortality rate was 9.1% for all patients and 10% for patients with penetrating trauma. Factors affecting mortality was ISS and the amount of blood transfusion. ConclusionET procedure is an important tool in management of selected trauma patients. Rapid assessment, multidisciplinary approach, good resuscitation and prompt surgical intervention reduce the mortality and improve the outcome.

Patterns of injury mechanism at a tertiary trauma center in Mumbai, India: Opportunities for injury prevention

ABSTRACTThis study aims to describe patterns of injury mechanism among patients treated at a tertiary trauma center in Mumbai to identify opportunities for targeted injury prevention strategies. Data were collected from an institutional trauma registry, and all patients presenting with life- or limb-threatening injuries over a 16- month period were included. Univariate and bivariate analyses were performed for demographic characteristics, injury mechanisms, and clinical outcomes. A total of 1,115 patients were treated during the study period, and the in-hospital mortality rate was 32% in this severely injured cohort. More than one half of patients were suffered transportation injuries (58%). Of victims of transportation injuries, 45% were victims of railway injuries and 28% were pedestrians struck by motor vehicles. Mortality was highest among victims of railway injuries (42%) and pedestrians struck by automobiles (38%). Although injury prevention is a major public health concern worldwide, it is important to understand local patterns of injury to guide targeted prevention strategies. This study highlights the utility of trauma registries in collecting crucial injury surveillance data. In this context, a focus on pedestrian safety and railway injury prevention is warranted.

Factors associated with receiving anti-osteoporosis treatment among older persons with minimal trauma hip fracture presenting to an acute orthogeriatric service

Background/AimThe aim of this study was to investigate factors that were associated with receiving anti-osteoporosis treatment (AOT) among patients with minimal trauma hip fracture admitted to an Australian tertiary trauma centre under the Acute Orthogeriatric Service (AOS) over a 6 month period. DesignObservational study using prospectively collected data. MethodsDemographic and clinical characteristics of 211 patients were extracted from the local hip fracture registry and electronic medical records. The outcome measure was receipt of AOT before separation from the AOS. Binary logistic regression was used to identify factors independently associated with treatment. Results91 (45%) patients received AOT, including 51 (25.2%) treatment-naive patients. Factors significantly associated with receiving treatment included higher serum vitamin D level (OR 1.44, 95% CI 1.23–1.70, p<0.001) and trochanteric vs. cervical fracture (OR 2.67, 95% CI 1.30–5.49, p=0.007). Living in a residential aged care facility (RACF) prior to the index fracture (OR 0.2, 95% CI 0.08–0.54, p=0.001) and higher American Society of Anaesthesiologists (ASA) physical status score (OR 0.5, 95% CI 0.25–0.98, p=0.04) significantly lowered the likelihood of treatment. Age, gender, cognitive impairment, premorbid walking ability, previous fragility fracture and renal impairment did not correlate with treatment. ConclusionA significant proportion (55%) of hip fracture patients did not receive AOT in hospital. The probability of receiving treatment appears to be significantly associated with serum vitamin D level, fracture type, place of residence and comorbidity burden.

Discharge Against Medical Advice in Traumatic Brain Injury: Follow-Up and Readmission Rate.

Patients who leave hospital against medical advice (AMA) may be at risk of adverse health outcomes, medical complications, and readmission. In this study, we examined the characteristics of patients who left AMA after traumatic brain injury (TBI), their rates of follow-up visits, and readmission. We retrospectively studied 106 consecutive patients who left the tertiary trauma center AMA (1.8% of all admitted patients with a TBI). Preinjury health and social issues, mechanism of injury, computed tomography findings, and injury markers were collected. They were correlated to compliance with follow-up visits and unplanned emergency room (ER) visits and readmission rates. The most prevalent premorbid health or social-related issues were alcohol abuse (33%) and assault as a mechanism of trauma (33%). Only 15 (14.2%) subjects came to follow-up visit for their TBI. Sixteen (15.1%) of the 106 subjects had multiple readmissions and/or ER visits related to substance abuse. Seven (6.6%) had multiple readmissions or ER visits with psychiatric reasons. Those patients with multiple readmissions and ER visits showed in higher proportion preexisting neurological condition (p=0.027), homelessness (p=0.012), previous neurosurgery (p=0.014), preexisting encephalomalacia (p=0.011), and had a higher ISS score (p=0.014) than those who were not readmitted multiple times. The significantly increased risks of multiple follow-up visits and readmission among TBI patients who leave hospital AMA are related to a premorbid vulnerability and psychosocial issues. Clinicians should target AMA TBI patients with premorbid vulnerability for discharge transition interventions.

