Injury. 2026 Mar 22:113157. doi: 10.1016/j.injury.2026.113157. Online ahead of print.

ABSTRACT

BACKGROUND: Hyponatremia is common in traumatic brain injury (TBI) population, and is associated with poor outcomes. The main mechanisms are the syndrome of inappropriate antidiuresis (SIAD) and cerebral salt wasting syndrome (CSW). This study aimed to assess hyponatremia prevalence and time of onset in patients with TBI and assess differences between SIAD and CSW.

METHOD: This retrospective cohort study was conducted between 2015 and 2018 in our level 1 trauma center. Patients admitted to the intensive care unit with TBI were included. Three subgroups were determined using urinary clinical and biological criteria: SIAD, CSW, and Undetermined. Predictive factors were assessed for each subgroup, especially the influence of free water, sodium, or fluid intake.

RESULTS: Among 351 trauma patients with TBI, 57 (16 % [95 %CI 12 %20 %]) developed hyponatremia within 30 days. 30 (9 % [95 %CI 6 %12 %]) developed a SIAD, 13 (4 % [95 %CI 2 %6 %]) a CSW, 14 (4 % [95 %CI 2 %6 %]) an undetermined form. CSW subgroup had higher Simplified Acute Physiology Score II (SAPS II), Injury severity score ISS, more cerebral injuries, intracranial pressure monitoring, mechanical ventilation than the SIAD subgroup. Fluid, sodium and free water intake in the 48 h preceding hyponatremia did not influence CSW or Undetermined hyponatremia development, whereas excessive free water intake in the 48 h preceding hyponatremia was associated with SIAD development.

CONCLUSION: Hyponatremia prevalence was 16 %, half were SIAD and one quarter were CSW. Patients with CSW were more severely injured than those who developed SIAD. Excessive free water intake could induce more SIAD-related hyponatremia due to impaired urine dilution.

LEVEL OF EVIDENCE: III, prognostic/epidemiological.

PMID:41927419 | DOI:10.1016/j.injury.2026.113157

Injury. 2026 Feb 17:113110. doi: 10.1016/j.injury.2026.113110. Online ahead of print.

ABSTRACT

OBJECTIVES: To describe a CT finding which indicates Posterior Ligamentous Complex (PLC) injury in acute thoracolumbar spinal fractures and to determine if this has been described previously.

METHODS: The anomaly was first described by the senior author. We reviewed 1235 trauma CTs looking for this sign. We identified all thoracolumbar fractures and classified these as thoracic or lumbar fractures depending on the spinal level of the injured vertebra. We sought to determine if the 'dirty fat pad' sign was present on the mid-sagittal CT images of the spine. If present we looked to see if there was MRI confirmation of disruption of the posterior ligamentous complex. A literature review was performed of the MEDLINE, Embase Classic and EMBASE databases for descriptions of the appearance of the posterior ligamentous complex on CT following spinal trauma, from their respective inceptions in 1946 and 1974, to 21.11.25.

RESULTS: We found 356 thoracolumbar fractures in the 1235 trauma CTs. Twenty scans showed the 'dirty fat pad' sign (5.6%). MRI in these cases confirmed the disruption of the posterior ligamentous complex. The literature review provided titles and abstracts describing CTs with spinal trauma. These papers were screened for relevance, and thirty-two texts then reviewed in full. No paper retrieved described the radiological appearance of the fat pads on CT or MRI, in health or injury.

CONCLUSION: In our study we found that the 'dirty fat pad sign' was relatively uncommon. However, when seen, it did indicate disruption of the posterior ligamentous complex of the spine. We recommend the use of this sign and suggest it should be sought when reviewing acute trauma CTs. If present it would suggest ligamentous disruption thus guiding clinicians to provide more caution in protecting the patient during transfers and treatments.

PMID:41927418 | DOI:10.1016/j.injury.2026.113110

Injury. 2026 Mar 26:113196. doi: 10.1016/j.injury.2026.113196. Online ahead of print.

NO ABSTRACT

PMID:41925414 | DOI:10.1016/j.injury.2026.113196

Injury. 2026 Mar 25;57(6):113181. doi: 10.1016/j.injury.2026.113181. Online ahead of print.

ABSTRACT

INTRODUCTION: The optimal surgical strategy for geriatric acetabular fractures remains controversial. While open reduction and internal fixation (ORIF) preserves native anatomy, fixation failure may necessitate conversion to total hip arthroplasty (THA). Conversely, acute THA enables immediate stability but carries higher perioperative risk. This study compared outcomes of ORIF and acute THA and evaluated whether conversion THA achieves comparable results to acute THA.

