Injury

Risk factors for elbow stiffness after surgery for AO / OTA type C distal humerus fractures

Injury. 2025 Jun 25;56(8):112560. doi: 10.1016/j.injury.2025.112560. Online ahead of print.

ABSTRACT

OBJECTIVE: The aim of this study is to identify risk factors for elbow stiffness following surgery for AO/OTA type C distal humerus fractures with a follow-up investigation.

METHODS: Data were collected from patients who underwent treatment for AO/OTA type C distal humerus fractures between March 2015 and March 2022.The patients were divided into a stiffness group and a control group based on whether their elbow flexion-extension or rotation range of motion was less than 100°at the final follow-up. Univariate analysis and multivariate logistic regression analysis was performed to identify independent risk factors. A nomogram prediction model was then constructed based on the factors identified. Receiver operating characteristic (ROC), calibration curve and decision curve analysis (DCA) were used to evaluate its discriminant and calibration. The subjects were randomly divided into modeling set and validation set according to 7:3, and the model was internally validated by random split validation.

RESULTS: Of the 207 patients, 68 developed elbow stiffness after ORIF for AO/OTA type C distal humerus fracture. Multivariate logistic regression analysis identified age,AO/OTA fracture classification,time from injury to surgery,postoperative professional functional rehabilitation, transverse screw,and modified trochleocapitellar index (mTCI), as independent risk factors for postoperative elbow stiffness (all P < 0.05). The modeling set curve demonstrated an AUC value of 0.877, while the validation set curve showed an AUC of 0.869. The calibration curve of the nomogram closely approximated the diagonal line, and decision curve analysis (DCA) revealed that utilizing the nomogram for prediction yielded greater net benefits within the threshold probability range of 0.3-0.8.

CONCLUSION: Age, AO/OTA type C classification, transverse screw, postoperative professional functional rehabilitation, mTCI and time from injury to surgery were identified as risk factors for postoperative elbow stiffness.

PMID:40617199 | DOI:10.1016/j.injury.2025.112560

Defining treatment outcome in fracture-related infections: A scoping review

Injury. 2025 Jun 25;56(8):112563. doi: 10.1016/j.injury.2025.112563. Online ahead of print.

ABSTRACT

BACKGROUND: The fracture-related infection (FRI) consensus definition, published in 2018, marked a crucial advance for clinical practice and research, enabling treatment standardization and better comparison of clinical studies. However, a lack of clear, standardized outcome parameters still impedes the evaluation of treatment success, potentially leading to a misreporting of treatment failure in current literature. This scoping review provides an overview of outcome parameters used in the current literature to describe treatment success or failure in FRI.

METHODS: A comprehensive literature search across four databases (PubMed, Embase, Scopus and Web of Science) was performed. Studies that reported on treatment outcome in adults with long-bone FRI, published between 2018 and 2023, were eligible for inclusion. The primary outcomes were the reporting of the persistence, eradication or recurrence of infection as well as radiological and functional outcome and the need for a return to theatre for infection control. The secondary aim was to screen the current FRI literature for applied follow-up duration.

RESULTS: A total of 111 studies were included for analysis and synthesis. Only 15.3 % (17/111) of the included studies used a clear definition of treatment success and/or failure in their methodology. Despite a high general reporting (85.6 %; 95/111) of infection eradication, recurrence and/or persistence, only few studies defined these parameters accurately: 16.2 % for eradication (18/111), 15.3 % for recurrence (17/111), 0 % for persistence. Bone healing was reported by 90.9 % (101/111) of the studies, with a standardized approach of radiological evaluation in 64.4 % (65/101). In total, 76 studies (68.5 %) assessed functional outcome, whereas no standardized score set was used. Correspondingly, no standardized follow-up duration could be identified. An unplanned return to theatre was considered by 16.2 % of the studies (18/111) to report outcome.

CONCLUSION: This scoping review highlights the lack of standardized outcome reporting in FRI. A clear definition on outcome reporting in FRIs is urgently needed to promote comparability and transparency in clinical research.

