Injury. 2025 Mar 7:112230. doi: 10.1016/j.injury.2025.112230. Online ahead of print.

ABSTRACT

BACKGROUND: Penetrating neck trauma poses significant risks due to critical anatomical structures. This study evaluates the impact of explosion fragment proximity to major vessels on the need for surgical exploration and outcomes, during a high-intensity urban warfare conflict.

METHODS: We conducted a retrospective review of medical records from penetrating neck trauma patients at a tertiary hospital from October 2023 to April 2024. Analyses included demographics, injury specifics, radiology, surgical interventions, and outcomes.

RESULTS: The cohort comprised 24 male soldiers, 10 of whom had vascular injuries. Those with suspected vascular injuries had notably higher rates of neck exploration (90 % vs. 21 %), ICU admissions (70 % vs. 29 %), and ICU stay duration [median 2.50 (IQR 0-55) days vs. 0 (IQR 0-10) days]. Complication rates were also higher in this group (80 % vs. 7 %), including, but not limited to, post-operative hoarseness (40 % vs. 0 %). A distance shorter than 5 mm from a fragment to a major blood vessel was correlated with the decision to undergo neck exploration (85 % vs. 9 %), ICU hospitalization (69 % vs. 18 %), to suffer from vascular injury 77 % vs. 9 %) or complications (77 % vs. 0 %).

CONCLUSIONS: Advanced imaging is crucial in managing penetrating neck trauma, with a <5 mm proximity threshold from a fragment to a major blood vessel influencing surgical and ICU decisions. Vascular injuries are associated with worse outcomes, emphasizing the need for precise diagnostics and multidisciplinary approach including head and neck surgeons, radiologists, interventional radiologists, orthopedics, ICU and Anesthesia. Future research should focus on prospective studies to refine clinical guidelines and enhance outcomes.

PMID:40102150 | DOI:10.1016/j.injury.2025.112230

Injury. 2025 Feb 28;56(4):112218. doi: 10.1016/j.injury.2025.112218. Online ahead of print.

ABSTRACT

OBJECTIVE: This study aimed to identify the optimal position for the femoral neck system (FNS) device when fixing Pauwels III #NOF, by analyzing the mechanical stability and stress distribution of FNS at different screw placement positions for the fixation of Pauwels III femoral neck fractures.

METHODS: We employed finite element analysis to create a 3D model of a Pauwels type III femoral neck fracture. Six models were designed, each with varied FNS screw placement positions. Axial stresses of 600 N, 1200 N, and 1800 N were applied to simulate physiological loads during different activities: standing on two legs, standing on one leg, and walking. The mechanical properties of these screw placements were assessed by comparing stress distribution, displacement, and fracture stability across models under varying load conditions.

RESULTS: Model 1, with the power rod aligned along the femoral neck axis, showed the best stability, with 42.40 % lower maximum VMS and 18.49 % less femoral displacement, compared to the worst model. Displacement of the internal fixation and fracture surface decreased by 21.72 % and 19.16 %, respectively. It also had superior results for internal fixation VMS and fracture surface compressive stress. Model 2, with the head screw centered axially, demonstrated good stability but had higher stress concentrations under 1800 N load. The displacement of the fracture surface and femur in model 2 increased by 18.37 % and 17.26 %, respectively, compared to model 1. Models 5 and 6, with the FNS nail near the lateral femoral cortex, showed significant stress concentrations, with compressive and shear forces rising by about 33 %. Model 5's maximum VMS increased by 46.68 %, and model 6's maximum compressive stress of the fracture surface increased by 46.37 %, compared to model 1. Models 3 and 4, with the power rod shifted up or down, displayed moderate stability, reducing displacement in some tests.

CONCLUSION: This finite element analysis highlights that centring the FNS power rod along the femoral neck axis significantly enhances fracture stability and minimises postoperative displacement. Conversely, poor screw placement may result in mechanical stress concentration, raising the risk of nonunion or malunion. Clinicians should prioritise screw placements with more excellent mechanical stability to optimise treatment outcomes.

PMID:40088553 | DOI:10.1016/j.injury.2025.112218

Injury. 2025 Mar 7;56(4):112258. doi: 10.1016/j.injury.2025.112258. Online ahead of print.

ABSTRACT

BACKGROUND: Recovery from a traumatic injury is a complex process that precipitates difficulties and isolation for survivors. Peers can provide valuable psychosocial support rooted in lived experience. The savings associated with peer support largely outweigh the costs. Despite this, research has yet to explore the ideal components of a cross-continuum peer support program or the factors that might impact its delivery.

OBJECTIVES: Understand the barriers/facilitators to integrating peer support across the continuum of care; and (2) Identify recommendations for the design and delivery of a cross-continuum peer support program.

