Injury. 2025 Dec 11;57(2):112959. doi: 10.1016/j.injury.2025.112959. Online ahead of print.

ABSTRACT

BACKGROUND: Psychiatric disorders are common after traumatic brain injury, impeding recovery and increasing health and social costs internationally. clinicians caring for patients with TBI need an evidence base to support assessment of risk of and intervention to reduce psychiatric morbidity.

METHOD: We systematically searched for original studies published in English reporting development of multivariate models predicting anxiety, depression, PTSD and psychotic disorders in civilian adults at least six months after injury. The electronic search was conducted on 12 August 2024. Authors independently screened records, assessed study quality, and extracted data for descriptive analysis and narrative synthesis.

RESULTS: We included 34 studies presenting 47 multivariable models predicting psychiatric disorder six to 120 months after TBI of varying severity. Study samples, ranging from 43 to 207,354, were predominantly male and Caucasian/White and aged 30-45 years. Models inconsistently included demographic, psychosocial and injury-related variables with mixed results. Female sex, psychiatric history, race/ethnicity, physical health and assault/violent mechanism of injury were statistically significant two-thirds of models in which they were included. Infrequently included variables including coping style and intoxication at injury were strongly associated with disorder.

DISCUSSION: Faced with inconsistency in evidence we recommend that clinicians assess risk of suboptimal outcome broadly, asking not whether a given patient is at risk of a specific psychiatric condition but of any psychiatric disturbance following TBI. Patients with a psychiatric history and/or injured violently should be monitored but assessment must encompass biopsychosocial circumstances. Employment of a conceptual model of psychiatric disorder would support development of a cohesive evidence base.

PMID:41494479 | DOI:10.1016/j.injury.2025.112959

Injury. 2025 Dec 17;57(2):112974. doi: 10.1016/j.injury.2025.112974. Online ahead of print.

ABSTRACT

HYPOTHESIS: The 22 Winchester Magnum caliber will not have enough momentum and kinetic energy to penetrate through a near-human porcine model in three constructs; a chest model, a bone model, and an extended muscle model.

METHODS: Two types of projectiles were evaluated, i.e. a jacketed hollow point in (JHP) and a full metal jacket (FMJ). These were fired through a hand-held pistol into the three models. The models were similar in size, weight, and dimensions. Velocity, depth of penetration, and residual projectile construction were measured.

RESULTS: The JHP penetrated through all layers in the muscle chest model, it fractured long bone but failed to exit the bone model and it did not penetrate the chest cavity in the extended muscle model. The FMJ, on the other hand, penetrated and exited all three constructs into a backstop. The JHP expanded well in the muscle models but fragmented completely in the bone model. The FMJ deformed and could be retrieved after exiting all three models.

CONCLUSION: The JHP is an effective self-defense round in a standard chest model but functioned inadequately after contacting a long bone or an extended muscle barrier. The FMJ is effective in penetrating the vitals even after piercing a long bone or extended soft tissue. These constructs represent real-life self-defense scenarios, better than any artificial model and should be used by manufacturers and enthusiasts as their final testing module evaluating a specific projectile.

PMID:41485320 | DOI:10.1016/j.injury.2025.112974

Injury. 2025 Dec 25;57(2):113013. doi: 10.1016/j.injury.2025.113013. Online ahead of print.

ABSTRACT

OBJECTIVE: Management of Gustilo 3B tibias remains problematic with high complication rate. Controversy persists about coverage timing, and whether the clock starts at time of injury or definitive fixation. Postoperative outcomes of 3B open tibia fractures and the effect of fixation and flap timing were reviewed retrospectively.

METHODS: Design: Retrospective observational study.

SETTING: Data derived from Bellwether PearlDiver, a multicenter insurance claims database. Patient Selection Criteria: 1066 Gustilo 3B tibia fractures were identified with flap coverage within 45 days of fixation (2009 ... 2021). Fixation within 3days of injury was classified as prompt. The remaining fixations were designated as delayed. Flap coverage within 3 days of fixation was considered prompt. Coverage after this was considered delayed. Outcome Measures and Comparisons: Complications and return to OR were analyzed. Separately, patients were divided by days to definitive fixation or days to flap coverage, irrespective to the other. One-year complication incidence was compared using linear regression analysis.

RESULTS: 252 (23.6 %) patients received prompt fixation and prompt flap. 519 (48.7 %) received prompt fixation and delayed flap. 271 (25.4 %) underwent both delayed fixation and flap while only 24 (2.3 %) received prompt flap following a delay in fixation. By linear regression analysis, surgical site infection (SSI), wound disruption (WD), and reoperation incidence increased by 0.53 % (p < 0.001), 0.84 % (p < 0.001), and 0.63 % (p < 0.001), respectively, with each day between fixation and flap coverage. Days from injury to fixation was significant for increased WD incidence (0.38 %, p = 0.03).

