Injury. 2025 Oct 31;56(12):112861. doi: 10.1016/j.injury.2025.112861. Online ahead of print.

ABSTRACT

BACKGROUND: Occupational injuries continue to be a significant health problem worldwide. The aim of this study is to define the epidemiological characteristics of occupational injuries and to evaluate their relationship with obstructive sleep apnea (OSA) and daytime sleepiness.

METHODS: This cross-sectional study included consenting patients who were admitted to Balıkesir Atatürk City Hospital Emergency Service due to occupational injuries between April-June 2024. The questionnaire form was used as a data collection tool and consisted of sociodemographic characteristics, clinical characteristics, work-related characteristics, previous occupational injuries, Epworth Sleepiness Scale, and Berlin Questionnaire. SPSS program was used for data entry and analysis. Descriptive statistics are presented as percentage, mean, standard deviation, median, minimum, and maximum values. Fisher's Exact test and Mann-Whitney U test were used in the analyses. Statistical significance value was accepted as p < 0.05.

RESULTS: During the study period, 101 out of 325 occupational injury admissions consented to participate in the study. Of the participants 32.7 % were female and the mean age of all participants was determined as 39.9 years(±10.3). Of the participants 31.7 % stated that they had previously sustained an occupational injury before the current admission and 44.6 % of them stated that they worked night shifts. According to the Berlin Questionnaire results, 9.9 % of the participants were at high risk for OSA and 5.9 % had high daytime sleepiness. 15.6 % of the 32 participants who had a prior occupational injury were at high risk for OSA while 84.4 % were at low risk. Of those who had not had an occupational injury before, 6.8 % were at high risk and 62.2 % were at low risk. There was no significant difference between the Berlin Questionnaire results according to the participants' previous occupational injury status (p = 0.281).

CONCLUSION: Occupational injuries tend to occur more frequently on Mondays and Tuesdays of the week and in male workers; furthermore, soft tissue injuries are the most common cause for emergency service admissions. Implementing educational programs and routine reminders regarding occupational safety during the start of the work week could be an effective measure to prevent these injuries.

PMID:41202587 | DOI:10.1016/j.injury.2025.112861

Injury. 2025 Oct 30;56(12):112852. doi: 10.1016/j.injury.2025.112852. Online ahead of print.

ABSTRACT

PURPOSE: Closed reduction and percutaneous pinning are the standard surgical treatment for displaced pediatric supracondylar humerus fractures. However, in some cases, open reduction is necessary. Research on this subject has not reached a consensus, and patient and fracture characteristics that can predict the need for closed or open reduction prior to treatment have not been clearly defined. In this study, we conducted a comprehensive evaluation of these characteristics with the aim of identifying variables that can predict the need for closed or open reduction.

MATERIALS AND METHODS: The study population consisted of patients aged 2 to12 years with supracondylar humerus fractures who underwent surgery at our institution's pediatric orthopedic and traumatology clinic between January 2013, and January 2021. The participants' demographic data and preoperative physical examination findings, the radiographic characteristics of the fractures, and the timing of surgery were recorded. The identified potential predictors were evaluated by multivariate logistic regression analysis.

RESULTS: Univariate analyses revealed that sex,the presence of rotation,the fracture type, the displacement direction, the fracture orientation, and the fracture subtype in the coronal plane were important factors in determining the need for closed or open reduction (P = 0.034,<0.001, 0.028,<0.001,0.001,0.007, respectively). These variables were included in a multivariate regression analysis. The multivariate model showed a 0.37-fold increase in the need for open reduction in cases of rotation (OR 0.376;CI: 0.196-0.724). A 6.36-fold increase (OR 6.359;CI: 2.540-15.920) was observed in cases where the fracture fragment was displaced posteriorly. When the fracture fragment was varus-oriented,there was a 3.85-fold increase in the likelihood of closed reduction (OR 3.848;CI: 1.506-9.831).

CONCLUSION: We found that the presence of rotation increases the likelihood that open reduction will be required for supracondylar humerus fractures.Posterior displacement of the fracture fragment and varus fracture orientation increases the likelihood of closed reduction. Hence, to achieve better clinical outcomes, we recommend that surgeons assess these factors when planning surgery for pediatric patients with supracondylar humerus fractures.

