Injury. 2025 Aug 24;56(11):112716. doi: 10.1016/j.injury.2025.112716. Online ahead of print.

ABSTRACT

Pedestrian crashes are a global safety issue impacting all age groups, and despite extensive research, understanding the severity of crashes among different age groups has remained incomplete. Older and young pedestrians represent two distinct demographics with unique vulnerabilities. This paper examines the factors that impact the severity of pedestrian crashes resulting in Killed or Serious Injuries in South Australia over ten years (2012-2020) for two age groups, namely young pedestrians (age < 18) and older pedestrians (age > 65). The study employs several descriptive and analytical methods, including logistic and Classification and Regression Tree models. The findings reveal that older pedestrians are primarily involved in fatal crashes (32 %), while their young cohorts predominantly suffer from serious injuries (30 %). Young pedestrians experience more severe consequences when vehicle speeds are below 60 km/hr, but older pedestrians suffer a greater likelihood of harm at speeds beyond 60 km/hr. Age has a role in how unique elements, such as curving roadways and damp weather, affect the intensity of the impact. Young individuals are particularly drawn to motorways and one-way highways, which are prominent areas that underscore the necessity for action. Intersections, including crossroads and one-way highways, pose significant challenges for older pedestrians, underscoring the need for safety precautions. Also, there is a negative correlation between weekend crashes and log-odds of KSI compared to weekdays, which leads to lower severity for both age groups. Customizing safety protocols for distinct age cohorts is crucial for ensuring efficient crash mitigation.

PMID:40907272 | DOI:10.1016/j.injury.2025.112716

Injury. 2025 Aug 25;56(11):112727. doi: 10.1016/j.injury.2025.112727. Online ahead of print.

ABSTRACT

PURPOSE: Guidelines recommended early surgery for hip fracture to improve outcomes, yet it is often hindered by prehospital delays. However, it remains unclear whether prehospital delay independently leads to poor outcomes of the well-recognized impact of in-hospital delay for hip fracture surgery.

METHODS: We included patients aged over 60 years old who underwent surgery for their first acute hip fracture between 2000 and 2022 at a national trauma center in Beijing, China. Patients were categorized into short prehospital delay (time from injury to hospital admission ≤ 48 h) or long prehospital delay (> 48 h) groups. The primary outcome was a composite endpoint of postoperative complications, and the secondary outcome was 5-year all-cause mortality. Multivariate logistic and Cox regression models were used to assess the association between exposure and outcomes.

RESULTS: Among 3103 included patients (mean age, 78.1 ± 8.3 years; 69.1 % female), 1152 (37.1 %) experienced a long prehospital delay. Patients with long prehospital delay had a higher risk of postoperative complications (28.8 % vs. 16.8 %; adjusted odds ratio = 1.41, 95 % CI, 1.12-1.76, P < 0.01) and 5-year all-cause mortality (63.9 vs. 43.3 per 1000 person-years; adjusted hazard ratio = 1.25, 95 % CI, 1.01-1.57, P < 0.05) compared to those with short prehospital delay after adjusting for potential confounders including in-hospital delay.

CONCLUSION: Prehospital delays is associated with higher risk of postoperative complications and 5-year mortality in older adults with hip fractures, highlighting the need for public health policies to minimize such delays.

PMID:40907271 | DOI:10.1016/j.injury.2025.112727

Injury. 2025 Aug 28;56(11):112730. doi: 10.1016/j.injury.2025.112730. Online ahead of print.

ABSTRACT

BACKGROUND: Substance use disorders (SUD) are common and associated with trauma [1-5]. Despite the high frequency of patients with SUDs presenting with trauma and the ubiquitous concerns about compliance, follow-up, and complications amongst providers caring for these patients there has been little attempt to quantify outcomes in this everyday group of patients. The purpose of the current study was thus to document basic demographics, follow-up rates, and surgical outcomes in orthopedic trauma patients presenting with substance use disorders.

METHODS: A retrospective review of an observational cohort was performed. All skeletally mature patients younger than 70 and with insurance that allowed long term follow-up and surgically treated for orthopedic trauma by a single author at an urban level-1 trauma center between November 2019 and December 2024 were enrolled. 202 patients did not have a pre-existing substance use disorder (NO-SUD), 96 patients did (SUD). Basic demographic information, injury characteristics, follow-up rates, and surgical complication rates over the first post-operative year were compared.

RESULTS: Mean age and percentage of male/female did not differ between SUD and NO-SUD cohorts. There were more white and fewer Asian/Pacific Islanders in the SUD cohort. Of the 10 most common comorbidities, there was only a significantly higher rate of congestive heart failure (CHF) in the SUD cohort. Injury location did not differ between cohorts. Those in the SUD cohort more often had high grade open fractures. Follow-up rates in both groups were poor, but worse at all time points for those in the SUD cohort. The SUD cohort also had significantly longer lengths of stay and a higher mortality rate at 1 year. Infection, construct failure, and amputations rates were all higher in the SUD cohort.