CONCLUSIONS: Early flaps demonstrated fewer complications. Very few patients with delayed fixation received prompt flap coverage. Prior research suggested that delayed fixation had few consequences when followed by prompt flap coverage. This appears to be rare in practice. Prompt multidisciplinary orthopaedic and plastics management of Gustilo 3B tibia fractures is important for optimal outcomes in these injuries.

LEVEL OF EVIDENCE: Level 3.

PMID:41483688 | DOI:10.1016/j.injury.2025.113013

Injury. 2025 Dec 25;57(2):113012. doi: 10.1016/j.injury.2025.113012. Online ahead of print.

ABSTRACT

BACKGROUND: Trauma care in Scotland is organised into four networks and the North of Scotland Trauma Network, covering 60 % of Scotland's landmass, was the first of the four regions to go live in October 2018. The trauma demographics, journeys and outcomes over the decade of 2013-2023, five years and nine months prior to and five years post implementation were examined.

METHODS: Data prospectively collected by Scottish Trauma Audit Group (STAG) during the time period was analysed. Patients of all ages, Injury Severity Score (ISS) > 8 and head injury Abbreviated Injury Scale (AIS) > 1 were included. The primary outcome was mortality. Multivariate logistic regression compared factors associated with mortality pre- and post - network.

RESULTS: Post-network, 47.8 % of ISS>15 presented at non-Major Trauma Centre (MTC) hospitals, of which 47.4 % underwent secondary transfer. Half (50.5 %) of serious head injuries (AIS>2) presented to the Trauma Unit (TU) / Local Emergency Hospitals (LEH), of which 34.4 % were transferred to the MTC. Of those transferred to the MTC, moving vehicle was the commonest mechanism (44.7 %) and median ISS was 22 (IQR 17 - 29). Ultimately, the majority (75 %) of major trauma patients were treated at the MTC post network. Whilst overall mortality was 7.8 %; this rose to 18.3 % for ISS > 15, and 20.6 % for serious head injury. Mortality for ISS > 15 first presenting outside of the MTC and then subsequently transferred was 8.3 %. There was significant difference in 30-day mortality in those presenting after network implementation (OR 0.76 [0.6 - 0.97], p = 0.03) adjusting for age, ISS, head injury severity and mechanism of injury. A sensitivity analysis of the two consistently contributing hospitals (TU and MTC) was performed and mortality improvement was maintained (OR 0.71, 95 % CI 0.55 - 0.93, p = 0.011) although this could have been due to improved data capture of lower acuity trauma, or other confounding variables.

CONCLUSION: In a geographically dispersed network, the contributions of TUs and LEHs and subsequent secondary transfers are substantial. Network investment in training, communication pathways and transfer governance is essential.

PMID:41483687 | DOI:10.1016/j.injury.2025.113012

Injury. 2025 Dec 24;57(2):113009. doi: 10.1016/j.injury.2025.113009. Online ahead of print.

ABSTRACT

BACKGROUND: Independent ambulation at hospital discharge is a critical determinant of discharge destination and caregiving burden in older adults with proximal femoral fractures. Preoperative prediction of walking independence may support discharge planning and early intervention.

METHODS: This retrospective observational study included 350 patients who underwent surgery for proximal femoral fractures between April 2018-April 2023. Independent ambulation was defined as Functional Ambulation Category (FAC) = 5. Preoperative variables included age, Body Mass Index (BMI), cognitive function (HDS-R), psoas muscle index (PMI), nutritional and inflammatory markers (GNRI, albumin, total protein, CRP), and pre-fracture walking ability. Patients were divided chronologically into a training set (n = 250) and a temporal external validation set (n = 100). An XGBoost model was developed and evaluated using area under the receiver operating characteristic curve (AUC). SHAP analysis was applied to identify major contributing factors.

RESULTS: Of the 350 patients, 186 (53.1 %) achieved independent ambulation at discharge. The optimized XGBoost model yielded a mean cross-validation AUC of 0.856 and an external validation AUC of 0.829, with accuracy = 0.771, precision = 0.872, recall = 0.774, and F1-score = 0.820. SHAP analysis identified HDS-R as the strongest contributor, followed by height, pre-fracture walking ability, GNRI, and CRP.

CONCLUSIONS: Preoperative prediction of discharge-time walking independence using XGBoost demonstrated high discriminatory performance. Cognitive function, nutritional status, and inflammatory markers were key predictors. SHAP analysis enhanced interpretability, supporting clinical applicability. This model may facilitate individualized discharge planning and early intervention strategies in patients with proximal femoral fractures.

PMID:41478088 | DOI:10.1016/j.injury.2025.113009

Injury. 2025 Dec 24;57(2):113011. doi: 10.1016/j.injury.2025.113011. Online ahead of print.