PMID:41202586 | DOI:10.1016/j.injury.2025.112852

Injury. 2025 Nov 1:112868. doi: 10.1016/j.injury.2025.112868. Online ahead of print.

ABSTRACT

We commend Bassa et al.'s study on VTE risk in acute SCI patients. We propose further exploring rehabilitation strategies, genetic polymorphisms (e.g., factor V Leiden), and inflammatory markers (e.g., CRP, IL-6) to refine personalized VTE prophylaxis and management in this population.

PMID:41198497 | DOI:10.1016/j.injury.2025.112868

Injury. 2025 Oct 31:112858. doi: 10.1016/j.injury.2025.112858. Online ahead of print.

NO ABSTRACT

PMID:41198496 | DOI:10.1016/j.injury.2025.112858

Injury. 2025 Nov 2;56(12):112864. doi: 10.1016/j.injury.2025.112864. Online ahead of print.

ABSTRACT

BACKGROUND: Open reduction and internal fixation (ORIF) is a standard treatment for lower extremity fractures, but the influence of body mass index (BMI) on postoperative outcomes is not well established. This study aims to evaluate the impact of BMI on short term and long term postoperative outcomes in patients undergoing ORIF for lower extremity fractures.

METHODS: We performed a prospective future-in-the-past cohort analysis using the TriNetX US network including adult patients undergoing lower extremity ORIF between 2003-2023 and with a minimum of 2-year follow-up. Patients were divided into obese (BMI ≥30) and nonobese (BMI <30) groups. Propensity score matching (1:1) controlled for age, race/ethnicity, and medical comorbidities. A subgroup analysis by BMI categories was also conducted. Risk ratios (RRs), 95 % confidence intervals (CIs) and p-values were calculated; categorical variables were analyzed with chi-squared tests and continuous variables with t-tests.

RESULTS: At 90 days postoperatively, patients with obesity (BMI ≥30) showed significantly increased risks of pulmonary embolism (RR 1.55, P < 0.0001), deep vein thrombosis (RR 1.30, P < 0.0001), renal failure (RR 1.217, P < 0.0001), wound disruption (RR 1.198, P = 0.017), and postoperative infections (RR 1.224, P < 0.0001) compared to nonobese patient (BMI<30). At 2 years, obesity was associated with higher risks of post-traumatic osteoarthritis (RR 1.61, P < 0.0001), malunion (RR 1.241, P = 0.001), nonunion (RR 1.293, P < 0.0001), and implant removal (RR 1.05, P < 0.002). Stratified analysis showed that complication rates rose progressively with BMI, with morbidly obese patients (BMI ≥50) having the highest risk of pulmonary embolism (RR 3.16, P = 0.001) and with severely obese patients (BMI 40-49.9) having a higher risk of mechanical failures (implant removal RR 1.21, P < 0.001). Underweight patients (BMI <18.5) had higher short-term risks of admission and pneumonia but lower long-term implant removal rates (RR 0.86, P = 0.006).

CONCLUSION: Higher BMI is significantly associated with increased short- and long-term postoperative complications following ORIF for lower extremity fractures. These findings emphasize the importance of preoperative risk assessment and postoperative monitoring in obese and severely obese patients to improve surgical outcomes.

LEVEL OF EVIDENCE: Level III, Prospective Cohort.

PMID:41197500 | DOI:10.1016/j.injury.2025.112864

Injury. 2025 Oct 31;56(12):112875. doi: 10.1016/j.injury.2025.112875. Online ahead of print.

ABSTRACT

OBJECTIVES: The optimal initial immobilization method for humeral shaft fractures remains undefined. This study evaluates whether initial emergency department (ED) immobilization type affects fracture alignment or the likelihood of requiring unplanned surgical intervention.

