Injury. 2025 Jan 31:112203. doi: 10.1016/j.injury.2025.112203. Online ahead of print.

ABSTRACT

INTRODUCTION: Traumatic brain injury (TBI) presents significant challenges in prehospital care, particularly during on-scene triage, where accurate decision-making is crucial for improving patient outcomes. This study, part of a mixed-methods project, aims to explore these challenges and identify gaps in current on-scene triage practices. Additionally, it seeks to understand paramedics' perspectives on potential diagnostic tools such as brain biomarkers, near-infrared spectroscopy, and decision aids.

METHODS: This study involved conducting semi-structured interviews by video conference, including interviews with paramedics of various experience levels who were recruited from UK ambulance trusts. The interviews were guided by a predeveloped and piloted topic guide. The interviews were audio-recorded, transcribed, and analysed using a thematic analysis approach.

RESULTS: Between June and December 2022, twenty participants (15 males and 5 females) with 4 to 24 years of experience were interviewed. Four key themes were identified. Theme 1, "Challenges in TBI Recognition," highlighted difficulties in identifying non-obvious TBI, especially in older adults or patients with comorbidities, and differentiating TBI from other conditions. Theme 2, "Need for Specific Triage and Diagnostic Tools," emphasised paramedics' need for a simple, evidence-based head injury-specific triage tool, as they felt that current tools lack the necessary specificity. Participants also highlighted the potential of new diagnostic technologies to improve decision-making. Theme 3, "Need for Evidence to Support Diagnostic Tools," stressed the importance of clinical effectiveness, feasibility, and cost before implementing new diagnostic technologies. Theme 4, "Implementation Requires Planning and Training," highlighted the need for effective implementation strategies, as well as adequate and ongoing training to ensure proficiency and proper use in the prehospital setting.

CONCLUSIONS: This study provides critical insights into the complexities of on-scene prehospital triage for patients with suspected TBI. Key recommendations include developing specific triage tools, exploring advanced technologies to support on-scene decision-making, enhancing paramedic training on TBI recognition, and addressing both barriers and facilitators to the implementation of new diagnostic technologies.

PMID:39929756 | DOI:10.1016/j.injury.2025.112203

Injury. 2025 Feb 4;56(3):112207. doi: 10.1016/j.injury.2025.112207. Online ahead of print.

ABSTRACT

This study investigates the impact of extraperitoneal pelvic packing (EPP) on the definitive surgical treatment of pelvic fractures (PF) in trauma patients. While EPP is recognized as an effective life-saving technique for controlling non-compressible retroperitoneal bleeding, concerns persist about its potential to complicate subsequent surgical interventions. A total of 220 trauma patients treated in a single First Level Trauma Centre from October 2016 to December 2021 were analysed. Demographic data, trauma mechanisms, hemodynamic stability, Injury Severity Scores (ISS), New ISS, PF classification (Tile), surgical timelines, and postoperative complications according to the Clavien-Dindo classification were collected. The study population was divided into two groups: those who underwent EPP (n = 42) and those who did not (n = 178). Statistical analyses included propensity score matching to balance baseline characteristics and reduce selection bias. Key findings show that EPP effectively improved survival rates in hemodynamically unstable patients, achieving a survival rate of 71.43 %. However, EPP was associated with delays in definitive surgical treatment and a higher incidence of major postoperative complications (41.67 % vs. 17.65 %, p = 0.014). Despite these delays, EPP did not significantly limit the possibility of achieving definitive surgery or the choice of fixation technique. Patients who underwent both EPP and open reduction internal fixation did not show a higher rate of severe complications compared to those managed without EPP. The study concludes that while EPP should be considered a practical emergency intervention for critically unstable PF patients, and even though it may affect the timing of definitive PF treatment, it does not prevent further surgical management.

PMID:39929088 | DOI:10.1016/j.injury.2025.112207

Injury. 2025 Feb 1:112202. doi: 10.1016/j.injury.2025.112202. Online ahead of print.

ABSTRACT

INTRODUCTION: Trauma care frequently happens in emergency departments (ED) outside of major trauma centers. Many injuries often exceed the specialty capabilities of referring hospitals, requiring transfer to larger trauma centers. However, the proportion of patients discharged home without admission from receiving facilities remains unclear, suggesting potential overutilization of transfers. We sought to determine the proportion of transfer patients that are discharged home from the receiving ED.

METHODS: We studied patients ≥15 years captured in the Trauma Quality Improvement Program (TQIP) database who were transferred from a referring institution and were subsequently discharged home from the receiving ED without additional services planned.

