Injury. 2025 Jun 11;56(8):112367. doi: 10.1016/j.injury.2025.112367. Online ahead of print.

ABSTRACT

INTRODUCTION: Hemorrhage causes 40 % of deaths from trauma. Low- and middle- income countries (LMICs) claim the majority of these deaths, in part due to lack of resources and organization in the prehospital and hospital arenas. Guatemala experiences a high burden of trauma-related injuries but does not have the resources nor the emergency response system to deal with it. In Guatemala, firefighters (bomberos) lead trauma responses, yet do not receive medical training. Recognizing these gaps in LMICs, we developed "CrashSavers", a low cost, openly accessible, self-training mobile phone-based platform to teach hemorrhage control techniques to first responders in Guatemala City. In this manuscript, we present the evaluation and outcomes of the bomberos who were trained with CrashSavers.

METHODS: Our self-administered educational program teaches first responders to train themselves in the decision making and psychomotor skills of tourniquet placement. This free platform, accessible via mobile phone, provides didactic material, virtual reality cases and instructions to construct a bleeding extremity simulator. Sixty-four bomberos were trained from July-August 2022. Eighteen months later they were retested to assess knowledge retention. Interviews were conducted with all bomberos to elicit feedback, which were then analyzed with narrative synthesis. We assessed medical knowledge, confidence, and surgical skills pre and post training.

RESULTS: After training, bomberos were able to apply the tourniquet more efficiently and more confidently. The time taken to stop a bleed on the simulator dropped from 58.5 s to 39.2 s, p < 0.003. Assessment of their skills 18 months after initial training showed that they were able to retain both confidence and psychomotor skill of tourniquet placement. Qualitative analysis showed overall positive experience with the course.

CONCLUSIONS: A low cost, easily accessible, self-taught course of didactics, VR cases and simulation successfully trained bomberos to control a bleeding extremity. This may be a solution for the large gaps in LMIC trauma response, as traditional programs designed for high income countries (HICs) are inaccessible, expensive and time intensive. With CrashSavers, learners became faster and more confident in stopping a bleed, and in a situation where time is blood and blood is life, efficiency is key.

PMID:40561809 | DOI:10.1016/j.injury.2025.112367

Injury. 2025 Jun 17:112532. doi: 10.1016/j.injury.2025.112532. Online ahead of print.

ABSTRACT

BACKGROUND: The frequent use of computed tomography (CT) scan in the evaluation of trauma patients has led to an increase in the diagnosis of hemothorax. This study aimed to assess whether a hemothorax volume of <300 ml, as determined by CT imaging, can be managed without tube thoracostomy and to identify the factors that recommend its use.

METHODS: A retrospective observational study was conducted at XXX Trauma Center, including all patients with traumatic hemothorax from June 2014 to January 2020. Patient demographics, injury mechanism, severity, associated chest injuries, indications for tube thoracostomy, mechanical ventilation, hospital length of stay, complications, and outcomes were reviewed. The study compared patients with hemothorax volumes < 300 ml and ≥300 ml and assessed the outcomes of conservative management without tube thoracostomy (conservative management) vs therapeutic management with tube thoracostomy placement (failed observation).

RESULTS: A total of 254 patients with hemothorax were included. Most patients (79 %) were successfully managed without tube thoracostomy insertion, while 53 patients (21 %) required tube thoracostomy after failure of conservative management. Patients with larger hemothorax volumes were significantly more likely to require tube thoracostomy (p = 0.001) and had significantly longer hospital stays (p = 0.021). Those with failed observation had higher injury severity scores (p = 0.001), more associated lung contusions (p = 0.015), pneumothorax (p = 0.024), and rib fractures (p = 0.001). They also had larger hemothorax volumes (p = 0.001), a greater need for mechanical ventilation (p = 0.001), and prolonged hospitalization (p = 0.001). Predictors of failed observation included high hemothorax volume (≥300 ml), ISS, and greater number of fractured ribs.

CONCLUSION: Conservative management (without tube thoracostomy) was adequate for most patients with <300 ml of hemothorax volumes. Quantitative assessment of hemothorax volume should be considered part of the clinical decision-making algorithm. Further research is needed to refine management strategies and improve outcomes for traumatic hemothorax.

PMID:40555636 | DOI:10.1016/j.injury.2025.112532

Injury. 2025 Jun 17;56(8):112529. doi: 10.1016/j.injury.2025.112529. Online ahead of print.

ABSTRACT

INTRODUCTION: Sternal fractures are uncommon but may result in significant morbidity when associated with respiratory compromise or severe pain. Conventional methods such as plate fixation are often invasive and technically challenging.

