Injury. 2025 Aug 8:112677. doi: 10.1016/j.injury.2025.112677. Online ahead of print.

ABSTRACT

BACKGROUND: Vestibular dysfunction (resulting in dizziness and imbalance) is common in acute traumatic brain injury (aTBI). The most frequently diagnosed cause of peripheral vestibular dysfunction in aTBI is benign paroxysmal positional vertigo (BPPV). However, post-traumatic BPPV is often undiagnosed and left untreated in these patients.

OBJECTIVES: To investigate clinical risk factors for BPPV in patients experiencing aTBI.

METHODS: Patients were recruited from three Major Trauma Centres in London. Logistic regression was used to derive the adjusted odds ratio (aOR) of diagnosed BPPV for sex, categorised age, severity of traumatic brain injury (TBI), and site of skull fracture.

RESULTS: 166 patients with aTBI were included. Approximately a third (n = 55; 33.1 %) tested positive for BPPV. Compared to patients aged less than or equal to 40 years, those aged 41 to 64 years were more likely to experience BPPV (aOR=3.86; 95 % CI: 1.47 to 10.16; p = 0.006), as were those aged 65 years and above (4.41; 1.52 to 12.81; p = 0.006). Patients that experienced both facial and cranial skull fracture were more likely to experience BPPV than those that didn't have a skull fracture (23.64; 6.36 to 87.89; p < 0.001).

CONCLUSION: The risk of post-traumatic BPPV increased with increasing age, plus in those with combined skull and facial fractures when compared to those without a skull fracture. We advocate routine BPPV screening of those with aTBI, especially in older adults and those with combined facial and skull fractures.

PMID:40885629 | DOI:10.1016/j.injury.2025.112677

Injury. 2025 Aug 25;56(11):112722. doi: 10.1016/j.injury.2025.112722. Online ahead of print.

ABSTRACT

Percutaneous fixation of certain types of acetabular fractures is a valid, minimally invasive, and successful procedure. However, the technique for proper insertion of such screws is sensitive and requires adequate understanding of radiographic images. Furthermore, an optimum entry point and trajectory of the screws should be guaranteed to avoid hip joint penetration and screws misplacement. Various tools and techniques were described; we provide a technical note describing a modification on the tip of the cannulated screwdriver where serrations were added, which helped in better stability over the bone while inserting the guidewires for screws insertion, besides protecting the soft tissue envelope, especially in obese patients. We presented two early cases, one with a pure anterior column fracture and the other with a combined anterior column fracture and disruption of the sacroiliac joint on the same side, where we used the technique we described to ease percutaneous insertion of an anterior column screw for acetabular fracture fixation.

PMID:40885165 | DOI:10.1016/j.injury.2025.112722

Injury. 2025 Aug 25;56(11):112726. doi: 10.1016/j.injury.2025.112726. Online ahead of print.

ABSTRACT

INTRODUCTION: Faster time to operative fixation and mobilization decreases morbidity and mortality for hip fracture patients. Many hospitals are working at or above their capacity and beds in surgical floors for surgical patients may not be available. The purpose of this study was to determine if the floor of admission after a hip fracture impacts time to surgical fixation and time to mobilization after surgery.

METHODS: 781 patients over the age of 50 who underwent hip fracture surgery between January 2011 and January 2021 were included in this analysis. Patient demographics, injury characteristics and floor of admission were collected and analyzed. Time of diagnosis was defined as the time of the initial presenting radiograph, and time of mobilization was defined as the time the patient stood at edge of bed with physical therapy. Floor of admission is determined based on admitting service (medicine, orthopaedics, trauma surgery) as well as bed availability. Floors were considered surgical or non-surgical based on standard patient populations.

RESULTS: Time to surgery from diagnosis was significantly longer on nonsurgical floors (28 vs. 22 hours p = 0.003). Time from surgery to mobilization out of bed was significantly shorter for patients on surgical floors (53 vs. 63 hours, p = 0.01). There was no difference in time to evaluation by physical therapy (p = 0.8). Time from diagnosis to surgery and time from surgery to injury was not different across patient races or language spoken.

CONCLUSIONS: Patients admitted to non-surgical floors had a significantly longer time to surgery as well as longer time to mobilization compared to patients who were admitted to surgical floors. Time to physical therapy evaluation following surgery was the same, suggesting different factors such as medical comorbidities, staff training, and resource availability likely contribute to the significant difference in time to mobilization. Race and language did not play a role in delaying time to the operating room or mobilization with physical therapy.

PMID:40885164 | DOI:10.1016/j.injury.2025.112726

Injury. 2025 Aug 23;56(11):112689. doi: 10.1016/j.injury.2025.112689. Online ahead of print.

ABSTRACT

BACKGROUND: Humeral shaft fractures treated surgically have a 5-10 % risk of nonunion. NSAIDs, including ketorolac, are frequently prescribed postoperatively for pain management, but concerns persist regarding their effects on bone healing. Although prior studies suggest a potential association between ketorolac and nonunion, findings remain inconclusive. This study aims to assess the impact of ketorolac on nonunion risk in adults undergoing surgical treatment for humeral shaft fractures.

