Injury. 2025 Dec 9;57(2):112949. doi: 10.1016/j.injury.2025.112949. Online ahead of print.

ABSTRACT

OBJECTIVE: To develop and validate a machine learning model for postoperative sepsis in critically ill traumatic spinal injury (TSI) patients, a frequent and severe complication without dedicated predictive tools.

METHODS: Model development used the MIMIC-IV 3.1 database, with external validation in the eICU-CRD 2.0 database and a Chinese TSI cohort. Variables documented within 24 h of postoperative ICU admission were screened using univariable testing and refined through Boruta and Group-Lasso regression to identify the final predictors. Thirteen base learners were trained and combined in a stacking ensemble optimized by fivefold cross-validation and hyperparameter tuning. Performance was assessed using receiver operating characteristic (ROC-AUC), average precision from precision-recall (PR-AP), calibration, decision, and lift curves, along with accuracy, sensitivity, specificity, precision, and F1 scores. Interpretability was evaluated through SHAP analysis.

RESULTS: The development cohort comprised 808 patients, with 461 (57.1 %) sepsis cases, and the external validation cohort consisted of 358 patients, with 86 (24.0 %) events. Twelve predictors entered modeling, with the stacking model achieving an ROC-AUC of 0.918 and PR-AP of 0.938 in training and 0.889 and 0.936 in validation, maintaining close calibration, superior clinical utility confirmed by decision and lift curves, and balanced classification metrics, while most first-level models deteriorated markedly. External validation confirmed consistent performance and effective high-risk stratification. SHAP analysis underscored surgical burden, severity, hemodynamic, renal, and coagulation domains as key contributors, ensuring interpretability at cohort and individual levels.

CONCLUSION: This first validated model for postoperative sepsis in critically ill TSI patients shows relatively robust performance and interpretability, enabling early risk stratification and supporting clinical decision-making.

PMID:41389427 | DOI:10.1016/j.injury.2025.112949

Injury. 2025 Dec 4;57(2):112947. doi: 10.1016/j.injury.2025.112947. Online ahead of print.

ABSTRACT

INTRODUCTION: While radiographic reduction quality is considered a key determinant of outcome in intraarticular calcaneal fractures, its quantification remains inconsistent and often unidimensional. Existing radiographic parameters only partially reflect the complex joint surface restoration while gradings often lack correlation to clinical outcomes. This study introduces the Calcaneal Fracture Outcome Score (CFOS), a composite score integrating joint-specific deformities and patient-level prognosticators to improve outcome prediction.

MATERIAL AND METHODS: Postoperative CT scans from 80 patients with surgically treated calcaneal fractures were evaluated for residual step, gap, and angulation at the posterior facet (PF) and calcaneocuboid (CC) joint. Additional parameters included Boehler's angle, Gissane's angle, Sanders classification, smoking status, and comorbidity burden. All variables were z-standardized and entered into a LASSO regression with 5-fold cross-validation. A weighted score (CFOS) was computed per patient and correlated with PROMS (VAS-FA; SF-12).

RESULTS: Higher CFOS grades were associated with significantly worse outcomes, i.e. posttraumatic osteoarthritis (p<0.001), VAS-FA (p=0.035) and SF-12 PCS (p=0.010), outperforming the traditional grading established by Kurozumi et al and adapted by Nosewicz et al. with a mean positive predictive value of 90 %.

CONCLUSIONS: The CFOS offers a clinically intuitive, multidimensional assessment of reduction quality and provides robust predictive value for postoperative functional outcome.

LEVEL OF EVIDENCE: III.

PMID:41389426 | DOI:10.1016/j.injury.2025.112947

Injury. 2025 Dec 4;57(2):112944. doi: 10.1016/j.injury.2025.112944. Online ahead of print.

ABSTRACT

INTRODUCTION: Kirschner wires (K-wires) are frequently used for pediatric fracture fixation. Infectious complications range from 1 % to 20 %, but the few available studies mostly focus on the adult population. The severity of infection varies from minor pin tract infections (PTIs) to severe osteomyelitis. Current literature on this topic is limited, especially regarding the pediatric population.

METHODS: In this retrospective observational study, we enrolled children (0-18 years old) with traumatic bone fractures treated with smooth (unthreaded) K-wires at the Orthopedics Unit of Meyer Children's Hospital in Florence between January 1, 2020, and December 31, 2024. The aim was to evaluate infection rates at our institution, describe clinical presentations and risk factors, identify the most frequent pathogens, and assess the treatment strategies adopted.

