Injury. 2026 Jan 30:113082. doi: 10.1016/j.injury.2026.113082. Online ahead of print.

ABSTRACT

BACKGROUND: The Noto Peninsula earthquake of January 1, 2024, was the most destructive seismic event in Japan since 2011, affecting a region characterized by its super-aging population, geographical isolation, and status as a medically underserved area. These vulnerabilities require a detailed analysis of the acute-phase medical response to improve disaster preparedness in similar environments. This study aims to characterize the morbidity and features of earthquake-affected patients admitted to a regional tertiary university hospital.

METHODS: We conducted a retrospective observational study of patients presenting to the emergency department of Kanazawa University Hospital between January 1, 2024, and January 31, 2024, with earthquake-related conditions. Patients with direct trauma or secondary health issues (e.g., exacerbation of chronic illness) were identified by a multidisciplinary Disaster Response Committee. All patients were triaged using the Japan Triage and Acuity Scale (JTAS). Descriptive statistics were used to summarize demographics, clinical characteristics, and transport modalities.

RESULTS: A total of 144 earthquake-related patients were managed. The cohort was characterized by a high mean age (79.7 years) and a female predominance (61.1%). The primary medical burden was the exacerbation of intrinsic diseases (74.3%), while trauma cases were less frequent (23.6%). The majority of patients presented with low to moderate acuity; severe cases (JTAS Levels 1-2) constituted 7.0% of the cohort, whereas low-acuity Level 4 was the largest (63.2%). Patient transport peaked on day five, almost exclusively by air evacuation (97.7% of arrivals that day), which was essential to overcome extensive road damage. The base-isolated hospital sustained no major damage and remained fully operational, serving as a regional DMAT command post.

CONCLUSIONS: The medical response to the Noto earthquake highlights a paradigm shift in disaster care for aging societies, where management of geriatric and chronic diseases takes precedence over mass-casualty trauma care. In isolated regions, air evacuation is a critical yet weather-vulnerable modality for effective patient transport. Future disaster preparedness requires a dual focus: medical response plans must prioritize systems for chronic and geriatric care, and strategic investment in seismically resilient tertiary hospitals is essential for them to function as stable operational hubs, ensuring regional continuity of care.

PMID:41651684 | DOI:10.1016/j.injury.2026.113082

Injury. 2026 Jan 30:113077. doi: 10.1016/j.injury.2026.113077. Online ahead of print.

ABSTRACT

INTRODUCTION: Post Traumatic Stress Disorder (PTSD) is not uncommon following major trauma. Despite increasing awareness of the psychological sequelae of trauma, there is often inadequate mental health follow-up for trauma patients. This can lead to significant rates of under-diagnosis and under-treatment.

AIMS: To examine rates of under-diagnosis and under-treatment of probable PTSD amongst major trauma patients admitted to Christchurch Hospital, New Zealand.

METHODS: A prospective questionnaire-based cohort study including patients 16 years and older who presented to Christchurch Hospital with major trauma (Injury Severity Score >/=12) between May 2016 and September 2018. Patients with severe brain injury were excluded. Patients who consented completed the Posttraumatic Stress Disorder Checklist for DSM-V (PCL-5), plus answered questions on any assessment, treatment or diagnosis of PTSD, depression or anxiety before and/or after injury. Demographic, injury-specific and hospital care data were collated from the New Zealand Major Trauma Registry.

RESULTS: There were 836 patients who met the eligibility criteria and were invited to participate in the study, with a 24% response rate (203 patients). Thirty-seven (18%) scored at or above the PTSD threshold, however only 8 (22%) reported having received a formal diagnosis of PTSD. All 8 patients who had received a formal diagnosis of PTSD were receiving some form of mental health treatment (either medication, 'talk therapy' or both). By comparison, within the group of 29 patients who had not received a diagnosis of PTSD but met criteria, only 11 (38%) were receiving any form of mental health treatment.

CONCLUSION: Many people who develop PTSD following trauma fail to receive appropriate assessment, diagnosis or treatment. Further work is needed to ensure adequate systems are in place to allow identification and treatment of patients who develop PTSD following a major trauma.

PMID:41651683 | DOI:10.1016/j.injury.2026.113077

Injury. 2026 Jan 26:113065. doi: 10.1016/j.injury.2026.113065. Online ahead of print.

ABSTRACT

BACKGROUND: Early and adequate analgesia is a critical component of injury care. While sociodemographic factors have been shown to impact the adequacy of analgesia in a variety of clinical settings, these relationships are poorly understood in trauma care. Our objective was to evaluate the association between patient and provider characteristics and time to analgesia during trauma resuscitation.

METHODS: We performed a retrospective cohort study of adult (age ≥ 16) patients presenting as trauma activations at a level I trauma center over 2 years (2019-2020). Data were derived from the institutional trauma registry and chart review. Time from presentation to first administration of analgesia was recorded. The primary outcome was delayed analgesia, defined as analgesia administered later than the 75th percentile of time to analgesia for all patients. Multivariable logistic regression was used to evaluate the effect of age, sex, and socioeconomic status on analgesia timing.