PMID:40614539 | DOI:10.1016/j.injury.2025.112563

Tracking the prehospital time course of open fracture patients

Injury. 2025 Jun 21;56(8):112536. doi: 10.1016/j.injury.2025.112536. Online ahead of print.

ABSTRACT

OBJECTIVES: A tenet of open fracture management is timely administration of antibiotics to reduce risk of fracture-related infection (FRI). Trauma centers strive to administer intravenous antibiotics within one hour of patient arrival. The foundation for this recommendation is based on relatively few studies, which base their findings on time from hospital arrival to antibiotic administration. Little attention has been paid to the prehospital time course of open fracture patients. We hypothesized that a significant portion of open fracture patients arrive at the hospital greater than one hour after their injury, which would represent an opportunity for improved care.

METHODS: Design: Retrospective Case Series Setting: Urban/Suburban Academic Level I Trauma Center Patient Selection Criteria: Subjects were identified using a retrospective search for open fracture patients arriving via emergency medical services (EMS). Patients were included if they were age 18 or greater, presented with an open fracture, and had complete pre-hospital documentation, in-hospital documentation, and radiographs. Outcome Measures and Comparisons: Data collected included patient demographics, fracture location, Gustilo-Anderson classification, dispatch time, on scene time, enroute to hospital time, arrival at hospital time, transfer of care time, modality of transport, whether intravenous antibiotics were administered prior to arrival at the hospital, and development of FRI. Descriptive statistics were used to analyze the findings.

RESULTS: 454 patients met the inclusion criteria. Mean time from dispatch to transfer of care was 66.8 ± 26.9 min in all transports; 84.1 ± 25.6 min with helicopter EMS; and 64.8 ± 26.4 min with ground EMS. 239 patients (52.6 %) had transfer of care time greater than one hour after dispatch time. Only 3.7 % of open fracture patients received antibiotics prior to hospital arrival. There was a positive correlation with the development of FRI and prolonged pre-hospital time.

CONCLUSIONS: Many patients with open fractures had transfer of care more than one hour after dispatch. FRI was associated with increased prehospital time. These results suggest an opportunity for prehospital antibiotic administration to mitigate the risk of infection in patients with open fractures.

LEVEL OF EVIDENCE: Level IV.

PMID:40609244 | DOI:10.1016/j.injury.2025.112536

A comparative finite element study of novel design hook plates for fixation of patella fracture

Injury. 2025 Jun 27;56(8):112567. doi: 10.1016/j.injury.2025.112567. Online ahead of print.

ABSTRACT

PURPOSE: To test the mechanical properties of novel design hook plates for fixation of the patellar fracture by finite element analysis.

METHODS: Finite element analysis was used to construct a model of transverse patellar fracture and inferior pole fracture of the patella (IPFP) based on the CT data of the knee joint of a healthy young male volunteer. For the transverse fracture, stress distribution within the winged hook plate fixation and displacement of the fracture was compared to that of tension-band wiring (TBW) fixation. For the IPFP, the stress distribution within the wingless plate and displacement of the fracture were calculated under the four different application methods. All the models were created by assuming the knee flexion in 45° during non-weight-bearing, and applying the quadriceps tension on the superior pole of the patella.

RESULTS: In the model of transverse patellar fracture: The displacement and stress incurred in the fixation of patellar fractures with winged hook plates are much less than with TBW fixation (0.05 mm vs 0.3 mm; 121 MPa vs 268 MPa). In the model of IPFP: The wingless hook plate-cable wire-screw construction resulted in the least amount of displacement, followed by the wingless hook plate-cable wire (0.18 mm vs 0.297 mm). Displacement of the inferior pole of the patella would be more obvious in the two constructions that did not combine cable wires, especially the construction with neither cable wires nor screws.

CONCLUSION: In consideration of improvement of mechanical rigidity, winged hook plate was superior to TBW technique when being used for fixation of transverse patellar fracture, while combination of cable wire should be recommended when wingless hook plate being used for fixation of IPFP.