METHODS: Qualitative descriptive approach. Interviews were conducted with trauma survivors (n = 16), caregivers (n = 4), and healthcare providers (HCPs) (n = 16). We employed an inductive thematic analysis to identify barriers and facilitators. We also conducted a deductive analysis using a framework for peer support interventions in physical medicine and rehabilitation to identify what should be included in a cross-continuum peer support program.

RESULTS: Barriers and facilitators included: (1) individual-level issues, (2) the physical and social environment, (3) clinical practice considerations, (4) finance and resourcing, and (5) organization/system issues. Peer support programming should be introduced early in recovery and continue into community living. Peer support programming should be offered flexibly (virtually or in-person) and provide: (1) education, (2) empowerment; and (3) social support. Participants agreed that a person with lived experience should be trained and centrally involved.

CONCLUSIONS: When designing peer support programming, we must consider who would benefit from support, what support should consist of, and ideal timing and mode of support delivery.

PMID:40088552 | DOI:10.1016/j.injury.2025.112258

Injury. 2025 Mar 8;56(4):112259. doi: 10.1016/j.injury.2025.112259. Online ahead of print.

ABSTRACT

BACKGROUND: Traumatic injuries significantly impact individuals' physical and mental health and are a leading cause of disability worldwide. Trauma recovery is complex and entails patients interacting with multiple places of care before returning to the community. Despite trauma recovery being optimized when patients' psychosocial needs are addressed early on and throughout recovery, care remains overwhelmingly focused on physical and functional improvement. Peer support is a cost-effective way of providing emotionally and experientially-driven psychosocial support that complements usual patient care. Thus, we aimed to explore the experiences of trauma survivors, family caregivers, and healthcare providers (HCPs) with engaging in and facilitating peer support and to identify their priorities for a future peer support program.

METHODS: Qualitative descriptive approach. Trauma survivors, caregivers and HCPs were recruited from three major trauma centres in Ontario. We conducted one-one-one interviews with participants which were recorded and transcribed. Data was thematically analyzed by multiple analysts to reduce bias and enhance data reliability.

RESULTS: We interviewed n=16 trauma survivors, n=4 caregivers, and n=16 HCPs. We identified four themes: (1) "It's a major change": Navigating life after injury is challenging and characterized by uncertainty; "I just needed somebody just to talk to:" Peer support helps trauma survivors feel like they're not alone; (3) "You can learn off each other": Peer support is multi-faceted and facilitates recovery in ways that other supports cannot; and (4) "If other people say negative things…that makes things worse": Tensions exist between the benefits of peer support and the risk of unintended negative consequences. Overall, to meet trauma survivors' socialization needs and enhance the efficacy of interventions, it is recommended that peer support to be offered via a range of modalities.

CONCLUSIONS: Our study demonstrates that peer support is valued across stakeholders and has the potential to positively impact the psychosocial health of trauma survivors throughout recovery. Future development of a cross-continuum peer support program will consider how to connect peers early on after injury and sustain these relationships into community recovery.

PMID:40088551 | DOI:10.1016/j.injury.2025.112259

Injury. 2025 Mar 4;56(4):112240. doi: 10.1016/j.injury.2025.112240. Online ahead of print.

ABSTRACT

INTRODUCTION: Lisfranc joint injuries are a severe cause of disruption of foot stability and function, often requiring surgical intervention such as open reduction and internal fixation (ORIF). The necessity of routine implant removal after healing remains controversial. This study aimed to compare functional recovery and postoperative complications among patients undergoing routine, on-demand, or no implant removal following ORIF for Lisfranc fracture-dislocations.

MATERIALS AND METHODS: This multicenter retrospective study analyzed 188 patients treated with ORIF for Lisfranc fracture-dislocations. Patients were divided into three groups: routine removal (RR), on-demand removal (ODR), and no removal (NR). Functional outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) midfoot score at the final follow-up. Complications were categorized as implant-related or post-removal. AOFAS midfoot scores and complication rates were compared between the three groups.

RESULTS: The median AOFAS midfoot scores at the final follow-up were 92 (IQR 83.00-95.00) in the RR group, 95 (IQR 85.00-95.00) in the ODR group, and 95 (IQR 82.00-95.00) in the NR group, with no significant differences among the three groups (p > 0.05). Implant-related complications were comparable across the groups, although irritation was significantly more frequent in the ODR group (42.9 %) than in the RR (24.4 %) and NR (11.9 %) groups (p = 0.013). Post-removal complications occurred in two cases in the RR group, including one case of loss of correction requiring reoperation.

CONCLUSION: Routine implant removal did not show superior outcomes in functional recovery or complication rates compared to selective removal or retention. Implant retention or selective removal based on individual needs minimizes complications and optimizes patient outcomes.