RESULTS: Among 2497 patients meeting inclusion criteria (mean age 44.8 years [SD 21.6], 25.7% female), 1957 (77.5%) received analgesia in the trauma bay. Among patients who received analgesia in the trauma bay, median time to analgesia was 9 min (IQR 7-14). The only sociodemographic characteristic independently associated with delayed analgesia was age. Relative to patients aged 16-54, those aged 55-64 were 1.5-fold more likely to receive delayed analgesia (OR 1.46; 95% CI 1.05-2.03), while those aged ≥ 65 were twice as likely to have delayed analgesia (OR 2.16; 95% CI 1.58-2.95). Irrespective of age or injury severity, patients injured in falls were more likely to experience delayed analgesia (OR 1.64; 95% CI 1.20-2.23).

CONCLUSION: Older adults and patients injured in a fall are more likely to experience delays in receiving analgesia. Strategies that ensure equity in pain management are needed such that all patients have equitable access to early and adequate pain control after injury.

PMID:41644342 | DOI:10.1016/j.injury.2026.113065

Injury. 2026 Jan 30:113076. doi: 10.1016/j.injury.2026.113076. Online ahead of print.

ABSTRACT

INTRODUCTION: Rapid economic growth may impact trauma mortality. We investigated the epidemiology, risk factors and trends in hospital mortality of admitted trauma patients in Guyana during a 5-year period of rapid economic growth in this country.

PATIENTS AND METHODS: The study was conducted at the Georgetown Public Hospital Corporation, Guyana's largest tertiary healthcare facility. The medical records of all patients admitted following trauma between 2018 and 2022 were reviewed. Patient demographics, injury characteristics, and clinical outcomes (mortality and length of stay) were obtained for each study year. Univariate analyses assessed the distributions of all variables while adjusted regression analyses were used to identify potential risk factors for in-hospital mortality. P-values ≤ 0.05 were considered statistically significant.

RESULTS: The in-hospital mortality rate was 3.5% (n=190). The highest in-hospital mortality rate occurred among burns patients (11.2%), and the lowest from assaults (1.9%). Risk factors for death were mechanism of injury, ethnicity, injury severity at presentation, and age. The leading mechanisms of injury for trauma-related deaths were motor vehicle crashes (39.5%) and falls (24.7%). Females had over twice the rate of death from falls compared to males (6.3% vs. 3.1%). Among ethnicities, Indo-Guyanese patients had the highest odds of dying from trauma compared to Afro-Guyanese (OR 2.37 CI 1.57-3.56, p<0.01) primarily driven by motor vehicle crashes (OR 3.29, CI 1.65, 6.55 p<0.01). The median (Q1, Q3) length of stay was 3 (1, 6) days. Most patients (73.5%) died within 7 days of admission. Late deaths (≥24h of admission) occurred in 53.6% of patients. Annual mortality rates fluctuated during the study period coinciding with Covid -19 restrictions but rose overall by 86.5% from 3.7% in 2018 to 6.9% in 2022. Annual comparisons of mortality rate with GDP growth rate showed parallel increases over most of the study period.

CONCLUSION: This study provides evidence to support targeted clinical practice and public health initiatives to prevent increases in trauma mortality in Guyana and other rapidly developing countries facing rising injury risks.

PMID:41644341 | DOI:10.1016/j.injury.2026.113076

Injury. 2026 Jan 30;57(3):113081. doi: 10.1016/j.injury.2026.113081. Online ahead of print.

ABSTRACT

INTRODUCTION: Trauma is a leading global health challenge, with hemorrhage being a major cause of preventable death. Resuscitative endovascular balloon occlusion of the aorta (REBOA) effectively halts hemorrhage but poses risks such as ischemic injury, especially to the kidneys. Partial REBOA (pREBOA) mitigates these effects by allowing limited distal blood flow. This study investigates crystalloid resuscitation as an alternative to whole blood during pREBOA release in a swine model, where all groups received an additional 2000 mL of Ringer's acetate prior to balloon deflation.

MATERIALS AND METHODS: 15 castrated male swine weighing 51-65 kg underwent controlled mean (SD) hemorrhage of 1200 (233) mL, followed by 60 minutes of pREBOA application and a 20-minute resuscitation phase, where the animals were randomized into three groups: low Ringer's acetate (0 mL) (n=5), high Ringer's acetate (2000 mL) (n=5), or whole blood transfusion (1000 mL)+ Ringer's acetate (1000 mL) (n=5). Hemodynamic variables, metabolic parameters, and renal blood flow were continuously monitored. Animals were observed for 60 minutes post-REBOA deflation.

RESULTS: High-volume Ringer's acetate improved stroke volume compared to low-volume crystalloids (p<0.001) and reduced heart rate (p<0.005) and systemic vascular resistance (p<0.01) immediately post-resuscitation. Hemoglobin levels were lower in the high-volume group than in the low-volume group (p<0.01), persisting for 40 minutes. Potassium remained within physiological limits.

CONCLUSION: Crystalloid resuscitation during pREBOA maintained mean arterial pressure and cardiac output comparable to whole blood, with high-volume crystalloids offering superior hemodynamic support compared to low-volume resuscitation. High-volume crystalloids improved stroke volume. Metabolic stability was preserved across groups, with no severe derangements observed. These findings highlight crystalloids as a potential alternative in resource-limited settings, although reduced renal perfusion warrants further investigation to optimize outcomes and ensure broader clinical applicability.

