Injury. 2025 Oct 17;56(12):112829. doi: 10.1016/j.injury.2025.112829. Online ahead of print.

ABSTRACT

OBJECTIVE: To evaluate the clinical efficacy of the bone transport with locking plate (BTLP) technique, which combines an external fixator and a locking plate for the treatment of infected bone defects in the lower extremities, within the induced membrane.

METHODS: A retrospective analysis was conducted on patients with infected bone defects of the F4 type according to the new FRI classification in the lower extremities treated at our hospital between July 2018 and September 2022. The treatment protocol was divided into two stages. In the first stage, debridement was performed, the bone defect was fixed with plate and filled with antibiotic-loaded cement to induce membrane formation. In the second stage(8 weeks later), removal of the bone cement and BTLP technique was applied within the induced membrane for bone transport to repair the defect. Outcomes, including infection control rate, bone union rate, and complications, the clinical efficacy were assessed using the Paley scoring system.

RESULTS: A total of 90 patients were included in this study, with 41 cases involving the tibia and 49 cases involving the femur. After an average follow-up of 20.5 months, infection recurrence was observed in 13 cases (14.4 %). Among these, 76.9 % of the recurrent infections did not affect bone healing and were controlled after removal of the internal fixation. The final infection control rate was 96.7 %, two patients with severe infection could not achieve control, and one underwent amputation. The initial bone union rate was 93.3 %, with an average union time of 7.8 months after bone transport completion. The final bone union rate was 95.6 %. The average external fixation index (EFI) was 16.3 days/cm. The average Visual Analogue Scale (VAS) score for the femur was higher than that of the tibia. Complications include the pin-tract leakage and skin inflamed for the femur was higher than that of the tibia. Functional outcomes were significantly better in the tibia compared to the femur.

CONCLUSION: The BTLP technique within the induced membrane is an effective method for the treatment of infected bone defects. However, attention should be given to the relatively high incidence of complications and the adverse effects on joint function when applied to the femur.

PMID:41130136 | DOI:10.1016/j.injury.2025.112829

Injury. 2025 Oct 14;56(12):112811. doi: 10.1016/j.injury.2025.112811. Online ahead of print.

ABSTRACT

Minimally invasive reduction of lateral compression type 2 (LC-2) pelvic ring fractures is not well described [1]. While the gold standard remains open reduction and internal fixation with plates and screws, this technique is associated with notable risks, including significant blood loss, nerve injury, wound dehiscence, and postoperative infection [1-3]. A minimally invasive technique of fracture reduction and fixation for LC-2 fractures is presented, with emphasis on imaging to visualize realignment of the reduced ilium.

PMID:41130135 | DOI:10.1016/j.injury.2025.112811

Injury. 2025 Oct 17;56(12):112833. doi: 10.1016/j.injury.2025.112833. Online ahead of print.

ABSTRACT

BACKGROUND: Tranexamic acid (TXA) is an established method of reducing blood loss during total hip arthroplasty (THA). Despite many randomized controlled trials (RCTs) examining its use, the optimal dose and route of administration of TXA in THA remain up for debate. Therefore, this study aimed to determine the robustness of RCT findings in this field by applying statistical fragility methodology, including fragility index (FI) and fragility quotient (FQ) calculations.

METHODS: Embase, MEDLINE, and Pubmed were searched for RCTs examining the dose, administration, or the pairing of TXA with another drug in THA. All dichotomous outcomes were extracted, for which the FI and FQ were calculated. The FI was found by determining the number of event reversals required to flip an outcome's statistical significance, and was then divided by sample size to yield the FQ.

RESULTS: Literature review yielded 25 RCTs totaling 73 outcomes. Across all outcomes, the median FI was 4.0, with an associated median FQ (mFQ) of 0.047. There were 12 statistically significant outcomes reporting a mFQ of 0.020, while the remaining 61 outcomes were deemed insignificant (mFQ = 0.049). 22 outcomes pertained to blood/platelet transfusion (mFQ = 0.033), 10 outcomes involved thromboembolic events (mFQ = 0.062), 12 outcomes described cases in which additional drugs were required after TXA administration (mFQ = 0.020), and 29 outcomes described other adverse events (mFQ = 0.049).

CONCLUSION: The results of RCTs examining the administration of TXA in THA were statistically fragility, resulting in a median FQ of 0.047. Outcomes reporting significance and those studying the need for additional drugs after TXA administered were particularly fragile. Thus, this study recommends RCTs report fragility statistics in combination with P-values and demonstrates that TXA administration in THA may warrant further level I evidence research.

PMID:41130134 | DOI:10.1016/j.injury.2025.112833

Injury. 2025 Oct 17;56(12):112832. doi: 10.1016/j.injury.2025.112832. Online ahead of print.