RESULTS: A total of 1386 patients were included, of whom 1349 (97.3 %) had fractures of the upper extremities (including the hand) and 37 (2.7 %) had fractures of the lower extremities (including the foot). We recorded 33 infections, with an infection rate of 2.4 %. PTIs were the most common infectious complication (16/33, 48.5 %), followed by osteomyelitis (11/33, 33.3 %) and deep soft tissue infections (3/33, 9.1 %). Fever of unknown origin (FUO), associated with elevated inflammatory markers, was observed in 3/33 (9.1 %) patients. The most common pathogen was Staphylococcus aureus, with no cases of methicillin-resistant strains. Children younger than 9 years were 2.8 times more likely to develop an infectious complication, as confirmed by both univariate (p = 0.012) and multivariate analysis (p = 0.036). Surgery during the summer season was significantly associated with a twofold increased risk of infection in univariate (p = 0.014) and multivariate analysis (p = 0.033). The timing of surgery, number of wires, fracture site, and type of reduction were not associated with a higher risk of infection.

CONCLUSION: This study describes the infection rate following K-wire fixation in a large pediatric cohort at a tertiary care facility. Based on our findings, these complications are rare, and patient education on wound and cast care may play a role in reducing their occurrence.

PMID:41389425 | DOI:10.1016/j.injury.2025.112944

Injury. 2025 Nov 1:112873. doi: 10.1016/j.injury.2025.112873. Online ahead of print.

NO ABSTRACT

PMID:41387072 | DOI:10.1016/j.injury.2025.112873

Injury. 2025 Dec 3;57(2):112939. doi: 10.1016/j.injury.2025.112939. Online ahead of print.

ABSTRACT

OBJECTIVES: Distal femur fractures in the elderly population are challenging to manage surgically. Treatment methods have traditionally focused on open reduction internal fixation (ORIF). More recently, distal femur replacement (DFR) has emerged as an alternative treatment method for geriatric distal femur fractures.

METHODS: DESIGN: Retrospective observational study.

SETTING: Data derived from TriNetX, a multicenter insurance claims database.

PATIENT SELECTION CRITERIA: 15,933 patients aged 65 years and older who sustained distal femur fractures and were treated with either DFR or ORIF within 30 days of injury were identified and matched, resulting in balanced cohorts of 584 patients each.

OUTCOME MEASURES AND COMPARISONS: Outcomes were analyzed at postoperative days 7, 30, and 90 as well as years 1 and 5. Endpoints were transfusion requirements, infections, revision surgery, and mechanical complications. The cohorts were matched using a greedy nearest neighbor algorithm, and the data was evaluated using relative risk (RR).

RESULTS: After matching, at days 7, 30, and 90 postoperative, the DFR cohort showed an increased risk of transfusion when compared to the ORIF cohort (p = 0.025, p = 0.008, and p = 0.005, respectively). At 90 days postoperative, the DFR cohort had an increased rate of infection (p = 0.028). At postoperative years 1 and 5, the matched DFR cohort was found to have a significantly higher risk of revision surgery (p < 0.001) and mechanical complications (p < 0.001) compared to the ORIF cohort.

CONCLUSION: This study found that the treatment of distal femur fractures with DFR is associated with a significantly higher risk of transfusion, infection, revision surgery, and mechanical complications compared to ORIF. This suggests that ORIF results in lower risk of complications in elderly patients with distal femur fractures.

PMID:41385827 | DOI:10.1016/j.injury.2025.112939

Injury. 2025 Dec 5;57(2):112940. doi: 10.1016/j.injury.2025.112940. Online ahead of print.

ABSTRACT

PURPOSE: To analyze characteristics, accident mechanisms, injury patterns, and treatment of pedelec accidents, focusing on older riders (≥65 years) and those requiring intensive care.

METHODS: This descriptive single-center study included all patients presenting after a pedelec accident at a level I trauma center (January 2017-December 2023). Data included demographics, accident mechanisms, injuries, and treatments. A subgroup analysis was performed for patients requiring intensive care.