PMID:41643361 | DOI:10.1016/j.injury.2026.113081

Injury. 2026 Jan 25;57(3):113037. doi: 10.1016/j.injury.2026.113037. Online ahead of print.

ABSTRACT

INTRODUCTION: This study aimed to enhance wound healing using a novel natural cocktail gel dressing composed of purslane, human amniotic membrane (hAM), and platelet-rich plasma (PRP). In addition, a new ratio-based analytical approach was applied to evaluate the healing dynamics in each treatment group, revealing correlations between the healing rate and the respective treatment compound.

METHODS: Under aseptic conditions, specific amounts of freeze-dried decellularized hAM, PRP, and hydroalcoholic extract of purslane (HAEP) powder were prepared. The study groups included hAM gel, PRP gel, HAEP gel, a cocktail gel (HAEP + PRP + hAM), and phenytoin gel (positive control). Cytotoxicity was evaluated using the MTT assay. In vivo, seven groups were assessed on days 7, 14, and 21. Wound closure rate was analyzed via photographic imaging, and tissue samples were collected for H&E staining. Wound healing dynamics were further evaluated using 14/7-day and 21/14-day ratios.

RESULTS: The cocktail gel significantly enhanced wound healing compared with other groups (p < 0.05), improving cell migration, M2 macrophage polarization, and angiogenesis. The ratio-based analysis indicated that the cocktail group exhibited the fastest healing between days 7 and 14, while purslane and hAM groups showed superior healing between days 14 and 21.

CONCLUSIONS: This study introduces the use of 14/7 and 21/14-day ratios for the first time as a quantitative measure of healing progression, bridging macroscopic closure rates with underlying cellular and molecular changes. The combination of purslane, PRP, and hAM significantly accelerated healing and reduced closure time, suggesting a synergistic effect. The proposed ratio-based approach provides a more accurate evaluation of wound healing phases.

PMID:41643360 | DOI:10.1016/j.injury.2026.113037

Injury. 2026 Jan 23;57(3):113059. doi: 10.1016/j.injury.2026.113059. Online ahead of print.

ABSTRACT

Acute compartment syndrome (ACS) is a surgical emergency that remains challenging to diagnose. Diagnosis is primarily clinical, with invasive intracompartmental pressure (ICP) monitoring recommended when available. However, clinical findings can be unreliable, and invasive ICP measurement carries procedural risks. Ultrasound has increasingly been investigated as a noninvasive diagnostic method for ACS. This review analyzed all reported uses of ultrasound in the context of ACS. Six primary ultrasound techniques were identified: conventional two-dimensional (2D) ultrasound, Doppler ultrasound, pulse phase-locked loop (PPLL) ultrasound, contrast-enhanced ultrasound (CEUS), pressure-related ultrasound (PrUS), and shear-wave elastography (SWE). Each method was described according to its mechanism and theoretical basis, then evaluated for its current clinical relevance. SWE appeared to hold the greatest promise for clinical implementation, with additional potential noted for Doppler ultrasound and tibial fascia angle (TFA) measurements. PrUS, CEUS, and PPLL showed practical limitations that currently restrict clinical application, though further research may address these concerns. Ultrasound offers a noninvasive, repeatable means of quantitatively assessing multiple compartments without the pain or infection risk associated with invasive ICP monitoring. While several methods demonstrate promise, none have yet been validated for clinical adoption. Larger, standardized clinical trials are needed to confirm their diagnostic accuracy and utility.

PMID:41643359 | DOI:10.1016/j.injury.2026.113059

Injury. 2026 Jan 29;57(3):113054. doi: 10.1016/j.injury.2026.113054. Online ahead of print.

ABSTRACT

BACKGROUND: Literature increasingly suggests that suture button (SB) fixation yields higher functional outcome scores, specifically the American Orthopaedic Foot Ankle Society (AOFAS) Ankle-Hindfoot score and the Olerud-Molander Ankle Score (OMAS), compared with syndesmotic screws (SS). This umbrella review evaluates whether these differences extend beyond statistical significance and meet thresholds for clinical relevance, using the Minimal Clinically Important Difference (MCID) as reference standard.

METHOD: A comprehensive PubMed search identified systematic reviews and meta-analyses published between 2010 and 2025. The methodological quality was assessed using the Joanna Briggs Institute checklist. Reported AOFAS and OMAS outcomes, as well as mean differences between SB and SS fixation, were extracted or independently calculated. These values were evaluated against established MCID ranges (OMAS 7.5-11.4, AOFAS 4.1-7.8), to determine whether statistically significant findings corresponded to clinically meaningful improvements RESULTS: Nineteen systematic reviews were included, of which fifteen performed a meta-analysis. Across these reviews, SB fixation was reported 18 times to result in statistically higher AOFAS and/or OMAS compared with SS fixation. However, most weighted mean differences fell below the MCID thresholds: in 11 reviews for OMAS and in 12 reviews for the AOFAS did not reach clinical relevance. Only one review reported an OMAS difference within the MCID range, and seven reviews reported AOFAS differences within or above the MCID range. These findings indicate that, although statistically significant results were observed, the corresponding functional gains were generally too small to be clinically meaningful.

