Injury

Hip fracture outcomes, risk prediction, and hospital comparisons: a population-based study in Ontario Canada

Injury. 2025 Jul 2;56(8):112577. doi: 10.1016/j.injury.2025.112577. Online ahead of print.

ABSTRACT

INTRODUCTION: Hip fracture repair is one of the most common urgent procedures performed in hospitals. Having a high burden of mortality, hip fracture repair is frequently targeted for health system quality improvement and hospital performance monitoring. In the present study, we measure hospital variability and explore factors associated with 90-day mortality and the time from emergency department (ED) visit until surgery.

METHODS: Patients were 50-105 years of age at the time of their hip fracture surgery between fiscal years 2015/16 and 2023/24 in Ontario Canada. Hospital variation was measured using random intercept models, risk-adjusted mortality rates, and funnel plots. Risk-adjusted mortality was computed as observed/expected (O/E) ratios multiplied by the population mortality rate. Expected mortality was estimated using logistic regression or CatBoost machine learning methods adjusted for age, sex, comorbidity, and other measures of healthcare utilization. Funnel plots were presented using crude and risk-adjusted mortality by hospital volume. Bootstrap sampling was used to compute 95 % confidence intervals.

RESULTS: A total 12,607 deaths (12.1 %) occurred within 90 days of hip fracture repair (N = 103,887), 4488 (36 %) of which occurred in hospital. Hospitals only accounted for 0.6 % of the total variation in 90-day mortality. Other predictors of mortality included older age, male, higher comorbidity score, facility transfer, pre-operative anemia, home care, residence in long-term care, no prior receipt of anti-osteoarthritic medication, and no previous bone-mineral density scan (p < 0.0001 for all). Hospitals accounted for 9.2 % of the variability in the odds of receiving surgery within 48 h of ED visit. There was no clear cut-point of the time from ED arrival until surgery on the risk of 90-day mortality. There was no ecological association between hospital performance on timeliness (receipt of surgery within 48 h) and performance on 90-day mortality.

CONCLUSION: There was little hospital variation in 90-day mortality. Using three different approaches, there were a few hospitals that consistently stood out as performing better/worse than expected. There was more substantial variation in the time until treatment across hospitals, but the relationship between the time until surgery and 90-day mortality was tenuous.

PMID:40618421 | DOI:10.1016/j.injury.2025.112577

Risk factors for elbow stiffness after surgery for AO / OTA type C distal humerus fractures

Injury. 2025 Jun 25;56(8):112560. doi: 10.1016/j.injury.2025.112560. Online ahead of print.

ABSTRACT

OBJECTIVE: The aim of this study is to identify risk factors for elbow stiffness following surgery for AO/OTA type C distal humerus fractures with a follow-up investigation.

METHODS: Data were collected from patients who underwent treatment for AO/OTA type C distal humerus fractures between March 2015 and March 2022.The patients were divided into a stiffness group and a control group based on whether their elbow flexion-extension or rotation range of motion was less than 100°at the final follow-up. Univariate analysis and multivariate logistic regression analysis was performed to identify independent risk factors. A nomogram prediction model was then constructed based on the factors identified. Receiver operating characteristic (ROC), calibration curve and decision curve analysis (DCA) were used to evaluate its discriminant and calibration. The subjects were randomly divided into modeling set and validation set according to 7:3, and the model was internally validated by random split validation.

RESULTS: Of the 207 patients, 68 developed elbow stiffness after ORIF for AO/OTA type C distal humerus fracture. Multivariate logistic regression analysis identified age,AO/OTA fracture classification,time from injury to surgery,postoperative professional functional rehabilitation, transverse screw,and modified trochleocapitellar index (mTCI), as independent risk factors for postoperative elbow stiffness (all P < 0.05). The modeling set curve demonstrated an AUC value of 0.877, while the validation set curve showed an AUC of 0.869. The calibration curve of the nomogram closely approximated the diagonal line, and decision curve analysis (DCA) revealed that utilizing the nomogram for prediction yielded greater net benefits within the threshold probability range of 0.3-0.8.