METHODS: Adult patients (≥18 years) with humeral shaft fractures (OTA/AO 12) treated between May 2018 and July 2023 at a single level I academic trauma center were included. Exclusion criteria were pediatric patients, open fractures (except ballistic injuries), and inadequate pre- or post-immobilization radiographs. Patients were grouped based on initial ED immobilization: posterior long-arm splint (PLA), cuff and collar sling, or coaptation splint/functional brace. The primary outcome was change in coronal and sagittal alignment following initial immobilization. Secondary outcomes included the proportion of patients achieving acceptable alignment (<30° coronal, <20° sagittal angulation) and the rate of unplanned surgical intervention despite an initial non-operative treatment plan. Multivariable regression analyses controlled for confounding variables.

RESULTS: Sixty-five patients met inclusion criteria (PLA: 22, cuff and collar: 24, functional brace/coaptation splint: 19). Groups were similar in demographics, injury mechanism, and initial alignment. Mean improvement in coronal and sagittal alignment was 8.3° and 7.3°, respectively, with no significant differences between immobilization types (p = 0.732, p = 0.623). Post-immobilization, 86.2 % of patients achieved acceptable alignment (p = 0.148). Among patients initially managed non-operatively, 10.9 % required unplanned surgery, with no significant differences between groups (p = 0.703).

CONCLUSIONS: Initial ED immobilization type does not significantly impact fracture alignment or unplanned surgical intervention. These findings support the feasibility of multiple immobilization methods, allowing patient comfort, resource availability, and cost considerations to guide decision-making.

LEVEL OF EVIDENCE: Level III.

PMID:41197499 | DOI:10.1016/j.injury.2025.112875

Injury. 2025 Oct 28:112851. doi: 10.1016/j.injury.2025.112851. Online ahead of print.

NO ABSTRACT

PMID:41193329 | DOI:10.1016/j.injury.2025.112851

Injury. 2025 Oct 31;56(12):112860. doi: 10.1016/j.injury.2025.112860. Online ahead of print.

ABSTRACT

OBJECTIVES: Open ankle fractures in the geriatric population display poor outcomes. However, limited data exists comparing operative outcomes between open and closed geriatric ankle fractures. Our purpose was to investigate differences in perioperative complications and mortality among open and closed ankle fractures in geriatric patients.

METHODS: The TriNetX US Collaborative Network database was queried to identify patients aged 65 and older who experienced operatively treated, isolated open or closed ankle fractures between 2014 and 2024. Patients were divided into two propensity-matched cohorts depending on open vs closed injuries. Rates of complications and mortality were compared between operatively treated open and closed ankle fractures in geriatric patients.

RESULTS: Overall, 27,860 patients met inclusion criteria. Of these, 25,257 (90.7 %) sustained closed ankle fractures and 2603 (9.3 %) sustained open ankle fractures. After 1:1 propensity matching, each cohort included 2565 patients. At early time points (<30 days), DVT, MI, sepsis, pneumonia, AKI, ABLA, opioid use, deep infection, ED visits and rehospitalizations were higher in open ankle fractures (p < 0.05). At delayed time points from 90 days to 1 year, DVT, pneumonia, ARDS, AKI, ABLA, SSI, deep infection, sepsis, BKA, emergency department visits, rehospitalizations and death remained significantly higher in open ankle fractures (p < 0.05). Notably, open ankle fractures had significantly increased rates of mortality at 90 days (p = 0.007), 180 days (p = 0.004), and 1 year (p < 0.0001). At 1 year, bimalleolar and trimalleolar open ankle fractures also demonstrated significantly higher mortality rates (p < 0.05).

CONCLUSIONS: Open geriatric ankle fractures, irrespective of fracture morphology, demonstrate significantly higher rates of mortality and postoperative complications including DVT, MI, pneumonia, AKI, sepsis, SSI, deep infections, BKA, emergency department visits and rehospitalizations. Our findings suggest the need for enhanced perioperative counseling and preventative strategies to address modifiable risk factors in geriatric orthopaedic patients undergoing operative fixation for open ankle fractures.

LEVEL OF EVIDENCE: retrospective cohort study, level of evidence III.

PMID:41192085 | DOI:10.1016/j.injury.2025.112860

Injury. 2025 Oct 25;56(12):112846. doi: 10.1016/j.injury.2025.112846. Online ahead of print.