PMID:40609243 | DOI:10.1016/j.injury.2025.112567

Distal biceps injuries: an overview

Injury. 2025 Jun 25;56(8):112556. doi: 10.1016/j.injury.2025.112556. Online ahead of print.

ABSTRACT

Distal biceps injuries frequently occur in middle-aged males after an eccentric load to the elbow in flexion. The diagnosis is often clinical with the aid of imaging where appropriate. Tears can be partial or full thickness. Surgery is the mainstay of treatment with non-operative management typically reserved for older, lower-demand patients. Those treated without an operation can expect a loss of a proportion of supination and flexion power. There are several surgical techniques described. In the acute setting, a repair may be performing using a number of available devices. In the chronic setting, reconstruction with a graft may be required. Surgical management carries with it complications such as damage to the surrounding structures, heterotopic ossification and re-rupture.

PMID:40609242 | DOI:10.1016/j.injury.2025.112556

Biomechanical evaluation of three different fixation methods for treating displaced tibial avulsion fracture of the posterior cruciate ligament: a finite element analysis

Injury. 2025 Jun 27;56(8):112568. doi: 10.1016/j.injury.2025.112568. Online ahead of print.

ABSTRACT

OBJECTIVE: Displaced tibial avulsion fractures of the posterior cruciate ligament (PCL) significantly compromise knee stability; however, existing clinical data regarding treatment and prognosis are limited. There exists a paucity of biomechanical research concerning various surgical methods for tibial avulsion fractures of the PCL, and optimal management remains controversial. Therefore, the objective of this study was to investigate the biomechanical stability of displaced tibial avulsion fracture using suture bridge fixation, screw fixation, and TightRope fixation at varying flexion angles.

METHODS: Finite element analysis was employed to evaluate the biomechanical stability of three surgical approaches. A type III PCL tibial avulsion fracture model was established, followed by the assembly of models for suture bridge fixation, screw fixation, and TightRope fixation. Varying angles of knee flexion were simulated, and the stress distribution on the implant, the PCL, and the bone fragment, as well as the displacement of the fragment, were assessed.

RESULTS: The findings indicated that the peak stress distribution on the implant for screw fixation was the highest, occurring near the midsection and tail of the implant, followed by TightRope fixation, which occurred near both ends of the fixation. In contrast, suture bridge fixation exhibited the lowest stress, occurring near the junction between the anchor and the suture. The stress distribution of the PCL in screw and TightRope fixation was slightly higher than that observed with suture bridge fixation. This stress was primarily concentrated in the upper portion and gradually increased, reaching a maximum at 120° The peak von Mises stress (VMS) on the bone fragment in the suture bridge fixation group was the highest, followed by the screw fixation group, and subsequently the TightRope fixation group. Furthermore, the displacement of the bone fragment was comparable among the three fixation methods across various angles of knee flexion.

CONCLUSION: The biomechanical properties of suture bridge fixation are superior to those of both TightRope and screw fixation. They are all alternative surgical treatment methods for displaced tibial avulsion fractures of the PCL. The ideal surgical approach should be selected based on the clinical context and a comprehensive evaluation.

PMID:40609241 | DOI:10.1016/j.injury.2025.112568

Modified plate-nail fixation for periprosthetic distal femur fractures following total knee arthroplasty in elderly patients - A technical note

Injury. 2025 Jun 25;56(8):112557. doi: 10.1016/j.injury.2025.112557. Online ahead of print.

ABSTRACT

The global rise in total knee arthroplasty (TKA), driven by an aging population, has led to an increased incidence of periprosthetic fractures (PPFs). Dual implants for distal femur periprosthetic fractures (PDFFs) are a growing area of interest for these challenging fractures with dual plating (DP) and plate-retrograde femoral intramedullary nail (PN) emerging as viable constructs for these injuries. However, dual implants have inherent limitations. Herein we focus on describing a modified PN fixation-retrograde tibial intramedullary nail (RTN) combined with a less invasive stabilization system (LISS) for PDFFs following TKA in elderly patients and providing the technical trick of this modified PN fixation.