METHODS: The TriNetX Research Database was queried using ICD and CPT codes to identify patients who underwent operative fixation of humeral shaft fractures with a minimum of 2 years of follow-up. Exclusion criteria included prior humeral shaft nonunion, pathologic fractures, and age under 18. Patients were divided into two cohorts based on whether they received ketorolac within 1 month postoperatively. Outcomes included nonunion diagnosis, nonunion surgery, opioid utilization, wound complications, superficial infection, deep infection, and hardware infection. Outcomes were analyzed at 30 days, 90 days, 1 year, 2 years, and final follow-up.

RESULTS: There was no significant difference in opioid utilization within 30 days postoperatively (HR 1.051, 95 % CI 0.987-1.118, p = 0.073; prescriptions 3.2 ± 4.9 vs. 3.2 ± 5.0, p = 0.721). However, at 1-year, 2-year, and overall follow-up, patients receiving ketorolac demonstrated a significantly increased risk of nonunion surgery. At final follow-up (2.9 ± 2.8 years vs. 3.4 ± 3.5 years), nonunion incidence was not significantly different (4.7 % vs. 4.2 %, p = 0.317), but ketorolac use was associated with a 45.1 % increased risk of nonunion surgery (95 % CI 1.050-2.006, p = 0.023).

CONCLUSION: Ketorolac use was associated with approximately 40 % increased risk of nonunion surgery without reducing postoperative opioid use. Further research is warranted to evaluate the perioperative administration of ketorolac and other NSAIDs in humeral shaft fractures.

LEVEL OF EVIDENCE: Level III Retrospective Cohort Comparison Using Large Database Prognosis Study.

PMID:40885163 | DOI:10.1016/j.injury.2025.112689

Injury. 2025 Aug 16;56(11):112683. doi: 10.1016/j.injury.2025.112683. Online ahead of print.

ABSTRACT

INTRODUCTION: To minimize the complications associated with proximal humerus open reduction internal fixation (ORIF), various augmentation strategies have been utilized to manage humeral head bone loss. The purpose of the study is to report clinical and patient reported outcomes of calcium sulfate hydroxyapatite bio-composite bone void filler augmentation of proximal humerus ORIF.

METHODS: A prospective cohort of patients who sustained a proximal humerus fracture (PHF) treated with ORIF were collected between 2022-2024. All patients were treated with adjunctive calcium sulfate hydroxyapatite bio-composite bone void filler (CERAMENT BONE VOID FILLER, BONESUPPORT INC, Needham, MA) after reduction and instrumentation. Peri-operative complications were recorded. PROMIS scores of physical function and pain interference were collected. Follow-up radiographs were evaluated for bone void filler resorption/remodeling and union. These patients were 1:1 propensity matched to a retrospective comparative cohort of PHF without augmentation for comparative analysis.

RESULTS: 24 patients were enrolled in the study. 20 patients (83 %) were female. Mean age was 68±11 years and mean BMI was 29±7 kg/m2. Patients had a mean follow up of 424±123 days. All patients had radiographic evidence of bone void filler resorption and remodeling at an average of 130±77 days. Of the 24 patients, 21 had available PROMIS scores. At final follow up, patients reported an average 46.3 ± 9.9 physical function score and 63.8 ± 6.3 pain interference score at an average of 273±191 days post operative. The 24 patients augmented with CBVF were matched to 24 patients with PHF without augmentation. Twenty-two patients in the CBVF group had fracture union compared to twenty in the non-augmented group(92 % vs 83 %, p = 0.38). Additionally, the CBVF group had reduced rates of screw penetration(4 % vs 21 %, p = 0.08), progressive fracture displacement(4 % vs 17 %, p = 0.16), and revision surgery(4 % vs 17 %, p = 0.16). On multivariate analysis, the use of CBVF significantly lowered the odds of developing intra-articular screw penetration(OR = 0.007, p = 0.02) CONCLUSION: This series demonstrates favorable outcomes in proximal humerus ORIF augmented using calcium sulfate hydroxyapatite bio-composite as bone void filler compared to a matched cohort of patients treated without augmentation. There is a low rate of loss of fracture fixation and high union rate with favorable patient reported outcome measures.

PMID:40885162 | DOI:10.1016/j.injury.2025.112683

Injury. 2025 Aug 25;56(11):112724. doi: 10.1016/j.injury.2025.112724. Online ahead of print.

ABSTRACT

INTRODUCTION: Acetabular fractures typically involve disruption of cortical columns or walls and are well-classified by Judet, Letournel, and AO/OTA systems. However, some injuries involve pure osteochondral impaction of the articular surface without cortical involvement, making them difficult to detect and unclassified by current systems. This study identifies and evaluates a rare, previously undescribed acetabular injury pattern-posterior dome osteochondral impaction without cortical fracture.

AIM: To characterize this unique injury pattern and assess clinical and radiological outcomes following two surgical techniques aimed at anatomical restoration.