RESULTS: From 2020 to 2022, there were 744,623 patients ≥15 years of age, of which, 82,316 (11 %) were discharged home with (1 %) or without (99 %) additional services planned. The median age was 40 (26-60), and 70 % were male. The most common mechanism of injury was a collision (40 %), followed by falls (30 %). The median composite injury severity score was 5 (1-5). Serious injury by body region was most frequent for the craniomaxillofacial (11 %) followed by the thorax (5 %). Most of the transfers were to level 1 centers (85 %). The most frequently performed procedures were CT brain followed by a CT cervical spine, abdominal ultrasound, MRI cervical spine, hand laceration repair, ocular evaluation, scalp repair, forearm fracture reduction, assessment of ocular pressure, and MRI of the lumbar spine. The most frequent diagnoses were nasal fracture, orbital floor fracture, macular fracture, subdural hematoma, dental fracture, pneumothorax, rib fracture, hand laceration, burns, and vertebral fracture.

CONCLUSIONS: We found that approximately 1 in 9 patients transferred to a higher level of care are discharged home from the ED, with most requiring neurosurgical, ophthalmologic, dental and craniomaxillofacial services. These findings suggest that virtual communication technology could reduce unnecessary transfers and associated costs.

PMID:39920022 | DOI:10.1016/j.injury.2025.112202

Injury. 2025 Jan 31;56(3):112198. doi: 10.1016/j.injury.2025.112198. Online ahead of print.

ABSTRACT

Unstable ankle injuries often comprise multiple fracture lines; including a posterior malleolus fracture in up to 40% of cases. Surgical fixation of such injuries often requires multiple incisions. The configuration of the posterior malleolus fracture can also vary greatly, and the presence of this fracture is known to poorly affect patient outcomes. In this paper, the authors describe a modified posterolateral approach to the ankle which provides three windows for fixation of complex ankle fractures.

PMID:39919672 | DOI:10.1016/j.injury.2025.112198

Injury. 2025 Jan 31;56(3):112196. doi: 10.1016/j.injury.2025.112196. Online ahead of print.

ABSTRACT

INTRODUCTION: Open lower limb fractures can carry significant morbidity and are typically managed with a well-defined care pathway. Thankfully such injuries are less frequent in paediatric populations. Management for children is the same as it is for adults. The aim of this study was to analyse paediatric patients undergoing treatment for open lower limb fractures at a UK major trauma centre over a ten-year period.

METHOD: A retrospective analysis was performed on all paediatric patients with an open lower limb fracture that required soft tissue coverage, presenting to a major trauma centre with orthoplastic services from December 2011 to February 2023. Patient data was analysed according to demographics, co-morbidities, injury classification, time to wound excision, time to definitive surgery, soft-tissue reconstruction type and size, types of anastomoses used, grades of operators, peri‑operative use of inotropes and blood products, return to theatre in 24 h, flap survival and long-term complications.

RESULTS: We treated 94 patients with a mean age of 11 years old and mean weight of 46 .21kg The majority were ASA Grade I (80 %), additional co-morbidities included asthma, obesity and ADHD. Open tibial fractures were most common (61 %) followed by open foot fractures (18 %). Admission was within 24 h for 84 of the 86 patients for whom there was data, with 71 % having definitive fixation within 72 h of injury. The scapular or scapular/parscapular flap was most used (52 %) followed by an anterolateral thigh flap (29 %). A consultant was main operator in 70 % and a microsurgical fellow in 15 % of the cases recorded. Five cases out of 78 we had data for returned to theatre within the first 24 h of definitive surgery. with a mean of 18.5 h. In long term follow up there was 1 total flap failure and 1 flap that survived 60 % out of 53 patients there was data for. There were no deep bone infections.

CONCLUSION: Paediatric patients should be treated as aggressively as adults with an open lower limb fracture. Scapular and scapular/parascapular flaps offer a more cosmetically and functionally appealing option. Prompt IV antibiotics, combined specialist orthopaedics and plastics experience help to reduce deep bone infections.

PMID:39914251 | DOI:10.1016/j.injury.2025.112196

Injury. 2025 Jan 29;56(3):112199. doi: 10.1016/j.injury.2025.112199. Online ahead of print.

ABSTRACT

PURPOSE: Discharge is a critical time point in the care pathway of geriatric hospital patients, and post-acute care facilities often have less monitoring possibilities. Active medical issues such as electrolyte disturbances should be treated before transfer. We studied the impact of in-hospital hypernatremia of older hip fracture patients to mortality at 90 days.

METHODS: A retrospective study population of 2240 hip fracture patients from 2015 to 2019 was collected from the Hospital District of Southwest Finland data pool. In the present study we included patients aged ≥65 years who were transferred from the operating hospital to primary health care wards after surgery (n = 1,125). Laboratory results were collected on admission and before discharge. The main outcome was mortality at 90 days.