PMID:40088550 | DOI:10.1016/j.injury.2025.112240

Injury. 2025 Jan 23:112173. doi: 10.1016/j.injury.2025.112173. Online ahead of print.

ABSTRACT

Hemostatic resuscitation is a mainstay in the management of trauma patients. Factors such as blood loss and tissue injury contribute to coagulation and hemodynamic status imbalances. Hemorrhage remains a leading cause of death in trauma patients, despite advances in strategies such as damage control surgery, massive transfusion protocol, and intensive care. Conventional hemostatic resuscitation often involves a 1:1:1 ratio of red blood cells, plasma, and platelets. However, this ratio has disadvantages, especially in low-resource settings. Whole blood transfusion maintains a physiological rate of cells, clotting factors, and hemostatic properties. Advances in the whole blood elucidated a new opportunity for its implementation in civilian trauma centers. However, the effect of initial resuscitation with whole blood in trauma patients is unclear. This study aims to determine the effect of hemostatic resuscitation using whole blood on mortality and evolution of organ dysfunction in severe trauma patients compared to blood components therapy. This clinical trial attempts to resolve the debate and uncertainty of using whole blood vs. blood components. An open-label, randomized, prospective, single-center and controlled trial will be performed. Participants will be randomly assigned to receive either 3 units of whole blood or 3 units each of red blood cells and fresh frozen plasma, plus half an apheresis unit of platelets (equivalent to 3 platelet units). A second intervention of the same ratio will be administered if further transfusion is required. The primary outcome is a hierarchical composite outcome based on mortality at 28 days and the evolution of organ dysfunction. Organ dysfunction will be measured as the difference in the score between the fifth and first days of the SOFA (Sequential Organ Failure Assessment). Secondary outcomes are mortality, coagulopathy profile, intensive care unit free days, length of hospital stay, and volumes of transfusion requirements. Safety outcomes are complications related to transfusion and complications related to trauma (acute distress respiratory syndrome, pulmonary embolism, deep vein thrombosis, acute kidney injury with or without dialysis, stroke, myocardial infarction, cardiac arrest, sepsis, abdominal complications, abdominal compartment syndrome). TRIAL REGISTRATION: ClinicalTrials.gov: NCT05634109 - Whole Blood in Trauma Patients with Hemorrhagic Shock (WEBSTER).

PMID:40087111 | DOI:10.1016/j.injury.2025.112173

Injury. 2025 Mar 7;56(4):112237. doi: 10.1016/j.injury.2025.112237. Online ahead of print.

ABSTRACT

BACKGROUND: Assessment of intraoperative syndemsotic instability remains a controversial topic. To date, no study has directly compared 5 available methods.

MATERIALS AND METHODS: The purpose of the present study was to assess the reliability of five stress assessment methods (Cotton Hook, External Rotation, Arthroscopic, Direct Palpation, and Direct Visualization) across various syndesmotic injury conditions (ventral disruption, 2-ligament injury, and 3-ligament injury) in an in-vitro model. It was hypothesized that the Cotton Hook (CHT) and External Rotation (ER) methods would be the least reliable. A cadaveric model of syndesmotic injury was employed in eight through the knee specimens and assessments were performed.

RESULTS: Overall, direct visualization was most reliable for discerning syndesmotic disruption, irrespective of the injury condition (p = 0.01). Arthroscopic assessment was reliable in 2 and 3-ligament injury conditions (p < 0.05); while Cotton Hook and External Rotation were reliable in 3-ligament injuries (p = 0.01, p = 0.04). Arthoscopic, Cotton Hook, and External Rotation assessment(s) were unreliable for discerning isolated ventral disruption (anterior inferior tibiofibular ligament).

CONCLUSIONS: In the present cadaveric model, direct visualization of the anterolateral articular surface of the ankle was the most reliable method for discerning syndesmotic injury. Discontinuity of the articular surface between the anterolateral tibia and anteromedial fibula was readily identified in all injury conditions. Surgeons should be cognizant of the inherent subjectivity, and limited reliability of historically popularized syndesmotic stress assessment methods.

LEVEL OF EVIDENCE: Level V, cadaveric.

PMID:40086323 | DOI:10.1016/j.injury.2025.112237

Injury. 2025 Feb 19;56(4):112220. doi: 10.1016/j.injury.2025.112220. Online ahead of print.

ABSTRACT

BACKGROUND: The Lower Extremity Assessment Project (LEAP) and Military Extremity Trauma Amputation/Limb Salvage Study (METALS) reported conflicting results with respect to severe lower extremity injuries treated with limb salvage versus amputation. The LEAP study reported no difference between amputation and limb salvage groups, while the METALS study reported improved outcomes with amputation. The purpose of this study was to re-evaluate the METALS data to determine whether the ankle/hindfoot injuries were the main driver of the results of improved outcome with amputation.