METHODS: A retrospective review was conducted on eight patients (six males, two females; mean age 34 years) treated at a tertiary referral center between 2008 and 2023. Inclusion criteria included isolated posterior dome osteochondral impaction confirmed by computed tomography, absence of cortical disruption, and minimum six months follow-up. Patients underwent surgical management via either posterior wall osteotomy or a cortical window technique, with subchondral support provided by autologous bone graft or rafting screws. Functional outcomes were measured using the Modified Merle d'Aubigné and Postel score. Radiological results were assessed according to Matta criteria.

RESULTS: All injuries followed high-energy trauma, predominantly motor vehicle collisions. Posterior wall osteotomy was performed in five patients: cortical window technique in three. Anatomical reduction was achieved and confirmed radiologically in all cases. At a mean follow-up of 12 months, no evidence of secondary collapse, hardware failure, or early osteoarthritis was noted. Functional outcomes were excellent in five patients and good in three (mean Merle d'Aubigné score 16.4).

CONCLUSION: Isolated osteochondral impaction of the posterior acetabular dome without cortical fracture is a distinct injury not encompassed by current classification systems. Surgical intervention using posterior wall osteotomy or cortical window elevation facilitates anatomical reduction and yields excellent mid-term outcomes. Recognition of this lesion and its inclusion in future acetabular fracture classifications are essential for accurate diagnosis and optimal treatment.

PMID:40885161 | DOI:10.1016/j.injury.2025.112724

Injury. 2025 Aug 26;56(11):112723. doi: 10.1016/j.injury.2025.112723. Online ahead of print.

ABSTRACT

BACKGROUND: Lateral compression type 1 (LC1) pelvic fractures are common injuries with ongoing debate regarding the cost-effectiveness of operative versus non-operative treatment. The goal of this study is to evaluate the cost-effectiveness of operative versus non-operative management for lateral compression type 1 (LC1) pelvic fractures, using pain (Brief Pain Inventory, BPI) and functional recovery (Majeed Pelvic Score, MPS) as outcome measures across early follow-up intervals.

METHODS: A decision tree model was developed to analyze the costs and outcomes of operative and non-operative management for LC1 fractures. Costs were derived from Medicare reimbursement rates, and probabilities were informed by clinical data and expert opinion. BPI and MPS scores were used as proxies for utility, with incremental cost-effectiveness ratios (ICERs) calculated at 2, 6, and 12-week follow-ups. An ICER exceeding the willingness-to-pay (WTP) threshold of $50,000 indicated that non-operative management was the more cost-effective option. Sensitivity analyses explored the utility improvements required for operative treatment to meet the WTP threshold of $50,000 per meaningful change in BPI or MPS.

RESULTS: Operative management was cost-effective for early pain relief, with an ICER of $33,466.08 per meaningful change in BPI at 2 weeks. However, it exceeded the WTP threshold at 6 weeks ($68,632.04) and only approached cost-effectiveness again at 12 weeks ($50,828.58). Using MPS, operative management was found to be cost-effective at 12 weeks ($44,992.90), but not at 2 or 6 weeks. Sensitivity analyses demonstrated that small utility gains could make operative management cost-effective at intermediate follow-up intervals.

CONCLUSION: Operative management of LC1 fractures may offer early cost-effective pain relief and possible delayed cost-effective functional recovery, particularly by 12 weeks. These findings may support surgical intervention for patients prioritizing rapid recovery by 12 weeks, but careful patient selection remains critical.

LEVEL OF EVIDENCE: Level 3.

PMID:40885160 | DOI:10.1016/j.injury.2025.112723

Injury. 2025 Aug 25;56(11):112693. doi: 10.1016/j.injury.2025.112693. Online ahead of print.

ABSTRACT

INTRODUCTION: Although ketorolac's association with poor bone healing remains debated, no study has examined the impact of ketorolac administration in adults with proximal humerus fractures (PHFs) after open reduction and internal fixation (ORIF), limiting surgeon decision-making. Therefore, the primary aim of this study was to examine the association between short-term ketorolac administration within the first three days after ORIF for PHF and the incidence and risk of nonunion or malunion through one year.

METHODS: A pre-registered retrospective propensity-matched cohort study was performed using a large United States health records-based database (TriNetX, LLC). Patients included adults (≥18 years old) who underwent first-time proximal humerus ORIF and received either acute (≤3 days) postoperative ketorolac (ketorolac cohort) or acetaminophen (control cohort). The primary outcome was the risk ratio (RR) of nonunion through one year. Secondary outcomes explored the incidence and risk of reoperation by surgery type, other relevant postoperative adverse events (such as malunion), and RR and mean count of postoperative oral opioid prescription. Over fifteen risk factors associated with bone union were used for propensity matching.

RESULTS: There were 2143 patients per cohort (n = 4286 total) with a mean age of 55 years. Comparing the ketorolac cohort to the control cohort, there was a statistically significant increase in risk of nonunion (p = 0.040; RR: 1.46 [1.02, 2.10]; 3.3% versus 2.2%; 70 patients versus 48 patients). Individual outcomes demonstrated no statistically significant difference in risk of malunion (p = 0.288; RR: 1.28; 1.9% versus 1.5%), revision ORIF (p = 0.493), total shoulder arthroplasty (p = 0.354), or acute kidney injury (p = 0.423). There was a statistically significant decrease in risk (p = 0.015) and mean count (p = 0.033) of oral opioid prescription.