ABSTRACT

BACKGROUND: Computed tomography (CT) is the current reference standard for evaluating intra-articular distal radius fractures, however concerns remain regarding radiation exposure and limited soft tissue assessment. Zero Echo Time (ZTE) MRI is a novel technique that enables direct cortical bone imaging with contrast similar to CT, while avoiding radiation. This proof-of-concept study aimed to compare the diagnostic performance of ZTE MRI with CT in fracture classification, articular involvement, and treatment planning.

METHODS: In this prospective comparative study, 28 patients with acute intra-articular distal radius fractures underwent both CT and ZTE MRI within 7 days of injury. Fractures were classified according to AO/OTA, Fernandez classifications, quantitative parameters (angulation, radial inclination, ulnar variance, articular fragment count) and binary findings (distal ulna fracture, distal radioulnar joint (DRUJ) involvement) were assessed. Two orthopedic surgeons and two musculoskeletal radiologists independently reviewed all images. Inter- and intraobserver agreement was calculated using Cohen's and Fleiss' kappa and intraclass correlation coefficients.

RESULTS: Agreement among surgeons for AO/OTA classification was good on CT (κ = 0.767) and good on ZTE MRI (κ = 0.680). For Fernandez classification, agreement was good on CT (κ = 0.780) and ZTE (κ = 0.736). Surgeons demonstrated higher agreement (κ ≈0.68-0.78) than radiologists (κ ≈0.56-0.65). For binary parameters, agreement among radiologists was very good (κ = 0.820-0.880), while inter-surgeon agreement ranged from moderate to good (κ = 0.500-0.714). Continuous measures showed good reproducibility for angulation (ICC = 0.762-0.858), but lower values for inclination among surgeons (ICC ≤ 0.492-0.531). ZTE MRI demonstrated sensitivity, specificity, and accuracy comparable to CT for classification and detection of DRUJ involvement and distal ulna fractures (approximately 85-93 %). Treatment decisions showed very good agreement (κ = 0.855), with ZTE altering CT-based management in 3/28 (10.7 %) cases for Surgeon 1 and 2/28 (7.1 %) for Surgeon 2.

CONCLUSION: ZTE MRI provides diagnostic performance comparable to CT for intra-articular distal radius fractures, with high reliability for fracture classification, joint involvement, and treatment decision-making. As a radiation-free modality that also permits concurrent soft tissue assessment, ZTE MRI may serve as a promising alternative to CT in selected clinical scenarios.

PMID:41187521 | DOI:10.1016/j.injury.2025.112846

Injury. 2025 Oct 29;56(12):112844. doi: 10.1016/j.injury.2025.112844. Online ahead of print.

ABSTRACT

INTRODUCTION: Patients with moderate to severe traumatic brain injury (TBI) often face prolonged rehabilitation. These individuals experience elevated nutrition needs and barriers to normal eating behaviours, necessitating effective nutrition therapy to enhance rehabilitation and recovery. Existing nutrition research focuses on intensive and acute care settings, with a notable lack of evidence in the rehabilitation and subacute contexts. This scoping review aims to describe evidence on nutrition therapy and outcomes for adult patients with moderate to severe TBI in inpatient rehabilitation and subacute settings and identify gaps to guide future research.

METHODS: A systematic scoping review was conducted in accordance with PRISMA guidelines, comprising of a literature search of CINAHL and MEDLINE for studies published between January 2010 and August 2024. Articles were included if they were: quantitative studies in adults (≥16 years) with a moderate to severe TBI, admitted to a rehabilitation or subacute facility, that addressed an aspect of nutrition therapy. Data were extracted on study design, patient characteristics, TBI severity, and nutrition-related results. Data were categorised and synthesised according to the study design, nutrition intervention, and outcomes.

RESULTS: A total of seventeen studies were identified, comprising between 7 to 1701 participants. Among these, nine studies were prospective observational, seven were retrospective observational, and one was a randomised controlled trial. The investigations covered various aspects of nutrition management: ten focused on the route of nutrition delivery, four assessed nutrition status, three evaluated specific nutrient intakes, and one examined eating behaviours (two studies addressed multiple interventions).