RESULTS: Between 2017 and 2023, 103 pedelec riders were injured, with annual cases rising steadily, peaking at 45 in 2023. Patients were predominantly male (57 %) with a mean age of 53 ± 19 years; 30 % were ≥65 years. Helmet use was documented in 34 %, alcohol in 10 %, and anticoagulant therapy in 15 %. Most accidents occurred during warmer months (66 %), in the afternoon (47 %), and were caused by rider errors (36 %) or car collisions (17 %). A total of 229 injuries were recorded (2.2 per patient), mainly affecting the head (33 %) and upper extremities (29 %). Thirty patients (30 %) required surgery, 41 (40 %) were hospitalized, and 11 (11 %) needed ICU care. The predominant reason for ICU admission was severe traumatic brain injury (TBI) with intracranial hemorrhage, present in 91 % of ICU patients. These patients were significantly older (mean 77 ± 13 years; OR 1.11 per year, 95 % CI [1.05-1.20]; p = 0.002), more often on anticoagulants (45 %; OR 5.33, 95 % CI [1.37-20.80]; p = 0.022), and none wore a helmet (0 %; OR 0.07, 95 % CI [0.00-1.23]; p = 0.015, Haldane correction). Males ≥65 years had a 25-fold increased ICU admission risk (OR 25.07, 95 % CI [4.89-128.53]; p < 0.001). Helmet use was associated with a 16.4 % absolute risk reduction (ARR) for ICU admission with a Number Needed to Treat (NNT) of 6. In-hospital mortality was 1.9 %.

CONCLUSION: Pedelec accidents have sharply increased, with injuries to the head and upper extremities most common. Older adults, especially men ≥65, face the highest risk of severe outcomes, including traumatic brain injury requiring ICU admission. Two-thirds of riders did not wear a helmet; helmet use significantly reduced critical injury risk. Focused prevention efforts-particularly promoting helmet use and rider safety education-are urgently needed.

PMID:41380375 | DOI:10.1016/j.injury.2025.112940

Injury. 2025 Dec 4;57(2):112943. doi: 10.1016/j.injury.2025.112943. Online ahead of print.

ABSTRACT

INTRODUCTION: Infection is one of the major complications associated with intramedullary nailing. Aim of this study is to analyze the outcome of infection after fixation of tibia and femur with intramedullary nailing and to compare the outcome in patients treated with nail retention versus removal.

PATIENTS AND METHODS: This is a retrospective cohort study including consecutive adult patients treated at our institution between 01/2015 and 03/2022 for infection involving the intramedullary nail used for fixation of femur or tibia fractures. Characteristics of infection and outcome data were evaluated by actively contacting the patients with a standardized questionnaire. Uniform predetermined definitions were used. The probability of infection-free survival was estimated using the Kaplan-Meier method and compared between the groups using log-rank test.

RESULTS: Fifty-one patients (37 males, 14 females) with infection associated with femur (n = 37) or tibia (n = 14) nail were included. The pathogen was identified in 45 (88 %) episodes, including 30 monomicrobial and 15 polymicrobial infections. The predominant pathogens in monomicrobial infections were coagulase-negative staphylococci (n = 11) and in polymicrobial infections gram-negative bacteria. The intramedullary nail was removed in 35 (69 %) patients and retained in 16 (31 %) patients. At follow-up (median follow-up 28 months; IQR 21-38 months), 19 of 31 (61 %) evaluable patients were infection-free. In patients with nail removal, 14 of 22 (64 %) were infection-free, whereas those with nail retention, 5 of 9 (56 %) were infection free.

DISCUSSION: The fact that patients in the nail retention group were of higher age, experienced earlier infection after surgery, and were mainly caused by high virulent pathogens suggest a potential selection bias. Nevertheless, it appears that certain infections may be treated successfully with nail retention, reducing the number of interventions for the patient, and increasing cost effectiveness.

CONCLUSIONS: Overall cure of infected intramedullary nails was 61 %. No significant difference in the infection eradication of infected intramedullary nails were observed, irrespective of the time of occurrence after nail implantation. These results should be confirmed in a larger prospective cohort.

PMID:41380374 | DOI:10.1016/j.injury.2025.112943

Injury. 2025 Dec 6;57(2):112930. doi: 10.1016/j.injury.2025.112930. Online ahead of print.