CONCLUSIONS: Demographics between the SUD and NO-SUD populations were similar. Injury severity, follow-up rates, and complication rates were all significantly worse in the SUD cohort. Such data can be used by surgeons to council patients on prognosis and when discussing the risks and benefits of surgical intervention in the SUD population.

LEVEL OF EVIDENCE: III.

PMID:40902314 | DOI:10.1016/j.injury.2025.112730

Injury. 2025 Aug 24;56(11):112715. doi: 10.1016/j.injury.2025.112715. Online ahead of print.

ABSTRACT

BACKGROUND: Urban expansion into natural habitats has increased human interactions with wild terrestrial and aquatic species, leading to a rise in animal-related injuries. These incidents often result in complex infections, posing major public health challenges. This study examines the epidemiology, therapeutic interventions, and clinical outcomes of infections from non-domesticated animal injuries in the Mornington Peninsula, Australia.

METHODS: This retrospective study (February 2021-April 2024) evaluated medical records of patients presenting with injuries from wild species who subsequently developed infections. Selection criteria included only cases with confirmed infections determined by clinical assessment or positive microbial cultures. Injuries from domestic animals, insects, or humans were excluded. The analysis assessed timing of infection onset, microbial culture results, antibiotic sensitivity profiles, and postoperative trajectories.

RESULTS: A total of 52 bites from non-domesticated animals were documented, with 23 % (12/52) being infected. Most were males with an average age of 43 years. Among the 12 infected cases, Staphylococcus aureus was isolated in 3/12 (25 %), β-haemolytic streptococci in 2/12 (17 %), Enterococcus faecalis in 1/12 (8 %), Pseudomonas aeruginosa in 1/12 (8 %), Prevotella bivia in 1/12 (8 %), and Vibrio vulnificus in 1/12 (8 %); mixed coliform growth was observed in 3/12 (25 %). Compared to typical dog and cat bites, usually caused by Pasteurella multocida, streptococci, staphylococci and anaerobes, our series revealed a higher presence of marine-associated pathogens such as Vibrio species and environmental Gram-negative bacilli. Management involved wound debridement with adjunctive medical therapy (7/12), delayed primary closure (3/12), and medical management alone (3/12). All patients received empirical broad-spectrum antibiotics, which were later adjusted based on culture results. Most isolates were pan-sensitive, except for Vibrio vulnificus (ciprofloxacin-sensitive, resistant to penicillins/cephalosporins) and penicillin-resistant Staphylococcus aureus. All patients recovered without complications following comprehensive wound care and targeted antibiotic therapy. Notably, some marine-derived infections exhibited unique resistance patterns that required specific antimicrobial regimens.

CONCLUSIONS: The necessity for immediate comprehensive wound management and empirically guided antibiotic therapy, adjusted based on culture results, was essential for managing these complex infections. The data derived from this study provides essential insights into the microbial dynamics and clinical management of wild animal bite infections, emphasizing the need for individualized medical strategies.

PMID:40902313 | DOI:10.1016/j.injury.2025.112715

Injury. 2025 Aug 28;56(11):112729. doi: 10.1016/j.injury.2025.112729. Online ahead of print.

ABSTRACT

BACKGROUND: Major limb amputation salvage procedures exhibit an increased risk of failure when revascularization is delayed beyond 360 min. Institutional delays persist as critical barriers, even with advancements in surgical techniques.

METHODS: Retrospective cohort study (November 2022- December 2024) at Level I Trauma Center. We implemented a systematized emergency protocol featuring: Prehospital activation → Green channel → OR-direct transport Parallel processing → revascularization.

PRIMARY OUTCOME: Revascularization time (limb arrival → arterial flow).

RESULTS: 30 consecutive amputees (M: F = 21:9; mean age 43.6 ± 14.35 yrs). Included 21 upper limbs (6 wrist, 9 forearm, 6 upper arm) and 9 lower limbs (6 ankle, 3 calf). Revascularization achieved in 142.0 ± 21.17 mins. All cases (100 %) met the ≤180-min golden window. Key timings: Door-to-OR: 19.7 ± 3.2 mins, OR preparation: 20 ± 3.45 mins, Surgery start to revascularization: 102.3 ± 19.8 mins. Limb survival rate reached 96.7 % (29/30). Vascular bridging reconstruction was performed in 17 cases (including 5 cases with emergent anterolateral thigh (ALT) flap arteriovenous bridging). Vascular crisis occurred in 2 cases and was relieved after surgical exploration. The final limb amputation salvage rate was 96.7 % (29/30). One case of ankle-level salvage resulted in postoperative infection and necrosis. At 12-month follow-up, 80 % of upper limbs achieved grasp function (S2-S4 sensibility), and 89 % of lower limbs regained ambulation without prosthesis.