CONCLUSION: Evidence on nutrition management practices for patients with a TBI admitted to a rehabilitation or subacute setting is sparce, with only one interventional study identified, and observational studies predominantly exploring route of nutrition delivery. Further research is essential to delineate optimal nutritional therapies for adults with TBI in rehabilitation and subacute settings to guide clinical care.

PMID:41187520 | DOI:10.1016/j.injury.2025.112844

Injury. 2025 Oct 29;56(12):112850. doi: 10.1016/j.injury.2025.112850. Online ahead of print.

ABSTRACT

INTRODUCTION: Sacral fractures are an increasingly recognized clinical entity, particularly among older adults with osteoporosis. However, national-level data on long-term trends in incidence, diagnostic imaging, treatment strategies, and the recognition of underlying bone fragility remain limited. This study aimed to evaluate nationwide trends in sacral fracture care in Germany over a 19-year period.

METHODS: We conducted a retrospective analysis of all inpatient cases with a primary diagnosis of sacral fracture (ICD-10-GM: S32.1) recorded in the German Federal Statistical Office database from 2005 to 2023. Fragility fractures were defined as cases in patients aged ≥65 years. Outcomes included use of CT and MRI (OPS codes), surgical versus conservative treatment, and coded diagnoses of osteoporosis (ICD-10: M80-M82). Time trends were analyzed using linear regression; group comparisons were conducted with t-tests and chi-square tests (p < 0.05).

RESULTS: A total of 162,116 sacral fractures were identified. Annual cases increased from 1,861 in 2005 to 7,695 in 2023. Fragility fractures in women aged ≥65 years rose significantly, from 985 to 12,901 cases (p < 0.0001). CT use increased by 241% and MRI by 175%, with a significant shift toward CT as the preferred modality (p < 0.0001). Despite increased access to minimally invasive options, surgical treatment rates remained stable at approximately 20% (p = 0.15). Osteoporosis was documented in only 1.5% of cases.

CONCLUSIONS: The incidence of sacral fractures in Germany has risen markedly, driven by an aging population and under-recognized bone fragility. While cross-sectional imaging use has expanded, surgical treatment remains underutilized, and osteoporosis continues to be grossly underdiagnosed. These findings underscore a systemic gap in secondary prevention and highlight the need for integrated, bone-focused trauma care models.

PMID:41183411 | DOI:10.1016/j.injury.2025.112850

Injury. 2025 Oct 19;56(12):112843. doi: 10.1016/j.injury.2025.112843. Online ahead of print.

ABSTRACT

OBJECTIVE: To evaluate total ankle arthroplasty (TAA) using 3D-printed navigation-assisted osteotomy with patient-specific cutting guides and standard implants, compared with conventional TAA.

METHODS: This retrospective analysis included 82 individuals diagnosed with end-stage ankle arthritis who received total ankle arthroplasty (TAA) between January 2020 and June 2023.Based on surgical technique, patients were divided into a patient-specific instrumentation (PSI) group (n = 33) and a control group (n = 49). The PSI group received preoperative 3D CT-based planning for personalized osteotomy guides patient-specific and implants, while the control group underwent standard procedures. Perioperative parameters, functional recovery (dorsiflexion, plantarflexion, MOXFQ, FAAM), radiographic alignment (α angle, β angle, ADTA), and complication rates were compared.

RESULTS: The PSI group showed significant advantages over the control group in operative time (1.01 ± 0.09 h vs. 1.47 ± 0.15 h)(P < 0.01). At 12 months postoperatively, the PSI group demonstrated significantly greater improvements in ankle dorsiflexion and plantarflexion range of motion, MOXFQ, and FAAM scores (all P < 0.01). Radiographic assessments indicated that the PSI group achieved superior correction and consistency in α angle, β angle, and ADTA compared to the control group (P < 0.01). The overall complication rate was significantly lower in the PSI group (2/33 vs 6/49, P < 0.05), with no cases of prosthesis subsidence or revision reported.

CONCLUSIONS: This approach improves surgical accuracy and efficiency, accelerates recovery, and reduces complications, supporting its use for precise management of end-stage ankle arthritis.