CONCLUSION: Acute postoperative ketorolac after ORIF for PHF is associated with a modest increase in risk of nonunion and reduction in opioid prescriptions, with no significant differences in malunion, reoperation, or acute kidney injury. These findings support the need for individualized decision-making to weigh risks and benefits in postoperative pain management, with future research needed on dosages.

PMID:40876112 | DOI:10.1016/j.injury.2025.112693

Injury. 2025 Aug 19;56(11):112685. doi: 10.1016/j.injury.2025.112685. Online ahead of print.

ABSTRACT

BACKGROUND: To prepare junior surgeons for possible increased trauma call burden and improve young surgeons' workplace marketability, there has been an increase in fellowship programs offering combined arthroplasty and trauma curriculums. The purpose of this study was to determine the relative importance of factors considered by applicants applying to combined programs. This information will serve program directors, who can improve applicant recruitment, along with improving the experiences of fellows.

METHODS: Survey respondents were asked to rate 23 fellowship program factors on a 1-to-5 Likert scale with 1 being "not important at all" and 5 being "critical". Respondents were also asked to list their top 5 factors in order of decreasing importance with 1 being the most important. A two-sample t-test was used to analyze subgroups. Statistical significance defined as P-value < 0.05.

RESULTS: Surveys were sent to 192 applicants, and 75 responses were received with a 39.1 % response rate. The overall highest rated factors were operative experience (mean 4.87; SD 0.34), revision total joint experience (mean 4.61; SD 0.61), periprosthetic fracture experience (mean 4.52; SD 0.60), and primary total joint experience (mean 4.17; SD 0.86). A subgroup analysis was performed by creating three groups: surgical experience, program details and history, and financial factors. Surgical experience group was ranked highest (mean 3.81; SD 1.72). Programs details and history (mean 3.12; SD 1.05) and financial factors (mean 2.35; SD 1.08) rated significantly lower than surgical experience (P-value < 0.01).

CONCLUSIONS: Applicants of combined arthroplasty and trauma fellowships value similar characteristics in a program as those applying to either arthroplasty or trauma alone. Combined fellowship programs should update their websites as applicants frequently use online sources to educate themselves on existing programs.

PMID:40876111 | DOI:10.1016/j.injury.2025.112685

Injury. 2025 Aug 24;56(11):112719. doi: 10.1016/j.injury.2025.112719. Online ahead of print.

ABSTRACT

BACKGROUND: Indications for stabilization of the medial collateral ligament (MCL) after repair of the lateral ulnar collateral ligament (LUCL) remain controversial. Here, we propose a standardized fluoroscopic sequence to reveal residual medial elbow instability to facilitate intraoperative decision-making.

METHODS: Eight matched cadaveric upper extremity pairs (N = 16) were mounted to simulate intraoperative positioning. Fluoroscopic images were acquired using the following: full extension, 45-degree flexion, 90-degree flexion, and full flexion with the forearm in neutral/pronation/supination. These were acquired at "baseline" and following destabilization of the LUCL/MCL. The proposed fluoroscopic sequence was then repeated following surgical fixation of the LUCL ("post-LUCL repair") followed by MCL repair ("post-LUCL & MCL repair). Blinded images were fitted using a best-fit circle to compute ulnohumeral distance (UHD, millimeters) and determine residual lateral (supination) and medial (pronation) instability defined by the presence of a drop sign (UHD>4 mm). Radiocapitellar ratio (RCR) was computed to determine radiocapitellar instability (RCR>10 %). Blinded images were also qualitatively evaluated against the contralateral baseline to simulate intraoperative assessment.

RESULTS: Apparent instability in supination status-post destabilization resolved following LUCL repair with evident residual medial-sided instability showed in pronation, which resolved after MCL fixation. Evaluation of the drop sign at 45 and 90 degrees of flexion showed comparable quantitative sensitivity at 97 % and 98 %, unlike in full extension or full flexion (sensitivity <35 %). Quantitative sensitivity was 88 % for RCR in mid-flexion. Qualitative evaluation for the drop sign and RCR resulted in sensitivity of 93 and 75 %, respectively.

CONCLUSIONS: The proposed fluoroscopic sequence provides reliable intraoperative assessment to evaluate for residual medial-sided instability in the setting of multi-ligamentous elbow injuries. After repair of the LUCL, medial residual instability due to MCL rupture is best revealed with the presence of a drop sign in full pronation and midflexion.

LEVEL OF EVIDENCE: IV.

PMID:40876110 | DOI:10.1016/j.injury.2025.112719

Injury. 2025 Aug 16;56(11):112682. doi: 10.1016/j.injury.2025.112682. Online ahead of print.

ABSTRACT

BACKGROUND: The classic surgical technique of the 15-mm incision minimally invasive approach is not suitable for AO 23-B3 distal radius fractures (abbreviated B3). We have modified this technique for B3. This study aimed to investigate the efficacy of the modified 15-mm incision minimally invasive approach with the conventional ORIF approach in the treatment of B3.