ABSTRACT

INTRODUCTION: In recent decades, there has been a shift in TBI epidemiology, with a rising incidence in older adults. Medication use is an often-overlooked modifiable TBI risk factor. There is a paucity of research specifically examining the relationship between individual medications, polypharmacy, and the risk of TBI. With the goal of informing TBI prevention strategies as well as future research, we conducted a systematic review to assess the association between specific medication use, polypharmacy, and the risk of TBI.

MATERIALS AND METHODS: This systematic review follows the PRISMA guidelines and was prospectively registered in PROSPERO. We conducted a literature search of the following databases: MEDLINE, EMBASE, PsycINFO, Global Health, CINAHL, and Web of Science. We included all randomized controlled, quasi-experimental or observational studies reporting on polypharmacy or single medications and the risk of TBI. We excluded pediatric studies, trauma studies that did not report specifically on TBI, animal studies, case series, and case reports. Reviewers independently evaluated studies according to inclusion and exclusion criteria and risk of bias.

RESULTS: After duplicate removal, our research strategy identified 18,528 studies, of which 197 abstracts were selected for full-text review. Sixteen studies met our inclusion criteria. In total, 7 medication classes and 27 single medications were studied. A single study reported on polypharmacy. Four studies on antithrombotics reported an association with an increased risk of TBI. In 2 studies, antidepressants were associated with an increased risk of TBI. Two studies on antipsychotics showed an association with an increased risk of TBI. One study found a significant increase in the risk of TBI with the use of benzodiazepines. Results on z-drugs were inconsistent, with one study reporting a significant increase in TBI risk with zolpidem but not eszopiclone. The single study evaluating opioids reported an increased risk of TBI. Finally, antiarrhythmics were associated with an increased risk of TBI.

CONCLUSION: In robust studies, antipsychotics, antidepressants, hypnotics, and opioids have all been associated with an increased risk of TBI, while studies on antithrombotics are inconsistent. Further studies are needed to evaluate the risk of these drugs in the general population, especially in the elderly.

PMID:41468799 | DOI:10.1016/j.injury.2025.113011

Injury. 2025 Dec 16;57(2):112976. doi: 10.1016/j.injury.2025.112976. Online ahead of print.

ABSTRACT

INTRODUCTION: The indications for fixation of posterior malleolar fragments in ankle fractures remain controversial, and the correct interpretation of the pathology underlying fracture morphology is still unclear. This study focused on the anatomical characteristics of the posterior inferior tibiofibular ligament (PITFL) and the fracture pattern and displacement of posterior malleolar fragments, to determine which types of posterior malleolar fragments contribute to syndesmotic stability.

METHODS: Seventy patients with Weber type B ankle fractures associated with posterior malleolar fragments involving ≤25 % of the articular surface were included. Following fibular fixation, syndesmotic stability was assessed using the Cotton test. The relationship between Mason and Molloy fracture classification, the presence of lateral displacement (LD), and syndesmotic instability were all investigated.

RESULTS: Syndesmotic instability was observed in 7/70 cases (10 %), including in 27.3 % of Mason and Molloy type 1 fractures and 55.6 % of LD-type fractures. Conversely, only 1 of the 54 cases that were neither Mason and Molloy type 1 nor LD-type demonstrated syndesmotic instability.

CONCLUSION: PITFL function is likely preserved in most Weber type B fractures with Mason and Molloy type 2 posterior malleolar fragments caused by external rotation injury. In contrast, LD-type fragments suggest complete disruption of the PITFL, including the deep layer, and require treatment strategies that take this into account.

PMID:41455294 | DOI:10.1016/j.injury.2025.112976

Injury. 2025 Dec 3;57(2):112923. doi: 10.1016/j.injury.2025.112923. Online ahead of print.

ABSTRACT

INTRODUCTION: Cement augmentation has the potential to reduce the high failure rates commonly associated with internal fixation in patients with unstable femoral trochanteric fractures. Although current treatment guidelines for femoral trochanteric fractures are comprehensive, most have not mentioned cement augmentation fixation as a treatment option. The objective of this study is to formulate expert consensus statements on the use of cephalomedullary nails with cement augmentation for managing femoral trochanteric fractures in Japan.

METHODS: A modified Delphi approach, comprising two rounds of anonymous surveys and one Expert Meeting, was used to establish consensus on the use of cement augmentation in unstable femoral trochanteric fractures among 15 orthopaedic surgeons (3 Steering Committee members, 12 Expert Panellists) from Japan who have insights into using cement augmentation. Expert Panellists indicated their agreement with each statement on a 5-point Likert scale. Consensus was defined as ≥75 % of Expert Panellists selecting either "Agree"/"Strongly Agree" or "Disagree"/"Strongly Disagree".

RESULTS: Consensus was reached for 53 % of statements (18/34) in Round 1 and 85 % of statements (11/13) in Round 2. Ultimately, 29 statements reached consensus, of which 10 statements were on "Patient Selection" (primary cases, age, bone density, surgery, revision cases and pre-operative assessments for cement augmentation), 9 were on "Surgical Approaches", 6 were on "Post-Operative Care and Rehabilitation" and 4 were on "Expected Functional Outcomes". There were 2 statements that did not reach consensus.