METHODS: We retrospectively reviewed eight cases of transverse sternal fractures treated using an intramedullary fixation technique with cannulated cancellous screws (CCS). Preoperative computed tomography with 3D reconstruction was used for surgical planning. Reduction was achieved percutaneously or through a limited incision, followed by guidewire insertion and screw fixation.

RESULTS: The minimally invasive procedure was completed in 18-35 min (mean, 22 min) with little blood loss (mean, 23 mL). Among six patients with ventilatory compromise, four were successfully extubated within three days postoperatively. There were no complications related to screw insertion, and bone union was confirmed in all cases.

CONCLUSION: Intramedullary screw fixation represents a safe, minimally invasive, and mechanically robust alternative for the management of sternal fractures, particularly in patients with flail chest or severe pain.

PMID:40554841 | DOI:10.1016/j.injury.2025.112529

Injury. 2025 Jun 18;56(8):112522. doi: 10.1016/j.injury.2025.112522. Online ahead of print.

ABSTRACT

OBJECTIVES: To determine (1) if early routine radiographic follow-up at 2-3 weeks for patients with operatively treated tibia, fibula or ankle fractures identified complications (i.e., complications only visible on radiographs and not associated with symptoms on history taking or clinical examination) and (2) if these complications were clinically relevant (i.e., led to treatment change).

METHODS: All adult patients who underwent operative treatment for a tibia, fibula or ankle fracture between January 2021 and January 2023 and who received early routine radiographic follow-up between 10 and 30 days postoperatively were included in this retrospective case series. Routine radiographs were defined as radiographs that were scheduled and obtained as part of the institution's standardized follow-up protocol. The primary outcome was the rate of complications detected on early routine radiographs, stratified by the presence of associated symptoms based on history taking or findings on physical examination. The secondary outcome was any documented treatment change for complications.

RESULTS: Six hundred and twenty-eight patients (median age of 47 years, 42 % male) were included. A total of 5 complications in 628 patients (0.8 %) were seen on early routine radiographs, of which 3 complications (0.5 %) were exclusively identified on radiographs (i.e., not associated with symptoms). None of these 3 complications led to a change in treatment strategy. The remaining 2 complications were visible on radiographs but were accompanied by symptoms on history taking or physical examination.

CONCLUSION: The results of the current study suggest that radiographs at 2-3 weeks following operative treatment of tibia, fibula or ankle fractures may not need to be ordered routinely. Obtaining radiographs should be guided by clinical indication or by patient and surgeon preference (e.g., for reasons beyond complications). These findings should be considered in light of increasing healthcare expenditures and the time investment required of patients and healthcare professionals.

PMID:40554111 | DOI:10.1016/j.injury.2025.112522

Injury. 2025 May 22;56(8):112449. doi: 10.1016/j.injury.2025.112449. Online ahead of print.

NO ABSTRACT

PMID:40544747 | DOI:10.1016/j.injury.2025.112449

Injury. 2025 Jun 12:112524. doi: 10.1016/j.injury.2025.112524. Online ahead of print.

ABSTRACT

BACKGROUND: Patients with blunt solid organ injury (BSOI) face heightened thromboembolic risks, prompting scrutiny of early versus late venous thromboembolic (VTE) prophylaxis effects.

METHODS: Analyzing TQIP data (2017-2019) for adults (≥18 years) with severe BSOI under non-operative management and VTE prophylaxis, we classified patients into early (≤48 h) and late (>48 h) prophylaxis groups. We conducted a propensity score matching (PSM) to balance the population based on demographics, organ injury severity, vital signs and need for blood transfusion. Data were compared post-PSM.

RESULTS: Among 23,668 patients, mortality was 3.1 %, with 42.2 % receiving early and 57.8 % late VTE prophylaxis. Early prophylaxis correlated with lower mortality (2.1 % vs. 3.9 %), lower rates of failure of non-operative management (12.4 % vs. 16.6 %), stroke (0.7 % vs. 1.2 %), DVT (2.1 % vs. 4.9 %) and PE (1.4 % vs. 2.3 %) (p < 0.001 for all). Late prophylaxis associated with longer hospitalization and ICU stays (p < 0.001 for both). Post-match data showed that compared to early VTE prophylaxis, patients that received late VTE prophylaxis had higher mortality rates (2.5 % vs. 1.9 %), failure of non-operative management (14.6 % vs. 11.8 %), longer hospital (15.8 (8.7) vs. 12.4 (6.7) days) and ICU (8.9 (4.7) vs. 6.8 (3.4) days) LOS, and higher rates of developing thrombotic complications during hospital stay (p < 0.05, for all).