RESULTS: Hypernatremia, defined as serum sodium ≥144 mmol/l, was present in 6.8 % (n = 91) before discharge. For patients with hypernatremia the crude mortality at 90 days was 35.8 % (95 % CI 27.1 to 46.3) and for patients with normal serum sodium 9.6 % (95 % CI 8.0 to 11.6). The age- and sex-adjusted hazard ratio of hypernatremia compared to normal serum sodium was 3.91 (95 % CI 2.62 to 5.82).

CONCLUSION: In-hospital hypernatremia had predictive value for 90-day mortality. We recommend active screening for and prompt treatment of perioperative hypernatremia in hip fracture patients. Local guidelines and discharge checklists are recommended to secure the discharge period.

PMID:39908771 | DOI:10.1016/j.injury.2025.112199

Injury. 2025 Jan 16;56(3):112172. doi: 10.1016/j.injury.2025.112172. Online ahead of print.

ABSTRACT

OBJECTIVES: The primary aim of this study was to determine if an association exists between traumatic posterior hip dislocations and aortic injuries. Secondarily, this study assessed the incidence of chest imaging in patients with hip dislocations.

METHODS: Design: Retrospective Review of a Consecutive Case Series.

SETTING: Academic level I trauma centre. Patient Selection Criteria: Fifteen-thousand-four-hundred-thirteen consecutive traumatically injured patients with at least one orthopaedic injury were initially identified. After excluding patients without a posterior hip dislocation after blunt trauma, seven-hundred-nine patients were included. Outcome Measurements and Comparisons: The primary outcome was the coincidence of blunt traumatic aortic injury with acute posterior dislocation of a native hip. The secondary outcome was the rates of chest imaging to screen for blunt aortic injuries in patients with posterior hip dislocations.

RESULTS: The incidence of aortic injury with blunt trauma was 5.1 % in patients with a posterior hip dislocation and 1.6 % in patients without a posterior hip dislocation (OR = 3.3, CI: [2.3: 4.7], p < 0.001). Of the seven-hundred-nine patients with posterior hip dislocation, six hundred fifty-nine (93 %) received chest imaging as part of their initial workup, while thirty-four (4.8 %) never received chest imaging during hospitalization.

CONCLUSIONS: Despite improvements in automobile safety, this injury complex remains highly relevant. The findings advocate for routine chest imaging as part of the diagnostic trauma workup for patients with a native posterior hip dislocation.

PMID:39908770 | DOI:10.1016/j.injury.2025.112172

Injury. 2025 Jan 27;56(3):112184. doi: 10.1016/j.injury.2025.112184. Online ahead of print.

ABSTRACT

INTRODUCTION: Radiation Personal Protective Equipment (RPPE) is the subject of safety guidance from the British Orthopaedic Association (BOA). This pilot study aimed to examine potential performance differences in Trauma and Orthopaedic (T&O) Higher Surgical Trainees (HST) undertaking simulated Dynamic Hip Screw (DHS) surgery related to different RPPE attire.

METHODS: Fourteen Higher Surgical Trainees took part in a randomised, repeated-measures, crossover study (8 male, 6 female HSTs) performing two simulated DHS procedures wearing two RPPE attire styles (One Piece (OP) tabard 0.35 mm thickness, and Two-Piece skirt/top (TP), with a 0.5 mm thyroid guard). Primary outcome measures included continuous Heart Rate (HR) monitoring, body temperature, and Visual Analogue Scales (VAS) for comfort and fatigue before and after simulations.

RESULTS: Mean (SD) HR in OP and TP were HR OP 98.8 bpm (10.3) vs. TP 98.1 bpm (10.8, p < 0.001), Maximum HR OP 115.1 bpm (SD 12.4) vs. TP 113.4 bpm (SD 11.9) (p < 0.001). Mean change in temperature were OP 0°C and TP -0.03 °C (p < 0.001). Mean temperature VAS scores in OP were 1.9 (1.7) vs. TP 2.0 (1.4, p < 0.001). Mean Comfort VAS scores were OP 3.1 (2.4) vs. TP 1.7 (2.1, p < 0.001) and Fatigue OP 1.4 (1.9) vs. TP 0.8 (1.5, p = 0.120).

DISCUSSION: Important differences in surgeon physiological measures (HR, temperature) and self-reported measures of comfort and temperature were found related to RPPE style. Understanding the effects that specific RPPE attire has on performance should influence RPPE choice and the findings help inform future research into this important topic.

PMID:39908769 | DOI:10.1016/j.injury.2025.112184

Injury. 2025 Jan 31;56(3):112201. doi: 10.1016/j.injury.2025.112201. Online ahead of print.