METHODS: A retrospective cohort analysis using the TriNetX Research Network (2005-2025) identified patients ≥ 65 years with acetabular fractures. ORIF and acute THA cohorts were 1:1 propensity-matched for demographics and comorbidities. The primary outcome was revision arthroplasty within 2 years. Secondary outcomes included infection, dislocation, venous thromboembolism, mortality, ED visits, and readmission. Subgroup analyses compared conversion THA (after ORIF) with acute THA. Statistical significance was set at p < 0.05 with Benjamini-Hochberg correction.

RESULTS: After matching, 2026 patients per group were analyzed. Revision was more frequent after ORIF than acute THA at 2 years (10.4% vs 6.1%; RR 1.69, p < 0.001) and across 15 years. Infection (4.5% vs 7.1%) and dislocation (4.3% vs 5.7%) were lower after ORIF (p < 0.05). Mortality favored ORIF at 5 and 10 years. Conversion and acute THA showed similar long-term revision and mortality rates, with dislocation lower after conversion at 5 years (p = 0.002).

CONCLUSION: In elderly acetabular fractures, ORIF offers lower early morbidity but higher long-term revision risk, whereas acute THA yields greater perioperative complications yet fewer reoperations. Conversion THA achieves outcomes comparable to acute THA, supporting it as an effective salvage strategy.

LEVEL OF EVIDENCE: III (Retrospective cohort study).

PMID:41921410 | DOI:10.1016/j.injury.2026.113181

Injury. 2026 Mar 26;57(6):113185. doi: 10.1016/j.injury.2026.113185. Online ahead of print.

ABSTRACT

INTRODUCTION: Amid the emerging popularity of recreational vehicles, there has been a subsequent increase in off-road vehicle injuries. The purpose of this study was to delineate trends in the incidence and volume of upper extremity injuries caused by all-terrain vehicles (ATVs), utility task vehicles (UTVs), and dune buggies in the United States and to bring awareness to these trends to guide the development of safety measures and modifications.

METHODS: The National Electronic Injury Surveillance System (NEISS) Database was queried for ATV, UTV, and dune buggy injuries between 2014 and 2024 for upper extremity injuries. Demographic data, diagnosis, injury type and location, descriptions of the accidents, and patient dispositions were accrued from the emergency department encounters collected in this database.

RESULTS: There were an estimated 319,403 cases of off-road vehicle injuries involving the upper extremity in the study period, most of which involved ATVs specifically. The volume of off-road vehicle injuries overall increased from 2014 to 2024, with approximately 105,796 injuries in 2014 and 111,613 injuries in 2024. Fractures were the most common type of injury, accounting for 47% of encounters. The greatest number of injuries in 2014 (10,361) and 2024 (8256) were among the 10- to 19-year-old cohort. There was a 10% decrease in upper extremity injuries from 2014 to 2024, with peaks in 2016 and 2020. Shoulder injuries accounted for the most common upper extremity injury among ATV (33%), UTV (25%), and dune buggy drivers (29%).

CONCLUSION: Fractures were the most common type of injury, and shoulders were the most prevalent injured upper extremity. Despite an overall decline in prevalence, off-road vehicle injuries pose a threat to adolescent safety, and there remains a need for increased safety measures, vehicle modifications, and protective legislation involving off-road vehicle use.

LEVEL OF EVIDENCE: IV.

PMID:41916011 | DOI:10.1016/j.injury.2026.113185

Injury. 2026 Mar 27;57(6):113197. doi: 10.1016/j.injury.2026.113197. Online ahead of print.

ABSTRACT

BACKGROUND: Intramedullary fibular nailing (IFN) offers a minimally invasive alternative to plate fixation for unstable ankle fractures, yet concerns persist regarding potential iatrogenic injury to the peroneal tendons during portal creation. No previous in vivo study has evaluated tendon integrity after IFN using advanced imaging. In this cohort, we examined peroneal tendon morphology and syndesmotic reduction following IFN using serial postoperative magnetic resonance imaging (MRI), comparing findings with a healthy control group.

METHODS: A prospective cohort of 102 adults with unstable Weber B or C ankle fractures underwent IFN and completed at least eight months of follow-up. All patients received standardized ankle MRI at 3 and 8 months postoperatively. Tendon morphology, signal characteristics, and thickness were assessed by a blinded musculoskeletal radiologist. Syndesmotic reduction was evaluated in patients requiring trans-syndesmotic fixation. A control group of ten healthy volunteers underwent the same MRI protocol. Statistical comparisons were performed using independent-samples t tests and equivalence testing with predefined margins.

RESULTS: Peroneal tendons demonstrated no MRI-detectable pathology at both 3 and 8 months. At 8 months, tendon thickness (peroneal brevis: 2.9 ± 0.3 mm; peroneal longus: 3.4 ± 0.4 mm) was comparable to controls (2.8 ± 0.3 mm and 3.4 ± 0.4 mm; p > 0.37), meeting equivalence criteria (TOST p < 0.001). Among patients requiring syndesmotic fixation (n = 28), tibiofibular alignment remained anatomic (clear space: 3.1 ± 0.4 mm; overlap: 8.7 ± 1.2 mm). Union was achieved in all cases, with no infections or tendon-related symptoms.