PMID:41175699 | DOI:10.1016/j.injury.2025.112843

Injury. 2025 Oct 25:112845. doi: 10.1016/j.injury.2025.112845. Online ahead of print.

ABSTRACT

INTRODUCTION: American College of Surgeons Committee on Trauma (ACS/COT) policy now requires that United States trauma centers perform mandatory posttraumatic stress disorder (PTSD) screening and referral, as well as alcohol screening and intervention. Few investigations, however, have evaluated patterns of trauma center mental health and substance use inpatient service delivery.

METHODS: The investigation was a secondary analysis of a randomized clinical trial in which screening and referral practices mirrored ACS/COT policy requirements. Hospitalized physical injury survivors ≥18 years of age underwent screening for elevated levels of PTSD symptoms. Symptomatic patients were randomized to either enhanced usual care control or collaborative care intervention conditions. Patients randomized to the enhanced usual care control condition underwent PTSD screening followed by a study team orchestrated trauma surgery referral recommendation for mental health and/or substance use services. One or more inpatient referral suggestions were made for the Psychiatry Consultation Liaison, Rehabilitation Psychology, Social Work, Spiritual Care, and Alcohol Screening, Brief Intervention and Referral (SBIRT)/Addiction Medicine Consult services. Patients randomized to the intervention condition were screened and received care from a trauma center based collaborative care team that addressed mental health and substance use problems, but did not receive inpatient referrals. Electronic medical record review documented the frequency of mental health and substance use consulting service visits. Analyses determined if randomization status or referral significantly contributed to the likelihood of receiving inpatient services.

RESULTS: Enhanced usual care patients were significantly more likely to receive one or more visits from any service when compared to intervention patients (odds ratio (OR)=1.91, 95 % confidence interval (95 % CI) =1.05, 3.57). Study team referral suggestions were associated with an increased likelihood of Addiction Medicine Consult (OR=9.14, 95 % CI =3.36, 25.60) and SBIRT visits (OR=7.15, 95 % CI =3.33, 15.39) for enhanced usual care patients.

CONCLUSION: Usual care patients experienced significantly enhanced inpatient service delivery when randomized to procedures that mirror ACS/COT policy requirements. In the United States, ACS/COT screening, intervention, and referral requirements may be associated with improved quality of trauma center mental health and substance use service delivery.

CLINICAL TRIAL REGISTRATION: NCT03569878.

PMID:41173731 | DOI:10.1016/j.injury.2025.112845

Injury. 2025 Nov;56 Suppl 1:112687. doi: 10.1016/j.injury.2025.112687.

ABSTRACT

Firearm-related vascular trauma is a significant public health issue in Cape Town, South Africa, where gunshot wounds (GSWs) are a leading cause of penetrating extremity injuries. This commentary reviews the experience of Groote Schuur Hospital's Trauma Centre in managing extremity arterial injuries due to GSWs. Groote Schuur Hospital is a tertiary academic institution situated in Cape Town, South Africa. As one of the country's foremost teaching hospitals, we serve a population of approximately 4 million people from the greater Cape Town metropolitan area and surrounding regions. On average, we manage approximately 1000 trauma patients per month, including both blunt and penetrating trauma. We are a designated Level 1 Trauma Centre, offering comprehensive emergency trauma care. Our facility is equipped with advanced imaging modalities, including Lodox full-body radiography, standard X-rays, CT scanning, MRI, and interventional radiology. We also have 24-h access to fully staffed and operational trauma theatres, ensuring timely surgical intervention when required. The institutional approach emphasizes life-saving interventions, restoration of perfusion, limb preservation, and function. Vascular trauma, though infrequent, is more common in penetrating than blunt injuries, with the brachial and femoral arteries most commonly affected. Patient management is dictated by hemodynamic status and limb viability, using ATLS® principles and tools like the ankle-brachial index (ABI), arterial pressure index (API), duplex ultrasound, and computed tomography angiography (CTA). While open surgery remains the cornerstone for definitive repair, endovascular techniques are increasingly utilized in selected cases. Fasciotomy plays a critical role in preventing compartment syndrome in high-risk patients. Outcomes are influenced by injury severity, time to intervention, and associated injuries, with delayed care contributing significantly to limb loss and mortality. Although patient and limb survival is achievable with timely management, long-term complications, including graft failure, chronic pain, and psychological impact, are common. Improving outcomes requires systemic investment in trauma care, from prehospital triage to post-operative rehabilitation and follow-up.