ABSTRACT

OBJECTIVES: To analyze outcomes of posterior wall acetabular fracture fragments fixed with the Synthes non locking 5 hole hind/midfoot plates (H-plates) in comparison to previously described methods. The hypothesis is that H-plates provide comparable outcomes to other fixation methods.

METHODS: DESIGN: Retrospective review SETTING: Level 1 Trauma Center (2018-2023) PATIENT SELECTION CRITERIA: Adult patients with an acetabular fracture (AO/OTA 62) that underwent open reduction and internal fixation (ORIF) of a posterior wall component with free screws, spring plates or H plates. Patients with <3 months follow up were excluded.

OUTCOME MEASURES AND COMPARISON: Primary outcomes included conversion to total hip arthroplasty (THA), revision ORIF, all other reoperations, and dislocations. Secondary outcomes included surgical site infection (SSI) and mortality. Outcomes were compared between fixation with H plate, Spring plate and screws.

RESULTS: Of 343 patients, 102 (29.7 %) had fixation of posterior wall fracture components with H plates. The average age was of 38.7 (18-84), with 69.7 % being males and follow up of 250 days (90-972). When comparing H plates with all other fixation methods there were no significant differences with regards to rates of THA conversion (5.9 % vs 11.6 %, P = 0.104), revisions (0 vs 0.8 %, P = 0.356) or reoperations (3.9 % vs 4.1 %, P = 0.922). When comparing H plates, spring plates, and independent screws as separate groups for fixation, THA conversion rate was lower with H plates (5.3 % vs 16.7 % vs 10.4 %, P = 0.042). Revision fixation (0.0 % vs 0.0 % vs 1.9 %;p = 0.017) and reoperations (4.2 % vs 4.4 % vs 2.8 %, P = 0.810) were not significantly different. Age (OR1.105, p < 0.001), spring plate (OR 11.63, p < 0.001 and free screw use (OR 4.2, p = 0.028) increased risk for THA conversion.

CONCLUSION: H-plate use was associated with lower rate of conversion to total hip arthroplasty compared to other fixation options. Future prospective research should focus on evaluating the outcomes of different fixation choices for acetabular fractures with posterior wall components.

LEVEL OF EVIDENCE: III.

PMID:41130133 | DOI:10.1016/j.injury.2025.112832

Injury. 2025 Oct 15;56(12):112809. doi: 10.1016/j.injury.2025.112809. Online ahead of print.

ABSTRACT

BACKGROUND: Foot fractures account for approximately 10 % of all fractures and 40 % of lower extremity fractures. They are associated with pain, mobility limitations, and prolonged recovery, contributing to considerable healthcare and societal costs. While the clinical and economic burden of foot fractures is recognised globally, data specific to the UK population are sparse, outdated, and often grouped under broader injury categories. Given rising demands on the UK's publicly funded NHS, an up-to-date, population-level understanding of foot fracture burden is essential for targeted prevention and planning.

METHODS: This retrospective cross-sectional study used publicly available model-based estimates from the Global Burden of Disease (GBD) 2021 study. Incidence and Years Lived with Disability (YLDs) for foot fractures (excluding ankle) were analysed across the UK from 1990 to 2021. Age-standardised incidence rates (ASIR) and age-standardised YLD rates (ASYR) were examined. Poisson regression and Pearson correlation were used to explore associations between geography, age, and incidence. Leading causes of injury were also described.

RESULTS: Between 1990 and 2021, the UK experienced an overall decline in ASIR for foot fractures, from 376.6 to 314.9 per 100,000. All four UK nations showed decreasing trends, with England demonstrating the steepest reduction (annual percentage change: -0.18 %). Regionally, London had the lowest incidence and highest rate of decline. Males had consistently higher incidence rates than females, with adolescent males (15-24) particularly affected. A strong negative correlation was observed between age and incidence (r = -0.850, p < .001), though incidence and YLDs in the elderly increased between 1990 and 2021. Falls were the leading cause of foot fractures, especially among older adults, and their incidence rose markedly over time.

CONCLUSION: Foot fractures remain a significant and evolving public health issue in the UK, particularly among young men and older women. The observed trends highlight successes in injury prevention but also reveal emerging needs-particularly in fall prevention and support for the ageing population. These findings support more targeted public health strategies and future economic evaluations of injury-related care in the NHS.

PMID:41124823 | DOI:10.1016/j.injury.2025.112809

Injury. 2025 Oct 15;56(12):112815. doi: 10.1016/j.injury.2025.112815. Online ahead of print.