ABSTRACT

BACKGROUND: According to the nationally imposed standard of care in the Netherlands, severely injured patients should be brought to a Level-1 trauma center for primary treatment. If not, they are considered to be undertriaged. This study aimed to determine the incidence of undertriage among severely injured geriatric patients and to evaluate the relation between hospital-undertriage and patient outcomes in elderly.

METHODS: This retrospective cohort study used anonymized data from the regional trauma registry of 1,431 patients aged ≥70 years with an Injury Severity Score ≥16 that were admitted to hospitals within the Trauma Region West-Netherlands between 2015 and 2022. Poor patient outcome was defined as in-hospital mortality or as a Glasgow Outcome Scale (GOS) score ≤3 at hospital discharge. The association between hospital level and poor outcomes was analyzed using multivariable logistic regression analysis with adjustment for confounders after multiple imputation of missing values.

RESULTS: Seventeen percent of the severely injured geriatric patients were primarily transported to a Level-2/3 hospital. Female patients, older patients, and patients that had suffered a low-energy fall were most likely to be undertriaged. The adjusted odds ratio's for in-hospital mortality and GOS score ≤3 in Level-1 versus Level-2/3 hospitals were 1.26 (95 % confidence interval, 0.83-1.93; p = 0.28) and 0.81 (95 % confidence interval, 0.57-1.15; p = 0.24), respectively.

CONCLUSION: Undertriaged severely injured geriatric patients did not have a higher risk for poor outcomes. Level-2/3 hospitals seem to present a safe alternative for the treatment of these patients.

PMID:39904059 | DOI:10.1016/j.injury.2025.112201

Injury. 2025 Jan 30;56(3):112164. doi: 10.1016/j.injury.2025.112164. Online ahead of print.

ABSTRACT

Traumatic brain injury remains a significant concern in public health, affecting millions of individuals globally and leading to long-term cognitive and physical impairments. Historically, research in this field has primarily focused on male subjects, often neglecting to consider the substantial biomechanical and anatomical differences between genders and individuals of varying ages. The present study investigates sex-specific biomechanical responses to head impacts in real-world accidents, employing an advanced female finite element head model, with a particular focus on critical brain structures such as the corpus callosum and pituitary gland. Two real-world accident scenarios were simulated: a non-fatal e-scooter collision and a fatal work-related incident involving a falling prop. A finite element analysis was conducted to determine the strain and stress distributions within the brain in response to impact conditions, assessing the potential for injury considering established failure criteria. The analysis revealed notable discrepancies in strain and stress distributions between anthropometric models. The smallest percentiles exhibited a higher risk of strain-related injury, while larger individuals demonstrated higher strain levels in key brain regions under similar impact conditions. Additionally, it was evaluated the efficacy of a safety helmet in a work-related scenario. These findings highlight the importance of subject-specific analyses in understanding TBIs and emphasise the need for continued refinement of FEHMs to improve the accuracy of injury prediction.

PMID:39893819 | DOI:10.1016/j.injury.2025.112164

Injury. 2025 Jan 17;56(3):112147. doi: 10.1016/j.injury.2025.112147. Online ahead of print.

ABSTRACT

OBJECTIVE: Metabolic bone disease (MBD, referring to osteopenia and osteoporosis) and its sequelae are associated with substantial morbidity, mortality, and healthcare costs. MBD screening and bone densitometry referral are underutilized in the general population despite published screening guidelines. Prior studies have correlated vertebral body Hounsfield unit (HU) measurements with MBD. The purpose of this study is to use this method to identify the prevalence of undiagnosed MBD in patients presenting to the hospital after high energy trauma, and to determine whether opportunistic MBD screening using this method would be valuable in this cohort.

DESIGN: Retrospective review.

SETTING: Level 1 trauma center and safety net hospital.

PATIENTS: 307 patients with a high energy femur fracture who underwent abdomen/pelvis computed tomography (CT) were identified from a trauma database.

INTERVENTION: L1 vertebral body radio density (in Hounsfield units, HU) was measured from trauma CT scans. Risk factors for MBD were identified from the medical record.

MAIN OUTCOME MEASUREMENTS: Prevalence of MBD and proportion of patients with MBD risk factors meriting further work-up.

RESULTS: The prevalence of MBD among high energy trauma patients was similar to the age-matched general population. Over half (50.5 %) of all patients had at least one risk factor for MBD. Among patients 50 to 64 years of age with any given MBD risk factor, over a third of individuals had MBD. In this population, the prevalence of MBD was highest (40.0 %) among those who used tobacco products and had a concurrent alcohol use disorder.