CONCLUSION: Age, AO/OTA type C classification, transverse screw, postoperative professional functional rehabilitation, mTCI and time from injury to surgery were identified as risk factors for postoperative elbow stiffness.

PMID:40617199 | DOI:10.1016/j.injury.2025.112560

Defining treatment outcome in fracture-related infections: A scoping review

Injury. 2025 Jun 25;56(8):112563. doi: 10.1016/j.injury.2025.112563. Online ahead of print.

ABSTRACT

BACKGROUND: The fracture-related infection (FRI) consensus definition, published in 2018, marked a crucial advance for clinical practice and research, enabling treatment standardization and better comparison of clinical studies. However, a lack of clear, standardized outcome parameters still impedes the evaluation of treatment success, potentially leading to a misreporting of treatment failure in current literature. This scoping review provides an overview of outcome parameters used in the current literature to describe treatment success or failure in FRI.

METHODS: A comprehensive literature search across four databases (PubMed, Embase, Scopus and Web of Science) was performed. Studies that reported on treatment outcome in adults with long-bone FRI, published between 2018 and 2023, were eligible for inclusion. The primary outcomes were the reporting of the persistence, eradication or recurrence of infection as well as radiological and functional outcome and the need for a return to theatre for infection control. The secondary aim was to screen the current FRI literature for applied follow-up duration.

RESULTS: A total of 111 studies were included for analysis and synthesis. Only 15.3 % (17/111) of the included studies used a clear definition of treatment success and/or failure in their methodology. Despite a high general reporting (85.6 %; 95/111) of infection eradication, recurrence and/or persistence, only few studies defined these parameters accurately: 16.2 % for eradication (18/111), 15.3 % for recurrence (17/111), 0 % for persistence. Bone healing was reported by 90.9 % (101/111) of the studies, with a standardized approach of radiological evaluation in 64.4 % (65/101). In total, 76 studies (68.5 %) assessed functional outcome, whereas no standardized score set was used. Correspondingly, no standardized follow-up duration could be identified. An unplanned return to theatre was considered by 16.2 % of the studies (18/111) to report outcome.

CONCLUSION: This scoping review highlights the lack of standardized outcome reporting in FRI. A clear definition on outcome reporting in FRIs is urgently needed to promote comparability and transparency in clinical research.

PMID:40614539 | DOI:10.1016/j.injury.2025.112563

Tracking the prehospital time course of open fracture patients

Injury. 2025 Jun 21;56(8):112536. doi: 10.1016/j.injury.2025.112536. Online ahead of print.

ABSTRACT

OBJECTIVES: A tenet of open fracture management is timely administration of antibiotics to reduce risk of fracture-related infection (FRI). Trauma centers strive to administer intravenous antibiotics within one hour of patient arrival. The foundation for this recommendation is based on relatively few studies, which base their findings on time from hospital arrival to antibiotic administration. Little attention has been paid to the prehospital time course of open fracture patients. We hypothesized that a significant portion of open fracture patients arrive at the hospital greater than one hour after their injury, which would represent an opportunity for improved care.

METHODS: Design: Retrospective Case Series Setting: Urban/Suburban Academic Level I Trauma Center Patient Selection Criteria: Subjects were identified using a retrospective search for open fracture patients arriving via emergency medical services (EMS). Patients were included if they were age 18 or greater, presented with an open fracture, and had complete pre-hospital documentation, in-hospital documentation, and radiographs. Outcome Measures and Comparisons: Data collected included patient demographics, fracture location, Gustilo-Anderson classification, dispatch time, on scene time, enroute to hospital time, arrival at hospital time, transfer of care time, modality of transport, whether intravenous antibiotics were administered prior to arrival at the hospital, and development of FRI. Descriptive statistics were used to analyze the findings.

RESULTS: 454 patients met the inclusion criteria. Mean time from dispatch to transfer of care was 66.8 ± 26.9 min in all transports; 84.1 ± 25.6 min with helicopter EMS; and 64.8 ± 26.4 min with ground EMS. 239 patients (52.6 %) had transfer of care time greater than one hour after dispatch time. Only 3.7 % of open fracture patients received antibiotics prior to hospital arrival. There was a positive correlation with the development of FRI and prolonged pre-hospital time.