CONCLUSION: Early VTE prophylaxis not only proves safe for isolated solid organ injury patients but also is associated with lower mortality, mitigating thromboembolic risks and shortening hospital and ICU stays.

LEVEL OF EVIDENCE: Level III retrospective study.

PMID:40544037 | DOI:10.1016/j.injury.2025.112524

Injury. 2025 Jun 11:112523. doi: 10.1016/j.injury.2025.112523. Online ahead of print.

ABSTRACT

INTRODUCTION: Traumatic brain injury (TBI) is a major contributor to emergency department (ED) visits worldwide, with older adults being particularly susceptible due to fall-related injuries. The widespread use of anticoagulants, including direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs), raises concerns about the risk of delayed intracranial haemorrhage (dICH), even in cases where the initial head computed tomography (CT) scan shows no abnormalities. The optimal strategies for managing and monitoring these patients remain a subject of ongoing debate.

MATERIALS AND METHODS: We conducted a monocentric retrospective observational study at Santa Croce e Carle Hospital, Cuneo, Italy, from January 2019 to August 2024. We included patients aged ≥18 years, on chronic anticoagulant therapy, presenting with mild TBI (GCS ≥13) and a negative initial CT scan. All patients underwent a second CT after 24 h of observation, regardless of clinical changes. The primary outcome was the incidence of dICH. Secondary outcomes included neurosurgical interventions and 30-day mortality.

RESULTS: The study included 596 patients (median age 83 years; 46.5 % male). Most patients were on DOACs (74.5 %), and falls were the most common trauma mechanism (90.4 %). dICH was diagnosed in 2 % of patients (n = 12), with subarachnoid haemorrhage and subdural hematoma being the most frequent findings (5 patients each). None of the dICH cases required neurosurgical intervention or resulted in mortality at 30 days. Patients with dICH were more likely to have a GCS <15 upon arrival (16.7 % vs. 3.9 %; p = 0.17) and experienced high-energy trauma mechanism, (16.7 % vs. 1.7 %; p = 0.044); among patients with dICH, 41.7 % were on VKA therapy, compared to 25.2 % of patients without dICH (p = 0,33). Complications during hospitalization, primarily nosocomial infections and delirium, occurred in 66 % of patients hospitalized for dICH.

CONCLUSION: Our findings confirm that dICH after TBI in anticoagulated patients with a negative initial CT is rare and typically benign. Routine prolonged observation and repeat CTs may not be necessary for all patients, particularly those without high-risk factors; individualized management based on clinical risk factors could minimize unnecessary hospitalizations, reduce complications, and optimize healthcare resources.

PMID:40537351 | DOI:10.1016/j.injury.2025.112523

Injury. 2025 Jun 5;56(8):112471. doi: 10.1016/j.injury.2025.112471. Online ahead of print.

ABSTRACT

INTRODUCTION: Tibial shaft fractures are common injuries seen particularly because of high velocity trauma. Considerable debate exists between the suprapatellar and infrapatellar approach for nailing of tibial shaft fractures. The aim of this study was to compare the clinical, radiological and functional outcomes and intra-operative fluoroscopy time, total blood loss and operative time between supra-patellar and infra-patellar insertion techniques in the treatment of extra-articular tibial shaft fractures.

METHODS: Sixty patients aged between 18-45 years who presented to our Level I trauma-centre with AO/OTA type 42 fractures were randomized into Suprapatellar (SP) and Infrapatellar (IP) groups. Operative time, intra-operative blood loss and radiation exposure was recorded. Severity of knee pain by VAS score and knee range of motion were documented at 2 weeks, 6 weeks, 3 months, 6 months, 12 months, 18 months and 24 months follow-up. Functional outcomes were measured using Knee Society Score, Lysholm Knee Score and KOOS-PF score and radiological union assessed with radiograph done at 6 weeks, 3 months, 6 months, 12 months, 18 months and 24 months post-operatively.

RESULTS: Thirty patients each underwent nailing by suprapatellar and infrapatellar approach. A statistically significant difference favouring the suprapatellar group was noted in the operative time (p-value 0.003) and mean intra-operative blood loss (p-value 0.027). There was no difference between the two groups in terms of knee pain or knee range of motion and the mean functional scores.

CONCLUSION: Suprapatellar nailing of tibial shaft fractures may help to reduce operative time and intra-operative blood loss with similar intra-operative radiation exposure, clinical and functional outcomes compared to infrapatellar nailing.