CONCLUSION: Opportunistic screening for MBD using a CT measurement technique can facilitate earlier diagnosis and treatment for affected individuals presenting after high energy trauma. Opportunistic screening may be particularly impactful in pre-menopausal women and in men, who frequently have MBD risk factors but who have a low referral rate for bone density testing and treatment.

LEVEL OF EVIDENCE: Diagnostic level III.

PMID:39893818 | DOI:10.1016/j.injury.2025.112147

Injury. 2025 Jan 24;56(3):112177. doi: 10.1016/j.injury.2025.112177. Online ahead of print.

ABSTRACT

BACKGROUND: Treatment of ankle and pilon fractures in the setting of diabetes mellitus (DM) is challenging due to a propensity for postoperative complications. Limb salvage is a primary concern following these injuries, as below knee amputation (BKA) occurs at an unacceptably high rate. Primary retrograde tibiotalocalcaneal (TTC) joint nailing without articular preparation has emerged as a solution to treat diabetics with ankle and pilon fractures to mitigate surgical complications and prevent BKA. The technique minimizes surgical dissection and has previously demonstrated utility in fragility fracture, however, there are few studies regarding the use of this technique in the setting of DM.

METHODS: A retrospective review of diabetic patients treated with retrograde TTC nailing without articular preparation was conducted over a seven-year period. Patients were included in the study if they were skeletally mature, diabetic, and treated with retrograde TTC nailing without articular preparation over a minimum follow up period of eight months. Treatment with other forms of fixation and pediatric or adolescents were excluded. A cohort of 25 patients met the inclusion criteria. Data was collected on demographics, injury characteristics, and surgical outcomes. The average follow up period was 2.45 years (IQR 986).

RESULTS: The averages for age, BMI, and Hemoglobin A1c (HbA1c) of the cohort were 64.6 (IQR 9.6), 36.7 (IQR 11.5), and 7.6 % (IQR 1.4), respectively. A majority of fractures were a closed supination-external rotation mechanism resulting from a fall from standing. The average LOS was 9.1 days (IQR 8). An ambulatory level was maintained in 72 % of patients. Limb salvage was achieved for 84 % of the cohort. Four patients ultimately required BKA. HbA1c and fracture-related infection (FRI) were statistically significant risk factors associated with BKA. For every 1 % increase in HbA1c, there was 2.63-fold odds of developing BKA. The surgical complication and reoperation rate were 56 %.

CONCLUSION: Although limb salvage was achieved for most patients within the cohort, high rates of postoperative complications and reoperations were observed using this technique. Prospective comparative studies are needed to further validate the use of retrograde nailing without articular preparation in the setting of DM.

PMID:39893817 | DOI:10.1016/j.injury.2025.112177

Injury. 2025 Jan 23;56(3):112181. doi: 10.1016/j.injury.2025.112181. Online ahead of print.

ABSTRACT

BACKGROUND: This systematic review aims to assess different effective hospital-based violence intervention programs (HVIP) design strategies and their effects on reducing the incidence of violence-related injuries, impact on healthcare outcomes including behavioral and psychosocial outcomes, and effects on healthcare system costs.

METHODS: A comprehensive search of five databases included studies that assessed the effects of HVIPs in adolescent and adult populations. The outcomes of interest included different effective HVIP design strategies that most effectively decreased the incidence of violence-related injuries, as well as their effects on behavior and psychosocial outcomes, effects on hospital costs, and whether they adequately addressed medico-legal aspects.

RESULTS: Following the application of inclusion and exclusion criteria, 25 studies were included in the final analysis. Effective HVIP design strategies primarily focused on mentorship and hands-on learning, contributing to successful program implementation. Overall, HVIPs significantly reduced the incidence of violence-related injuries and recidivism rates among participants. Improvements in psychosocial outcomes were observed, with increased employment rates and educational engagement reported among HVIP participants. Additionally, the included studies demonstrated that implementing HVIPs led to cost-effectiveness as well as cost savings from reduced injury recidivism. Despite the acknowledgment of medico-legal resources' importance, the absence of formal partnerships hinders HVIPs from fully addressing legal barriers to recovery, such as housing insecurity, employment discrimination, and protection from violence.

CONCLUSION: HVIPs are effective in reducing violence-related injuries, enhancing psychosocial outcomes, and offering cost savings, however, they often lack established medico-legal resources. Further research on establishing effective medico-legal partnerships within these programs is needed.

PMID:39893816 | DOI:10.1016/j.injury.2025.112181

Injury. 2025 Jan 22;56(3):112151. doi: 10.1016/j.injury.2025.112151. Online ahead of print.