CONCLUSION: While SB fixation often demonstrates superior functional scores relative to SS fixation, these differences seldom exceed established MCID thresholds. The clinical relevance of these improvements therefore remains uncertain. As routine removal of syndesmotic screws is no longer advocated in the contemporary literature, and considering the findings of the present study, one could argue that the cost-effectiveness of using a suture-button in under scrutiny. Future studies should focus on refining MCID values for ankle-specific PROMs and improving methodological rigour in systematic reviews and meta-analyses to better determine whether SB fixation provides a meaningful advantage for patients.

PMID:41638088 | DOI:10.1016/j.injury.2026.113054

Injury. 2026 Jan 23;57(3):113063. doi: 10.1016/j.injury.2026.113063. Online ahead of print.

ABSTRACT

INTRODUCTION: Distal locking during intramedullary femoral nailing remains a technically demanding and radiation-intensive procedure. Since the last systematic review by Whatling et al., numerous innovations over the past two decades have aimed to improve accuracy, shorten operative time, reduce radiation exposure, and simplify the learning curve. A comprehensive synthesis of available techniques is lacking in the recent literature.

METHODS: A systematic review was conducted, according to PRISMA guidelines, including all studies published between January 2006 and January 2025 that reported on distal locking techniques for femoral intramedullary nails. Five databases (PubMed, Cochrane, Embase, Web of Science, Google Scholar) were screened using predefined keywords. Data were extracted on technique type, associated advantages and disadvantages, operative time, radiation exposure, accuracy, and complication rates. Risk of bias was assessed using RoB 2, ROBINS-I, JBI, NOS, and ROBIS as appropriate. PROSPERO registration: CRD42025626521 RESULTS: Thirty-six studies met the inclusion criteria, covering several categories: fluoroscopy-free techniques, modification of traditional freehand, targeting devices, and navigation-assisted systems (electromagnetic, robotic, optical, laser-guided). Low-tech solutions such as the "nail-over-nail" or auditory-guided techniques demonstrated promising accuracy in low-resource settings but lacked standardization. Meta-analyses confirmed the efficacy of electromagnetic navigation systems, particularly in reducing radiation exposure and operative time, without compromising success rates. Overall, navigation-based systems showed significant reductions in radiation time and promising accuracy across multiple trials.

CONCLUSION: This review highlights the broad spectrum of available distal locking techniques, from conventional approaches to advanced technological solutions. Navigation-assisted systems offer measurable benefits but remain limited by cost and accessibility. Simpler mechanical or acoustic methods remain relevant alternatives in specific contexts. No universal gold standard currently exists that can fully replace "freehand technique". Technique selection should be guided by clinical context, surgeon experience, and available resources. Ultimately, technique adoption will depend on clinical context, available resources, and surgeon familiarity.

PMID:41638087 | DOI:10.1016/j.injury.2026.113063

Injury. 2026 Jan 27;57(3):113061. doi: 10.1016/j.injury.2026.113061. Online ahead of print.

ABSTRACT

INTRODUCTION: Distal radius fractures (DRFs) are frequently managed with volar locking plates (VLP). The Soong classification, which grades plate prominence relative to the volar rim, is widely used because of its association with flexor tendon irritation, but its value in predicting postoperative radiographic restoration and patient-reported outcomes is less clear. This study examined whether Soong grade correlates with alignment (radial height and radial inclination) and patient-rated outcomes after VLP fixation of DRFs.

METHODS: We conducted a retrospective review of consecutive patients undergoing surgical fixation for DRF, 44 met the inclusion criteria. Demographics, fracture characteristics, operator grade, time from injury to operation, radiation dose, postoperative imaging and clinic utilisation, antibiotic use, and a patient-rated outcome score were collected. Pre- and postoperative anteroposterior radiographs were used to measure radial height and radial inclination. Plate prominence was graded as Soong 0-2.

RESULTS: The cohort was predominantly female (72.7%) with a mean age of 53.5 years (range 23-82, SD 16.3). Most fractures were intra-articular (88.6%) and dorsally angulated (79.5%). Mean time from injury to operation was 9.8 days (SD 5.8). Patient-rated outcome scores typically ranged 60-80 and did not appear to vary by sex, operator grade, or fracture configuration. By Soong grade, Grade 0 (n = 23) demonstrated the most favourable radiological restoration with mean postoperative radial height 13.6 mm and inclination 26.4°, alongside the highest mean patient-rated outcome score of 74.1. Grade 1 (n = 14) showed slightly lower restoration (radial height 12.1 mm, inclination 26.4°) and a mean outcome score of 65.3 with wider variability. Grade 2 (n = 7) had the least favourable radiology (radial height 11.7 mm, inclination 24.3°) and the lowest mean outcome score of 61.5; one patient in this group underwent plate removal for flexor tendon irritation.