ABSTRACT

INTRODUCTION: A regional anaesthesia list was introduced in an outpatient clinic for the manipulation of distal radius fractures. Outcomes in patients managed with regional anaesthesia were compared with those managed using a haematoma block.

METHODS: Data was collected prospectively on 66 patients with displaced distal radius fractures manipulated using a haematoma block. Following introduction of the regional anaesthesia list, data was collected on 55 patients prospectively. Radiological parameters were recorded pre and post manipulation. Patient's pain was measured following anaesthesia and following reduction. Surgical intervention rates were recorded for fractures that lost reduction in the weeks following manipulation. PROMs were measured at 18-month follow-up using the PRWE and EQ5D-3 L.

RESULTS: Post reduction volar tilt was superior in the regional group (2.4 degrees) compared to the haematoma group (0.5 degrees). Surgical intervention was required in 22 patients in the haematoma group due to loss of reduction, compared to six in the regional anaesthesia group. Pain levels were reported to be lower in patients managed using regional anaesthesia. At 18-month follow-up PROMs were comparable in both groups.

CONCLUSION: The paper supports the use of regional anaesthesia to manipulate distal radius fractures. Regional anaesthesia provides better pain relief, achieves better fracture reduction and reduces the need for surgical intervention.

LEVEL OF EVIDENCE: IV.

PMID:41124822 | DOI:10.1016/j.injury.2025.112815

Injury. 2025 Oct 11;56(12):112807. doi: 10.1016/j.injury.2025.112807. Online ahead of print.

ABSTRACT

INTRODUCTION: Avulsion fractures of the anterior inferior tibiofibular ligament (AITFL), historically described as Wagstaffe-Le Fort fractures, are under-recognized indicators of syndesmotic injury. This study aimed to determine the prevalence of AITFL avulsion fractures in ankle fractures, classify their morphology, evaluate fragment size, and assess correlations with established fracture classification systems.

MATERIALS AND METHODS: We retrospectively reviewed 1022 patients admitted with distal tibial and/or fibular fractures between January 2016 and June 2024 at a level I trauma center. After exclusions, 573 patients with ankle fractures and complete radiographic data were included. All patients underwent plain radiography. AITFL avulsion fractures were identified and classified into five types according to morphological criteria. Fracture mechanisms were analyzed using the Weber and Lauge-Hansen systems. Fragment size was measured and reported as median with interquartile range (IQR).

RESULTS: AITFL avulsion fractures were identified in 116 of 573 patients, yielding a prevalence of 20.2 %. Type 2 was the most common variant (82.8 %), followed by type 4 (8.6 %). Type 2 fractures showed a strong association with supination-external rotation injuries and Weber B patterns, whereas type 4 fractures correlated predominantly with pronation-external rotation injuries and Weber C patterns (p< 0.05). Rare types (1 and 5) accounted for < 3 % of cases. The median fragment size was 16.6 mm (IQR 9.2-21.5), notably larger than previously reported. In several cases, fragment dimensions were sufficient to potentially interfere with syndesmotic alignment or fibular reduction.

CONCLUSION: AITFL avulsion fractures are more frequent than traditionally appreciated, with reproducible associations between fracture morphology and specific injury mechanisms. Their relatively large size in many cases suggests potential feasibility for direct fixation, though treatment thresholds remain unproven. Recognition of these lesions may improve detection of syndesmotic injury and guide surgical planning. Prospective studies are needed to validate proposed size-based criteria and clarify their impact on clinical outcomes.

PMID:41110375 | DOI:10.1016/j.injury.2025.112807

Injury. 2025 Oct 14;56(12):112812. doi: 10.1016/j.injury.2025.112812. Online ahead of print.

ABSTRACT

BACKGROUND: To explore the impact of the ERAS-based (Enhanced Recovery After Surgery) Multidisciplinary Treatment Model (MDT) on perioperative management indicators of elderly patients with hip fractures in primary hospitals.

METHODS: A retrospective study was conducted on 120 elderly patients with hip fractures treated at our hospital from October 2020 to October 2024. The patients were divided into two groups: one group received the conventional model, while the other group received the ERAS-guided MDT model, with 58 and 62 patients in each group, respectively. Perioperative indicators and secondary outcomes (pain scores, symptom self-assessment scores, hip joint function, daily living abilities, and postoperative complication rates) were compared between the two groups. Data that met normality assumptions were compared using repeated measures ANOVA.