METHODS: This is a retrospective secondary analysis of METALS data including military personnel deployed to Afghanistan or Iraq between 2003 and 2007 with severe lower extremity combat injuries. METALS patients with a unilateral transtibial amputation, or unilateral limb salvage of a qualifying injury distal to the femoral condyles were included. Amputation patients were compared to two separate limb salvage groups: severe ankle/hindfoot injuries (ie. ankle/hindfoot salvage group) versus mid/proximal tibia injuries (ie proximal limb salvage group). Short Musculoskeletal Function Assessment (SMFA) scores were compared between groups. Multivariable regression models compared outcomes across treatment groups, adjusting for age, race/ethnicity, time from injury, combat experience, and social support.

RESULTS: 161 patients were included: 60 amputation, 41 ankle/hindfoot salvage, 62 proximal limb salvage. Amputation patients reported better function (lower SMFA scores) compared to both limb salvage groups for the daily activities sub-score. Amputation patients reported better function than proximal salvage patients in all domains. There was no difference in SMFA scores between the two limb salvage groups. On adjusted analysis, amputation patients reported significantly better function for total dysfunction and daily activity scores than either limb salvage group.

CONCLUSIONS: This secondary analysis of the METALS data reveals that amputation resulted in superior functional outcomes compared to limb salvage after both ankle/hindfoot and more proximal tibial combat related injuries. This study highlights differences between civilian and military traumatic extremity injuries and indicates that treatment results cannot be generalized between populations.

LEVEL OF EVIDENCE: Prognostic Level II.

PMID:40081154 | DOI:10.1016/j.injury.2025.112220

Injury. 2025 Mar 8;56(4):112236. doi: 10.1016/j.injury.2025.112236. Online ahead of print.

ABSTRACT

INTRODUCTION: Serotonergic antidepressants, including both selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been linked to adverse outcomes following orthopedic procedures. This study aims to evaluate the impact of SSRIs/SNRIs on outcomes in patients following operative fixation of the femur. We hypothesized that perioperative use of SSRIs would be associated with worse outcomes post-surgery.

METHODS: A retrospective cohort analysis was conducted using the TriNetX global federated research network. Adult patients (>18 years) with femur fractures treated surgically were identified using Current Procedural Terminology (CPT) and International Classification of Disease (ICD-10) codes. Propensity score matching was performed to create two cohorts: patients using SSRIs/SNRIs and non-users, each consisting of 5,477 matched patients. Outcomes assessed included postoperative bleeding complications, intensive care unit (ICU) requirement, and wound dehiscence.

RESULTS: On the day of surgery, there were no differences in rates of acute post-hemorrhagic anemia (12 % vs 12 %, p = 0.86), hemoglobin <7g/dL (6 % vs 6 %, p = 0.97) or transfusion (4.9 % vs 4.4 %, p = 0.24). From postoperative day 1-7, rates of acute post-hemorrhagic anemia (18 % vs 16 %, p < 0.01), hemoglobin < 7 g/dL (29 % vs 24 %, p < 0.01) and transfusion (9.5 % vs 8.0 %, p < 0.01) were significantly higher in the SSRI/SNRI cohort. From postoperative day 7-30, there were no observed differences in rates for acute post-hemorrhagic anemia, hemoglobin <7g/dL, transfusion and hematoma incision and drainage.

CONCLUSIONS: Perioperative use of SSRIs/SNRIs in patients with femur fractures is associated with increased risk of acute bleeding complications (Day 1-7); however, the increased risk of bleeding complications is not observed beyond one week postoperatively. Balancing surgical risk with mental health needs is crucial. These findings underscore the importance of careful management of patients with SSRIs/SNRIs undergoing orthopedic procedures, particularly in terms of postoperative blood loss anemia and the need for transfusion.

PMID:40073712 | DOI:10.1016/j.injury.2025.112236

Injury. 2025 Mar 8;56(4):112233. doi: 10.1016/j.injury.2025.112233. Online ahead of print.

ABSTRACT

PURPOSE: The aim of the present study was to explore the impact of different planes of popliteal artery injury (PAI) on the risk of amputation in affected limbs.

METHODS: A retrospective analysis was conducted on ninety-four patients who underwent PAI; these patients were divided into an amputation group (n = 26) and a nonamputation group (n = 68) on the basis of whether limb preservation was successful. The data were reconstructed from computed tomography angiography (CTA) of the patients' lower limbs and measured via AW Volume Share 5 software. The height of the popliteal artery injury surface was quantified as follows: "L" was defined as the distance from the origin of the descending genicular artery of the contralateral limb to the origin of the anterior tibial artery; "S" was defined as the distance from the origin of the descending genicular artery of the affected limb to the blood flow interruption site; and "R" was defined as the ratio of S to L (S/L). The risk factors for amputation in patients with PAI were also analysed.