METHODS: This retrospective study included 62 patients with B3 who underwent surgical treatment from January 2020 to May 2024, including 31 patients undergoing the modified 15-mm incision minimally invasive approach (M group) and 31 patients undergoing the conventional ORIF approach (C group). The two groups had similar baseline characteristics (P > 0.05). The perioperative data, follow-up data, and imaging results of the two groups were compared. At the last follow-up, the limb function was assessed using the PRWE and DASH scores.

RESULTS: In the C group, 1 patient experienced infection and 1 patient experienced complex regional pain syndrome, whereas in the M group, there were no such patients. In the M group, the incision length, intraoperative bleeding, hospital stay, hospitalization expenses, swelling, and VAS on postoperative days 2 and 7, flexion-extension, ulnar-radial deviation and pronation-supination at postoperative 3 months, and pronation-supination ROM in 12-24 months of follow-up were superior, but the surgical and fluoroscopy time was longer compared to the C group (P < 0.05). There was no difference between the two groups in terms of fracture reduction, fracture healing time, full weight-bearing time, complications, and flexion-extension ROM, PRWE and DASH in the last follow-up (P > 0.05).

CONCLUSION: Both methods were effective for treating B3. The M group was superior in terms of aesthetic appeal of the incision, surgical trauma and associated risks, hospital stay, early recovery, and final rotational function, which are consistent with the principles of MIPO and rapid recovery, but requires longer surgical and fluoroscopy time.

PMID:40876109 | DOI:10.1016/j.injury.2025.112682

Injury. 2025 Aug 8;56(10):112659. doi: 10.1016/j.injury.2025.112659. Online ahead of print.

ABSTRACT

Train-related injuries represent a significant yet underreported public health challenge in developing countries, particularly in sub-Saharan Africa, where contemporary data are scarce. This study characterizes the epidemiology, clinical presentation, and outcomes of train-related trauma at a South African Level I trauma center, with a focus on identifying predictors of severe outcomes and informing context-specific interventions for this high-risk population.

METHOD: A retrospective analysis was conducted on 63 patients presenting to Groote Schuur Hospital between April 2008 and June 2013. Data collected included demographics, injury mechanisms, clinical findings, and outcomes. Multivariable logistic regression was performed to evaluate the association between key severity markers (GCS ≤8, hypotension, mangled extremities) and ICU admission.

RESULTS: The cohort was predominantly male (96.8 %) with a median age of 26 years (IQR: 22-33). Injuries clustered during winter months (April-October), with 62 % occurring between 4:00 PM and midnight. The most common mechanisms were boarding or alighting from moving trains (46.2 %) and interpersonal assault (33.3 %). Lacerations were the most frequent soft tissue injury (69.8 %), while lower (25.4 %) and upper limb (22.2 %) fractures were the predominant orthopedic injuries. The amputation rate was 20.6 %, strongly associated with mangled extremities. Median hospital stay was 6 days (IQR: 1-17), extending significantly for patients with spinal trauma. Severe traumatic brain injury (GCS ≤8) was independently associated with ICU admission (adjusted OR 15.0; 95 % CI: 2.7-82.4; p < 0.001). Mangled extremities and hypotension were not significantly associated with ICU requirement.

CONCLUSION: Young male commuters are more likely to sustain severe, preventable train-related injuries. Significant musculoskeletal trauma, head, and spinal injuries increased hospital stay, underscoring the need for comprehensive assessment to reduce morbidity and improve outcomes. Our findings support protocolized neurosurgical and orthopaedic triage and targeted prevention strategies in resource-limited settings.

PMID:40865178 | DOI:10.1016/j.injury.2025.112659

Injury. 2025 Aug 7;56(10):112657. doi: 10.1016/j.injury.2025.112657. Online ahead of print.

ABSTRACT

BACKGROUND: Nonunion is a significant complication following nonoperative treatment of displaced midshaft clavicle fractures, potentially leading to impaired shoulder function, pain, and decreased quality of life. This study aims to identify predictors of nonunion in adults treated nonoperatively to optimize treatment decisions and improve outcomes.

METHODS: A retrospective cohort study was conducted using data from 374 patients treated nonoperatively between 2012 and 2024. Patient and fracture characteristics, including age, sex, smoking, diabetes mellitus, and fracture comminution, were assessed. Univariable and multivariable logistic regression analyses identified predictors of nonunion. Model performance was assessed using the area under the receiver operating characteristic (ROC) curve (AUC). Diagnostic statistics and number needed to screen (NNS) were calculated.

RESULTS: Of 374 patients, 72 (19.3 %) developed nonunion. Multivariable analyses revealed that increasing age (odds ratio [OR]: 1.03, 95 % confidence interval [CI]: 1.01-1.04, p = 0.002) and smoking (OR: 2.49, 95 % CI: 1.31-4.71, p = 0.005) were independently associated with increased risk of nonunion. Fracture comminution was associated with reduced risk (OR: 0.34, 95 % CI: 0.20-0.58), p < 0.001). The model's AUC was 0.70. At a probability threshold of 0.4, the NNS was 6.