PMID:40532333 | DOI:10.1016/j.injury.2025.112471

Injury. 2025 May 28;56(8):112456. doi: 10.1016/j.injury.2025.112456. Online ahead of print.

ABSTRACT

BACKGROUND: Preoperative planning is a helpful tool for orthopaedic trauma cases, but clinical experience dictates that its use remains inconsistent. The primary aim of this cross-sectional survey study was to investigate practices and applications of preoperative planning for orthopaedic trauma cases and to identify factors influencing its use.

METHODS: A cross-sectional 26-item survey was distributed to members of the Orthopaedic Trauma Association and The Netherlands Orthopaedic Trauma Association between April 2024 and August 2024. Four key areas of interest were assessed: (1) general preoperative planning practices; (2) features of the preoperative plan; (3) use of preoperative planning for resident training; and (4) factors influencing the decision to make a preoperative plan. General preoperative planning practices were compared between attendings and residents or fellows.

RESULTS: Two-hundred-eleven orthopaedic surgeons, fellows, or residents completed the survey (84 % male, 74 % attending, 55 % of attendings trauma-fellowship-trained). Overall, 84 % of respondents considered preoperative planning very or extremely important. Formal preoperative planning was performed on average for 50 % of cases. Residents or fellows planned significantly more often than attendings (76 % vs. 30 %, p < 0.001) and used digital templating more often (59 % vs. 38 %, p= 0.006). The most common features of the plan were tactical, including positioning of implants and specific steps of approach and reduction. Residents reported that preoperative plans were discussed preoperatively in 75 % of cases and postoperatively evaluated in 40 %. Case complexity was the most influential factor in deciding to plan.

CONCLUSION: Respondents considered preoperative planning to be very or extremely important for orthopaedic trauma cases but made a formal preoperative plan on average in only half of cases. Residents or fellows made a preoperative plan twice as often. Complexity of the case was the most important factor in deciding to make a preoperative plan. Benefits of preoperative planning such as improving resident teaching and learning, efficiency, and teamwork should be considered more often in the decision to make a preoperative plan.

PMID:40532332 | DOI:10.1016/j.injury.2025.112456

Injury. 2025 Jun 8;56(8):112465. doi: 10.1016/j.injury.2025.112465. Online ahead of print.

ABSTRACT

BACKGROUND/PURPOSE: Forearm lacerations are frequently associated with involvement of tendon, nerve, and vessel injuries. An accurate diagnosis and timely intervention are critical to avoid any functional impairment, but clinical examination alone may not always be reliable, particularly in combined injuries or uncooperative patients. High-resolution ultrasound (USG) is a useful tool for the rapid assessment of these injuries. This study aims to evaluate the effectiveness of pre-operative USG in diagnosing tendon, nerve, and vascular injuries in acute trauma cases, using surgical exploration as the gold standard.

METHODS: This prospective observational study was conducted at the Department of Plastic Surgery of a tertiary care Trauma centre, between April 2022 and July 2024. Thirty-eight patients with forearm lacerations were included. All patients underwent clinical examination followed by USG (3-15 MHz) for injury assessment. The cases were examined by the operating surgeon. USG findings were compared with intraoperative findings to assess the diagnostic accuracy.

RESULTS: USG demonstrated diagnostic accuracy of 99.62 % in tendon injuries, with a high sensitivity (98.61 %) and specificity (100 %). It identified nerve injuries with a accuracy of 96.49 %, and interpreting arterial injuries was more challenging, with an accuracy of 90.7 %. The outcome of evaluation with high resolution USG with clinical examination was better than that of isolated clinical examination for tendon and neurovascular injuries. The mean time for an USG diagnosis in forearm laceration was 9.53 min.

CONCLUSION: High-resolution ultrasound is an effective, non-invasive tool for a quick assessment of forearm lacerations. It offers a high sensitivity and specificity for tendon and nerve injuries, aiding in targeted surgical interventions. While it is less sensitive for vascular injuries, it remains valuable for surgical planning in combined injuries. This study supports its integration into routine trauma care to improve diagnostic accuracy and better outcomes.

LEVEL OF EVIDENCE: Level IIIA, Prospective observational study.

PMID:40532331 | DOI:10.1016/j.injury.2025.112465

Injury. 2025 Jun 7:112472. doi: 10.1016/j.injury.2025.112472. Online ahead of print.

NO ABSTRACT

PMID:40518338 | DOI:10.1016/j.injury.2025.112472

Injury. 2025 Jun 9;56(8):112515. doi: 10.1016/j.injury.2025.112515. Online ahead of print.