CONCLUSION: Intramedullary fibular nailing preserves peroneal tendon integrity and provides reliable syndesmotic stability when performed with proper technique. Tendon morphology and signals remained indistinguishable from healthy controls, and postoperative alignment was consistently anatomic. These findings support IFN as a safe, biologically respectful option for the treatment of unstable ankle fractures.

PMID:41916010 | DOI:10.1016/j.injury.2026.113197

Injury. 2026 Mar 24;57(6):113180. doi: 10.1016/j.injury.2026.113180. Online ahead of print.

ABSTRACT

INTRODUCTION: Interimplant femoral fractures (IFFs), occurring between or adjacent to implants such as hip prostheses and intramedullary nails, pose complex treatment challenges, particularly in osteoporotic patients. Biomechanical research highlights the need to protect the interimplant region from high strains, however, optimal configurations for plate fixation remain unclear. This study analyzes strains in the interimplant region under various protective plate configurations.

MATERIALS AND METHODS: Twelve synthetic proximal femora, mimicking osteoporotic bone, were instrumented with a proximal femoral nail (PFN) and a distal femoral nail (DFN) creating a 40 mm interimplant gap. Four implant configurations were tested: no protective plating (Stage 1), screws placed inside the innermost nail interlocking screws (no overlapping, Stage 2), screws placed outside and close to the innermost nail interlocking screws (short overlapping, Stage 3), and screws placed outside and far from the innermost nail interlocking screws (long overlapping, Stage 4). A non-destructive axial compressive load (200 N) was applied, and bone surface strains were measured beneath the plate using digital image correlation.

RESULTS: Stage 1 (no protective plating) exhibited significantly higher maximum strains versus Stages 2-4 (p ≤ 0.015). Stage 2 (no overlapping) showed maximum strains being significantly higher compared to both short and long overlapping (p ≤ 0.007), without further significant difference between the latter two (p > 0.999). Similar trends were observed for strains at point-specific locations defined intermittently between the innermost nail interlocking screws. The highest point-specific strains were located in the middle of the interimplant region.

CONCLUSION: From a biomechanical perspective, the application of a protective plate fixation of the interimplant region significantly reduces strains, with long and short overlapping providing optimal mechanical protection. Adequate protection with plates should be prioritized to mitigate the risk of interimplant fractures.

PMID:41905180 | DOI:10.1016/j.injury.2026.113180

Injury. 2026 Mar 25;57(6):113192. doi: 10.1016/j.injury.2026.113192. Online ahead of print.

ABSTRACT

BACKGROUND: The Physician Payments Sunshine Act was proposed in 2007 and adopted as a part of the Affordable Care Act in 2010 to address the ongoing concerns regarding the monetary relationships between physicians and the medical industry. We aim to identify the prevalence of industry payments to orthopaedic surgery Residency Program Directors (PDs) and Department Chairs. We further aim to quantify the subspecialty among PDs and chairs receiving the largest payments. Additionally, we aim to quantify the categories for which PDs and chairs received the most funding.

METHODS: The Centers for Medicare & Medicaid Services Open Payments Database was queried to identify all payments made to orthopaedic surgery residency program directors and residency department chairman from the years 2017-2023 to determine the trends in payments by program. PDs and chairs of orthopaedic residency programs were identified using the Fellowship and Residency Electronic Interactive Database provided by the American Medical Association.

RESULTS: A total of 209 PDs and 169 chairs were included in the study of 209 orthopaedic surgery residency programs. There were 41,465 payments totaling $126.3 million over the study period. The majority (95%) of PDs and chairs received industry funding. Smith & Nephew Inc. (26%) and Stryker Co. (21.6%) highly supported residency program directors and residency department chairman. Males (91.1%) and Doctor of Medicine degree holders (MD) (88.9%) received the most industry funding. The majority of payments were for Food and Beverage for PDs (60.7%) and chairs (47.5%).

CONCLUSIONS: From 2017 to 2023, the vast majority of orthopaedic surgery residency program directors and department chairs received industry funding. Trauma-trained PDs and Total Joints-trained chairs received the highest average payments, while Trauma subspecialists received the greatest total funding overall. Most payments were under $1000 and primarily for Food & Beverage. Industry support was predominantly from Smith & Nephew Inc. and Stryker Co. Funding was disproportionately directed toward male orthopaedic surgeons and those with MD degrees.

PMID:41905179 | DOI:10.1016/j.injury.2026.113192

Injury. 2026 Mar 20;57(6):113188. doi: 10.1016/j.injury.2026.113188. Online ahead of print.