RESULTS: Univariate and multivariate logistic regression analyses revealed that R (odds ratio [OR]=0.876, P = 0.006,95 % CI:0.797-0.963), S (OR=0.792, P = 0.166,95 % CI:0.570-1.102), ischemic time (OR=1.195, P = 0.017,95 % CI:1.032-1.383), and compartment syndrome (OR=5.509, P = 0.055,95 % CI:0.967-31.376) were independent risk factors for amputation in patients with PAI. The receiver operating characteristic (ROC) curve revealed that the AUC values were 0.887 (P < 0.000, 95 % CI: 0.805-0.943) and 0.775 (P < 0.000, 95 % CI: 0.677-0.854) for R and S, respectively. The diagnostic efficiency was highest when the diagnostic threshold values were 0.573 and 11.3 cm, for R and S, respectively. Moreover, the AUCR was greater than the AUCS (Z = 2.403, P = 0.0162).

CONCLUSION: The height of the PAI plane is an independent risk factor for amputation in patients with PAI. Greater planes of vascular injury result in greater risk of amputation. R is better than S in the diagnosis of amputation risk in patients with PAI.

PMID:40073711 | DOI:10.1016/j.injury.2025.112233

Injury. 2025 Mar 3:112238. doi: 10.1016/j.injury.2025.112238. Online ahead of print.

ABSTRACT

INTRODUCTION: Enhanced Recovery Protocols (ERPs) are designed to improve postoperative recovery. Since their inception, ERPs have become the standard of care across multiple surgical specialities, with numerous guidelines established for elective procedures. While ERP principles have been extended to emergency abdominal surgeries, their application in trauma laparotomy remains limited. This study details the development of an ERP tailored for trauma laparotomy patients and evaluates outcomes following its implementation.

METHODS: A multidisciplinary team developed an ERP, termed the Trauma Laparotomy Care Pathway (TLCP), grounded in best available evidence and adapted to our clinical setting through a rigorous consensus process. Following implementation, we conducted a single-center pilot study as part of a quality improvement initiative, comparing trauma laparotomy patients managed with TLCP from February to July 2024 to a historical cohort as the baseline group. We analyzed adherence to five key postoperative components and assessed impacts on postoperative outcomes.

RESULTS: In the first six months post-implementation, 31 patients were managed using TLCP. The median age was 32.0 years, with males comprising 87.1 % of patients. Stab wounds were the most frequent injury mechanism, followed by motor vehicle-related accidents and falls. Isolated abdominal injuries accounted for 64.5 % of cases. Adherence to key pathway components ranged from 54.5 % to 67.7 %. The hospital length of stay was significantly shorter for the TLCP group, showing a two-day reduction compared to the historical cohort (4.0 days [3.5, 6.5] vs 6.0 days [4.0, 10.0], p = 0.002). There was no significant difference in in-hospital complications or 30-day readmission rates between the groups.

CONCLUSION: Following TLCP implementation, a reduction in hospital length of stay was observed, with no apparent increase in complications or 30-day readmission rates. These findings suggest that ERPs may be applicable to selected trauma laparotomy patients, with the potential to improved clinical outcomes. Further large-scale studies are warranted to validate these results.

PMID:40059024 | DOI:10.1016/j.injury.2025.112238

Injury. 2025 Mar 3;56(4):112234. doi: 10.1016/j.injury.2025.112234. Online ahead of print.

ABSTRACT

INTRODUCTION: Assessment of mobility in orthopaedic trauma patients is commonly performed using the Lower Extremity Functional Assessment (LEFS). Computerized adaptive testing (CAT) utilizing the Patient-Reported Outcomes Measurement Information System (PROMIS) is an advanced method for assessing multiple aspects of patient-reported health and may provide an effective alternative for this purpose. The objective of this study was to correlate and psychometrically compare PROMIS (Mobility (MOB) and Physical Function (PF)) CATs to legacy mobility PROMs (Lower Extremity Functional Scale (LEFS)/ Short Musculoskeletal Function Assessment (SMFA)), and to evaluate factors associated with worse mobility.

PATIENTS AND METHODS: In this Cross-sectional study performed in a single Level-I trauma center, 123 patients were recruited who were treated for a lower-extremity fracture (October 1, 2021-July 1, 2023). Correlations (Pearson), known-group validity (Two-sample T test), reliability (Standard error (SE) and Cronbach's alpha), items and completion time, and floor/ceiling effects were assessed. Factors associated with PROMIS-MOB scores were also identified based on multivariable regression analysis.