ABSTRACT

BACKGROUND: Depression and post-traumatic stress disorder (PTSD) are becoming more prevalent among post-burn populations. With the increase in awareness of the significance of psychosocial injury adjustment for holistic health-related quality of life, beyond just physical, occupational, and functional recovery. However, the incidence of depression and PTSD in the adult population is inconsistent across published studies. To describe the baseline predictors of depression and post-traumatic stress disorder (PTSD) symptoms in hospitalised adult burn survivors over the first 12 months post-burn.

METHOD: A total of 274 participants, aged 18 years or over, with burn injuries, were hospitalized and treated at a tertiary burns centre in Queensland, Australia between October 2015 and December 2017. Additional follow-up data collected at 3-, 6- and 12-months post-burn injury. Dataset was analysed using gamma generalized mixed effects modelling techniques to assess the predictors of depression (PHQ-9) and PTSD (PCL-C) symptoms over time. Baseline predictors from personal, environmental, burn injury and burn treatment factors were assessed.

RESULTS: Both mental health outcomes followed a similar trend, with the largest decrease in symptom severity occurring between 3- and 6-months. A smaller decrease then occurred between 6- and 12-months. The baseline predictors of depression and PTSD symptoms post-burn in adults varied, however, the common predictors were increased age, a pre-injury mental health diagnosis and financial insufficiency. In addition to these predictors, intentional injury and recreational drug use were also statistically significant predictors of increased PTSD symptoms, while previous trauma exposure, longer hospital length of stay (LOS) and, surprisingly, stable housing status were also predictors of higher PHQ-9 depression scores. All predictors included in the final models were statistically significant with a p-value < 0.10.

CONCLUSION: Overall, mental health symptoms in burns survivors generally improved over the 12 months of follow-up, with the largest improvement noted between 3 and 6 months. Age, pre-injury mental health diagnosis and insufficient financial status, however, were all found to be associated with poorer mental health outcomes over the first 12 months post-burn.

PMID:39883967 | DOI:10.1016/j.injury.2025.112151

Injury. 2025 Jan 22;56(3):112168. doi: 10.1016/j.injury.2025.112168. Online ahead of print.

ABSTRACT

OBJECTIVES: The purpose of this study was to systematically review available strategies for diagnosing traumatic arthrotomy.

METHODS: A comprehensive literature search was conducted on October 8th, 2023 using Ovid Medline, Cochrane Central Register of Controlled Trials, Embase, and Embase Classic. Studies were included in the review if they evaluated a diagnostic strategy for traumatic arthrotomy.

RESULTS: There were 26 studies included after application of the exclusion criteria. 12 studies investigated traumatic arthrotomy of the knee, 8 of the elbow, 4 of the shoulder, 4 of the wrist, and 5 of the ankle. 23 studies implemented the saline load test as a diagnostic strategy, 7 considered CT scan, 1 study used x-ray, and 1 study used ultrasound. Of the studies that considered saline load tests, 8 of them also used methylene blue. CT scans were found to have 100% sensitivity when diagnosing traumatic arthrotomy of the knee. Saline load test was shown to have 60% to 100% sensitivity when diagnosing traumatic arthrotomies of the elbow. Saline load tests had sensitivities ranging from 75% to 100% when considering a shoulder traumatic arthrotomy. The saline load test was able to diagnose traumatic arthrotomies of the wrist, and ankle with sensitivities up to 100% and 99%, respectively.

CONCLUSIONS: When considering the infectious risks associated with undiagnosed traumatic arthrotomy, clinicians should seek modalities with the highest diagnostic performance. The saline load test has long been considered the gold standard for diagnosing traumatic arthrotomy, however, imaging modalities hold appeal as a less invasive and technically challenging procedure. Although diagnostic performance is joint-dependent, this review indicates that the saline load test continues to be the most reliable method for diagnosing most traumatic arthrotomies other than the knee.

LEVEL OF EVIDENCE: III.

PMID:39883966 | DOI:10.1016/j.injury.2025.112168

Injury. 2025 Jan 19;56(3):112165. doi: 10.1016/j.injury.2025.112165. Online ahead of print.

ABSTRACT

PURPOSE: Standard operating procedures aim to achieve a standardized and assumedly high-quality therapy. However, in orthopaedic surgery, the aspect of temporal urgency is often based on surgical tradition and experience. At a time of evidence-based medicine, it is necessary to question these temporal guidelines. The following review will therefore address the most important temporal guidelines in orthopaedic surgery and discuss their practical relevance and potential need for optimization.