ABSTRACT

PURPOSE: Household head injuries in infants are a significant concern due to their high incidence and potential for serious morbidities. Therefore, understanding the patterns, mechanisms, and outcomes of these injuries is crucial for prevention and management. This study aimed to measure domestic head trauma frequency, study the demographic features, and measure outcomes in pediatric patients aged < 2 years at King Fahad Medical City in Riyadh, Saudi Arabia.

PROCEDURES: This retrospective observational cohort study included all children aged < 2 years who presented with domestic head trauma at King Fahad Medical City, Riyadh, Saudi Arabia, between June 2018 and June 2022. Associations between age, injury mechanisms, and outcomes were analyzed using descriptive statistics and chi-square tests.

FINDINGS: The study included 133 patients (45.1 % were infants) who presented to the pediatric emergency department with head trauma. Head injuries were due to household falls (42.1 %), falls with a caregiver (8.3 %), and falls from baby walkers (8.3 %). Only 22.6 % of injured children underwent computed tomography. Of all injured children, 3 % had complications. A significant relationship was observed between age (months) and cause of head injury and management outcomes among the study participants.

IMPORTANCE: Household falls were the most common cause of head injuries in infants and children aged < 2 years. Imaging plays a vital role in assessing head trauma severity. Given the difficulties in assessing head injury severity and the delay in presentation, a diagnostician must be aware of the basic diagnostic methods used in determining brain injury severity.

LEVEL OF EVIDENCE: LEVEL IV: Type of Study: Retrospective observational cohort study.

PMID:41905178 | DOI:10.1016/j.injury.2026.113188

Injury. 2026 Mar 24;57(6):113167. doi: 10.1016/j.injury.2026.113167. Online ahead of print.

ABSTRACT

AIM: This study aimed to evaluate the association of hematological and biochemical markers with the development of complications and mortality in patients undergoing surgical treatment for acute peripheral arterial thromboembolism or traumatic vascular injury. In addition to classic inflammatory indicators, the prognostic value of derived parameters such as the Inflammatory Burden Index (IBI) and Systemic Immune-Inflammation Index (SII), which have recently gained prominence in the literature and whose clinical applicability is debated, was analyzed.

METHOD: A retrospective evaluation was conducted on 86 patients who underwent surgical treatment between 2022 and 2025 (thromboembolism: n = 27, trauma: n = 59). Patients were subgrouped based on clinical outcomes such as complications, mortality, amputation, and revision. The relationship between these clinical outcomes and inflammatory markers derived from hemogram parameters, including neutrophil-to-lymphocyte ratio (NLR), CRP, IBI, SII, and initial lactate levels, was statistically analyzed. Each group was evaluated internally, and no comparisons were made between groups.

RESULTS: In the thromboembolism group, IBI, SII, NLR, and lactate levels were significantly higher in patients who developed mortality (p < 0.05). IBI > 100, SII > 1500, and NLR > 5, along with lactate > 3.5 mmol/L, were significantly associated with an increased risk of mortality, complications, and amputation, respectively. In the trauma group, IBI, SII, NLR, and lactate levels were significantly higher in patients who developed both mortality and complications (p < 0.05). IBI > 50, SII > 1200, and the combination of NLR > 4 + SII > 1200 were associated with an increased risk of amputation, mortality, and revision, respectively.

CONCLUSION: IBI, SII, NLR, and lactate levels show a significant association with complications and mortality in thromboembolic and traumatic vascular events. High values of IBI and SII, in particular, emerge as important biomarkers for clinical prognosis. Early evaluation of these parameters may assist in risk stratification and the prediction of potential adverse outcomes.

PMID:41905177 | DOI:10.1016/j.injury.2026.113167

Injury. 2026 Mar 26;57(6):113175. doi: 10.1016/j.injury.2026.113175. Online ahead of print.

ABSTRACT

INTRODUCTION: Pediatric electric scooter injuries are increasing alongside expanding availability. Although national data across all ages suggest racial and ethnic disparities, pediatric-specific analyses are limited. We aimed to quantify the burden of e-scooter injuries among pediatric patients, describe trends by age, sex, race/ethnicity, and injury characteristics, and assess disparities in incidence and severity.

MATERIALS AND METHODS: We conducted a retrospective cross-sectional study using 2020-2024 data from the National Electronic Injury Surveillance System, a nationally representative sample of U.S. emergency departments. We included patients < 18 years with e-scooter injuries. Injury characteristics were summarized by age, sex, and race/ethnicity. Chi-square tests compared injury patterns, and survey-weighted logistic regression evaluated associations between race/ethnicity and hospitalization or death (severity proxy), adjusting for age and sex.