CONCLUSIONS: Japanese orthopaedic surgeons were largely aligned on patient selection, surgical approaches, post-operative care, rehabilitation, and expected outcomes of cement-augmented cephalomedullary nail fixation for femoral trochanteric fractures. When monitored, this technique lowers the potential risk of cement leakage and may also reduce complications, reoperation rates, and postoperative pain, while improving functional outcomes, indicating a favourable safety profile. This consensus serves as an important reference for orthopaedic surgeons in Japan and beyond, particularly given the growing concern over these fractures in Japan's ageing population and that of the wider region. However, consensus was not reached on some aspects due to the limited availability of Japan-specific evidence. Further studies on efficacy and safety outcomes, particularly among the Japanese population, are needed to establish best practices.

PMID:41453239 | DOI:10.1016/j.injury.2025.112923

Injury. 2025 Dec 4;57(2):112937. doi: 10.1016/j.injury.2025.112937. Online ahead of print.

ABSTRACT

INTRODUCTION: For 20 years, Israel has experienced periods where it has been attacked by missile fire from Gaza resulting in civilian deaths and injuries. The Iron Dome air defense system detects incoming missiles and then triggers an air-raid siren that can result in physical injuries and emotional distress as civilians seek shelter. The objective of this study was to compare the epidemiology of responses by Magen David Adom, Israel's National Emergency Medical System (EMS) during the 2021 Gaza War and the 2023 Israel-Hamas War, that were associated with injuries during air-raid sirens but not directly related to the missiles.

METHODS: This is a retrospective comparative study of all EMS responses during air-raid sirens which occurred during the 2021 Gaza War (May 10 -21, 2021) and the 2023 Israel-Hamas War (data from October 7- November 3, 2023).

RESULTS: The study included a total of 1155 EMS responses. Across both conflicts, physical injuries and anxiety-related responses were more common in women than in men (71.8 % vs. 28.2 %; p ≤ 0.05) and 63.5 % vs. 36.5 %; p ≤ 0.05). Comparative analysis between the two conflicts demonstrated that the odds of a response being for an elderly patient (age >75) was higher in the 2023 Israel-Hamas War compared to the 2021 Gaza War (OR 1.83, 95 % CI 1.35-2.48). In addition, there were more EMS responses for injuries in the 2023 Israel-Hamas War compared to the 2021 Gaza War, whether orthopedic (OR 1.66, 95 % CI 1.22-2.25), light injuries (OR 1.35, 95 % CI 0.98-1.86), or head injury (OR 3.31, 95 % CI 1.74-6.30). Additionally, the mean ratio of responses per air-raid siren was higher in the 2023 Israel-Hamas War compared to the 2021 Gaza War (M = 0.15, SD = 0.08 vs M = 0.06, SD = 0.03; p < 0.0001).

CONCLUSION: Air-raid sirens are important in reducing civilian injuries and deaths from missiles. However, the siren itself may cause significant anxiety and can lead to injury as civilians try to seek shelter. Increased public messaging about staying calm and carefully moving to shelter could help prevent injuries.

PMID:41447871 | DOI:10.1016/j.injury.2025.112937

Injury. 2025 Dec 9;57(2):112953. doi: 10.1016/j.injury.2025.112953. Online ahead of print.

ABSTRACT

Accurate placement of pedicle screws is crucial for avoiding complications such as nerve damage or vascular injury. Screws are typically placed freehand using fluoroscopy-guidance. Recently, portable CT combined with 3D navigation (3D-N-iCT) has been developed to guide the placement of pedicle screws. This study compares the accuracy of pedicle screw placement using 3D-N-iCT versus the conventional freehand fluoroscopy guidance for thoracolumbar surgery. The records of patients who underwent thoracolumbar spine surgery with pedicle screw placement from November 2017 to December 2022 at Kaohsiung Chang Gung Memorial Hospital were retrospectively reviewed. Patients were divided into those in which 3D-N-iCT was used and those in whom screws were placed with freehand fluoroscopy guidance (FH-F). Outcomes compared between the 2 groups included screw placement accuracy assessed using the Gertzbein classification, and post-operative complications. A total of 244 patients were included in the study, with 182 in the 3D-N-iCT group and 62 in the FH-F group. The accuracy of screw placement was significantly higher in the 3D-N-iCT group, with 98 % of screws classified as Grade 0 (indicating perfectly positioned) compared to 93 % in the FH-F group (p = 0.010). The placement time was similar between groups (36.0 vs. 33.0 min, p = 0.120). The 3D-N-iCT group had a significantly lower rate of post-operative neurological defects (0 % vs. 5 %, p = 0.016) and complications (0.5 % vs. 8 %, p = 0.004). In conclusions, the use of 3D-N-iCT is associated with greater accuracy in pedicle screw placement during thoracolumbar spine surgeries compared to the freehand technique, without prolonging placement time.