ABSTRACT

Introduction In 2020, we published a new minimally invasive anteromedial distal approach for plate fixation of the humerus (MIAMDAH) to address extra-articular distal shaft fractures in a cadaveric study. After operating on our first patients, it was noted that the distal MIPO window was too small to comfortably fix the plate distally. So, a wider MIPO window was developed to make the surgical procedure more comfortable. This study aimed to evaluate clinical outcomes in patients who underwent surgery using either the original approach or its modified version and to determine whether the modification provided technical or clinical advantages over the original.

MATERIAL AND PATIENTS: Forty-five patients underwent surgery using either the original or modified approach. Twenty-one received the original technique, and twenty-four received the modified one. The primary outcome measured was the Mayo Elbow Performance Scale (MEPS) score at 18 months. The secondary outcome measures included the University of California at Los Angeles (UCLA) score and the elbow motion of the damaged arm at 18 months. A statistical bivariate analysis was performed to compare various subgroups based on the original or modified approach.

RESULTS: All patients were followed for 18 months. The average distance from the fracture to the coronoid fossa was 3.72 cm for the original approach and 3.95 cm for the modified approach. Both approaches showed no statistically significant differences between primary and secondary outcomes. The original approach yielded good to excellent results in all patients (21/21) at the last follow-up, with a mean MEPS score of 98.5 and a UCLA score of 34.7. The modified approach resulted in good to excellent functional outcomes in 22 of 24 patients, with a mean MEPS score of 95.8 and a UCLA score of 34.3. The mean arch elbow motion was 125.3° (11° less than the undamaged arm) in the original approach and 123.5° (13° less than the undamaged arm) in the modified approach.

CONCLUSION: MIAMDAH provides a reliable alternative to laborious open approaches or risky MIPO approaches described to date. The modified version offers a broader MIPO window, which enhances surgery comfort and may reduce the complication rate.

PMID:40517641 | DOI:10.1016/j.injury.2025.112515

Injury. 2025 Jun 6;56(8):112506. doi: 10.1016/j.injury.2025.112506. Online ahead of print.

ABSTRACT

PURPOSE: Certain trauma populations require rehabilitation services after inpatient management. However, studies have shown implicit bias against African American patients regarding the access to rehabilitation services. The purpose of this study was to assess the variance in rehabilitation discharges of adult patients who sustained lower extremity bilateral long bone fractures comparing African American and Caucasian patients.

METHODS: The study included African American and Caucasian adult patients who sustained bilateral long bone fractures of the lower extremities. Data was extracted from the National Inpatient Sample (NIS) database of 2019. Demographic information, clinical characteristics, comorbidities, and outcomes for all qualifying patients were compared using propensity score matching analysis.

RESULTS: Propensity matching analysis created 361 pairs of patients. The two groups (Caucasian patients and African American patients) had comparable characteristics including age (median years [IQR], 42 [30 - 57] vs. 42 [29 - 58], P = 0.790), sex ([male] 60.7 % vs, 60.7 %), injury severity score (ISS) score (median [IQR], 14 [4 - 26] vs. 14 [5 - 29], P = 0.344) and insurance status (private, 125 (34.6 %) vs. 125 (34.6 %)). The analyses found no significant differences in rehabilitation disposition (199 (56.9 %) vs. 185 (53.8 %), P = 0.460, hospital length of stay (median days [95 % CI], 9 [8, 10] vs. 10 [9, 11], P = 0.116) and overall in-hospital mortality (11 (3.0 %) vs. 17 (4.7 %), P = 0.327) between the groups.

CONCLUSION: Our study identified no significant bias against African American patients who suffered from bilateral long bone fractures of the lower extremities and required rehabilitation services.

PMID:40517640 | DOI:10.1016/j.injury.2025.112506

Injury. 2025 Jun 6;56(8):112513. doi: 10.1016/j.injury.2025.112513. Online ahead of print.

ABSTRACT

BACKGROUND: Increasing awareness about fall prevention and osteoporosis screening could reduce the incidence of hip fractures in the elderly, and comprehensive care can improve outcomes. There is limited nationwide data on the health outcomes of hip fractures when comparing operative and non-operative approaches. The study objectives were to ascertain the short-term outcomes of older patients hospitalized with hip fractures and to elucidate the variables correlated with in-hospital mortality.