CONCLUSIONS: In this single-centre retrospective series of VLP fixation for DRF, lower Soong grade-particularly Grade 0-was associated with better restoration of radial height and inclination and higher patient-rated outcome scores, whereas higher grades demonstrated a stepwise reduction in radiographic and functional results. These findings support meticulous plate positioning to minimise volar rim prominence and justify prospective, adequately powered studies to confirm the observed trends and evaluate longer-term tendon-related complications.

PMID:41638086 | DOI:10.1016/j.injury.2026.113061

Injury. 2026 Jan 9;57(3):113028. doi: 10.1016/j.injury.2026.113028. Online ahead of print.

ABSTRACT

Hydrogels have emerged as effective tools in medication delivery and tissue engineering due to their adjustable characteristics and water retention capabilities. The purpose of this work was to investigate the potential of a novel thermosensitive hydrogel composed of Pluronic F127 and polyglutamic acid (PGA) to enhance the treatment of MRSA-infected full-thickness excision wounds. The viscosity and gelation temperature of the hydrogels were evaluated using viscometry and rheometry, while their injectability was assessed with a texture analyzer. Swelling and biodegradation were measured in PBS at 37 °C, and antibacterial and antioxidant activity was determined using MIC/MBC tests and DPPH radical scavenging. In mouse infected wound healing investigations, hydrogels were applied to wounds, and tissue examination was done with Masson's Trichrome staining and biochemical assays for TAC and MDA. The F127/PGA hydrogel converted from a liquid to a gel at body temperature more efficiently than F127 alone, with lower gelation temperatures and improved mechanical characteristics. F127/PGA had higher swelling capacity and a slower degradation rate than F127. In antibacterial assays, the F127/PGA hydrogel showed stronger inhibitory and bactericidal activity against MRSA, as reflected by its lower MIC and higher MBC values. In addition, the hydrogel showed increased antioxidant activity and lower oxidative stress during wound healing, resulting in much better wound contraction and tissue regeneration than F127 and control treatments. These characteristics make F127/PGA an attractive choice for improved drug delivery systems and wound healing applications.

PMID:41638085 | DOI:10.1016/j.injury.2026.113028

Injury. 2026 Jan 22;57(3):113055. doi: 10.1016/j.injury.2026.113055. Online ahead of print.

ABSTRACT

INTRODUCTION: Multiple sclerosis (MS) is a chronic neurological condition characterized by muscle spasticity, which may influence the outcomes of hip arthroplasty procedures, particularly in patients undergoing total hip arthroplasty (THA) or hemiarthroplasty for femoral neck fractures. It is unclear whether implant complications and revision rates differ between these two surgical approaches in patients with MS. The aim of this study was to compare patient demographics and 2-year implant complications in patients with MS undergoing THA versus hemiarthroplasty for femoral neck fractures.

METHODS: A retrospective analysis was performed using a nationwide claims database (2010-2022). MS patients who did not have dementia who underwent THA or hemiarthroplasty for femoral neck fractures were identified. Two-year implant complications, including hip dislocations, aseptic loosenings, periprosthetic joint infections (PJIs), periprosthetic fractures, and all-cause revisions, were compared between the two groups using multivariable logistic regressions while controlling for age, sex, comorbidities, and overall Elixhauser Comorbidity Index (ECI).

RESULTS: A total of 2018 patients with MS (604 THA and 1414 hemiarthroplasty) were included. Patients had no difference in overall comorbidity burden (ECI 7.47 vs. 6.93, p = 0.015). At 2 years, THA was associated with significantly higher rates of aseptic loosenings (OR: 4.17, p = 0.001) and all-cause revisions (OR: 3.04, p < 0.0001). Patients undergoing THA also showed trends toward higher rates of hip dislocations (OR: 1.53, p = 0.087) and PJIs (OR: 1.73, p = 0.059) compared to hemiarthroplasty.

CONCLUSIONS: Patients with MS undergoing THA for femoral neck fractures are associated with a higher risk for implant complications, including aseptic loosening and all-cause revisions, compared to those undergoing hemiarthroplasty. Surgeons should consider these outcomes when selecting the appropriate surgical option for patients with MS who do not have dementia with femoral neck fractures.

PMID:41633030 | DOI:10.1016/j.injury.2026.113055

Injury. 2026 Jan 30;57(3):113084. doi: 10.1016/j.injury.2026.113084. Online ahead of print.

ABSTRACT

BACKGROUND: Malnutrition is a potentially modifiable risk factor that may influence perioperative complications and fracture healing. This study evaluated the association between preoperative laboratory-defined malnutrition and short-term complications and 2-year outcomes following operative fixation of tibial shaft fractures.

METHODS: Using the TriNetX Research Network (112 healthcare organizations), adults (≥18 years) undergoing operative management for tibial shaft fracture were identified. Preoperative malnutrition was defined as albumin ≤3.5 g/dL and/or leukocytes ≤1.5 × 10³/µL within 1 year prior to the index event. Cohorts were propensity score matched 1:1 on demographics and comorbidities. Outcomes were assessed from day 1 post-index through 90 days (medical/surgical complications) and 730 days (healing-related and limb outcomes). Risk ratios (RR) and hazard ratios (HR) with 95% confidence intervals (CI) were reported.