CONCLUSIONS: This study highlights the potential of predictive models to identify patients at risk for nonunion. Age and smoking increase the risk of nonunion, while comminution showed a protective effect. These findings support personalized care to optimize treatment decisions and improve patient outcomes. Further refinement and inclusion of additional risk factors are essential to improve the model's accuracy and clinical applicability.

PMID:40850009 | DOI:10.1016/j.injury.2025.112657

Injury. 2025 Aug 5;56(10):112646. doi: 10.1016/j.injury.2025.112646. Online ahead of print.

ABSTRACT

BACKGROUND AND AIMS: Complex open tibial fractures with soft tissue defects in children represent a major clinical challenge due to high risks of infection, osteomyelitis, and long-term functional impairment. This study aimed to evaluate the effectiveness of a combined orthopedic and reconstructive approach using external fixation and free anterolateral thigh (ALT) flaps in pediatric patients.

METHODS: In this prospective, controlled clinical trial, 78 children (mean age 12.4 ± 3.1 years) with open tibial fractures and extensive soft tissue loss from road traffic accidents were enrolled. Patients were randomized into two groups: the experimental group (n = 40) received Ilizarov external fixation with microsurgical ALT flap reconstruction; the control group (n = 38) underwent conventional internal fixation with standard wound management. Renal function markers (creatinine, urea, GFR) were monitored to assess the impact of trauma, systemic inflammation, and nephrotoxic antibiotic exposure. Healing was evaluated using the Zygo-Scale at 7, 30, 60, 90 days, and 12 months. Incidence of osteomyelitis, joint ankylosis, flap complications, and revision surgeries was recorded.

RESULTS: The experimental group demonstrated significantly faster and more complete soft tissue healing (p ≤ 0.05), with lower rates of osteomyelitis at 6 and 12 months (2.5 % and 0 % vs. 10.5 % and 5.25 %, respectively; p < 0.05). Joint ankylosis scores were also significantly reduced (p = 0.02 and p = 0.01). Flap survival rate was 95 %, with no cases of total necrosis. Donor site morbidity was minimal. While renal function improved in both groups, a modest but significant difference in creatinine levels at 12 months favored the experimental group (p = 0.03). The combined approach was associated with shorter healing times and fewer complications.

CONCLUSION: The integration of Ilizarov fixation with ALT flap reconstruction is a safe and effective strategy for managing severe pediatric lower limb injuries, enhancing healing, reducing infections, and improving functional outcomes. Monitoring renal markers provides insight into systemic stress and antibiotic safety in trauma care.

PMID:40850008 | DOI:10.1016/j.injury.2025.112646

Injury. 2025 Aug 7;56(10):112663. doi: 10.1016/j.injury.2025.112663. Online ahead of print.

ABSTRACT

AIMS: This study aimed to explore safety and feasibility of at-home softcast removal in children with displaced injuries undergoing manipulation; understand caregiver experience; and determine its impact on service at our tertiary centre.

METHODS: Paediatric patients (<16 years) with any fracture requiring application of a circumferential softcast, later removed at home without planned routine follow-up, were retrospectively analysed from two time-points: July-September 2022; February-April 2023. Demographic data including age, fracture location, angulation, whether manipulation was undertaken, and unplanned re-attendances were recorded. Caregivers completed a telephone Likert questionnaire (1=extremely positive, 5=extremely negative) reviewing cast removal time and qualitative descriptors of experience. Cost analysis was performed based on use of consumables, staff and clinical areas.

RESULTS: 77 caregivers completed the questionnaire at mean 93.4 days post-injury. Mean patient age was 7.6 years at time of injury. 41 (53.2 %) were distal radius, 20 (26.0 %) forearm and 16 (20.8 %) were elbow, hand or tibia fractures. Mean sagittal angulation was 24.7 degrees and 40 (52.0 %) injuries underwent manipulation under sedation. 13 (16.9 %) patients re-attended with cast problems. Caregivers estimated a mean 13.3 min to remove the cast. 83.1 % found it 'extremely' or 'somewhat' easy. 75.3 % were 'extremely' or 'somewhat' satisfied. 71.4 % were 'extremely' or 'somewhat' likely to recommend it. Qualitative descriptors ranged from "traumatic" to "easy". Since introduction of this practice, subsequent clinic attendances for children diagnosed with a fracture in the Emergency Department has reduced by >50 %, equating to savings of approximately £22,600 per annum.

CONCLUSION: Our experience confirms at-home softcast removal without further orthopaedic follow-up is safe and feasible, even in displaced injuries undergoing manipulation. The majority of families reported positive experiences. However, this was not universal and adequate patient education was integral to this.

PMID:40850007 | DOI:10.1016/j.injury.2025.112663

Injury. 2025 Aug 7;56(10):112660. doi: 10.1016/j.injury.2025.112660. Online ahead of print.