CONCLUSIONS: Many patients with open fractures had transfer of care more than one hour after dispatch. FRI was associated with increased prehospital time. These results suggest an opportunity for prehospital antibiotic administration to mitigate the risk of infection in patients with open fractures.

LEVEL OF EVIDENCE: Level IV.

PMID:40609244 | DOI:10.1016/j.injury.2025.112536

A comparative finite element study of novel design hook plates for fixation of patella fracture

Injury. 2025 Jun 27;56(8):112567. doi: 10.1016/j.injury.2025.112567. Online ahead of print.

ABSTRACT

PURPOSE: To test the mechanical properties of novel design hook plates for fixation of the patellar fracture by finite element analysis.

METHODS: Finite element analysis was used to construct a model of transverse patellar fracture and inferior pole fracture of the patella (IPFP) based on the CT data of the knee joint of a healthy young male volunteer. For the transverse fracture, stress distribution within the winged hook plate fixation and displacement of the fracture was compared to that of tension-band wiring (TBW) fixation. For the IPFP, the stress distribution within the wingless plate and displacement of the fracture were calculated under the four different application methods. All the models were created by assuming the knee flexion in 45° during non-weight-bearing, and applying the quadriceps tension on the superior pole of the patella.

RESULTS: In the model of transverse patellar fracture: The displacement and stress incurred in the fixation of patellar fractures with winged hook plates are much less than with TBW fixation (0.05 mm vs 0.3 mm; 121 MPa vs 268 MPa). In the model of IPFP: The wingless hook plate-cable wire-screw construction resulted in the least amount of displacement, followed by the wingless hook plate-cable wire (0.18 mm vs 0.297 mm). Displacement of the inferior pole of the patella would be more obvious in the two constructions that did not combine cable wires, especially the construction with neither cable wires nor screws.

CONCLUSION: In consideration of improvement of mechanical rigidity, winged hook plate was superior to TBW technique when being used for fixation of transverse patellar fracture, while combination of cable wire should be recommended when wingless hook plate being used for fixation of IPFP.

PMID:40609243 | DOI:10.1016/j.injury.2025.112567

Distal biceps injuries: an overview

Injury. 2025 Jun 25;56(8):112556. doi: 10.1016/j.injury.2025.112556. Online ahead of print.

ABSTRACT

Distal biceps injuries frequently occur in middle-aged males after an eccentric load to the elbow in flexion. The diagnosis is often clinical with the aid of imaging where appropriate. Tears can be partial or full thickness. Surgery is the mainstay of treatment with non-operative management typically reserved for older, lower-demand patients. Those treated without an operation can expect a loss of a proportion of supination and flexion power. There are several surgical techniques described. In the acute setting, a repair may be performing using a number of available devices. In the chronic setting, reconstruction with a graft may be required. Surgical management carries with it complications such as damage to the surrounding structures, heterotopic ossification and re-rupture.

PMID:40609242 | DOI:10.1016/j.injury.2025.112556

Biomechanical evaluation of three different fixation methods for treating displaced tibial avulsion fracture of the posterior cruciate ligament: a finite element analysis

Injury. 2025 Jun 27;56(8):112568. doi: 10.1016/j.injury.2025.112568. Online ahead of print.

ABSTRACT

OBJECTIVE: Displaced tibial avulsion fractures of the posterior cruciate ligament (PCL) significantly compromise knee stability; however, existing clinical data regarding treatment and prognosis are limited. There exists a paucity of biomechanical research concerning various surgical methods for tibial avulsion fractures of the PCL, and optimal management remains controversial. Therefore, the objective of this study was to investigate the biomechanical stability of displaced tibial avulsion fracture using suture bridge fixation, screw fixation, and TightRope fixation at varying flexion angles.

METHODS: Finite element analysis was employed to evaluate the biomechanical stability of three surgical approaches. A type III PCL tibial avulsion fracture model was established, followed by the assembly of models for suture bridge fixation, screw fixation, and TightRope fixation. Varying angles of knee flexion were simulated, and the stress distribution on the implant, the PCL, and the bone fragment, as well as the displacement of the fragment, were assessed.