RESULTS: After matching, 44,780 patients were included in each cohort (89,560 total), with good balance across covariates (all SMDs <0.10). At 90 days, malnutrition was associated with higher risk of acute respiratory failure/mechanical ventilation (13.9% vs 3.4%; RR 4.10 [95% CI 3.88-4.33].; HR 4.32 [4.09-4.57].), sepsis (5.2% vs 1.2%; RR 4.35 [3.97-4.77].; HR 4.47 [4.07-4.91].), postoperative infection (5.7% vs 1.8%; RR 3.14 [2.90-3.39].; HR 3.23 [2.99-3.50].), acute kidney injury (8.6% vs 3.0%; RR 2.90 [2.73-3.08].; HR 2.99 [2.81-3.18].), and DVT/PE (6.5% vs 2.7%; RR 2.36 [2.21-2.52].; HR 2.42 [2.26-2.59].) (all p < 0.001). At 2 years, malnutrition was associated with increased nonunion (4.4% vs 1.6%; RR 2.69 [2.47-2.92].; HR 2.85 [2.62-3.10].), chronic osteomyelitis (12.5% vs 3.9%; RR 3.19 [3.02-3.36].; HR 3.50 [3.32-3.69].), hardware removal (10.1% vs 6.0%; RR 1.68 [1.61-1.76].; HR 1.83 [1.74-1.92].), and amputation (1.4% vs 0.4%; RR 3.47 [2.95-4.08].; HR 3.59 [3.05-4.23].) (all p < 0.001). Revision fixation did not differ (8.4% vs 8.1%; p = 0.096).

CONCLUSIONS: Preoperative laboratory-defined malnutrition was independently associated with substantially higher 90-day morbidity and increased 2-year nonunion and limb-complication risk following operative tibial shaft fracture management. These findings support preoperative nutritional risk stratification and targeted optimization efforts in this population.

PMID:41633029 | DOI:10.1016/j.injury.2026.113084

Injury. 2026 Jan 22:113068. doi: 10.1016/j.injury.2026.113068. Online ahead of print.

ABSTRACT

INTRODUCTION: Preliminary results suggest that placement of stent grafts is a safe method of treating carotid traumatic injuries, but data on late follow-up are limited, therefore this study evaluated in hospital and long-term outcomes of endovascular treatment of carotid artery injuries DESIGN: single centred, retrospective METHODS: This study evaluated patients admitted at University of São Paulo School of Medicine from 2011 to 2024. Complications, mortality, stroke rates and carotid patency were assessed.

RESULTS: Sixteen patients underwent endovascular treatment of their carotid artery injuries during the study period. They were male; with a mean age of 34 ± 11 years. Most injuries resulted from penetrating trauma (12 out of 16). At hospital admission, the median Injury Severity Score (ISS) was 13 (IQR 9-18.5), Revised Trauma Score (RTS) was 8 (IQR 6.75-8) and Glasgow Coma Score (GCS) was 15 (IQR 4.25-15) and five patients had neurological deficits. The common carotid artery was the most frequently injured artery (9/16), while pseudoaneurysms constituted the most common type of arterial injury (13/16). Patients underwent endovascular repair of their vascular injuries via stent graft implantation (nine stent grafts were placed in the common carotid artery, three in the carotid bulb and four in the internal carotid artery). There was no intervention related stroke. Eleven patients were discharged in good condition, four patients had neurological impairment (stable comparing to their deficit at hospital admission) and one patient died due to a contralateral haemorrhagic stroke. Ipsilateral stroke-free survival rate was 62 % at hospital discharge. The mean follow-up time was 43.5 months (IQR 16-61.75). The primary patency of the stent grafts was 100 % at 12 months, 83 % at 24 months, and 73 % at 24 months. Three occlusions were reported, all occurring in stent grafts located within the internal carotid artery. these occlusions were asymptomatic.

CONCLUSION: This study highlights the safety of stent graft repair in a selected cohort of patients with carotid injury. It was observed that stent grafts implanted in the internal carotid artery are prone to late, often asymptomatic occlusion, underscoring the importance of surveillance. However, multicentre prospective studies are still needed to establish best practice.

PMID:41622057 | DOI:10.1016/j.injury.2026.113068

Injury. 2026 Jan 22;57(3):113053. doi: 10.1016/j.injury.2026.113053. Online ahead of print.

ABSTRACT

OBJECTIVES: Artificial intelligence (AI) has revolutionized public access to extensive information with large language model (LLM)-based chatbots allowing users to receive comprehensive, individualized responses. In this study, we aimed to evaluate the quality of LLM responses to questions about common orthopedic conditions. We hypothesized that both ChatGPT and Gemini would demonstrate high quality, evidence-based responses across evaluation criteria.

METHODS: Responses from ChatGPT and Gemini to prompts based on the 14 AAOS Clinical Practice Guidelines for clavicle fracture management were evaluated on six criteria by seven fellowship-trained shoulder and trauma orthopedic surgeons. Statistical analyses including mean scoring, standard deviation and two-sided t-tests were calculated to compare performance between ChatGPT and Gemini. Scores were then evaluated for inter-rater reliability (IRR).