RESULTS: PROMIS-MOB and LEFS/SMFA (0.75/0.86), PROMIS-PF and LEFS/SMFA (0.76/0.84), and both PROMIS-CATs (0.88) were highly correlated. Regarding know-group validity, all PROM scores were worse among patients with moderate-extreme pain. Only PROMIS-CATs scores were worse among older (≥65 years) and short-term follow-up (3≤months) patients. Reliability was very high for PROMIS-MOB (SE2.1), PROMIS-PF (SE2.0), LEFS (alpha0.97) and SMFA (apha0.97). Fewer items were needed for PROMIS-MOB (6) and PROMIS-PF (5) compared to LEFS (20) and SMFA (34). Completion time (mean seconds) of PROMIS-MOB (65) and PROMIS-PF (70) was less compared to LEFS (338) and SMFA (367) (p<0.001). Neither PROMIS-CATs nor LEFS/SMFA exhibited floor/ceiling effects. Advancing age, depression, pain intensity, shorter follow-up were associated with worse PROMIS-MOB scores.

CONCLUSION: PROMIS-MOB and PROMIS-PF CATs exhibited a strong correlation with the LEFS and SMFA, indicating that they offer the same information regarding mobility and general physical functioning. Nonetheless, CATs took less time to complete and were better able to detect (subtle) differences between certain groups than traditionally used PROMs. Given that both PROMIS-MOB and PROMIS-PF CATs were also highly correlated, it is questionable whether the more specific mobility CAT provides distinct information in lower extremity fracture patients.

LEVELS OF EVIDENCE: Diagnostic study, Level II.

PMID:40058156 | DOI:10.1016/j.injury.2025.112234

Injury. 2025 Mar 4:112229. doi: 10.1016/j.injury.2025.112229. Online ahead of print.

ABSTRACT

INTRODUCTION: Effective pre-hospital care is critical for improving trauma outcomes, yet pre-hospital systems are underdeveloped in low-and middle-income countries (LMICs) like Nepal, where trauma-related deaths are rising. Community health responders (CHRs) have the potential to reduce time to post-injury care in rural settings, where other health infrastructure may be unavailable. This pilot study assessing the feasibility and preliminary impact of CHR based program in rural Nepal.

METHODS: This quasi-experimental study adapted and implemented a trauma training intervention for CHRs in Achham, Nepal. The program adapting the trauma portion of the World Health Organization's (WHO) Basic Emergency Care (BEC) course for the Achham context through a modified Delphi process. The final implemented program included three items: initial two-day skills-based training, a pictorial guide handbook for CHR's quick reference, and a one-day refresher training at three months. Two rural municipalities of Achham district were assigned into intervention or control. All CHRs from the intervention municipality underwent the training program. Assessment includes the program's impact on CHRs' knowledge and confidence, and impact on pre-hospital trauma care metrics, which was assessed through pre-, immediately, and six-months post-course evaluations, and pre-hospital service metrics data, respectively. A repeated measures ANOVA was used to assess change in knowledge over time by study groups. Bivariate analysis was performed to explore differences in pre-hospital patient metrics of trauma care by study group.

RESULTS: The intervention group showed a significant increase in knowledge and confidence immediately post-course and sustained over six months. There was no significant difference in mean patient age (26.5 years versus. 22.1) and trauma mechanism (p = 0.14) across two groups. The most common mechanism was falls (n = 165, 77.5 %). Intervention municipalities had higher rates of pre-hospital care provision, including fracture immobilization (51.4 % versus. 17.1 %, p < .001) and cervical collar use, compared to controls.

CONCLUSION: This study adapted and implemented a contextual trauma training program for CHRs in rural Nepal. Results shows early feasibility and appropriateness in this context. The program leverages existing community networks and offers a potential approach in LMICs to bridge the existing critical gaps in rural pre-hospital trauma care that requires further investigation.

PMID:40057400 | DOI:10.1016/j.injury.2025.112229

Injury. 2025 Mar 4;56(4):112239. doi: 10.1016/j.injury.2025.112239. Online ahead of print.

ABSTRACT

AIM: Information on patient-reported recovery from lower limb fractures includes limited information with >10 years follow-up. The aim was to investigate the long-term effect of lower limb fractures on the Hip Disability and Osteoarthritis Outcome Score (HOOS), the Knee Injury Osteoarthritis Outcome Score (KOOS) and the Foot and Ankle Outcome Score (FAOS) five subscales.

METHODS: Study design was a national register-based cohort study. A representative national sample of 26,877 citizens were invited to participate by completing the HOOS, KOOS or FAOS. Individual information on fractures to the foot/ankle, knee and hip as well as date/year of diagnoses was derived from the Danish National Patient Register.