PMID:40602036 | DOI:10.1016/j.injury.2025.112557

Traumatic Self-Harm in Older People: A 7-Year Descriptive Analysis from a London Major Trauma Centre

Injury. 2025 Jun 21:112542. doi: 10.1016/j.injury.2025.112542. Online ahead of print.

ABSTRACT

BACKGROUND: Suicide in older people is increasing. We know less about serious deliberate self-harm in this population or the impact of this on Major Trauma Centres (MTC).

OBJECTIVES: Investigate demographics, injury mechanism and outcomes in older people admitted with self-inflicted injury.

DESIGN: Retrospective service evaluation.

SETTING: Single MTC in London, UK.

SUBJECTS: 60 people aged 65 years and over admitted to a MTC with self-inflicted injury.

METHODS: Retrospective analysis of trauma registry data (February 2015-2022).

VARIABLES: age, sex, past medical and psychiatric history, home and marital status, injury type and narrative, injury severity score (ISS), critical care admission, length of stay, discharge status and destination.

RESULTS: Self-inflicted injury represented 1.5 % of trauma admissions aged 65 and over (80 % male, median age 73 years). Most females and over half of men had a psychiatric history (females n = 11, 91.7 %; males n = 28, 58.3 %). Depression was the most common psychiatric comorbidity (n = 15). Males were more likely to suffer penetrating injury (males n = 37, 77.1 %; females n = 4, 33.3 %). The most common injury mechanism was self-stabbing amongst males (n = 37, 77.1 %) and a jump from height amongst females (n = 6, 50.0 %). Median ISS (8.5) and mortality (n = 8, 13.3 %) was low across the cohort. The most common discharge destination was psychiatric admission (males n = 28, 58.3 %; females n = 6, 50.0 %).

CONCLUSION: Older people who present with traumatic self-inflicted injury are predominantly male, utilise violent methods, have significant psychiatric comorbidity and require psychiatric admissions.

PMID:40592662 | DOI:10.1016/j.injury.2025.112542

From early complications to delayed failures: Revision surgery after tibial plateau fracture fixation in 1027 cases

Injury. 2025 Jun 23;56(8):112543. doi: 10.1016/j.injury.2025.112543. Online ahead of print.

ABSTRACT

BACKGROUND: Tibial plateau fractures (TPFs) are complex injuries associated with significant postoperative complications including infection, deformity and wound healing disorders. Limited data exist on risk factors for complications following surgical treatment, particularly in large multicenter cohorts.

METHODS: This retrospective study analyzed 1027 patients with intra-articular TPFs treated surgically at two level-I trauma centers in Germany (2011-2020). Preoperative CT imaging and follow-up data were required for inclusion. Complications were categorized into seven groups (infection, deformity, wound healing disorders, postoperative compartment syndrome, range of motion deficit and others). Statistical analyses assessed associations with fracture type (Schatzker classification), surgical approach, duration, and patient factors (BMI, age, smoking).

RESULTS: Nineteen percent of patients required surgical revision, with deformity (5.7 %), infection (5.4 %), and wound healing disorders (3.3 %) being the most common complications. Complex fractures (Schatzker V-VI) and prolonged or multi-approach surgeries were associated with higher complication rates. Elevated BMI increased overall complication risk, while smoking was linked to wound healing disorders.

CONCLUSION: The 19 % revision rate highlights the challenges of managing TPFs. Surgical factors, including operative duration and approach, play a critical role in the occurrence of complications, emphasizing the need for tailored strategies based on fracture complexity and surgical considerations.

PMID:40577996 | DOI:10.1016/j.injury.2025.112543

Geriatric fractures presenting to emergency departments in the United States: an epidemiologic analysis of national injury data from 2019 to 2023

Injury. 2025 Jun 23;56(8):112550. doi: 10.1016/j.injury.2025.112550. Online ahead of print.