CONCLUSION: The multidisciplinary emergency protocol significantly reduced ischemia time, with rapid revascularization serving as the critical determinant of high limb amputation salvage rates. The protocol achieved functional limb salvage in 83 % of cases, demonstrating that rapid revascularization correlates with both viability and functional recovery.

PMID:40897128 | DOI:10.1016/j.injury.2025.112729

Injury. 2025 Aug 24;56(11):112717. doi: 10.1016/j.injury.2025.112717. Online ahead of print.

ABSTRACT

BACKGROUND: Coronoid fractures significantly impact elbow stability, yet limited biomechanical data exists comparing fixation methods for different fracture types. This study aimed to compare the biomechanical performance of threaded K-wire versus cortical screw fixation in O'Driscoll type 2 and 3 coronoid fractures.

METHODS: Twenty-eight synthetic ulnar bones were divided into four groups (n = 7 each): Type 2 with K-wire fixation, Type 2 with screw fixation, Type 3 with K-wire fixation, and Type 3 with screw fixation. Fractures were created, reduced, and fixed under fluoroscopic guidance. Specimens underwent biomechanical testing using a custom-made apparatus to evaluate load to failure (N), displacement (mm), and stiffness (N/mm). Two-way ANOVA and post-hoc Tukey's tests were used for statistical analysis.

RESULTS: Type 2 fractures with screw fixation demonstrated the highest load to failure (1392.59 ± 76.77 N), followed by Type 2 with K-wire fixation (1155.00 ± 200.81 N), Type 3 with K-wire fixation (1093.65 ± 248.68 N), and Type 3 with screw fixation (1058.54 ± 320.46 N), though differences were not statistically significant (p = 0.086). For stiffness, Type 2 fracture fixation fractures exhibited significantly higher values (∼256 N/mm) compared to Type 3 fractures (∼160 N/mm) regardless of fixation method (p = 0.002, Cohen's d = 1.55). The fixation method itself (K-wire vs. screw) did not significantly affect any biomechanical parameter (p > 0.05).

CONCLUSION: O'Driscoll Type 2 fracture fixation provide superior biomechanical stability compared to Type 3 fractures, primarily through enhanced stiffness. While Type 2 screw fixation demonstrated the highest load to failure values, K-wire fixation in Type 2 fractures offered comparable stiffness. These findings suggest that fracture type has a more profound impact on mechanical performance than the choice between K-wire and screw fixation, giving surgeons flexibility in fixation choice for Type 2 fractures while maintaining adequate stability for early rehabilitation.

PMID:40889444 | DOI:10.1016/j.injury.2025.112717

Injury. 2025 Aug 19;56(11):112686. doi: 10.1016/j.injury.2025.112686. Online ahead of print.

ABSTRACT

Percutaneous fixation of the pubic symphysis is a relatively novel treatment strategy in the management of pelvic ring injuries with symphyseal disruption. While the current gold standard for surgical treatment of pubic symphysis diastasis is open reduction and plate fixation, high rates of implant failure and recurrent diastasis persist. Furthermore, blood loss, operative time, and postoperative infection associated with open approaches to the pelvis should be considered. Percutaneous fixation of the posterior pelvic ring has proven to be safe and effective. Percutaneous fixation of the pubic symphysis has been described in China and Spain, with promising results. We present here our surgical technique for percutaneous reduction and fixation of the pubic symphysis with emphasis on the risks to nearby anatomic structures.

PMID:40889443 | DOI:10.1016/j.injury.2025.112686

Injury. 2025 Aug 25;56(11):112690. doi: 10.1016/j.injury.2025.112690. Online ahead of print.

ABSTRACT

BACKGROUND: The incidence of proximal humerus fractures is rising, with increasing use of reverse total shoulder arthroplasty (rTSA). This study analyzed treatment trends, readmission rates, and causes of readmission.

METHODS: The Nationwide Readmissions Database (NRD) was queried for admissions with a primary diagnosis of proximal humerus fracture in the U.S. (2016-2021) using ICD-10 codes. Patient demographics, comorbidities, facility characteristics, and 30-/90-day readmission rates were analyzed. Treatments included non-operative (Non-Op), hemiarthroplasty (HA), anatomic total shoulder arthroplasty (aTSA), rTSA, open reduction internal fixation (ORIF), and intramedullary nailing (IMN).

RESULTS: Among 218,425 admissions, rTSA use increased (20.27 % to 22.30 %), while ORIF decreased (20.77 % to 14.86 %). Non-Op had the highest readmission rates at 30- and 31-90 days (10.5 % and 8.9 %), even after adjusting for age/comorbidities. rTSA had the lowest readmission rates (5.9 % and 4.6 %), with instability being the most common cause.

CONCLUSION: There is a trend towards increased rTSA utilization for treating proximal humerus fractures. The readmission rate following rTSA was the lowest of all treatment modalities, including non-operative management.

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

PMID:40889442 | DOI:10.1016/j.injury.2025.112690

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