PMID:41173560 | DOI:10.1016/j.injury.2025.112687

Injury. 2025 Nov;56 Suppl 1:112782. doi: 10.1016/j.injury.2025.112782.

NO ABSTRACT

PMID:41173559 | DOI:10.1016/j.injury.2025.112782

Injury. 2025 Nov;56 Suppl 1:112773. doi: 10.1016/j.injury.2025.112773. Epub 2025 Sep 22.

ABSTRACT

Acute Compartment Syndrome (ACS) is a time-critical, limb-threatening condition best characterized by increased intracompartmental pressure that compromises tissue perfusion, leading to ischemia, hypoxia, and ultimately irreversible necrosis. Fractures to the extremities account for >80 % of all ACS cases, and those involving the tibia account for more than two-thirds of all ACS cases. Open fractures and those secondary to high-energy trauma and penetrating injuries like gunshots are at higher risk of ACS. Despite decades of research and technological advancement, early diagnosis has remained a significant clinical challenge due to the nonspecific symptoms and the absence of a definitive diagnostic gold standard. This review aims to provide a comprehensive overview of the pathophysiology, risk factors, diagnostic modalities, and current challenges associated with ACS. It emphasizes the importance of shifting the diagnostic paradigm from binary criteria toward objective outcome-based clinical decision-making. ACS should be redefined as a pathophysiological continuum rather than a binary diagnosis. Accurate, early recognition, and timely intervention are crucial for minimizing long-term morbidity. Future diagnostic approaches should prioritize objective markers of tissue health and clinical outcomes over static thresholds. Several learned bodies have recommended continuous pressure measurement, which is seen in the newer literature as highly accurate. Continued research is needed to develop standardized classification systems or treatment protocols.

PMID:41173558 | DOI:10.1016/j.injury.2025.112773

Injury. 2025 Nov;56 Suppl 1:112753. doi: 10.1016/j.injury.2025.112753.

ABSTRACT

BACKGROUND: The optimal treatment for intracapsular neck of femur fractures secondary to civilian gunshot injuries (GSI) remains a challenge. Surgical fixation is associated with a high failure rate due to avascular necrosis and non-union. This manuscript reports on the largest series of patients who underwent total hip arthroplasty (THA) for civilian GSI involving the hip joint. The objectives are to assess clinical outcomes and to report on complications as well as associated injuries.

METHODS: All patients who had undergone THA for a civilian GSI to the hip joint at a single Level 1 Trauma Centre from 2009 -2022 were included. Patients with incomplete clinical records were excluded.

RESULTS: A total of 14 patients were identified, and all were males with an average age of 32 years (range 18-49). The mean follow-up time was 20 months (range 2 - 108). Ten of these patients received acute primary THA, whilst 4 had delayed THA for failed open reduction and internal fixation. The average time to surgery for the acute group was 7,6 days (range 3 - 14) and for the delayed group it was 39 months (range 10 - 120). Visceral injuries, mostly bowel and bladder, and other pelvis ring fractures, were the most commonly encountered associated injuries. One patient (7%) developed prosthetic joint infection (PJI) within 2 weeks of acute primary THA, despite negative microbiological samples obtained at index THA. He had associated large bowel injury, caused by a different projectile with no direct communication with the hip joint. No patients presented with PJI in the delayed group. In the delayed THA cohort, the mean pre-operative Harris Hip Score (HHS) was 53.2 points, and the mean postoperative HHS at 6 months was 85.5 points.

CONCLUSION: Total hip arthroplasty is a safe and feasible option for these complex injuries that carry poor surgical fixation outcomes. THA can be performed both in the acute setting, or in a delayed manner following failed surgical fixation.

PMID:41173557 | DOI:10.1016/j.injury.2025.112753

Injury. 2025 Nov;56 Suppl 1:112750. doi: 10.1016/j.injury.2025.112750.