METHODS: This study utilized a retrospective dataset comprising hospitalized individuals aged ≥60 years who were admitted due to hip fractures during the fiscal years spanning from 2019 to 2023. The National Health Security Office conducted the diagnosis, employing the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Thai Modification (ICD-10-TM) code S72. Surgical procedures pertinent to hip fractures were categorized under ICD-9-79.1, ICD-9-79.3, ICD-9-81.51, ICD-9-81.52, and ICD-9-81.53. Demographic information was analyzed through descriptive statistical methods. Factors associated with in-hospital mortality were assessed through both univariate and multivariate analyses.

RESULTS: Out of 115,333 diagnosed cases, the admission rate was 205.5 per 100,000 population, with 46.9 % undergoing surgery. The overall in-hospital mortality rate was 4.04 per 100,000 individuals. Patients who underwent surgery showed a lower in-hospital mortality rate compared to those who did not, recorded at 1.3 vs 1.9 (p < 0.05) for males and 2.1 vs 2.6 (p < 0.05) for females per 100,000 population. Outcomes at discharge for those receiving operative versus non-operative treatment revealed a mean length of stay (LOS) of 11.5 versus 10.8 days (p < 0.05), mean healthcare costs of $1973 versus $1554 (p < 0.05), and in-hospital mortality rates of 1.8 % versus 2.1 % (p < 0.05). Factors increasing mortality included age (70-80 years: OR 1.51, 95 %CI 1.30-1.74; ≥80 years: OR 2.59, 95 %CI 2.27-2.97), male gender: OR 1.69, 95 %CI 1.55-1.85, extracapsular fracture: OR 1.15, 95 %CI 1.05-1.25, and a LOS ≥10 days: OR 1.63, 95 %CI 1.49-1.78. Surgery associated with lower mortality: OR 0.88, 95 %CI 0.81-0.96.

CONCLUSION: Hip fracture patients who underwent surgery had better mortality outcomes than those who did not. Less than half of patients opted for surgery in the past five years. Therefore, it is essential to encourage surgical treatment for these patients.

PMID:40513174 | DOI:10.1016/j.injury.2025.112513

Injury. 2025 Jun 3:112514. doi: 10.1016/j.injury.2025.112514. Online ahead of print.

ABSTRACT

INTRODUCTION: Major Trauma Hospitals are receiving increasing numbers of older patients after serious injury. Outcomes in these patients vary with the nature of the injury and other factors such as frailty. We aimed to determine the prevalence of frailty and adverse events in older patients managed by acute trauma services during the index hospital admission, and the frequency of adverse outcomes at three, six and twelve months after discharge in an Australian setting.

METHODOLOGY: This study assessed the prevalence of frailty in a prospective multicentre cohort study of seriously injured patients aged ≥ 70 years admitted to three Major Trauma Services in Australia. Patients were followed for twelve months after injury to assess for adverse outcomes associated with the presence of frailty or other factors. During the index admission patients were assessed for frailty, co-morbidities, Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Patients were monitored for adverse events and whether a Geriatrician review occurred. Outcomes assessed at three, six and twelve months included increased dependency, falls, confusion, readmission to hospital, transfer to a Residential Aged Care Facility and death.

RESULTS: 217 patients were recruited between 2018 and 2023 across the three hospitals. At index admission, 32 (14.7%) patients were frail and another 28 (12.9%) were near frail. Geriatrician review was more likely for frail patients and there were similar rates of inpatient complications for both frail and non-frail patients. Frailty at index admission was associated with increased dependency, falls, readmission and confusion at three, six and twelve months and with an increased risk of death at three and six months.

CONCLUSIONS: Frailty was associated with delayed adverse outcomes up to 12 months following admission for serious trauma in older people at three major Australian trauma services. Assessment of frailty on admission may be useful in stratifying outcome risk for older patients. Further research into frailty interventions and pathways is recommended.

PMID:40506331 | DOI:10.1016/j.injury.2025.112514

Injury. 2025 Jun 7;56(8):112520. doi: 10.1016/j.injury.2025.112520. Online ahead of print.

ABSTRACT

OBJECTIVE: To evaluate the clinical outcomes of a novel hybrid bone transport technique using an antibacterial-coated nail for the treatment of infected segmental tibial bone defects.

METHODS: This retrospective study included 19 patients with infected segmental tibial bone defects treated using hybrid bone transport with an antibacterial-coated nail, the ZNN™ Bactiguard® nail. Patients were divided into two groups: nailing after bone transport (NABT, n = 11) and bone transport over nail (BTON, n = 8). These groups were compared with a control group of 10 infected patients treated with conventional external fixation bone transport (EFBT). The primary endpoint was infection eradication, while secondary endpoints included external fixation time (EFT), external fixation index (EFI), complications, and bone regeneration quality.