RESULTS: From 2020-2024, there were 2117 pediatric e-scooter injuries, with incidence increasing annually; 42.2% occurred in 2024. Males accounted for 70.1% of injuries, and children aged 11-14 years represented the largest age group (38.3%). Most injuries involved the musculoskeletal system (40.4% fractures, dislocations, strains, or sprains) or soft tissues (36.7%). The weighted hospitalization rate was 7.7%, and 0.3% of cases resulted in death. Black (16.0%) and Hispanic (15.7%) children accounted for a greater proportion of e-scooter injuries compared with their representation among all pediatric injuries. In adjusted analyses, race and ethnicity were not significantly associated with hospitalization (Black vs White: aOR 0.92, 95% CI 0.54-1.56; Non-Hispanic vs Hispanic: aOR 0.63, 95% CI 0.30-1.31).

CONCLUSIONS: The incidence of electric scooter injuries is increasing, with younger adolescent males most often impacted. Black and Hispanic children account for a disproportionate share of pediatric e-scooter injuries, although adjusted analyses did not demonstrate significant racial or ethnic differences in hospitalization. Targeted prevention strategies combining educational, legislative, and environmental measures will be essential to curb rising incidence and address disparities.

PMID:41905176 | DOI:10.1016/j.injury.2026.113175

Injury. 2026 Mar 25;57(6):113193. doi: 10.1016/j.injury.2026.113193. Online ahead of print.

ABSTRACT

BACKGROUND: Distal radius torus fractures (DRTFs) are among the most common pediatric skeletal injuries, yet management strategies vary widely between institutions. Repeated outpatient visits and imaging associated with rigid immobilisation impose direct medical costs and indirect burdens on families that are rarely quantified. This study aimed to compare outpatient revisit frequency, imaging burden, direct medical costs, indirect caregiver costs, and total societal costs among children with DRTFs managed with soft bandage (SB), short arm splint (SAS), or long arm splint (LAS).

METHODS: A retrospective cohort study was conducted at a tertiary orthopedic centre. Consecutive patients aged 0-16 years with a radiographically confirmed DRTF presenting between 2024 and 2025 were stratified by immobilisation type: SB (n = 69), SAS (n = 492), and LAS (n = 106). Direct costs comprised outpatient visit fees, imaging, and immobilisation material costs derived from National Social Security Institution reimbursement tariffs. Indirect costs were estimated using the human capital approach, valuing caregiver time at the 2025 national minimum wage (0.053 USD/minute). Between-group comparisons were performed using the Kruskal-Wallis and Mann-Whitney U tests.

RESULTS: A total of 667 patients were included (mean age 8.6 ± 3.9 years; 67.0% male). SB was associated with significantly fewer outpatient visits (median 2 vs 3 vs 4; p < 0.001), fewer radiographs (median 2 vs 3 vs 3; p < 0.001), and lower total caregiver time (median 120 vs 176 vs 204 min; p = 0.005). Mean direct cost was lower in the SB group ($12.35 vs $19.74 vs $27.00; p < 0.001), as were indirect ($11.11 vs $15.08 vs $17.06; p = 0.005) and total societal costs ($23.46 vs $34.82 vs $44.06; p < 0.001). Immobilisation material cost was the most discriminating component, differing 4.2-fold between SB and SAS and 8.7-fold between SB and LAS. Had all splint-treated patients been managed with SB, a combined societal saving of $7773 could have been achieved over the study period.

CONCLUSION: SB immobilisation was associated with fewer revisits, reduced imaging burden, and lower direct and indirect costs compared with rigid splinting, supporting its adoption as a cost-effective strategy in resource-conscious healthcare settings.

PMID:41904913 | DOI:10.1016/j.injury.2026.113193

Injury. 2026 Mar 21;57(4):113174. doi: 10.1016/j.injury.2026.113174. Online ahead of print.

ABSTRACT

Popliteal artery injuries are rare even in urban Trauma Centers. The vast majority occur secondary to penetrating trauma. These injuries are uncommon; therefore, few Trauma Surgeons and Trauma Centers have developed significant experience with their management. Experiences reported in both military and civilian publications consistently report the highest complications and amputation rates of all vascular injuries due to popliteal vessel injuries. The popliteal artery is an end artery. Injuries cause significant ischemia that significantly threaten limb viability. The popliteal vein provides the main outflow from the calf musculature. Repair is preferred to preserve venous outflow in the injured limb. Popliteal vessel injuries require excellent surgical technique to repair and restore blood flow in a timely fashion, prioritizing operative efficiency to decrease ischemia, preserve limbs and avoid amputations. These factors are of the utmost importance to achieve excellent results. Past and recent military conflicts have provided Trauma Surgeons with experiences to develop protocols to manage these injuries, most importantly experiences from the Vietnam conflict. If there are any lessons to be learned from the recent conflicts in Iraq, Afghanistan, and currently Ukraine; is that Trauma Surgeons must be well trained to rapidly deal and effectively repair these injuries. We have endeavored to provide updates and explore current controversies, but most important is the call to formulate a comprehensive surgical plan to adequately train competent Trauma, Vascular, and General Surgery residents to deal with vascular injuries, given the current controversies as to which surgical specialists should deal with these injuries. How will the field of academic surgery proceed to train future generations of surgeons? This remains an unknown.