PMID:41447870 | DOI:10.1016/j.injury.2025.112953

Injury. 2025 Dec 16;57(2):112977. doi: 10.1016/j.injury.2025.112977. Online ahead of print.

ABSTRACT

OBJECTIVES: Road injury is a major cause of fractures, but its global burden remains unclear.

METHODS: Based on data from the Global Burden of Disease (GBD) 2021 study, this study systematically analyzed the incidence, prevalence, and years lived with disability (YLDs) of road injury-related fractures at the global, regional, and national levels, as well as the trends in disease burden from 1990 to 2021. Additionally, the risk factors for road injury deaths and disability-adjusted life years (DALYs) were evaluated through the GBD study's Comparative Risk Assessment framework.

RESULTS: In 2021, global fracture cases from road injuries were 19,113 thousand (95 % uncertainty interval [UI]: 16,571 thousand - 21,839 thousand), a 6.1 % decrease from 1990. From 1990 to 2021, the age-standardized incidence rate (ASIR) fell from 376.5 (95 % UI: 324.43 - 430.91) to 238.2 (95 % UI: 206.63 - 271.01), age-standardized prevalence rate (ASPR) from 1364.4 (95 % UI: 1258.88 - 1471.32) to 825.2 (95 % UI: 764.72 - 884.41), and age-standardized YLD rate (ASYR) from 78.6 (95 % UI: 54.34 - 109.89) to 45.9 (95 % UI: 31.60 - 64.55) per 100,000 population. Among fractures, patellar, tibial/fibular, or ankle fractures had the heaviest burden, with 2021 ASIR of 65.8 (95 % UI: 49.26 - 87.90) per 100,000. Geographically, disease burden varied by region and country: parts of the Middle East, South Asia, Africa, and Latin America remained heavily burdened, while ASIR rose in 19 countries (including Paraguay). Correlation analysis showed ASIR, ASPR, and ASYR correlated positively with Socio-Demographic Index (SDI). Occupational injuries, low bone mineral density, alcohol consumption, high temperature, and smoking have been identified as risk factors for road injuries. Among these, occupational injuries remain the primary global risk factor, though their proportion is decreasing; meanwhile, the risk proportion of low bone mineral density is on the rise.

CONCLUSIONS: Over the past three decades, the global burden of road injury-related fractures has declined, but regional and national disparities persist. While high SDI regions achieved significant reductions, severe challenges remain in the regions such as the Middle East and West Asia. Additionally, apart from occupational injuries, the risk of low bone mineral density in road injury cannot be ignored.

PMID:41447869 | DOI:10.1016/j.injury.2025.112977

Injury. 2025 Dec 4;57(2):112932. doi: 10.1016/j.injury.2025.112932. Online ahead of print.

ABSTRACT

Periprosthetic fracture is a devastating complication of total hip arthroplasty that is associated with significant morbidity and mortality. Cement-in-cement revision of the femoral component is a technique that has been proposed as an efficient revision technique to treat femoral periprosthetic fractures where the femoral stem is loose, but the bone-cement interface is intact. By eliminating the need to remove the existing cement mantle, proposed advantages include shorter operative time, reduced blood loss, easy restoration of pre-fracture version and soft tissue tension, and eliminating the risk of iatrogenic damage from cement removal. However, the technique has not been widely popularised due to concerns over the fixation stability and risk of non-union from cement extrusion into the fracture site. Herein, an up-to-date review of the indications for, surgical technique of, and outcomes of cement-in-cement revision of the femoral component of a total hip arthroplasty for periprosthetic fracture is provided.

PMID:41442906 | DOI:10.1016/j.injury.2025.112932

Injury. 2025 Dec 14;57(2):112972. doi: 10.1016/j.injury.2025.112972. Online ahead of print.

ABSTRACT

INTRODUCTION: Brachial plexus injuries (BPI) are devastating conditions that frequently result in flail, insensate upper limbs associated with severe neuropathic pain and loss of function. When reconstructive options such as nerve grafts, transfers, or free muscle transplantation fail to restore meaningful function, transhumeral amputation may be considered as a salvage strategy. The advent of advanced prosthetic technologies, particularly myoelectric and osseointegrated devices, has renewed interest in elective amputation for select patients.

OBJECTIVES: This systematic review evaluates functional, pain, prosthetic, and quality-of-life outcomes following transhumeral amputation for traumatic BPI.