RESULTS: The mean external fixation time (EFT) for the entire cohort was 280.2 ± 142.7 days. The BTON group had the shortest EFT (150 ± 45 days), significantly lower than both NABT (279 ± 99 days) and EFBT (927 ± 1710 days, p = 0.001). The external fixation index (EFI) was also significantly lower for BTON compared to EFBT (25 ± 10.7 vs. 77.5 ± 38.7 days/cm, p = 0.009). A single case of a recurrent infection was reported in the BTON group (5.3 %), which was managed with nail removal and the continuation of external fixation bone transport without further complications. The infection was fully resolved in all cases (29/29) at the end of the follow-up period. Complication rates were similar across groups. The primary docking site union rate was 89.7 %, with no significant differences between groups.

CONCLUSIONS: The BTON technique using an antibacterial-coated nail reduces EFT by threefold compared to traditional external fixation bone transports methods, without increasing complications. A notable reduction was also observed in the NABT group, although it did not reach statistical significance. This approach offers a promising alternative to conventional methods for the treatment of infected tibial bone defects.

PMID:40505442 | DOI:10.1016/j.injury.2025.112520

Injury. 2025 Jun 4;56(8):112519. doi: 10.1016/j.injury.2025.112519. Online ahead of print.

ABSTRACT

INTRODUCTION: A Fracture-related infection (FRI) is a rare but serious complication of surgical fracture treatment in children and adolescents. Exact data on the incidence of FRI in children and adolescents are not available in the literature. In adults, criteria for the diagnosis and treatment of FRI were published in 2018 by an expert group and divided into suggestive and confirmatory categories. However, there is no recommended approach for diagnosing and treating FRI in children or adolescents.

PURPOSE OF THE STUDY: This study aimed to determine the incidence of FRI in children and adolescents who underwent operative fracture treatment at a Level I trauma center between 2019 and 2023, to evaluate age distribution, anatomical sites and bacterial spectrum of FRI in children and adolescents, to evaluate risk anatomical locations and initial fracture treatment methods in relation to the development of FRI and to assess the applicability of FRI diagnostic criteria in the pediatric patients.

MATERIALS AND METHODS: It is a retrospective monocentric study conducted by reviewing hospital database. The study included all patients under 18 years of age with present growth plates who underwent surgical fracture treatment between 2019 and 2023.

RESULTS: The incidence of FRI in children was 0,95 % among 1156 osteosynthesis procedures performed between 2019 and 2023. The average age of pediatric patients with FRI was 11,18 years. The most common anatomical site of FRI in out cohort was the forearm (36,36 %). High-risk locations in terms of developing FRI relative to the number of osteosyntheses performed included the proximal femur (20 %) and the diaphysis of the humerus (7.69 %). The most common pathogen causing FRI in children was S. aureus (63,6 %). On average, 2.1 additional surgical procedures were required to eradicate the infection.

CONCLUSION: FRI in children is a rare but serious complication, which most commonly occurs in the upper extremity, specifically in the forearm area. However, some anatomical sites with a lower incidence of fractures demonstrate a significantly higher relative risk for the development of FRI. The recommended guidelines developed in 2018, including diagnostic criteria for FRI, can be successfully applied to the pediatric population.

PMID:40505441 | DOI:10.1016/j.injury.2025.112519

Injury. 2025 Jun 3;56(8):112512. doi: 10.1016/j.injury.2025.112512. Online ahead of print.

ABSTRACT

OBJECTIVE: To determine if 4-8-week radiographs are useful for predicting nonunions in patients with femoral shaft fractures treated with an intramedullary nail (IMN).

METHODS: A retrospective case-control study; 1:2 ratio was conducted at a level I trauma center. Adult patients with a femoral shaft fracture (OTA/AO 32) treated with IMN between 2016 and 2022 were identified via Current Procedural Terminology code. The included cases underwent nonunion surgery a minimum of 3 months after the index procedure. The controls were randomly selected from the cohort and had a minimum of 6 months postoperative follow-up and evidence of radiographic union. The modified Radiographic Union Score of the Tibia (mRUST) applied to femur fractures was determined on radiographs obtained 4-8 weeks after the index surgery.

RESULTS: One hundred forty-eight patients (mean age, 35 [SD, 15] years) were included. A significant difference was found between cases and controls relating to the distribution of mRUST scores at 4-8 weeks postoperatively (median, 6 versus 9; p < 0.0001). Logistic regression analysis demonstrated that the mRUST score at 4-8 weeks is a strong predictor of union with an area under the curve of 0.85 (95 % CI: 0.78-0.92). If the mRUST score at 4-8 weeks postoperatively is 9 or above, the probability of eventual union is 99 % (95 % CI: 94-100 %).