Post traumatic bone defects treated with induced biomembrane technique in a tertiary care trauma centre - technique, results in 6 patients and a review of literature

Post traumatic bone defects treated with induced biomembrane technique in a tertiary care trauma centre - technique, results in 6 patients and a review of literature

Outcome of locking plate fixation for proximal humerus fractures

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The objective of the study was to evaluate functional outcome of open reduction and internal fixation with proximal humeral internal locking system (PHILOS) plate for proximal humerus fractures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Methods:&lt;/span&gt;&lt;/strong&gt;&lt;span lang="EN-US"&gt; We reviewed 30 patients who underwent open reduction and internal fixation with PHILOS plate between the years 2010 to 2015. There were 23 men and7 women with a mean age of 36 years (range 20-64).There were 22 patients in the age group of &amp;lt;60 years and 8 patients in the age group of &amp;gt;60 years. According to Neer classification system, 12, 11 and 4 patients had2-part, 3-part, and 4-part fractures, respectively and 2 patients had 4-part fracture dislocation. All surgeries were carried out at our tertiary care trauma center. Functional evaluation of the shoulder at final follow-up was done using Neer’s Evaluation Criteria.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Results:&lt;/span&gt;&lt;/strong&gt;&lt;span lang="EN-US"&gt; The mean follow-up period was 20 months (range 14-40 months). All fractures united clinically and radio logically. The mean time for radiological union was 13.2 weeks (range 9-26 weeks).At the final follow-up the mean Neer’s Evaluation Criteria was 90 (range 76-100). The results were excellent in 17patients, Satisfactory in 8 patients, Unsatisfactory in 4 patients and Failure in 1 patient. During the follow-up, 3 cases of varus malunion, 1 case of failure of fixation were noted. No cases of AVN, hardware failure, locking screw loosening, infection or nonunion were noted.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Conclusions:&lt;/span&gt;&lt;/strong&gt;&lt;span lang="EN-US"&gt; PHILOS provides stable fixation in proximal humerus fractures. In order to prevent the complications like avascular necrosis, knowledge of anatomy and vascular supply of head of humerus and good surgical dissection to preserve vascularity of humeral head is important.&lt;/span&gt;&lt;/p&gt;

Factors Associated with the Use of Helicopter Inter-facility Transport of Trauma Patients to Tertiary Trauma Centers within an Organized Rural Trauma System

Objective: A review of the literature yielded little information regarding factors associated with the decision to use ground (GEMS) or helicopter (HEMS) emergency medical services for trauma patients transferred inter-facility. Furthermore, studies evaluating the impact of inter-facility transport mode on mortality have reported mixed findings. Since HEMS transport is generally reserved for more severely injured patients, this introduces indication bias, which may explain the mixed findings. Our objective was to identify factors at referring non-tertiary trauma centers (NTC) influencing transport mode decision. Methods: This was a case-control study of trauma patients transferred from a Level III or IV NTC to a tertiary trauma center (TTC) within 24-hours reported to the Oklahoma State Trauma Registry between 2005 and 2012. Multivariable logistic regression was used to determine clinical and non-clinical factors associated with the decision to use HEMS. Results: A total of 7380 patients met the study eligibility. Of these, 2803(38%) were transported inter-facility by HEMS. Penetrating injury, prehospital EMS transport, severe torso injury, hypovolemic shock, and TBI were significant predictors (p<0.05) of HEMS use regardless of distance to a TTC. Association between HEMS use and male gender, Level IV NTC, and local ground EMS resources varied by distance from the TTC. Many HEMS transported patients had minor injuries and normal vital signs. Conclusions: Our results suggest that while distance remains the most influential factor associated with HEMS use, significant differences exist in clinical and non-clinical factors between patients transported by HEMS versus GEMS. To ensure comparability of study groups, studies evaluating outcome differences between HEMS and GEMS should take factors determining transport mode into account. The findings will be used to develop propensity scores to balance baseline risk between GEMS and HEMS patients for use in subsequent studies of outcomes.