RESULTS: HOOS, KOOS or FAOS were completed by 7,850 citizens. 489 (2 %) patients were registered with a lower limb fracture. The mean follow-up time from fracture to survey was 16.7 years, ranging from 0 to 45 years. The mean age of participants with a lower extremity fracture was 62.9 years and 61 % were women, compared to patients without a lower extremity fracture with a mean age of 60.2 years and 54 % were women. The HOOS/KOOS/FAOS mean differences between patients with and without a lower limb fracture were pain:4.4 (95 % CI -6.1- -2.7); symptoms:4.2 (95 % CI -5.9- -2.6); ADL:3.8 (95 % CI -5.4- -2.1); sport/rec:8.2 (95 % CI -10.9- -5.5); and QOL:6.5 (95 % CI -8.7- -4.2). Further subgroups analysis comparing hip-related fractures to the HOOS, knee-related fractures to the KOOS and foot/ankle-related fractures to the FAOS showed comparable results.

CONCLUSION: We showed that long-term patient-perceived complaints following lower limb fractures are common even decades after treatment. Most complaints were observed in high performance activities such as running, jumping and kneeling as well as QOL. More research is needed to address questions regarding causality.

PMID:40056731 | DOI:10.1016/j.injury.2025.112239

Injury. 2025 Feb 19;56(4):112216. doi: 10.1016/j.injury.2025.112216. Online ahead of print.

ABSTRACT

BACKGROUND: The defect of the distal index finger may cause tissue necrosis, osteomyelitis, even dysfunction, disability in hand, and psychological problems. This study aimed to present our experiences using a modified second toe nail-skin flap to repair and reconstruct the distal index finger defect.

METHODS: From February 2018 to April 2022,48 patients with the distal index finger defects received the modified second toe nail-skin flap to reconstruct the defect. Among them, 35 males and 13 females, with a mean age of 39.4 years (ranged, 11∼48 years) and irregular wound, and exposed or damaged tendons, nerves, or bones. The length of the bone defect was 0.3∼1.4 cm and the mean dimension of the soft tissue defect was 0.7 × 2.1 cm (ranged,0.4 × 1.5∼1.0 × 2.5 cm). All the flaps were individually designed according to the defect condition. Combined pedicled first dorsal metatarsal artery flap and cosmetic sutures was used for repair in all donor areas. We regularly followed up all patients and completed the results of some standardized assessment based on hand function and aesthetic scores.

RESULTS: 48 modified second toe nail-skin flaps survived completely. The fingers were available for a mean follow-up of 10.5 months (ranged, 6∼13 months) without serious complications, such as necrosis of distal index finger, deformity, nonunion, muscle spasms of the index finger, paronychia, pain, abnormal temperature and touch sensation. The functional and aesthetic results of all the flaps were satisfactory.

CONCLUSION: The modified second toe nail-skin flap is one of the preferred ways to reconstruct distal index finger defect. This approach provides cosmetic coverage, functional recovery, allows for faster wound healing and reduced tendon adhesion, and lessens damage to the donor area, and does not affect the functions of foot.

PMID:40048806 | DOI:10.1016/j.injury.2025.112216

Injury. 2025 Feb 28;56(4):112231. doi: 10.1016/j.injury.2025.112231. Online ahead of print.

ABSTRACT

INTRODUCTION: There have been no published studies evaluating the impact of humeral stem length on humeral shaft periprosthetic fractures. We sought evaluate the differences in fracture patterns between periprosthetic fractures around a short stem and standard stem humeral implants.

MATERIALS AND METHODS: This is a retrospective cohort study. Patients sustaining a humeral shaft periprosthetic fracture around shoulder arthroplasty implants from December 2011 to January 2021 were identified using ICD-9/10 codes. Three upper extremity trained surgeons evaluated all radiographs assessing fracture location and configuration, as well as signs of stem stability before and after the fracture. They classified the fractures based on two classification schemes: Wright & Cofield, and the Unified Classification System (UCS), and they recorded their recommended treatment for each case based on fracture pattens and implant stability.

RESULTS: 76 patients with periprosthetic humeral shaft fractures were identified and divided into two groups: short stem (n=18) and standard stem (n=58). Patients with a short stem were more likely to be classified as having an unstable prosthesis after fracture (67% versus 33%, p=0.01). Additionally, the proposed plan for treatment was different between the two groups (p=0.004): more patients in the standard stem group were recommended open reduction internal fixation (50% vs. 33%) or non-operative treatment (17% vs. 0%), and more patients in the short stem group were recommended revision arthroplasty (50% vs. 29%).

CONCLUSION: Patients sustaining a periprosthetic fracture around a short implant may be more likely to have an unstable prosthesis compared to a standard stem, which may have an impact on treatment options.