RESULTS: Patients in the ERAS-MDT group had a shorter time to mobilization (16.55 ± 1.17 h) compared to the conventional group and walked for a longer duration daily (2.00 ± 0.66 h). Compared to preoperative, VAS (Visual Analog Scale) scores significantly decreased on postoperative day 7 in both groups (P < 0.05), with the ERAS-MDT group showing superior results (P < 0.05). At discharge, SCL-90 (Symptom Checklist-90) scores were significantly lower in the ERAS-MDT group compared to the conventional group (P < 0.05). Harris scores for hip function in the ERAS-MDT group were significantly higher than those in the conventional group at all time points (P < 0.05). Before intervention, there was no difference in daily living ability between the two groups (P > 0.05), but postoperative daily living abilities improved significantly in the ERAS-MDT group (P < 0.05). The complication rate during hospitalization was significantly lower in the ERAS-MDT group compared to the conventional group (P < 0.05).

CONCLUSIONS: The ERAS-based MDT model has a potential impact on perioperative management indicators for elderly hip fracture patients in primary hospitals.

PMID:41108798 | DOI:10.1016/j.injury.2025.112812

Injury. 2025 Oct 14;56(12):112818. doi: 10.1016/j.injury.2025.112818. Online ahead of print.

ABSTRACT

OBJECTIVE: To determine if (1) fixation of the anterior ring is required, (2) is indirect (external fixator or InFix) or internal fixation favored, and (3) are there differences between long and short percutaneous screws for stabilization of the anterior ring in patients receiving surgical fixation of lateral compression type 1 (LC1) pelvic ring injuries when the posterior ring is stabilized?

METHODS: A retrospective review of all acute LC1 (AO/OTA 61-B1/B2) pelvic ring injuries from January 2019 to January 2024 managed operatively with posterior ring fixation at Two Level I Trauma Centers. Indications for operative management were radiographic evidence of instability or a failed "trial of mobilization." Minimum three month follow-up and until confirmation of radiographic healing was required. Anterior-posterior, inlet and outlet radiographic imaging at initial, post-operative and final follow-up were assessed. The primary outcome measure was the presence of pelvic ring deformity defined as >1 cm of medial pelvic ring displacement from immediate post-operative radiographs to final radiographs showing fracture healing. Secondary outcomes were major unplanned surgical procedures (reoperation for loss of fixation, deformity, non-union repair, removal of symptomatic implants or infection) and other surgical complications. It was recorded if anterior ring fixation was applied and whether fixation was indirect (external fixator or InFix) or internal. Percutaneous screws were noted to be antegrade or retrograde, and length noted (long or short). A comparison of outcome measures was made between the different anterior ring constructs.

RESULTS: 120 patients were included; most were female (n = 69; 58 %) and the mean age was 63.9 years (18.6SD, range 17-93). Surgical fixation of the anterior ring was most common (n = 86, 72 %) and produced lower rates of deformity compared with no fixation (20 % vs. 41 %, p = 0.016), despite the presence of an increased amount of superior ramus fracture comminution (48 % vs. 26 %, p = 0.034) and unstable superior ramus fracture patterns (p = 0.034). Indirect fixation (n = 15, 17 %) had a higher rate of deformity relative to internal fixation (n = 71, 83 %) (53 % vs. 13 %, p < 0.001). A long percutaneous screw (n = 50, 72 %) was most often applied antegrade (p = 0.014), and long screws had lower rates of deformity when compared with short screws (n = 19, 28 %) (4 % vs. 32 %, p = 0.004).

CONCLUSIONS: When surgical fixation of LC1 injuries was indicated, the application of anterior ring fixation in conjunction with posterior ring fixation decreased the risk of fracture displacement. Long percutaneous screws stabilizing the anterior ring best maintained reduction and prevented deformity.

LEVEL OF EVIDENCE: Level III, therapeutic study.

PMID:41108797 | DOI:10.1016/j.injury.2025.112818

Injury. 2025 Oct 10;56(12):112798. doi: 10.1016/j.injury.2025.112798. Online ahead of print.

ABSTRACT

BACKGROUND: Factors associated with injuries and performance have been less studied in trail running than in road running. Our original research carried out on a large sample of trail runners had 3 aims: 1) describe the habits and health of runners 2) evaluate the causal effect of training variables, anthropometric factors, lifestyle, recovery on the incidence of injuries 3) evaluate causal effect of these parameters on performance.

METHODS: We developed a 65 questions trail-running-specific survey including 97 variables characterizing 3 dimensions. This anonymous questionnaire was distributed via social networks and the MSOChrono® mailing list between May 2019 and May 2020. We tested all potentially predictive variables with all injuries using standard frequentist tests. Then, we used causal Bayesian networks to evaluate the effect of a specific set of variables on injury probability and performance.