Success of free flap anastomoses performed within the zone of trauma in acute lower limb reconstruction

Traditionally, in free flap cover of lower limb injuries, every attempt is made to perform anastomoses proximal to the zone of injury. We report on the success of anastomoses within the zone of trauma, at the level of the fracture, avoiding further dissection and exposure. The records of free flap reconstructions for fractures of the lower extremity at a tertiary trauma centre between 2004 and 2010 were retrospectively reviewed. A total of 48 lower limb fractures required free flap reconstruction, performed at 28 days post injury (0-275 days). Anastomoses were proximal (21), distal (5) or within the zone of trauma (22). There was no significant difference (p>0.05) in return to theatre, revision of anastomosis or flap survival between groups. Of the 22 performed within the zone of injury, five returned to theatre but only two for revision of anastomosis and 20 (91%) of these flaps survived. Of the 48 free flaps, arterial anastomoses were end to end in 34 (71%) and end to side in 14 (30%). There was no significant difference (p>0.05) in return to theatre, revision of anastomosis or flap survival between the end-to-end and end-to-side groups. There was a tendency for arterial anastomoses to be performed end to end outside the zone of trauma (23/26) compared to within the zone of trauma (11/22). Our data suggest that free flap anastomoses can be performed safely in the zone of trauma in lower limb injuries.

Axillary Artery Injury Associated with Proximal Humeral Fractures: Review of Long-Term Vascular, Orthopedic, and Neurologic Outcomes

Fracture and dislocation of the proximal humerus is common. It is associated with a number of vascular, neurologic, and orthopedic complications; these include brachial plexopathy and avascular necrosis (AVN) of the humeral head. These complications are rare but can potentially cause severe disability to patients; however, they remain poorly described in the literature. To describe vascular, orthopedic, and neurologic outcomes after axillary artery repair, in patients with proximal humeral fractures or dislocations. We conducted a retrospective review of patients admitted to 2 tertiary trauma centers in Victoria, Australia, with fracture or dislocation of the proximal humerus and associated axillary artery injury. Patients were selected according to guidelines for trauma call or alert and the presence of high-risk mechanism of injury. Data on vascular, orthopedic, and neurologic complications were collected. Twenty-one patients were identified. Injury to the first part of the axillary artery was noted in 11 patients (52%). Brachial plexus exploration was performed in 17 patients (81%). Four patients (19%) underwent nerve repair. Long-term neurologic recovery was universally poor. Major orthopedic complications included AVN of the humeral head, delayed union, and the need for prosthesis or arthrodesis. Eleven patients (52%) received upper limb fasciotomy. Five patients (24%) underwent delayed secondary upper limb amputation. There was an unusually high rate of injuries to the first part of the axillary artery. Close clinical observation is recommended for such patients. AVN of the humeral head and brachial plexopathy remain significant and debilitating complications.

The functional outcome of blow-out fractures managed surgically and conservatively: our experience in 100 patients.