ABSTRACT

Pathophysiology and incidence for VTE: Deep vein thrombosis and pulmonary embolism, collectively referred to as venous thromboembolism (VTE), represent significant complication in trauma patients, particularly in combat settings where injuries often involve high-energy mechanisms such as blasts and ballistic trauma. Combat casualties face additional risks less prevalent in civilian settings, including early transfusion of blood products, the use of fresh frozen plasma outside of large volume blood transfusions, the use of tourniquets and multiple or above-knee amputations, contributing to the higher VTE incidence in military subgroups. The incidence of VTE in civilian patients who sustain firearm injuries is not available in the literature. Risk factors and scores for VTE: Trauma Embolic Scoring System (TESS) stands out as the most validated and effective clinical tool that assesses the risk of VTE for combat casualties due to its sensitivity in military trauma settings, addressing factors like shock and major leg injuries. Thromboprophylaxis strategies and guidelines: Guidelines for preventing VTE in patients suffering combat gunshot wounds emphasizes early prophylaxis, typically within 24 h of injury, using both mechanical and chemical methods.

PMID:41173556 | DOI:10.1016/j.injury.2025.112750

Injury. 2025 Nov;56 Suppl 1:112787. doi: 10.1016/j.injury.2025.112787.

ABSTRACT

Low energy gunshot wounds (GSW) sustained in the civilian setting are an increasing burden on the orthopaedic and trauma services. They differ significantly in presentation and therefore treatment when compared to high energy injuries. Initial assessment should focus on assessment of life-threatening blood loss, early antibiotics, soft tissue injury and possible associated injuries (vascular and neurological). Fracture patterns differ from blunt injuries, and this should be considered when planning surgical fixation where appropriate. There is controversy regarding surgical debridement of the bullet tract, but possible iatrogenic complications should be considered with simple entry and exit wounds. Bullets need only be removed when retained metal is exposed to synovial fluid or cerebrospinal fluid. Consensus and high-level multicentre trials are required in future to better guide our assessment and management of these unique, but increasingly more common injuries.

PMID:41173555 | DOI:10.1016/j.injury.2025.112787

Injury. 2025 Nov;56 Suppl 1:112665. doi: 10.1016/j.injury.2025.112665.

ABSTRACT

Civilian firearm violence is a significant healthcare burden and particularly fractures after gunshot injuries are at risk for fracture related infection (FRI). This risk has been reported between 3.6 and 22 % in different retrospective case series. A central question is how to prevent this complication after ballistic injuries. Antibiotic prophylaxis - or better preemptive antibiotic therapy - should be applied early and recent data do not show benefits for long duration. A recent paper demonstrated that prophylactic antibiotic administration for ≥48 h is unwarranted for patients with ballistic fractures to the extremities and may even be associated with a higher infection risk. Three days of preemptive antibiotic therapy or even 24 h was not inferior compared to longer-duration therapy in the development of infectious sequelae after gunshot fractures to the pelvis. The microbiological profile of FRIs following gunshot injuries is diverse, though Gram-positive pathogens dominate but also polymicrobial infections are of significance. Narrow-spectrum agents, such as cefazolin or clindamycin, showed comparable effectiveness compared to extended gram-negative coverage in uncomplicated case in the absence of visceral involvement or gross contamination. However, in cases with bowel injuries or other high-risk features, broader-spectrum therapy may still be justified. A further important question is whether or not retained bullied fragments should be removed. Recent data showed a statistically significant increased risk of FRI when retained bullied fragments are not removed at the time of internal fracture fixation. Treatment of FRI after gunshot injuries should be based on the recently developed diagnostic, classification and treatment principles of FRI in general. This includes a straight forward diagnostic approach using suggestive and confirmatory criteria. Treatment strategy should rely on a multidisciplinary approach, including all relevant disciplines, e.g. plastic surgery, microbiology, infectious disease etc. Treatment goal is the infection free consolidation of the fracture with good function of the limb with restoration of quality of life, including psycho-social health of the patient.

PMID:41173554 | DOI:10.1016/j.injury.2025.112665