ABSTRACT

INTRODUCTION: The incidence of postoperative neurocognitive disorder (PND) in elderly patients with hip fractures poses a significant clinical challenge, with current management strategies offering limited efficacy in prevention or resolution. This prospective study evaluated the effectiveness of pre-and postoperative electroacupuncture (EA) intervention in mitigating PND in this patient cohort.

METHODS: A double-masked, randomized controlled trial was conducted involving 60 elderly patients (≥65 years) with fragility hip fractures scheduled for surgical repair. Participants were randomly assigned to either the EA intervention group (Group A) or a non-stimulated control group (Group C). Mini-Mental State Examination (MMSE) scores were recorded at baseline and 1, 3, and 7 days postoperatively, while ELISA was used to assess IL-1β, IL-6, and S-100β levels. Time-varying MAP, SpO2, and HR were measured. Adverse cardiovascular events, extubation duration, recovery room stay, VAS scores, analgesia pump use, postoperative adverse responses, and hospitalization length were recorded.

RESULTS: Among 60 randomized patients (mean age 74.02 years; 54.7 % male), 53 were analyzed for primary outcomes. Postoperative day 1 PND incidence was significantly lower in Group A (25.0 %) than Group C (56.0 %; P < 0.05), persisting on day 3 (Group A: 14.3 %, Group C: 48.0 %; P < 0.05). By day 7, PND incidence was similar in both groups. Time-group interactions were significant for IL-1β, IL-6, and blood pressure (P < 0.05). Group A exhibited a lower VAS score at 24 h postoperatively (2.65 ± 0.94 vs. 3.96 ± 0.96; P < 0.05). Adverse events were reported in 26 Group A and 32 Group C cases. Postoperative nausea and vomiting (PONV) significantly differed (Group A: 3.7 %, Group C: 30.8 %).

CONCLUSIONS: The findings suggest that pre- and postoperative EA stimulation may significantly reduce the risk of PND, modulate inflammatory responses, and lower blood pressure. Furthermore, EA intervention was associated with reduced postoperative pain and a marked decrease in the incidence of PONV in elderly patients with hip fractures. These results highlight the potential therapeutic benefits of EA in managing PND in this vulnerable patient population and warrant further investigation. SUBJECT WORDS: electroacupuncture, transcutaneous electrical acupoint stimulation, hip surgery, perioperative neurocognitive disorders, pain, postoperative nausea and vomiting.

PMID:40848689 | DOI:10.1016/j.injury.2025.112660

Injury. 2025 Aug 15;56(10):112684. doi: 10.1016/j.injury.2025.112684. Online ahead of print.

ABSTRACT

BACKGROUND: Humeral shaft fractures are common in young adults following high-energy trauma. While open fractures often result in infections, infections in closed fractures are rare, making such cases particularly challenging to manage when they occur.

CASE PRESENTATION: We report a unique case of a 25-year-old pregnant female who sustained a closed humeral shaft fracture after a high-energy injury. Although there was no initial open wound, a purulent infection was discovered at the fracture site during surgery a few days after the injury. Cultures identified Haemophilus influenzae as the causative organism. This report details the management of the fracture and associated infection, highlighting the diagnostic challenges and therapeutic steps taken to address this acute osteomyelitis-like infection in a closed fracture.

DISCUSSION: This case represents the first documented instance of an acute Haemophilus influenzae infection in a closed adult humeral fracture, a pathogen traditionally associated with pediatric respiratory infections. Contributing factors may have included the patient's complex medical and social background, including pregnancy, polysubstance abuse, homelessness, and the use of immunomodulatory medications. This case highlights the importance of heightened vigilance, the need for modifications in surgical decision-making, and possibly revised empirical antibiotic protocols in the management of closed fractures in immunocompromised patients.

CONCLUSION: Acute infections in closed humeral fractures, though rare, pose significant diagnostic and therapeutic challenges, particularly in immunocompromised individuals. This case prompts a reconsideration of management strategies in similar contexts, advocating for a broad differential diagnosis and tailored antimicrobial strategies to address atypical pathogens in complex clinical scenarios.

PMID:40848688 | DOI:10.1016/j.injury.2025.112684

Injury. 2025 Aug 10;56(10):112680. doi: 10.1016/j.injury.2025.112680. Online ahead of print.

ABSTRACT

Hip fractures in the older persons are associated with high morbidity and mortality rates, with a growing incidence due to an aging population. Early readmission increases dependence and healthcare costs, and identifying the factors associated with readmission could improve care. This study aims to identify factors associated with 30-day readmission following hip fracture in patients aged 75 and older, as well as to explore the relationship between various clinical variables. A multicentric, retrospective observational study was conducted using data from the National Hip Fracture Registry (NHFR) involving 57,544 patients admitted from January 1, 2017, to December 31, 2022. Patients were excluded if they had died during acute hospitalization or were lost to follow-up. Key demographic, clinical, and surgical variables were collected and analysed. Statistical analyses were performed using RStudio, employing both univariate and multivariate regression models to identify predictors of 30-day readmission. The study revealed a 30-day readmission rate of 5.18 %. Factors significantly protective against readmission included female gender (OR 0.84 p < 0.001), intertrochanteric (OR 0.81 p < 0.008) and subtrochanteric (OR 0.74 p < 0.007) fracture type, neuraxial anaesthesia (OR 0.82 p < 0.015), and increased length of stay (OR 0.98 p < 0.001). Conversely, ASA IV (OR 1.93 p < 0.05), ASA V (OR 5.59 p < 0.05) and discharge to residential care were associated with increased readmission risk. Notably, patients discharged home showed a reduced risk of readmission compared to those transferred to other care facilities such as residential care (OR 1.26 p < 0.001), acute hospitalization (OR 35.46 p < 0.001) and long-term care hospital(OR 2.36 p < 0.001). The readmission rate observed was lower than the reported by comparable registries. Identifying patients at high risk of early readmission following hip fracture is critical for enhancing patient care, and specific variables can serve as effective predictors, enabling targeted interventions to reduce readmission rates.