LEVEL OF EVIDENCE: Prognosis Study, Level III.

PMID:40043641 | DOI:10.1016/j.injury.2025.112231

Injury. 2025 Feb 20;56(4):112225. doi: 10.1016/j.injury.2025.112225. Online ahead of print.

ABSTRACT

Lacerations rank as the most common paediatric injury that requires a physician evaluation. Glass is a frequent cause of such lacerations, however there is currently little to no information on this. Hence, this paper aims to describe the burden and characteristics of such injuries in Singapore. This study is a retrospective review of glass-related trauma presented to paediatric hospital KKH Emergency Department between 1st January 2017 and 4th July 2023. Data on patient and injury characteristics, as well as treatment plans were collected. 680 patients up to 18 years old (average 6.93) were included in the study. 420 (62 %) were male. The number of glass-related injuries were stable at about 100 per year from 2017 to 2023. 649 (95 %) cases were unintentional. 528 (78 %) injuries occurred indoors.159 (23 %) children had adult supervision at time of injury. A majority of 458 (67 %) injuries occurred during the weekday. Primary blunt injuries were the highest at 414 (61 %), followed by 230 (34 %) penetrating injuries. 317 (37 %) injuries occurred at the lower limb, 305 (36 %) at the upper limb, and 105 (12 %) at the face. 596 (87.6 %) patients had "None to mild" injuries, 31 (4.6 %) with "Moderate" injuries, and 53 (7.8 %) with "Severe" injuries. Glass doors led to 315 (46 %) cases, with glass shards and glass panels causing 85 (12.5 %) and 84 (12.5 %) cases respectively. 555 (82 %) of patients received definitive treatment in the Emergency Department and 74 (11 %) required surgery. The average duration of hospitalization of all patients is 0.36 days. 430 patients averaged 3.66 weeks of follow-up, while 247 were discharged immediately. 85 (13 %) patients required inpatient care. Only 1 patient required fluid resuscitation in the Emergency Department. Most glass injuries are unintentional, caused by glass doors, occur indoors and are, fortunately, mild cases.

PMID:40037263 | DOI:10.1016/j.injury.2025.112225

Injury. 2025 Feb 22;56(4):112227. doi: 10.1016/j.injury.2025.112227. Online ahead of print.

ABSTRACT

Interlocking screw backout is a significant complication of femoral nailing that may lead to pain, fixation failure, and need for reoperation. The risk for this is increased in osteoporotic bone or in cases of so-called "extreme nailing" when the articular segment is short, and fixation is limited. A newly developed retrograde femoral nailing system (DePuy Synthes RFN-Advanced™ Retrograde Femoral Nailing System (DePuy Synthes, Monument, CO)) was designed specifically to prevent this known failure mode and was recently approved for use within the United States. A preassembled polymer inlay at the distal portion of the nail (through which the distal interlocking screws are placed) is marketed as eliminating interfragmentary motion and screw toggle which can ultimately lead to screw backout. Despite this purposeful design, multiple surgeons at our Level I trauma center in the southeastern US have noted a relatively high occurrence of distal interlocking screw backout when compared to other nail designs used in the same time. We present a single institution retrospective review of placed retrograde femoral nails and their complications, particular loss of interlock bolt fixation and revision surgery in the DePuy Synthes RFN-A group (21.43 %), compared to other implant designs (5.41 %) during the initial implementation period at our institution.

PMID:40031117 | DOI:10.1016/j.injury.2025.112227

Injury. 2025 Feb 21;56(4):112226. doi: 10.1016/j.injury.2025.112226. Online ahead of print.

ABSTRACT

Diabetes mellitus is a chronic condition which disrupts bone homeostasis leading to impaired healing and profound complications in ankle fractures. Hyperglycaemia and chronic inflammation cause increased generation of advanced glycation end products and reactive oxygen species which ultimately drive osteoclastogenesis and increase bone resorption. Together with a lack of insulin signalling, these mechanisms compromise bone metabolism and increase the risk of complications in fracture healing. Diabetes is associated with comorbidities such as vasculopathy and neuropathy which further contribute to the risk of complications. The complications identified in diabetic patients with ankle fractures include non-union, malunion, infection, amputation, and mortality. Thus, careful consideration is needed when deciding between surgical and conservative treatment. This narrative review provides a synthesis of the literature covering the impact of diabetes on ankle fractures, considering their high prevalence in the UK.

PMID:40023923 | DOI:10.1016/j.injury.2025.112226

Injury. 2025 Feb 25;56(3):112228. doi: 10.1016/j.injury.2025.112228. Online ahead of print.

NO ABSTRACT

PMID:40022873 | DOI:10.1016/j.injury.2025.112228