PMID:41903235 | DOI:10.1016/j.injury.2026.113174

Injury. 2026 Mar 25:113169. doi: 10.1016/j.injury.2026.113169. Online ahead of print.

ABSTRACT

BACKGROUND: Early common femoral artery (CFA) access in trauma resuscitation has the potential to improve hemodynamic monitoring and facilitate interventions. However, data on its utilization and impact are limited. This study aimed to collect objective data on early CFA access.

METHODS: We conducted a prospective observational study using trauma video review at a Level 1 trauma center. Critically injured trauma patients were included based on predefined criteria. Video and chart review were used to collect data on patient demographics, injury characteristics, procedural details of CFA access (including time of procedural milestones), and hemodynamic measurements. Trauma team leaders were also surveyed to determine their impressions on early arterial access.

RESULTS: Among 72 patients, 34.7% underwent early CFA access. Early CFA access was associated with blunt mechanism (p < 0.001), lower presenting GCS (p = 0.006), and worse functional status at discharge (p = 0.028). The median time from arrival to visualizing an arterial waveform was 16.5 min (IQR 13.2, 26.2). Ultrasound improved first-pass success rates (median attempt number: 1 vs 2, p = 0.030). Noninvasive systolic blood pressure measurements were, on average, 13.5 mmHg higher than invasive measurements; the discrepancy was more pronounced in patients with arterial SBP < 90 mmHg, and 9 paired measurements revealed occult shock diagnosed only by CFA access. Early CFA access was associated with a longer time to incision (49 min [IQR 42-69] vs 34 min [IQR 26-37]; p = 0.002), but not with a delay in time to hemostasis (162 [IQR 127-220] vs 160 [IQR 92-271]; p > 0.999).

CONCLUSIONS: Early CFA access in trauma resuscitation is feasible and can be performed rapidly, particularly with the use of ultrasound. While early CFA access may increase time to incision, it does not delay hemostasis. Further research should evaluate the direct impact of early CFA access on patient outcomes and resource utilization.

PMID:41896154 | DOI:10.1016/j.injury.2026.113169

Injury. 2026 Mar 25;57(6):113195. doi: 10.1016/j.injury.2026.113195. Online ahead of print.

ABSTRACT

Fragility fractures are a major cause of morbidity, functional decline, and loss of independence in older adults. Although surgical management restores structural stability, postoperative outcomes are strongly influenced by the timing, intensity, and quality of rehabilitation. Contemporary guidelines advocate early mobilization, timely weight-bearing, and multidisciplinary orthogeriatric care; however, rehabilitation practice often remains overly cautious. Despite increasing evidence supporting early mobilization after fragility fractures, clinical rehabilitation pathways remain highly variable, contributing to delayed recovery, increased complications, prolonged hospitalization, and reduced quality of life. This narrative review synthesizes current evidence on rehabilitation after fragility fractures and examines the persistent gap between evidence-based recommendations and real-world clinical practice. In addition, the review proposes a structured clinical decision-making framework designed to bridge the gap between evidence and orthopedic rehabilitation practice. A structured literature search was conducted across PubMed, Scopus, Web of Science, Google Scholar, and EBSCO for studies published between 2015 and 2025. Priority was given to systematic reviews, meta-analyses, and randomized controlled trials addressing early mobilization, orthogeriatric co-management, fall prevention, and emerging rehabilitation strategies. The findings indicate that risk-averse rehabilitation practices are driven by interacting clinician-, patient-, and system-level factors. Clinician concerns about fixation stability, patient-related barriers such as pain, fear of falling, and cognitive impairment, and system-level constraints including limited geriatric rehabilitation pathways contribute to delayed mobilization. Based on these findings, a clinical framework integrating fixation stability, medical readiness, functional capacity, and environmental support is proposed to guide progressive and individualized rehabilitation after fragility fractures.

PMID:41894946 | DOI:10.1016/j.injury.2026.113195

Injury. 2026 Mar 20;57(4):113176. doi: 10.1016/j.injury.2026.113176. Online ahead of print.

ABSTRACT

BACKGROUND: Distal radius metaphyseal-diaphyseal junction (MDJ) fractures in children are technically demanding, and the optimal fixation strategy remains controversial. The clinical performance of proximal-forearm antegrade elastic stable intramedullary nailing (A-ESIN) was compared with conventional retrograde crossed Kirschner-wire fixation (R-KW).

METHODS: This retrospective study included 79 children treated for distal radius MDJ fractures at [blinded for review] between January 2018 and April 2024, with a minimum follow-up of 12 months. Thirty-eight underwent A-ESIN and 41 received R-KW fixation. Intraoperative variables (operative time, blood loss, fluoroscopic exposures, open-reduction rate), postoperative recovery (time to cast removal, time to implant removal, excellent/good rates of forearm rotation and wrist flexion-extension), radiographic alignment, and complications were analyzed.