PMID:40848687 | DOI:10.1016/j.injury.2025.112680

Injury. 2025 Aug 12;56(10):112667. doi: 10.1016/j.injury.2025.112667. Online ahead of print.

ABSTRACT

OBJECTIVE: To compare prevalence and severity of sacral dysmorphism in Indigenous and non-Indigenous Australian populations.

METHODS: We performed a single centre retrospective matched cohort study in consecutive Indigenous and non-Indigenous Australian patients who received a CT scan of the pelvis between January and March 2024 at our institution. Patients were excluded if they were under the age of 18 at the time of the scan or had a history of pelvic fractures or fixation. CT scans were assessed for both qualitative and quantitative features of sacral dysmorphism. The primary outcome of interest was the prevalence and severity of sacral dysmorphism in Indigenous and non-Indigenous Australian populations.

RESULTS: 120 patients were included in the study - 60 Indigenous and 60 non-Indigenous Australians. All patients exhibited at least one characteristic of sacral dysmorphism. There was no difference in the prevalence of qualitative sacral dysmorphism between the two groups. Compared to their non-Indigenous counterpart, Indigenous patients demonstrated a lower S1 transsacral corridor coronal diameter (20.50 vs. 21.85 mm, p = 0.005), S1 oblique corridor axial diameter (17.90 vs. 19.60 mm, p = 0.028), S1 pelvic width (144.85 vs. 158.70 mm, p < 0.001), S2 transsacral corridor coronal diameter (13.70 vs. 14.95 mm, p = 0.013), S2 transsacral corridor axial diameter (10.60 vs. 11.55 mm, p = 0.013), and S2 pelvic width (126.60 vs 136.00 mm, p < 0.001). Additionally, in Indigenous patients, S1 and S2 transsacral and oblique S1 iliosacral fixation lengths were shorter. Where an S1 trans-sacral osseous corridor was not present, the S2 corridor was significantly larger in coronal, axial measurements across both groups (p < 0.001).

CONCLUSIONS: Indigenous Australian patients exhibited more severe forms of sacral dysmorphism when compared to their non-Indigenous counterparts. Additionally the overall prevalence of sacral dysmorphism across this Australian population was amongst the highest reported in the literature. This may present significant technical challenges and warrants consideration when performing percutaneous iliosacral screw fixation.

PMID:40848686 | DOI:10.1016/j.injury.2025.112667

Injury. 2025 Aug 7;56(10):112650. doi: 10.1016/j.injury.2025.112650. Online ahead of print.

ABSTRACT

OBJECTIVES: In acknowledgement of the ongoing transition of surgical education from a time-based approach to competency-based curricula, this study aimed to identify key parameters for assessing the performance of surgical trainees in open reduction and internal fixation (ORIF) of a simple ulnar shaft fracture (AO/OTA classification 2U2A3.B).

METHODS: A 4-round Delphi process regarding seven different orthopedic osteosynthesis surgeries was conducted with an international panel of orthopedic surgeons involved in surgical education. This manuscript focuses on compression plating of isolated ulna fractures. Round 1 focused on item generation, round 2 on importance rating, round 3 on defining optimal intervals and borderline error values for a specific fracture model (not reported in this manuscript), and round 4 on assigning weights to each parameter. Data collection was carried out online.

RESULTS: Ninety-eight surgeons agreed to participate in the study. Round 1 generated 30 assessment parameters. In round 2 and 3, these were reduced to 26 parameters. In round 4, parameters received an overall mean weight of 8.27 out of 10 (SD 0.66) with a range of individual parameter mean weights from 6.7 to 9.4. The assessment parameters that achieved the highest weights were anatomical fracture reduction and assessment of forearm range of motion after fixation. In the final list of parameters, five were related to fracture reduction, three to hardware choice, five to plate placement, nine to screw placement, and four to concluding the procedure.

CONCLUSIONS: Utilizing a Delphi process, expert consensus was reached generating a comprehensive list of 26 assessment parameters that can be used to assess surgeon performance in open reduction and internal fixation of an isolated adult ulnar shaft fracture. This will allow educators to provide standardized feedback (formative assessment) to trainees and use a mastery-learning training approach (summative assessment).

PMID:40845526 | DOI:10.1016/j.injury.2025.112650