RESULTS: ChatGPT and Gemini demonstrated overall mean scores greater than 3.5 for both platforms. Mean overall score for ChatGPT was highest in evidence-based (4.52 ± 0.16) and lowest in clarity (4.22 ± 0.19). Mean overall score for Gemini was highest in clarity (4.31 ± 0.17) and lowest in evidence-based (3.81 ± 0.22). ChatGPT had significantly better performance in the overall completeness category (4.50 ± 0.17 vs 4.11 ± 0.19, p < 0.005) than Gemini but scores were otherwise not significantly different. Over 70 % of respondents rated the responses of ChatGPT as higher quality than Gemini.

CONCLUSIONS: ChatGPT and Gemini produced responses that were generally in line with the 2022 AAOS guidelines on the treatment of clavicle fractures. Scores were comparable in every overall category except completeness, with ChatGPT outperforming Gemini. These results suggest that both LLMs are capable of providing clinically relevant responses to questions related to clavicle fracture management.

PMID:41621222 | DOI:10.1016/j.injury.2026.113053

Injury. 2026 Jan 22;57(3):113056. doi: 10.1016/j.injury.2026.113056. Online ahead of print.

ABSTRACT

PURPOSE: This pilot study aims to validate the "ground truth" accuracy and consistency of proximal femur fracture classification using a large radiographic image database. The project, a collaboration between expert groups from the University of Turin and the AO Foundation, seeks to ensure that expert consensus-based annotations are reliable for future artificial intelligence (AI) model development.

METHODS: A cross-sectional, diagnostic accuracy study was conducted using a randomly selected subset of 300 anteroposterior pelvic radiographs from a single-center image repository created at the University of Turin within the AO Innovation Translation Center framework. Fracture classification annotations were independently provided by the local clinical expert group (LC-EG) and by an independent AO expert group of surgeons (AO-EG). To assess interrater reliability between the two groups, Cohen's kappa coefficient was calculated for categorical agreement on the presence of a fracture and AO/OTA classification.

RESULTS: The comparison of annotations from LC-EG and AO-EG yielded a Cohen's kappa of 0.81 (95 % confidence interval: 0.75-0.87) and a percentage agreement of 87.67 % (95 % confidence interval: 87.63-87.70) for the classification of proximal femur fractures into three defined categories: no fracture, fracture type 31A, and fracture type 31B. These results confirm a high level of consistency between the two expert groups in annotating the image dataset.

CONCLUSION: The observed interrater reliability between the LC-EG and AO-EG supports the credibility of the reference annotations, establishing a validated ground truth for proximal femur fractures. This evidence justifies using the radiographic image database as a benchmark for future studies and as a foundation for transparent, reproducible AI development and evaluation, thereby facilitating safer integration of decision support tools into orthopedic trauma workflows.

PMID:41616725 | DOI:10.1016/j.injury.2026.113056

Injury. 2026 Jan 22;57(3):113066. doi: 10.1016/j.injury.2026.113066. Online ahead of print.

ABSTRACT

INTRODUCTION: Ankle fractures are among the most common fractures in older adults, associated with substantial morbidity and healthcare burden. This study aimed to evaluate recent trends in incidence and injury characteristics of ankle fractures among adults aged ≥65 years presenting to United States emergency departments.

METHODS: The National Electronic Injury Surveillance System (NEISS) database was queried for ankle fractures in adults aged ≥65 years from 2016 to 2023. Demographics, injury mechanisms, fracture types, and hospitalization rates were analyzed. Annual incidence rates per 100,000 persons were calculated. Trends over time, as well as age- and sex-specific differences, were analyzed.

RESULTS: An estimated 241,449 ankle fractures occurred among adults aged ≥65 years between 2016 and 2023, with an overall incidence rate of 55.8 per 100,000 person-years. The incidence increased from 49.1 to 63.0 per 100,000 persons during the study period (P < 0.0001). Incidence rates increased significantly in both males (from 25.7 to 34.7 per 100,000 persons; P < 0.0001) and females (from 67.7 to 86.4 per 100,000 persons; P < 0.0001). Most fractures occurred in women (76.2 %), resulted from low-energy trauma (92.8 %), and were closed fractures (96.9 %). Open fracture incidence rose from 0.64 to 2.40 per 100,000 persons, representing a 275 % increase (P < 0.0001). Hospitalization rates increased from 20.3 to 29.7 per 100,000 persons (P < 0.0001). Women aged ≥80 years accounted for the highest fracture burden. Women were more likely to sustain low-energy injuries (P < 0.0001), while men had a higher proportion of open fractures (P = 0.011). Hospitalization rates increased with age, reaching 56.6 % among patients aged ≥80 years (P < 0.0001).

CONCLUSIONS: Ankle fracture incidence among older adults in the U.S. increased significantly from 2016 to 2023, with rising rates in both males and females. Low-energy mechanisms remain the predominant cause in this population. Further studies are needed to identify optimal surgical treatments and rehabilitation strategies. Improving bone health and reducing morbidity and mortality remain key priorities in managing geriatric ankle fractures.

PMID:41616724 | DOI:10.1016/j.injury.2026.113066

Injury. 2026 Jan 22;57(3):113067. doi: 10.1016/j.injury.2026.113067. Online ahead of print.