RESULTS: Compared with R-KW, A-ESIN resulted in lower blood loss (3.8 ± 2.8 mL vs 5.6 ± 4.1 mL; P = 0.024) and a reduced need for open reduction (10.5 % vs 36.6 %; P = 0.007). Casts were removed earlier (25.1 ± 2.0 days vs 39.4 ± 6.9 days; P < 0.001). Excellent/good functional outcomes were more frequent for forearm rotation (92.1 % vs 65.9 %; P = 0.006) and wrist flexion-extension (97.4 % vs 70.7 %; P = 0.003). Radiographic alignment was excellent/good in 84.2 % of A-ESIN cases versus 65.9 % of R-KW cases (P = 0.048). Fewer complications occurred with A-ESIN (one superficial wound infection) than with R-KW (five pin-tract infections, one transient radial-nerve palsy, two redisplacements, and two physeal injuries).

CONCLUSIONS: Proximal-forearm A-ESIN is a less invasive, more stable technique that expedites functional recovery and lowers complication rates relative to retrograde crossed K-wires. It represents a safe and effective alternative for managing pediatric distal radius MDJ fractures.

PMID:41894945 | DOI:10.1016/j.injury.2026.113176

Injury. 2026 Mar 20;57(4):113154. doi: 10.1016/j.injury.2026.113154. Online ahead of print.

ABSTRACT

International studies report that paediatric trauma patients retrieved by paediatric specialist teams have a shorter length of hospital stay, reduced mortality and fewer adverse events during transport when compared with generalist adult teams.This 10-year retrospective review of prospectively collected databases and electronic medical records compares paediatric trauma inter-hospital transport patient morbidity and mortality outcomes in New South Wales, Australia, between the state-wide paediatric specialist team and other medical retrieval teams, paramedics and flight nurses. We hypothesised that the duration of IHT does not adversely affect patient outcomes and that retrieval by a dedicated paediatric retrieval team is associated with better patient outcomes.Nine-hundred and thirty-two paediatric trauma inter-hospital retrievals to a paediatric trauma centre were included for analysis in this study. The paediatric specialist team completed 74 % of these retrievals. Comparing the adult medical retrieval service (AMRS) with the paediatric specialist team, there was no difference in the odds of a patient being admitted to PICU (OR 1.003, 95 %CI 0.63-1.59, p = 0.99). The odds of admission to PICU were higher for patients with an ISS 16-24 (OR 2.6, 95 %CI 1.78-3.81, p = <0.001) or 25-75 (OR 5.3, 95 %CI 3.3-8.4, p = <0.001) when compared to those with an ISS less than 12. Similarly, there was no significant difference in hospital length of stay between retrieval providers.Both AMRS and paediatric specialist teams delivered equitable patient outcomes, with no difference in PICU admission rate or LOS, and no difference in hospital LOS. The question remains, how does the current model of care for IHT of paediatric trauma patients in NSW achieve equity between the different medical retrieval teams unlike the published international experiences?

PMID:41887088 | DOI:10.1016/j.injury.2026.113154

Injury. 2026 Mar 21;57(4):113187. doi: 10.1016/j.injury.2026.113187. Online ahead of print.

ABSTRACT

BACKGROUND: Lisfranc injuries are uncommon but potentially debilitating midfoot injuries associated with chronic pain, arthritis, and gait dysfunction. Open reduction and internal fixation (ORIF) is commonly performed for unstable injuries, yet concerns remain regarding fixation failure and subsequent need for arthrodesis. However, large-scale data defining mid- and long-term conversion rates to arthrodesis after primary ORIF are limited.

METHODS: A retrospective cohort study was performed using the TriNetX Research Network to evaluate adults undergoing ORIF of Lisfranc injuries between 2005 and 2025, identified by CPT code 28615. Postoperative outcomes were evaluated at 5 and 10 years. Primary outcomes included reoperation rates, specifically hardware removal and secondary midfoot arthrodesis. Secondary outcomes included postoperative infection and gait abnormalities. Kaplan-Meier survival analyses were used to estimate event-free survival.

RESULTS: A total of 8101 patients met inclusion criteria. Hardware removal was the most frequent cause of reoperation, occurring in 19.4 % of patients at 5 years and 19.8 % at 10 years. Secondary arthrodesis was less common, occurring in 2.7 % and 2.8 % of patients at 5 and 10 years, respectively. Postoperative infection occurred in 2.0 % of patients at 5 years and 2.2 % at 10 years, and abnormal gait was documented in 4.9 % and 5.3 % of patients at 5 and 10 years, respectively. Event-free survival remained high for arthrodesis and infection (>95 %), whereas hardware retention progressively declined over time.