The proportion of orbital blow-out fractures (BOFs) which are operated upon varies. The purpose of this study was to determine the treatment pattern of BOFs at our tertiary trauma centre and to evaluate the functional outcomes in patients according to whether they were managed surgically or conservatively. The study design is a retrospective cohort study and the setting is Tertiary care University Hospital. The participants include patients with isolated BOFs admitted to our Trauma Unit from 2010 to 2013. Of the 100 consecutive patients included, 60 had available follow-up data. The presence of diplopia and enophthalmus was determined by reviewing the medical records. Data from the patients' initial consultation and their 3-month follow-up were also collected. Of the 60 patients whose data could be analysed, 36 had been managed surgically and 24 conservatively. Of the patients managed surgically, 25 had diplopia in peripheral gaze before surgery and 12 at 3-month follow-up. Nine had diplopia in primary gaze before surgery and none at 3-month follow-up. Five had enophthalmus before surgery and two at 3-month follow-up. Of the patients managed conservatively, eight had diplopia in peripheral gaze initially and seven at 3-month follow-up. Three had diplopia in primary gaze initially and one at 3-month follow-up. One had enophthalmus initially which was still present at 3-month follow-up. Primary gaze diplopia disappeared while secondary gaze diplopia was present in about a third of patients, whether managed surgically or conservatively at the 3-month follow-up. Standardised follow-up as well as clear indications for and against surgery are warranted.

To compare the outcome of intramedullary nailing and locking compression plate fixation in treatment of proximal one third tibia fracture: A randomized control trial

Background: Fractures of tibia shaft are most common of long bone fractures. Proximal tibia fractures account for approximately 5% to 11% of all tibial injuries and affect knee function and stability in most of the cases. Higher rates of malunion and increased incidence of associated complications have made these fractures particularly problematic. In recent years due to advancement in technique, proximal tibia plating and multidirectional locked intramedullary nailing, both have become widely used treatment modalities for proximal tibial metaphyseal fractures. This study was performed to compare plating and nailing options in proximal tibia extra-articular fractures. Materials and methods: This randomized prospective clinical study was conducted on 62 skeletally mature patients with closed extra-articular fracture of the proximal tibia treated with proximal tibial locking compression plating (PTLCP) or intramedullary nailing (IMN) by expert surgeons at a tertiary trauma center. Results: Postoperative hospital stay (p = 0.043), postoperative infection rate (p = 0.036) were significantly high in the PTLCP group than in the IMN group, while rate of malunion (p=0.041) and nonunion(0.037) were significantly high in IMN group than in PTLCP group. However there was no clear advantage of either technique in terms of functional recovery of knee. Conclusion: Present comparison of IMN and PTLCP for the treatment of proximal one third tibia fracture showed no clear advantage of either technique. Present study concluded that both forms of treatment (IMN and PTLCP) provide adequate fracture stability. Level of evidence: Level 2, randomized controlled trial.

Presenting characteristics of children who required neurosurgical intervention for head injury.

The purpose of this study is to describe the presenting characteristics of a large group of children who required neurosurgical intervention (NSI) following a head injury and to retrospectively assess which of the criteria for imaging from Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), Pediatric Emergency Care Applied Research Network (PECARN), and Canadian Assessment of Tomography for Childhood Head Injury (CATCH) clinical decision rules (CDRs) were met by these patients. We retrospectively reviewed all patients undergoing NSI following a head injury, between 2000 and 2008, at a large tertiary pediatric trauma center. We excluded patients having non-accidental injury, other neurosurgical interventions, penetrating injuries, and patients with incomplete data. To those who presented initially with mild head injury (GCS 14-15), we retrospectively applied the criteria for imaging of the CHALICE, PECARN, and CATCH CDRs. Out of 289 patients undergoing NSI, 182 met inclusion criteria and comprised our cohort. Of the 72 (39.6%) with mild head injury (GCS 14-15), 71 (98.6%) met at least one criteria for imaging from each of the three CDRs, including severe mechanism of injury (68, 94.4%), clinically evident skull fracture (35, 48.6%), neurological deficit (19, 26.3%), or severe headache (6, 8.3%). Of the 182 patients in the entire cohort, only 1 (0.5%) did not present with an obvious indication for CT on all three CDRs. In a large sample of children requiring NSI after head trauma, the vast majority met CT criteria listed in each of the three CDRs. The most common indication for CT was a severe mechanism of injury. This, combined with clinically evident skull fracture, neurological deficit, and severe headache, identifies almost all patients requiring NSI.