CONCLUSION: The results suggest that healing on 4-8-week radiographs after IMN fixation for femoral shaft fractures may help identify patients at elevated risk of nonunion. Patients with mRUST scores 9 or above on the 4-8-week postoperative radiographs have a low likelihood of nonunion and less frequent radiographic follow-up may be needed.

PMID:40505440 | DOI:10.1016/j.injury.2025.112512

Injury. 2025 May 28;56(8):112464. doi: 10.1016/j.injury.2025.112464. Online ahead of print.

ABSTRACT

AIMS: The aim of this study was to compare clinical outcomes of the Femoral Neck System (FNS) (Depuy Synthes) and the Dynamic Hip Screw (DHS) (Depuy Synthes) in the head preserving treatment of femoral neck fractures.

METHODS: A multicenter retrospective study was performed in three level II trauma centers in The Netherlands. All patients younger than 90 years treated with the DHS or the FNS for a femoral neck fracture between 2012 and 2022 were included. The follow-up of the included patients was two years. The primary outcome was treatment failure, defined as avascular necrosis, non-union or implant cut-out. Secondary outcomes were postoperative infections, total hip prosthesis conversion rates and mortality.

RESULTS: A total of 505 patients were included in this study: 239 patients with the DHS and 266 patients with the FNS. Patients treated with the FNS had a higher prevalence of Garden I type fractures and a lower prevalence of Pauwels' type III fractures. Treatment failure occurred in 77 patients, with 39 in the DHS and 38 in the FNS group. After correction for Garden and Pauwels' classification, no significant difference was noted regarding treatment failure within 2 years follow-up between both groups. No differences in conversion rates to total hip arthroplasty (coxarthrosis as surgical indication) was observed. However, patients treated with the DHS underwent implant removal more often. No differences in mortality rate between the groups was observed during two years of follow-up.

CONCLUSION: This multicenter study showed that no difference in treatment failure was found between the two groups, making the FNS a viable alternative for head preserving treatment of femoral neck fractures.

PMID:40494184 | DOI:10.1016/j.injury.2025.112464

Injury. 2025 May 31;56(8):112470. doi: 10.1016/j.injury.2025.112470. Online ahead of print.

ABSTRACT

BACKGROUND: Plastic surgeons must document initial facial injuries before surgery for medicolegal purposes. Distinguishing between accidental and assaultive injuries poses a challenging issue. Therefore, this study explored the features that differentiate assaultive facial soft tissue injuries from accidental injuries.

METHODS: This prospective cross-sectional study included 179 patients with facial soft tissue injuries. We recorded sex, age, occupation, marital status, residence, and history of drug abuse. Additionally, the traumatic events were analyzed, and injuries were assessed. All patients received standard medical care.

RESULTS: Males constituted 82.7 % of patients. 62.57 % of patients had accidental facial injuries, while the rest of the patients attributed their injuries to assaults. A significantly higher percentage of assaultive injuries were located on the left side of the face, with p < 0.001 (OR = 5.966, 95 % CI=3.013- 11.813). Whereas a significantly higher percentage of accidental injuries were located on the midface, with p < 0.001. A multivariate binary logistic regression analysis that identified strong predictors of assaultive facial injuries, including a history of drug abuse (OR = 44.998, 95 % CI: 3.049-661.107), injury with sharp instruments (OR = 638.601, 95 % CI: 20.296-20,093), and a cutting/piercing mechanism of injury (OR = 89,298.81, 95 % CI: 196.963-404,861). Regarding the characteristics of soft tissue facial injuries, the probability of assaultive trauma increases with the presence of injuries on the left side of the face (OR = 27.309, 95 % CI: 1.653-451.157), involvement of the mandibular zone (OR = 40.780, 95 % CI: 1.147-1449.419), neurovascular or duct injury (OR = 121.806, 95 % CI: 1.110-13,369.2), and the presence of multiple associated injuries (OR = 1.005, 95 % CI: 1.001-1.254).

CONCLUSIONS: Accidental facial injuries are more common than assaultive injuries, and males are particularly vulnerable to both traumas. This study helps differentiate between assault-related and accidental facial injuries. A history of drug abuse, injuries caused by sharp instruments, and mechanisms involving cutting or piercing are strong indicators of assaults. Clinical signs that strongly suggest assault-related injuries include injuries on the left side of the face, involvement of the mandibular area, damage to neurovascular structures or ducts, and the presence of multiple associated injuries.

PMID:40483942 | DOI:10.1016/j.injury.2025.112470