METHODS: The systematic review features a literature review by database search in "PubMed" (https://pubmed.ncbi.nlm.nih.gov) for time to surgery in terms of (1) "proximal femoral fractures", (2) "femoral neck fractures", (3) "proximal humeral fractures", (4) "ligament and tendon injuries", (5) "spinal cord injuries", (6) "open fractures" and (7) "fracture-related infections". For every diagnosis, hypotheses on timing were set up and checked for evidence.

RESULTS: There is solid clinical evidence supporting the initiation of treatment within 24 h for specific conditions like the surgical treatment of proximal femur fractures and prompt decompression of spinal cord injuries. However, for other scenarios such as the 6-hour rule for open fractures, joint-preserving femoral neck fractures, timing of ligament injuries, humeral head fractures and fracture-related infections there is currently no reliable evidence to guide prompt surgical treatment.

CONCLUSION: Based on the current data, resource-adapted surgical planning seems reasonable. Further research in these areas is necessary to determine the best timing of treatment and address existing doubts.

PMID:39879862 | DOI:10.1016/j.injury.2025.112165

Injury. 2025 Jan 25;56(3):112183. doi: 10.1016/j.injury.2025.112183. Online ahead of print.

ABSTRACT

PURPOSE: Reduction and intraoperative maintenance of fracture fragments during minimally invasive plate osteosynthesis (MIPO) pose technical difficulties, particularly when the interposed fragment is angulated, prompting surgeons to attempt reduction due to concerns about nonunion or malunion. We aimed to compare the clinical and radiological outcomes of MIPO for mid-shaft clavicular fractures based on the reduced status of the interposed fragments.

METHOD: Fifty-seven patients who underwent MIPO for acute mid-shaft Robinson type 2B clavicular fractures were divided into two groups based on the alignment of the interposed fracture fragment. A vertical fracture fragment was defined as one tilted by >45° relative to the long axis of the proximal clavicular shaft. Radiological outcomes were evaluated using time to union, clavicle thickness, and length ratio after union compared with the healthy side. Clinical outcomes were assessed using the visual analog scale (VAS); the Korean Shoulder Score (KSS); Disability of the Arm, Shoulder, and Hand (DASH) score; and shoulder range of motion (ROM). Continuous variables were analyzed using Student's t-test or Mann-Whitney U test, based on data distribution.

RESULT: The vertical fragment group comprised 21 patients, and the nonvertical fragment group comprised 36. The mean time to union was similar between the vertical (4.48 ± 1.20 months) and nonvertical group (4.64 ± 1.17 months, p = 0.162). The groups showed comparable clavicular length and thickness ratios: 0.992 ± 0.040 vs. 1.076 ± 0.045 (p = 0.175), 1.189 ± 0.102 vs. 1.186 ± 0.271 (AP view, p = 0.165), and 1.121 ± 0.238 vs. 1.112 ± 0.230 (Lordotic view, p = 0.655), respectively. At 12 months, no significant differences were observed in VAS (0.3 ± 0.7 vs. 0.8 ± 0.8, p = 0.667), KSS (97.10 ± 6.30 vs. 96.75 ± 6.77, p = 0.940), and DASH (1.44 ± 3.64 vs. 2.00 ± 4.05, p = 0.501), or in ROM forward flexion (165.24 ± 9.28 vs. 162.78 ± 12.56, p = 0.464) and external rotation (60.95 ± 13.00 vs. 60.00 ± 13.47, p = 0.965).

CONCLUSION: Favorable radiological and clinical outcomes were achieved in all patients who underwent MIPO for mid-shaft clavicular fractures, regardless of whether the interposed fracture fragment after reduction was vertical.

PMID:39879861 | DOI:10.1016/j.injury.2025.112183

Injury. 2025 Jan 21;56(3):112178. doi: 10.1016/j.injury.2025.112178. Online ahead of print.

ABSTRACT

INTRODUCTION: Severe open lower limb fractures are complex and costly injuries. Studies reporting the costs associated with these injuries, the economic impact of complications, and the clinical benefit of adherence to national guidelines have been previously reported. However, the economic benefits of national guidelines and their relationship with length of inpatient stay have not been described.

METHODS: An international retrospective cohort study, using length of stay as a proxy for in-hospital economic impact, comparing the duration of inpatient stay in countries with national guidelines and those without.

RESULTS: In a cohort of 2641 patients from 16 countries, length of stay was 17 % lower in countries with national guidelines, equivalent to 2-3 fewer inpatient days per patient. This difference was primarily driven by a lower incidence of deep infection observed in countries with national clinical guidelines.

CONCLUSION: The presence of national guidelines for the management of severe lower limb injuries is associated with both improved clinical outcomes and reduced length of stay and therefore healthcare burden. Whilst application and adoption of national guidelines is not without challenges, their implementation is associated with significant clinical and economic benefits.