RESULTS: 697 subjects were included (468 men). Sixteen types of injury were reported. The risk of injury was higher with weight, less interval trainings, lower weekly training volume and yearly elevation gain, lower regular passive recovery practice, lower sleeping time. The number of previous injuries didn't affect the risk of current injury. Performance increased with training, passive recovery and sleeping, but decreased with increasing age, weight, and height.

CONCLUSION: The analysis of this cohort showed that some aspects of training and recovery were protective factors against injuries. There might however exist an upper limit, where some of these variables could become detrimental. More research is needed to determine this threshold.

PMID:41108796 | DOI:10.1016/j.injury.2025.112798

Injury. 2025 Oct 11;56(12):112805. doi: 10.1016/j.injury.2025.112805. Online ahead of print.

ABSTRACT

INTRODUCTION: Appropriate surgical management of hip fractures has major clinical and economic consequences. Recently Intramedullary nail (IMN) use has increased compared to Sliding Hip Screw (SHS) constructs, despite no clear evidence demonstrating superiority of outcome. We therefore set out to provide further evidence about the clinical and economic implications of implant choice when considering hip fracture fixation strategies.

METHODS: A retrospective cohort study using Scottish hip fracture audit (SHFA) data was performed for the period 2016-2022. Patients ≥50 with a hip fracture and treated with IMN or SHS constructs at Scottish Hospitals were included. Comparative analyses, including adjustment for confounders. A sub-group analysis was also performed focusing on AO-A1/A2 fracture configurations. Cost differences in Length of Stay (LOS) were calculated using defined costs from the NHS Scotland Costs book.

RESULTS: There were 13,638 fractures (72 % female) identified which included 9867 (72 %) that received a SHS. No significant differences were identified in 30 or 60-day survival (Odds Ratio [OR] 1.05, 95 %CI 0.90-1.23; p = 0.532), (OR 1.10, 95 %CI 0.97-1.24; p = 0.138) between SHS and IMN, respectively. There was however a significantly lower early mobilisation rate with IMN (OR 0.64, 95 %CI 0.59-0.70; p < 0.001), and lower likelihood of discharge to domicile by day-30 post-admission (OR 0.77, 95 %CI 0.71-0.84; p < 0.001) compared to SHS. Acute and overall, LOS were significantly lower for SHS vs IMN (11 vs 12 days and 20 vs 24 days respectively; p < 0.001). Findings were similar across a sub-group analysis of 559 AO A1/A2 fracture configurations. Differences in LOS was associated with an increase cost of £1481 per-patient, irrespective of the higher implant costs of an IMN compared to a SHS.

CONCLUSIONS: Appropriate SHS use is associated with early mobilisation, reduced LOS and likely with reduced cost of treatment. Further research exploring potential reasons for the identified differences in early mobilisation are warranted.

PMID:41108795 | DOI:10.1016/j.injury.2025.112805

Injury. 2025 Oct 8:112788. doi: 10.1016/j.injury.2025.112788. Online ahead of print.

ABSTRACT

BACKGROUND: Mild traumatic brain injury (mTBI) is commonly associated with alcohol use. We investigated how inpatient admission patterns after mTBI vary for patients with alcohol use disorder (AUD).

METHODS: This was a retrospective cohort study of patients with mTBI from the American College of Surgeons Trauma Quality Program dataset. Mixed regression models measured associations with inpatient admission, including among a subgroup of patients with AUD. Effect modification was tested for age, race, and acute intoxication.

RESULTS: 78,937 patients with mTBI were included, and 7.0 % had AUD. AUD was associated with increased admission odds (OR, 1.83; 95 % CI, 1.67-2.01). Black patients and those presenting intoxicated had this effect reduced. Among a subgroup of patients with AUD, acute intoxication reduced admission odds (OR, 0.73; 95 % CI, 0.59-0.91).

CONCLUSIONS: AUD increased inpatient admission odds after mTBI, while acute intoxication reduced these odds among patients with AUD. These findings help contextualize care for the common diagnostic constellation of mTBI and AUD.

PMID:41077492 | DOI:10.1016/j.injury.2025.112788

Injury. 2025 Oct 4;56(12):112785. doi: 10.1016/j.injury.2025.112785. Online ahead of print.

ABSTRACT

INTRODUCTION: The treatment options of orthopedic surgeons for older adults with proximal humeral fractures (PHF) may vary according to chronological age. This study aimed to present the treatment modalities, complications, and mortality rates after PHF in octogenarians, nonagenarians, and centenarians from the Turkish national database.