ABSTRACT

Introduction Geriatric fractures are a major contributor of morbidity and mortality in elderly patients and represent a large resource burden on healthcare institutions across the United States. Elderly populations are predicted to increase in the coming decades, motivating epidemiological studies that may inform more effective and targeted prevention measures for these injuries. Methods Data analyzed in this study was extracted from the National Electronic Injury Surveillance System (NEISS), a public database representing approximately 100 US EDs to provide national injury estimates. NEISS was queried for all fracture ED admissions among patients age 65 and older. Fracture events were restricted to injuries from January 1, 2019 to December 31, 2023. Results A geriatric fracture NEISS query resulted in 82,953 ED visits, extrapolating to a total national estimate of 3852,261 fractures presenting to US EDs across the study period. The overall hospitalization rate was 54.8 %, increasing to 74.5 % by age 99. Linear regression of fractures rates by year demonstrated a significant increase in male fractures over time (p = 0.047, β = 7688). Compared to females, males were also more likely to sustain trunk fractures and become injured at sporting facilities. Older patients also saw higher rates of trunk fractures (including upper and lower trunk), while rates of extremity fractures (upper and lower extremities) decreased with age. Fractures in the home also decreased with age, while those occurring on public property (including assisted living facilities) increased with age. Conclusion Increasing fracture rates among males indicates an opportunity for improved prevention measures among men 65 and older. Males were also more likely to sustain fractures while participating in sports, and may therefore benefit from education programs on fracture risk. Geriatric fractures were more likely to occur on public property such as sidewalks and assisted living facilities as patients aged, demonstrating the need for improved precautionary measures such as low-floor beds, hip protectors, fall alarms, and wearable devices.

PMID:40577995 | DOI:10.1016/j.injury.2025.112550

Resuscitation at a cost: Excessive perioperative crystalloid administration is associated with increased fascial complications following damage control laparotomy for trauma

Injury. 2025 Jun 17:112521. doi: 10.1016/j.injury.2025.112521. Online ahead of print.

ABSTRACT

INTRODUCTION: Over the past two decades, damage control laparotomy and resuscitation (DCL and DCR, respectively) have become the dominant paradigms for the management of exsanguinating trauma. Fascial complications are common after DCL. Minimizing crystalloid administration is a key component of DCR, but there is little direct evidence that it reduces fascial complications. This study was designed to test the hypothesis that lower crystalloid administration volume during the perioperative period for DCL is associated with an increase in fascial closure rates and a decreased rate of fascial dehiscence.

METHODS: This was a retrospective observational study at a single urban trauma center. Adult trauma patients who underwent emergent DCL between March 2019 - December 2022 were included. Patients who died within 7 days of definitive closure or underwent additional intracavitary operations (e.g., thoracotomy) before or concurrent with laparotomy were excluded. Risk factors for fascial dehiscence and planned ventral hernia (PVH) were evaluated using univariate and multiple logistic regression analysis.

RESULTS: Among 287 included patients, median age was 32 (IQR 23-44), median injury severity score (ISS) 25 (17-34), median base deficit 6 (2-9), and 56.1 % had penetrating mechanism. The median crystalloid intravenous fluid (IVF) received from prehospital period to 48 h after index operation was 16.3 L (13.0-20.1 L). ISS, base deficit, and vital signs (systolic blood pressure, heart rate, and respiratory rate) did not differ between patients discharged with PVH or primary fascial closure, nor between patients who experienced a documented dehiscence event versus those who did not. Crystalloid volume was statistically different across both comparisons (primary fascial closure vs PVH at discharge: 15.6 vs 20.5 L, p < 0.001; no dehiscence vs any dehiscence 15.0 vs 18.1 L, p < 0.001). By multiple logistic regression, early IVF administration was associated with both PVH at discharge (odds ratio (OR) 1.14, 95 %CI 1.07-1.23) and fascial dehiscence (OR 1.17, 95 %CI 1.04-1.20).

CONCLUSION: Increased volume of perioperative crystalloid is associated with higher risk of fascial complications among patients requiring DCL for trauma. The DCR paradigm may reduce surgical complications as well as mortality among patients with severe trauma requiring laparotomy.

PMID:40571541 | DOI:10.1016/j.injury.2025.112521

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