PMID:39879860 | DOI:10.1016/j.injury.2025.112178

Injury. 2025 Jan 20;56(3):112174. doi: 10.1016/j.injury.2025.112174. Online ahead of print.

ABSTRACT

OBJECTIVES: Long bone fractures with concomitant vascular injury have the potential to be life and limb threatening injuries, with increased risk for limb loss. There is currently no established surgical order of operations for orthopaedic and vascular intervention. This study compares injury classification, warm ischemia time and patient outcomes in patients with long bone fractures and associated vascular injury after orthopaedic versus vascular primary intervention.

METHODS: Design: Retrospective review Setting: Level 1 Trauma Center Patient Selection Criteria: Included were patients treated between 2016 and 2021 with fractures of the femur, tibia, fibula, or knee dislocation (OTA/AO 32, 33, 41, 42 and 43) with associated vascular injury necessitating vascular repair. Outcome Measures and Comparisons: Warm ischemia time, intraoperative transfusion requirements, readmission, definitive amputation, fasciotomy, infection, need for vascular revision, and return to weight bearing were compared between the two groups (primary vascular intervention (VP) and primary orthopaedic intervention (OP)).

RESULTS: 35 patients were included with 29 patients in the VP group and 6 patients in the OP group. There was no significant difference in the warm ischemia time between groups (p = 0.52) or total operative time (p = 0.13). 3/29 patients in the VP group required definitive amputation and 0/6 patients in the OP group required amputation (p = 1.00). There were no statistically significant differences in rates of infection, fasciotomy, readmission, length of stay, vascular revision, or time to weight bearing between groups.

CONCLUSIONS: This study demonstrates collaborative care between surgical teams to minimize warm ischemia time is crucial in patients with lower extremity fractures associated with vascular injury. There is no significant difference in patient outcomes including definitive intraoperative transfusion requirements, amputation, time to weight bearing or infection when comparing primary orthopaedic versus vascular intervention.

PMID:39874867 | DOI:10.1016/j.injury.2025.112174

Injury. 2025 Jan 23;56(3):112182. doi: 10.1016/j.injury.2025.112182. Online ahead of print.

ABSTRACT

INTRODUCTION: Blunt chest trauma represents a major risk factor for complications in polytrauma patients. Various scoring systems have emerged, but their impact is not fully appreciated. This review evaluates changes in chest trauma scoring over time and potential shifts in complication rates linked to modified surgical approaches in long bone fractures.

METHODS: A systematic review was performed utilizing Medline and EMBASE. Included studies analyzed the clinical course following blunt chest trauma with orthopedic injuries requiring surgical fixation. Quantification of chest injury severity was assessed based on the utilized scores in the respective publication such as the Abbreviated Injury Scale, Injury Severity Score, Thoracic Trauma Score (TTS) or the Chest Trauma Score (CTS). The studies were categorized into two groups: "ante-millenium" (AM) (<31.12.2000) and "post-millenium" (PM) (>01.01.2000). Endpoint analysis focused on chest-injury-related complications, including acute respiratory distress syndrome (ARDS), pneumonia, multiple organ failure (MOF), and pulmonary embolism. A meta-analysis examined the influence of surgical timing (early vs. late) on clinical outcomes.

RESULTS: Of 9,682 studies on chest trauma, 20 (4,079 patients) met the inclusion criteria. Most studies in both AM and PM reported the thoracic AIS scale for severity assessment. In group PM more clinical parameters were included in the decision making. Incidences of pooled and weighted mortality were higher in AM (5.1 %) compared to PM (2.3 %, p = 0.003), and ARDS incidence was also greater in AM (12.1 %) versus PM (8.9 %, p = 0.045), though these findings were not confirmed through indirect meta-analysis. Early fracture fixation (<24 h) displayed a non-significant trend toward lower ARDS (OR: 0.60; 95 % CI, 0.23-1.52) and mortality (OR: 0.66; 95 % CI, 0.28-1.55), but significantly reduced pneumonia risk (OR, 0.53; 95 % CI, 0.40-0.71).

CONCLUSION: Prior to 2000, chest injuries were quantified using the AIS alone, while afterwards multiple scoring systems that incorporated pathophysiologic response were utilized. Possibly related to changes in timing of surgery, fixation techniques, or general improvements in-patient care seems to have improved in patients with concomitant thoracic trauma regarding mortality and ARDS. Overall, polytrauma patients with concomitant thoracic injuries might benefit from early definitive fracture care if their physiology and overall injury pattern allows it.

LEVEL OF EVIDENCE: Systematic Review; Level IV.

PMID:39874866 | DOI:10.1016/j.injury.2025.112182