METHODS: This retrospective study was conducted using health records from the National Health Record System of Ministry of Health Turkey for individuals aged 80 and over who presented to public, private, and university hospitals from January 2016, to October 2024. The International Statistical Classification of Diseases and Related Health Problems (ICD-10) code S42.2 (code for closed PHFs) was used to identify patients. A total of 9799 patients were included and categorized into three age groups: octogenarians (80-89 years), nonagenarians (90-99 years), and centenarians (≥100 years) and 4 groups according to treatment modalities (conservative, osteosynthesis, reverse shoulder arthroplasty (RSA), and hemiarthroplasty). Early systemic complications, revision surgery and mortality rates regarding 30-day and 90-day were recorded.

RESULTS: The mean age of the study population was 85.1 ± 4.2, ranging between 80-106 years. The female ratio was 76.1 %. Octogenarians comprised 84.3 % of the entire study population, whereas 15.5 % were nonagenarians and 0.3 % were centenarians. Conservative treatment was the most preferred across all age groups (62.3 %). Among patients initially managed conservatively, 7.0 % (n = 425) subsequently required surgical intervention, with no statistically significant difference in surgical conversion rates across the three age groups. Only 77 patients (0.8 %) underwent RSA. No differences were observed in the ratio of early systemic complications between octogenarians, nonagenarians, and centenarians. 30-day and 90-day mortality rates were 4.9 % and 10.2 %, respectively. RSA was associated with the highest risk of 90-day mortality (HR: 2.222, 95 % CI: 1.328-3.718; p = 0.002), with centenarians exhibiting an even greater risk (HR: 2.879, 95 % CI: 1.193-6.949; p = 0.019).

CONCLUSION: Conservative treatment remains the most preferred approach for PHFs in the patient population over the age of 80. Given the significantly higher mortality rates in centenarians and in patients undergoing RSA, individualized treatment decisions should prioritize functional outcomes, patient comorbidities, and life expectancy.

PMID:41075714 | DOI:10.1016/j.injury.2025.112785

Injury. 2025 Oct 4;56(12):112783. doi: 10.1016/j.injury.2025.112783. Online ahead of print.

ABSTRACT

BACKGROUND: Upper extremity fractures (UEFs) are a growing public health concern in China, yet comprehensive epidemiological data remain limited. This study examines the burden, trends, and risk factors of UEFs in China from 1990 to 2021.

METHODS: Using data from the Global Burden of Disease (GBD) 2021 study, we analyzed the incidence, years lived with disability (YLDs), and causes of UEFs in China. Age-standardized rates (ASRs) were calculated, and trends were assessed using regression models. Sociodemographic index (SDI) associations and global comparisons were evaluated.

RESULTS: In 2021, China recorded 11.1 million new UEF cases, a 31.92% increase since 1990. The age-standardized incidence rate (ASIR) rose by 7.97%, contrasting with a 20.92% global decline. Fractures of the radius and/or ulna had the highest ASIR (404.52 per 100,000), while shoulder fractures saw the steepest YLD increase (42.69%). UEFs were more prevalent in males, except among children (<1, 10-14 years) and older adults (≥65 years), where females predominated. Falls accounted for 72.98% of UEFs, followed by road injuries (13.38%). Rehabilitation needs (YLDs) grew by 32.28%, with SDI-linked trends showing a plateau at SDI 0.59-0.72.

CONCLUSIONS: China's increasing burden of UEF, influenced by factors such as falls, an aging population, and urbanization, contrasts with the global downward trends. Immediate targeted actions (implementing fall prevention strategies for the elderly, enhancing road safety for young people, and broadening access to rehabilitation services) are essential to address this escalating public health issue.

PMID:41075713 | DOI:10.1016/j.injury.2025.112783

Injury. 2025 Sep 30;56(12):112779. doi: 10.1016/j.injury.2025.112779. Online ahead of print.

ABSTRACT

AIM: The aim of this study was to investigate on the influence of physical workload and workers' compensation status on fulfillment of patients' expectations, return to initial work, and functional outcome after surgical treatment of complex proximal tibial fractures.

METHODS: This prospective study included 114 patients with complex tibial fractures (AO/OTA type B and C). At final follow-up, an individualized questionnaire based on the Hospital For Special Surgery-Knee Surgery Expectations Survey (HFSS-KSES) was used to assess whether preoperative expectations had been met. In addition, the condition of the knee joint, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were used. Physical workload was assessed using the REFA classification. Physical workload and workers' compensation status was corelated to duration of incapacity to work (weeks), fulfillment of expectations, and functional outcome.

RESULTS: Patients with higher physical workloads showed longer incapacity to work (20.1 weeks on average) and were significantly less likely to report a complete return to their initial professional activity (r=-0.21). Their preoperative expectations were significantly less frequently fulfilled (r=-0.29). Workers' compensation status was associated with lower satisfaction and higher workload demands. Reintegration programs proved effective, enabling a high percentage of patients to return to work without restrictions (p = 0.04). Significant negative correlations were found between workload and functional outcomes (KOOS dimensions, residual pain, quality of life).