CONCLUSION: In the largest ORIF-specific cohort to date, reoperation following Lisfranc ORIF was common and largely driven by hardware removal, affecting nearly one in five patients at both five and ten years. In contrast, secondary arthrodesis and postoperative infection were infrequent. The low rate of conversion to fusion suggests that joint-preserving fixation is structurally durable for most patients, supporting ORIF as a viable and lasting first-line operative strategy despite a meaningful implant-related reoperation burden.

LEVEL OF EVIDENCE: Level III, retrospective cohort study.

PMID:41887087 | DOI:10.1016/j.injury.2026.113187

Injury. 2026 Mar 20;57(4):113158. doi: 10.1016/j.injury.2026.113158. Online ahead of print.

ABSTRACT

BACKGROUND: Trauma volume can vary significantly throughout the year. Identifying factors associated with trauma volume variation can be helpful in allocating resources and staff during busy trauma periods. The present study aimed to determine the relationship between overall orthopaedic trauma volume, mechanism of injury, site and acuity of injury and weather variables.

MATERIALS AND METHODS: Orthopaedic trauma consultations between July 1, 2019 and July 1, 2022 at a single Level 1 trauma center were identified using an institutional database. Patient demographics, mechanism and location of injury, and acuity were collected. Time-series analysis with Poisson models and multivariate analysis was utilized to examine the relationship between daily weather variables and the total number consults, acuity, and mechanism or site of injury.

RESULTS: 8699 patients were included. Overall trauma consults were positively associated with temperature and negatively associated with precipitation and humidity. Trauma acuity was positively correlated with temperature. Motor vehicle collision (MVC) and falls were positively associated with temperature and negatively associated with humidity. Gunshot wounds (GSW) were only positively associated with temperature. Of the injury sites examined, only cervical injuries were not positively associated with temperature. Shoulder and elbow, cervical, leg and knee, and foot and ankle injuries were negatively associated with humidity. Foot and ankle injuries were negatively associated with precipitation.

CONCLUSIONS: Overall, temperature was positively associated with trauma volume and acuity, while precipitation and humidity were negatively associated. By contrast, snow, wind speed, baro pressure, visibility, UV index, and moon phase were not associated with outcomes. As peak temperatures occurred in the summer while the greatest humidity and lowest precipitation occurred in the winter, these findings confirm long-held theories about increased trauma volumes in summer months and support increasing access and resource allocation in trauma.

PMID:41887086 | DOI:10.1016/j.injury.2026.113158

Injury. 2026 Mar 20;57(4):113189. doi: 10.1016/j.injury.2026.113189. Online ahead of print.

ABSTRACT

Falls among older adults constitute a critical public health concern, ranking as the leading cause of hospital admissions and contributing significantly to healthcare expenditures and socioeconomic burden. A shorter length of stay (LOS) after a fall typically indicates earlier mobilization, lower healthcare costs, and better outcomes, while a longer LOS often reflects higher resource use and poorer prognosis.. This prospective cohort study aimed to assess the average of fall-related hospitalizations among older adults (aged ≥55 years), identify key predictors of prolonged hospital stay, and examine subgroups with the highest utilization of inpatient services. Conducted at Al-Razi Orthopaedic Hospital in Kuwait, the study evaluated 393 older adults admitted for fall-related injuries and discharged alive over 12-months. Logistic regression, random forest, Cox proportional hazards modeling, and survival analysis were used to analyze factors influencing the duration of stay in fall-related hospitalizations. The median LOS was 14days, with wide variability. Prolonged LOS (exceeding the 75th percentile = 25 days) accounted for approximately 23.2%of the admitted patients. Across all analytical approaches, advanced age was the strongest predictor of LOS (OR = 3.66, 95% CI: 1.39-9.65, p = 0.008). older adults aged 75-84 years had a significantly increased hazard of prolonged hospitalization (HR = 1.41, 95% CI: 1.01-1.97, p = 0.04). Social support factors such as widowhood and single status showing additional influence to increase the length of hospital stay (HR = 1.45, 95% CI: 0.99-2.11, p = 0.05). Dependence level was significantly associated with increased hazard (HR = 1.22, 95% CI: 1.01-1.48, p = 0.03). Conversely, a history of previous falls was linked to a reduced risk of extended hospital stay (HR = 0.76, 95% CI: 0.64-0.89, p = 0.001). Length of hospital stay may serve as a broader indicator of healthcare system discharge planning complexity, age-related factors, and social care needs, rather than a direct proxy for injury severity. These findings underscore the importance of integrating clinical and social determinants into discharge planning for older adults hospitalized due to falls, and highlight the need for age-sensitive care pathways, strengthened fall-prevention strategies, and enhanced social support services to improve recovery outcomes and reduce hospital burden.

PMID:41887085 | DOI:10.1016/j.injury.2026.113189