METHODS: A systematic search of PubMed, Embase, and Scopus (May 2025) was conducted according to PRISMA guidelines. Eligible studies reported outcomes of transhumeral amputation following traumatic BPI. Non-English, non-original, and non-BPI amputation studies were excluded. Data extraction and quality assessment were performed independently by two reviewers using the MINORS tool. Continuous data (e.g. DASH, VAS) were pooled using a random-effects meta-analysis (RevMan 5.4). Heterogeneity was assessed using the I² statistic, and subgroup analyses explored differences by prosthesis type (myoelectric vs. cosmetic/traditional).

RESULTS: Ten studies encompassing 93 patients met inclusion criteria (Level III-IV evidence, follow-up 3-19 years). Mean postoperative DASH score was 35.0 (95 % CI 28.0-42.0), indicating moderate residual disability but a significant functional improvement from preoperative values (ΔDASH = -13.5; 95 % CI -21.9 to -5.1). Myoelectric users demonstrated superior functional outcomes (mean DASH 30.7) compared with cosmetic or traditional users (means 37-43; p = 0.008). Pooled VAS pain score was 5.6 (95 % CI 3.1-8.1) with a nonsignificant trend towards improvement (ΔVAS -1.2). Regular prosthesis use occurred in 51 % (95 % CI 27-74 %), and approximately 37 % of patients returned to work. Patient satisfaction exceeded 80 % in most series, particularly among myoelectric prosthesis users.

CONCLUSION: Transhumeral amputation following brachial plexus injury yields clinically meaningful functional gains and high patient satisfaction, especially when combined with modern prosthetic technology. Pain reduction is variable, and return-to-work rates remain modest. Amputation should be considered a valid reconstructive endpoint in selected patients when conventional nerve reconstruction fails. Future multicentre prospective studies employing standardised outcome measures are essential to refine patient selection, quantify long-term benefit, and optimise multidisciplinary rehabilitation strategies.

PMID:41442905 | DOI:10.1016/j.injury.2025.112972

Injury. 2025 Dec 17;57(2):112978. doi: 10.1016/j.injury.2025.112978. Online ahead of print.

ABSTRACT

AIM: The aim of this investigation is to study the effect of intramedullary reaming on the repair of a rabbit tibial osteotomy stabilised by a specially designed locking nail.

MATERIALS AND METHODS: A tibial osteotomy was carried out in two similar groups of ten New Zealand White rabbits. In one group, reaming was carried out prior to nailing, while in the second group, the nail was inserted without reaming. At four weeks postoperatively, CT scans of operated and non-operated contralateral tibiae enabled the percentage increase in bone volume of the whole tibial shaft to be measured in both reamed and unreamed groups.

RESULTS: Although there was larger increase in callus volume in the tibial shaft of the reamed group (40.21 % ± 25.87) than the unreamed group (37.94 % ±15.12), this was not statistically significant (p = 0.81).

DISCUSSION: Intramedullary reaming of the intact rabbit tibia results in the production of vascular external callus formation. Although the medullary circulation is initially damaged, this is subsequently restored. Intramedullary reaming produces reaming debris that enters the osteotomy gap and acts as an autologous bone graft. In this study, all the rabbit tibial osteotomies stabilised by intramedullary nails progressed to bony union. Intramedullary reaming did not produce more callus than that following the insertion of an unreamed intramedullary nail.

CONCLUSION: All of the rabbit tibial osteotomies stabilised by intramedullary nails progressed to bone union and additional intramedullary reaming did not produce additional callus. The potential of the rabbit tibia to produce callus appears to be limited to the amount of callus required to achieve bone union.

PMID:41442904 | DOI:10.1016/j.injury.2025.112978

Injury. 2025 Dec 17;57(2):112979. doi: 10.1016/j.injury.2025.112979. Online ahead of print.

ABSTRACT

BACKGROUND: Traumatic brain injury (TBI) is a major cause of mortality worldwide. The goals of TBI management include prevention of secondary brain injury by reducing pathological increase in intracranial pressure. Craniotomy is an effective intervention for relieving refractory increased intracranial pressure. Therefore, we aimed to clarify the association between time from hospital arrival to craniotomy and outcomes in patients with severe TBI using data from a nationwide trauma registry.

METHODS: We identified patients who underwent craniotomy owing to severe blunt TBI (Glasgow Coma Scale score ≤ 8 and Abbreviated Injury Scale score 4 or 5 for the head region) between 2019 and 2023 from the Japan Trauma Data Bank. Exclusion criteria were transfer from another hospital, extracranial surgery, time from arrival to craniotomy > 8 h, or missing data regarding time to surgery or in-hospital mortality. Patients were categorized into the early (≤ 4 h) or delayed (> 4 h) surgery groups based on the time to craniotomy. The primary outcome was in-hospital mortality. Secondary outcomes included probability of favorable neurological outcomes (Glasgow Outcome Scale score 4 or 5), discharge to home rate, length of hospital stay, length of intensive care unit (ICU) stay, and duration of mechanical ventilation. Multivariable logistic regression analysis was performed to adjust for potential confounders.