CONCLUSION: Individualized, job-oriented rehabilitation with realistic expectations is crucial for improving return to work, especially for high-workload patients. Future research should integrate physical and psychosocial factors in rehabilitation strategies.

PMID:41072123 | DOI:10.1016/j.injury.2025.112779

Injury. 2025 Sep 30:112778. doi: 10.1016/j.injury.2025.112778. Online ahead of print.

ABSTRACT

OBJECTIVE: Prehospital performed Extended Focused Assessment with Sonography in Trauma (EFAST) has poor sensitivity for pneumothorax (PTX) when compared to scans performed in hospital. This study describes the computed tomography (CT) location of PTX detected after an initial negative prehospital EFAST.

METHODS: Trauma patients treated by New South Wales Ambulance (Aeromedical Operations) who underwent prehospital EFAST between 1st August 2022 and 31st December 2023 were included if they were found to have PTX on CT imaging following a negative or indeterminate prehospital EFAST ultrasound. Patients were excluded if prehospital pleural decompression was undertaken. Corresponding CT imaging was manually analysed for the location of each PTX and mapped to two-dimensional coordinates on an unfurled thoracic cage.

RESULTS: Of 58 patients median (IQR) age was 29 (20, 58) years. The majority (76 %) were male who had sustained blunt trauma. The median (IQR) estimated PTX volume was 8 % (4-10) with 43 % of patients having a pneumothorax located to either the second intercostal space or most anterior portion of the chest on CT-mapping. The midpoints of each locule were anatomically distributed with a median (IQR) of 4th (3rd-5th) intercostal space and distance from the sternal edge (cm) of 4.1 (2.5-5.1) on the right, and 4.4 (3.5-5.2) on the left. Most PTX were sonographically occult due to apical, retrosternal, or posterior position.

CONCLUSION: Most traumatic PTX missed by prehospital EFAST were truly sonographically occult, but a significant number corresponded with the traditional scanning landmarks, particularly the parasternal 4th intercostal space. This reinforces current literature advocating this scanning region. The balance between optimal detection and sono-paralysis should be considered for ongoing education and governance.

PMID:41067963 | DOI:10.1016/j.injury.2025.112778

Injury. 2025 Sep 30;56(12):112780. doi: 10.1016/j.injury.2025.112780. Online ahead of print.

ABSTRACT

OBJECTIVES: Nonsteroidal anti-inflammatory drugs (NSAIDs), including ketorolac, are commonly used for postoperative pain management. Concerns about their potential impact on bone healing have been raised. This study investigated the relationship between ketorolac use and postoperative complications following clavicle surgery, including nonunion rates.

METHODS: This retrospective cohort study used the TriNetX Research Database to identify patients who underwent surgical fixation of clavicle fractures between 2002 and 2022. Two propensity-matched cohorts were created: patients who received postoperative ketorolac and those who did not. Primary outcomes included nonunion diagnosis and revision surgery; secondary outcomes included opioid use, wound disruption, surgical site infection, and infected hardware at 30 days, 90 days, 1 year, and 2 years postoperatively.

RESULTS: 5,264 patients were in each cohort after matching. Nonunion diagnosis was similar between the ketorolac and no-ketorolac groups at 30 days (16 vs. 18, P=0.731), 90 days (31 vs. 40, P=0.284), 1 year (93 vs. 88, P=0.708), and 2 years (104 vs. 100, P=0.777). Similarly, revision surgery for nonunion was comparable between the two groups at all time points, 30 days (<10 vs <10, P=1), 90 days (<10 vs <10, P=1), 1 year (24 vs. 20, P=0.546), and 2 years (27 vs 26, P=0.890). Opioid prescription rates were comparable across all time points but trended lower in the ketorolac group: 30 days (1,827 vs. 1,906, P=0.108), 90 days (1,967 vs. 2,051, P=0.092), 1 year (2,340 vs. 2,428, P=0.085), and 2 year (2,574 vs 2,642, P=0.185).

CONCLUSION: Ketorolac use following clavicle surgery was not associated with increased nonunion or revision surgery rates. Although opioid prescription rates trended lower in the ketorolac group, the difference was not statistically significant.

PMID:41061370 | DOI:10.1016/j.injury.2025.112780

Injury. 2025 Sep 20;56(11):112770. doi: 10.1016/j.injury.2025.112770. Online ahead of print.