RESULTS: The findings indicated that the peak stress distribution on the implant for screw fixation was the highest, occurring near the midsection and tail of the implant, followed by TightRope fixation, which occurred near both ends of the fixation. In contrast, suture bridge fixation exhibited the lowest stress, occurring near the junction between the anchor and the suture. The stress distribution of the PCL in screw and TightRope fixation was slightly higher than that observed with suture bridge fixation. This stress was primarily concentrated in the upper portion and gradually increased, reaching a maximum at 120° The peak von Mises stress (VMS) on the bone fragment in the suture bridge fixation group was the highest, followed by the screw fixation group, and subsequently the TightRope fixation group. Furthermore, the displacement of the bone fragment was comparable among the three fixation methods across various angles of knee flexion.

CONCLUSION: The biomechanical properties of suture bridge fixation are superior to those of both TightRope and screw fixation. They are all alternative surgical treatment methods for displaced tibial avulsion fractures of the PCL. The ideal surgical approach should be selected based on the clinical context and a comprehensive evaluation.

PMID:40609241 | DOI:10.1016/j.injury.2025.112568

Modified plate-nail fixation for periprosthetic distal femur fractures following total knee arthroplasty in elderly patients - A technical note

Injury. 2025 Jun 25;56(8):112557. doi: 10.1016/j.injury.2025.112557. Online ahead of print.

ABSTRACT

The global rise in total knee arthroplasty (TKA), driven by an aging population, has led to an increased incidence of periprosthetic fractures (PPFs). Dual implants for distal femur periprosthetic fractures (PDFFs) are a growing area of interest for these challenging fractures with dual plating (DP) and plate-retrograde femoral intramedullary nail (PN) emerging as viable constructs for these injuries. However, dual implants have inherent limitations. Herein we focus on describing a modified PN fixation-retrograde tibial intramedullary nail (RTN) combined with a less invasive stabilization system (LISS) for PDFFs following TKA in elderly patients and providing the technical trick of this modified PN fixation.

PMID:40602036 | DOI:10.1016/j.injury.2025.112557

Traumatic Self-Harm in Older People: A 7-Year Descriptive Analysis from a London Major Trauma Centre

Injury. 2025 Jun 21:112542. doi: 10.1016/j.injury.2025.112542. Online ahead of print.

ABSTRACT

BACKGROUND: Suicide in older people is increasing. We know less about serious deliberate self-harm in this population or the impact of this on Major Trauma Centres (MTC).

OBJECTIVES: Investigate demographics, injury mechanism and outcomes in older people admitted with self-inflicted injury.

DESIGN: Retrospective service evaluation.

SETTING: Single MTC in London, UK.

SUBJECTS: 60 people aged 65 years and over admitted to a MTC with self-inflicted injury.

METHODS: Retrospective analysis of trauma registry data (February 2015-2022).

VARIABLES: age, sex, past medical and psychiatric history, home and marital status, injury type and narrative, injury severity score (ISS), critical care admission, length of stay, discharge status and destination.

RESULTS: Self-inflicted injury represented 1.5 % of trauma admissions aged 65 and over (80 % male, median age 73 years). Most females and over half of men had a psychiatric history (females n = 11, 91.7 %; males n = 28, 58.3 %). Depression was the most common psychiatric comorbidity (n = 15). Males were more likely to suffer penetrating injury (males n = 37, 77.1 %; females n = 4, 33.3 %). The most common injury mechanism was self-stabbing amongst males (n = 37, 77.1 %) and a jump from height amongst females (n = 6, 50.0 %). Median ISS (8.5) and mortality (n = 8, 13.3 %) was low across the cohort. The most common discharge destination was psychiatric admission (males n = 28, 58.3 %; females n = 6, 50.0 %).

CONCLUSION: Older people who present with traumatic self-inflicted injury are predominantly male, utilise violent methods, have significant psychiatric comorbidity and require psychiatric admissions.

PMID:40592662 | DOI:10.1016/j.injury.2025.112542

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