RESULTS: Among the 1058 eligible patients, 960 (90.7%) and 98 (9.3%) underwent early and delayed craniotomy, respectively. In-hospital mortality was not significantly different between the groups even after adjusting for confounders. Furthermore, probability of favorable neurological outcomes, discharge to home rate, length of hospital stay, length of ICU stay, and duration of mechanical ventilation were not significantly different between the groups. A generalized additive model revealed no significant non-linear association between time to craniotomy and in-hospital mortality.

CONCLUSIONS: Short-term outcomes in patients with severe TBI were not significantly associated with time from hospital arrival to craniotomy. This finding highlights the importance of flexible, individualized clinical decision-making in patients with TBI. Further studies are warranted to identify specific patient subgroups that may benefit from early craniotomies.

PMID:41442903 | DOI:10.1016/j.injury.2025.112979

Injury. 2025 Dec 4;57(2):112941. doi: 10.1016/j.injury.2025.112941. Online ahead of print.

ABSTRACT

INTRODUCTION: Revised Trauma Quality of Life (RT-QOL) measurement among violence survivors is challenging because of loss to follow-up. This study evaluated RT-QOL instrument completion during follow-up phone calls after hospital discharge and assessed if time to follow-up call was associated with instrument completion.

MATERIALS AND METHODS: This was an observational cohort study of intentional interpersonal violence survivors treated at a Level 1 urban trauma center from March 2018-April 2024. Depression (Beck's Depression Inventory II), Post-Traumatic Stress Disorder (Breslau Post Traumatic Stress Disorder Scale 7-item), and Revised Trauma-specific Quality of Life (RT-QOL) instruments were phone administered after discharge in English or Spanish. Multivariable regression tested if time to follow-up call was associated with instrument completion while controlling for survivors' demographic, injury, hospital course and follow-up characteristics.

RESULTS: A total of 566 intentional interpersonal violence survivors were eligible. Survivors were mostly male (82.0 %), 25-64 years old (77.9 %), Black (65.2 %), and injured by firearm (44.7 %). Among the 566 eligible survivors, 115 survivors (20.3 %) had an inaccurate phone number in the medical record, and 32 (5.7 %) died after hospital discharge. Two survivors (0.4 %) partially completed and 51 (9 %) completed instruments. Survivors who completed instruments were called fewer times, 2 calls (IQR: 1-2.5) versus 3 calls (IQR: 1-3). Approximately 43 % of survivors who completed instruments, completed them on the first call. Time to follow-up call was not associated with instrument completion. Females had 2.45 higher adjusted odds of instrument completion after controlling for time to follow-up call, age, race, ethnicity and injury mechanism (p = 0.008). Among survivors who completed instruments, 21(41.1 %) screened positive on Beck's Depression Inventory II, 31 (60.8 %) screened positive on Breslau Post Traumatic Stress Disorder Scale 7-item, and 39 (76.5 %) reported RT-QOL symptoms impairing work.

CONCLUSIONS: Only female sex, not time to follow-up call, was associated with increased instrument completion among violence survivors.

PMID:41442902 | DOI:10.1016/j.injury.2025.112941

Injury. 2025 Dec 10;57(2):112952. doi: 10.1016/j.injury.2025.112952. Online ahead of print.

ABSTRACT

OBJECTIVE: To determine the diagnostic performance of single-energy CT (SECT) scan for detecting contralateral posterior pelvic ring injuries in patients with an operative pelvis fracture.

METHODS: Retrospective cohort study.

SETTING: Level I Trauma Center PATIENT SELECTION CRITERIA: Consecutive adults with operatively-treated pelvic ring injuries and preoperative and postoperative pelvis CT scans. Exclusion criteria were incomplete or unreadable imaging, pelvis CT obtained on a spine board or with a pelvic binder in place, prior pelvic instrumentation, or sacroiliac joint fusion.

OUTCOME: Measures and Comparisons: An "occult" contralateral sacroiliac joint injury was defined as either (A) a positive change of ≥2.0 mm between preoperative and postoperative CT measurements at this level on the "uninjured" side or (B) an intraoperatively fluoroscopic finding of ≥2.0 mm of sacroiliac joint widening on either static or dynamic stress fluoroscopic imaging on the "uninjured" side not present on the initial, preoperative CT RESULTS: One hundred forty-six adults, 62 % male sex, with a mean age of 42.5 years were included. A unilateral posterior pelvic ring injury was identified on the initial pelvis CT in ninety patients. An occult contralateral sacroiliac joint injury was identified in 11 patients (12.2 %), 5 by intraoperative fluoroscopic examination, none during instrumentation, and 6 by postoperative pelvis CT. One U-type sacral fracture was identified on postoperative CT. The diagnostic performance of pelvis SECT in the initial trauma evaluation for correctly classifying bilateral pelvic ring injuries was 84 % sensitivity with a 16 % false negative rate, 100 % specificity, 88 % negative predictive value, and 92 % accuracy.