ABSTRACT

INTRODUCTION: A dedicated Major Trauma Ward (MTW) is core to the function of a Major Trauma Centre (MTC). MTCs are central to the hub-and-spoke model of an inclusive Major Trauma System (MTS). The implementation of the London Major Trauma System is heralded to have increased the in-hospital odds ratio of survival of traumatically injured patients by 19 %. There is no one universal definition of Major Trauma, but the National Institute for Health and Clinical Excellence (NICE) provides the definition, "Major trauma is defined as an injury or combination of injuries that are life-threatening and could be life changing because it may result in long-term disability". Major Trauma is a disease requiring multidisciplinary and multi-specialty input at every stage of the continuum of care. However, there is no formal education for staff on a MTW on the care of these complex, severely injured patients. The Trauma ORchestration of Continuing Healthcare (TORCH) course was established in 2018 to help to address this educational void. The aims of this paper are to describe the rationale for the course, report the feedback, and identify key strengths and areas for improvement.

METHODS: A mixed methods study was undertaken with simultaneous quantitative and qualitative analysis. Descriptive statistics of quantitative data was undertaken to describe delegate demographics. Thematic analysis of the 136 attendee responses to course feedback was performed. Course feedback was assimilated contemporaneously at the end of each course via online survey.

RESULTS AND DISCUSSION: There was an 88 % (136/154) response rate to feedback. Attendees included 96 doctors, and 16 nurses and allied health professionals. The 2019 course of 24 delegates did not stratify participant demographics. The largest group of doctors (39 %) were Senior House Officer grade, with 41 % of all doctors coming from a surgical background. Feedback themes identified as course strengths include the multidisciplinary curriculum approach. Speakers include Consultants from 12 different specialties and multiple therapists across the continuum of trauma care. Lectures based on real life case discussion was found to be an engaging and thought provoking medium of education with the focus on MTW based decision making commonly required of MTW junior staff. Areas for future development include the continued delivery of the TORCH course outside of London and consideration of course validation for quality assurance, and a "train the trainer" model to allow for course expansion and sustainability in other MTSs of the UK and Ireland to implement formal, high quality education for staff on MTWs.

PMID:41045758 | DOI:10.1016/j.injury.2025.112770

Injury. 2025 Sep 30;56(11):112777. doi: 10.1016/j.injury.2025.112777. Online ahead of print.

ABSTRACT

BACKGROUND: Anterior shoulder dislocations are common in emergency settings, requiring effective procedural sedation and analgesia (PSA). Ketofol (ketamine-propofol) and etofen (etomidate-fentanyl) are widely used, but their comparative efficacy remains debated.

OBJECTIVES: The aim of this study was to compare the efficacy and safety of ketofol versus etofen for PSA in shoulder dislocation reduction.

METHODS: This randomized clinical trial enrolled 92 patients (46 per group). Ketofol (0.75 mg/kg) or etofen (0.15 mg/kg etomidate + 1.5 µg/kg fentanyl) was administered. Outcomes included sedation depth, hemodynamics, adverse events, and recovery times.

RESULTS: Ketofol provided deeper sedation (RSS 4.5 vs. 4.1, p < 0.001), better analgesia (VAS 1.64 vs. 2.64, p < 0.001), and easier reduction but had more emergence reactions. Etofen showed faster onset and fewer respiratory events but caused myoclonus.

CONCLUSION: Ketofol offers superior analgesia and sedation, while etofen ensures rapid recovery and hemodynamic stability. The choice depends on clinical priorities.

CLINICAL TRIAL REGISTRATION: IRCT20220824055790N1.

PMID:41045757 | DOI:10.1016/j.injury.2025.112777

Injury. 2025 Sep 24;56(11):112775. doi: 10.1016/j.injury.2025.112775. Online ahead of print.

ABSTRACT

OBJECTIVE: Although rare, shark bites can cause complex injuries requiring specialized management. This study aims to describe the surgical and medical management of shark bite injuries in New Caledonia.

METHODS: A retrospective, descriptive, single-center study including 22 patients hospitalized between 2011 and 2023. Demographic data, attack context, injury types, surgical treatments, infectious complications, and length of hospital stay were analyzed.

RESULTS: The median age was 33.5 years (IQR 15); 82 % were male. Spearfishing was the most common context (32 %). Injuries predominantly affected limbs, with musculoskeletal damage (82 %), nerve injuries (32 %), vascular injuries (27 %), and fractures (18 %). Infectious complications were rare (9 %), but identified pathogens were polymicrobial and marine-derived. The median hospital stay was 5 days (IQR 6, range 1-50 days).

CONCLUSION: Shark bites require rapid, specialized surgical care. Local organization enabled effective management. Empirical antibiotic therapy should cover marine pathogens.

LEVEL OF EVIDENCE: IV.

PMID:41037958 | DOI:10.1016/j.injury.2025.112775