ABSTRACT

BACKGROUND: Revision amputation is a common treatment in the emergency department (ED) for traumatic finger injuries, yet there is limited data on outcomes for procedures completed in the emergency room versus the operating room. This study aims to assess outcome differences between ED revision amputation and delayed OR management.

METHODS: 103 consecutive patients with traumatic finger(s) amputations were identified from a single tertiary care center. Patients were evaluated by the on-call hand team and staffed with a fellowship-trained hand attending. ED revision amputations were performed with the goal of definitive care. Data was collected for injury/patient demographics, follow-up, and further revision procedures. Odds ratios were calculated to assess for predictive factors for ED management failure.

RESULTS: 55 patients were treated with ED revision amputation, 18 of whom (32.7 %) required further surgical management. Presence of multiple digit amputations was associated with increased initial treatment in the operating room. The most common indication for surgery was revision amputation and soft tissue coverage (88.9 %), followed by additional bony fixation for underlying fractures (44.4 %). Number of fingers amputated, fracture presence, and significant soft tissue injury were not associated with failure. Of the 48 patients with planned delayed management in the OR, 11 were treated with nonoperative wound care.

CONCLUSIONS: Definitive ED revision amputation was associated with a high rate of failure, need for revision surgery, and loss to follow up. Injuries with complex wound coverage or bony fixation may be better suited to OR management. Some patients may ultimately be appropriate for management without revision amputation and may be overtreated with this procedure in the ED.

PMID:41616723 | DOI:10.1016/j.injury.2026.113067

Injury. 2026 Jan 29;57(3):113032. doi: 10.1016/j.injury.2026.113032. Online ahead of print.

ABSTRACT

INTRODUCTION: Safe return to driving after orthopaedic injury or surgery is important, but standardised and feasible in-hospital assessments are lacking. We evaluated the feasibility of a simple simulator-based fitness-to-drive assessment in an orthopaedic outpatient department and its ability to discriminate between orthopaedic patients and professional drivers.

METHODS: In this prospective feasibility study (January 2024-January 2025), two identical driving simulators were installed in an orthopaedic outpatient department and a vocational training centre for professional drivers. Participants were ≥18 years, held a driving licence, and had no medical driving ban. All completed a 3-lap, 6-event scenario with predefined speed progression (50/60/70 km/h). Outcomes were completion, errors, speed progression, maximum reaction time and braking length (metres) at 50 km/h, simulator sickness, perceived realism, and subgroup test-retest reliability.

RESULTS: We included 57 patients and 92 drivers. Overall completion was 96.6% (144/149); 31.2% achieved speed progression. Patients were older, more often female, and more functionally impaired than drivers. Drivers had a shorter braking distance (23.3 m; 95% CI 22.1-24.5) and faster reaction time (0.5 s; 95% CI 0.5-0.6) than patients (39.4 m; 95% CI 36.7-42.1 and 1.2 s; 95% CI 1.0-1.4). Simulator sickness leading to discontinuation occurred in 3.4%. Most patients (98.2%) and 64.0% of drivers perceived simulator driving as comparable to real driving. Repeat testing showed a shorter braking distance, particularly in patients.

CONCLUSION: The simulated assessment was feasible, well tolerated, and discriminated between patients and professional drivers. Variation indicates a need for individualised assessment. Validation against on-road driving is required before clinical implementation.

PMID:41616722 | DOI:10.1016/j.injury.2026.113032

Injury. 2026 Jan 22:113064. doi: 10.1016/j.injury.2026.113064. Online ahead of print.

ABSTRACT

BACKGROUND: Traumatic Brain Injury (TBI) affects 64-74 million people annually, often causing long-term disability. The influence of social determinants of health (SDOH), particularly neighborhood and built environments, on functional outcomes post-TBI remains underexplored. This study examines the association between census tract-level median household income- a proxy for area income- and self-reported functional outcomes in TBI-patients seen in a Southern California TBI clinic.

METHODS: A retrospective cohort study of Neurology TBI & Concussion Clinic data (9/2022-1/2025) included patients ≥18 years with a known TBI mechanism and neurological symptoms who completed SDOH and functional assessments. SDOH factors included sex, race, ethnicity, insurance status, and median area income, determined by ZIP code using 2023 US census data. Disability was defined as Glasgow Outcome Scale-Extended-score ≤6 at index clinic-visit. Multivariable logistic regression was performed.

RESULTS: Among 148 patients (median age 46.5 years; 41% female, 75% mild TBI), the disabled cohort had higher proportions of poor insurance status (38% vs. 8%, p < 0.001), greater injury severity score (ISS) (9.0 vs. 1.0, p = 0.002), and lower median household income ($104,981 vs. $114,747, p = 0.020). Regression analysis showed poor insurance status (OR 5.80, CI 2.01-21.24, p = 0.003) and ISS (OR 1.06, CI 1.01-1.12, p = 0.027) predicted disability, but area income did not (OR 0.93, CI 0.79-1.10, p = 0.387).

CONCLUSION: Lower area income was associated with disability in unadjusted analysis but was not an independent predictor after adjusting for insurance and ISS. Findings highlight the need to explore individual and community factors influencing long-term TBI outcomes for targeted screening.

PMID:41605747 | DOI:10.1016/j.injury.2026.113064