CONCLUSIONS: In this cohort, 16 % of bilateral posterior ring injuries were incorrectly classified as unilateral from the initial pelvis CT. A complete unilateral posterior ring injury should raise suspicion for an occult contralateral injury and may warrant additional radiographic or fluoroscopic stress examination if clinically appropriate.

PMID:41442901 | DOI:10.1016/j.injury.2025.112952

Injury. 2025 Dec 16:112975. doi: 10.1016/j.injury.2025.112975. Online ahead of print.

NO ABSTRACT

PMID:41436346 | DOI:10.1016/j.injury.2025.112975

Injury. 2025 Dec 13:112973. doi: 10.1016/j.injury.2025.112973. Online ahead of print.

ABSTRACT

BACKGROUND: Needle thoracostomy (NT) is a frontline intervention for suspected tension pneumothorax in prehospital trauma care. The necessity for intervention in patients with relative indications is unclear, and locoregional protocols guiding NT placement by prehospital personnel vary. This study aims to identify factors associated with a positive response to NT and how often objective measures are utilized to prompt intervention, which may help better define indications for the procedure.

METHODS: A retrospective review of adult trauma patient who received prehospital needle decompression was performed utilizing the trauma registry database from a level 1ACS accredited trauma center in Omaha, Nebraska. A positive response was defined as increased oxygen saturation by 10 %, increased systolic blood pressure by 10 mmHg, improved ventilation or breath sounds, or return of spontaneous circulation.

RESULTS: A total of 214 patients were included, with an overall mortality rate of 52 % of which 144 (68 %) sustained blunt trauma and 67 (32 %) penetrating trauma. Mortality was 49 % for blunt trauma and 60 % for penetrating trauma (p = 0.182). Only 63 patients (30 %) responded to NT with an improvement in clinical parameters. The most common indication(s) for NT was documented as absent/reduced breath sounds (n = 118, 55 %), CPR (n = 79, 37 %), and hypoxia (n = 40, 19 %). After excluding patients with CPR en route (n = 135/214, 63 %), positive NT response increased to 48 % and overall mortality rate decreased to 26 %. There was no significant change in systolic blood pressure (mean difference: 0.3 mm Hg, 95 % CI:4.8-5.3, p = 0.910) or heart rate (-1.1 bpm, 95 % CI:5.8-3.6, p = 0.650) post-decompression. The incidence of hypoxia decreased from 68 % to 48 % (p < 0.001). Complications were identified in 14 % of patients and one patient did have a needle inserted into the heart, required a cardiac operation, and had subsequent anoxic brain injury.

CONCLUSIONS: This study highlights the low success rates of prehospital NT, with the majority of procedures being performed based on subjective indicators. Prehospital protocols should be refined by incorporating objective criteria, such as confirmed hypoxia, to better identify patients who may benefit from NT.

PMID:41436345 | DOI:10.1016/j.injury.2025.112973

Injury. 2025 Dec 10;57(2):112936. doi: 10.1016/j.injury.2025.112936. Online ahead of print.

ABSTRACT

PURPOSE: This study assessed whether ultrasonographic (U/S) detection of bridging callus can serve as an early sign of tibial fracture healing. By comparing U/S with serial radiographs, the goal was to identify the best predictors of fracture union. Previous studies indicate that early radiographic bridging callus may signal eventual healing, and U/S could detect this sooner than X-rays. Thus, U/S may provide earlier predictions of bone union or impaired healing.

METHODS: A prospective evaluation was conducted on a consecutive cohort of patients with tibial fractures managed by intramedullary nailing. Patients were followed until complete bone healing or determination of nonunion at twelve months. Demographic and clinical data were collected contemporaneously. Radiographic and ultrasound images were obtained monthly and independently assessed by two experienced orthopaedic surgeons.

RESULTS: Of the 42 initially enrolled patients 6 were lost to follow-up, resulting in the 36 included in the final cohort. There were 29 males and 7 females, aged between 22 and 64 years (mean, 39; median, 36.5). Fourteen fractures were open, with 20 classified as AO/OTA A, seven B, and nine C patterns. Of the 36 patients who completed the study, 31 healed uneventfully, while 5 did not achieve healing. An ultrasonographic bridging callus was observed between the first and third month following surgery. A "V"-shaped ultrasound corkscrew sign appeared in areas where no callus developed, and may serve as a prognostic factor for eventual nonunion. Bridging callus detected by ultrasound during the initial three months was identified as a positive prognostic indicator of bone healing.

CONCLUSION: Ultrasonography is rarely used to assess fracture healing, but it may help predict outcomes. Portable point-of-care ultrasound (POCUS) can reduce radiation in follow-ups. Detecting bridging callus on ultrasound within three months reliably indicates bone healing, often appearing a month before seen on X-ray and suggesting eventual union.

PMID:41435710 | DOI:10.1016/j.injury.2025.112936