ABSTRACT

INTRO: Clinically significant pediatric cervical spine injuries (CSIs) are rare, and most literature focuses on operatively managed cases. However, many children with persistent neck pain after trauma are discharged in rigid collars despite normal or equivocal CT findings. This group remains poorly characterized. We aimed to characterize injury patterns, imaging findings, and management of pediatric CSI patients, with a specific focus on those discharged in rigid collars.

METHODS: We performed a retrospective cohort study of pediatric trauma patients (<18 years) at a Level 1 Pediatric Trauma Center from 2012 to 2021. Patients were included if they underwent cervical spine imaging (radiograph, CT, and/or MRI) and were diagnosed with a CSI. Demographics, injury mechanisms, imaging results, and treatments were collected. Subgroup analysis was performed on patients discharged in rigid collars. Univariate logistic regression stratified by injury level assessed associations between age and operative intervention.

RESULTS: Among 4477 pediatric trauma patients who underwent cervical spine imaging, 309 (6.9 %) were diagnosed with a CSI. Of these, 60 (19 %) underwent surgical intervention, 138 (45 %) were observed without immobilization, and 106 (34 %) were discharged in rigid collars. Operative intervention was associated with increasing age (p = 0.006) and high-energy trauma (p = 0.012), particularly for subaxial injuries. Most patients discharged in collars had persistent pain despite normal or mild CT findings and underwent MRI or neurosurgical consultation prior to discharge. CT identified all patients ultimately discharged in collars. Five injuries initially concerning to the trauma team were reviewed by a pediatric spine surgeon and determined not to be unstable; MRI showed ligamentous strain or normal variants, and none required surgery.

CONCLUSION: A substantial proportion of pediatric CSI patients are managed nonoperatively with rigid collars due to persistent symptoms. CT identified all patients needing further evaluation, and MRI clarified soft tissue injuries in symptomatic cases. Spine surgeon review confirmed these injuries were not unstable and did not require surgery. These findings highlight CT as an effective screening tool, the value of MRI in select cases, and the importance of clinical judgment and multidisciplinary evaluation in managing children discharged in collars.

PMID:41380373 | DOI:10.1016/j.injury.2025.112930

Injury. 2025 Dec 4;57(2):112933. doi: 10.1016/j.injury.2025.112933. Online ahead of print.

ABSTRACT

INTRODUCTION: The Ilizarov method is an established technique for complex cases. Decisions about circular frame removal are imprecise, with no fully reliable method to confirm union. Errors can lead to complications such as refracture, deformity, and non-union. Traditionally, radiological union is assessed by "dynamisation," a period of systematic frame destabilisation before removal. This study evaluates an institutional shift to selective dynamisation, where patients at perceived lower risk of non-union underwent same-day removal after destabilisation.

MATERIALS AND METHODS: A retrospective review was conducted on a continuous series of prospectively identified patients from the institutional frame database. All adults with tibial frames applied between April 2020 and February 2022 were included. Patients were grouped into dynamised and non-dynamised cohorts. The primary outcome was refracture within six weeks or non-union at any point after removal.

RESULTS: Among 207 patients, non-union or refracture rates did not differ significantly between non-dynamised and dynamised groups (3 [3.7%] vs 2 [1.7%], p = 0.38). Frame removal without dynamisation was non-inferior to removal with dynamisation (margin 5%). Mean frame time was 34 days shorter in the non-dynamised group (185 vs 151 days, p = 0.002). Treatment failure was more common in patients with a distraction gap vs no bone loss (14% vs 1%, p < 0.01) and in open vs closed fractures (7% vs <1%, p < 0.05), indicating higher risk in these subgroups.

CONCLUSION: Omitting outpatient dynamisation for tibial frames did not increase non-union or early refracture rates. In this cohort, dynamisation was 96% specific but only 25% sensitive for union. Outpatient dynamisation may benefit higher risk fractures, such as open fractures or those with bone loss. However, for most patients, removal without dynamisation appears safe and offers advantages: shorter frame time, fewer outpatient visits, and reduced radiation exposure.

PMID:41370961 | DOI:10.1016/j.injury.2025.112933

Injury. 2025 Dec 3;57(2):112926. doi: 10.1016/j.injury.2025.112926. Online ahead of print.

ABSTRACT

BACKGROUND: Opioid use can be common in patients who require surgical fixation of lower extremity fractures. While common, these medications place patients at risk for developing opioid-related disorders (OD) which can in turn affect bony healing and propagate endocrinopathies. This study aims to investigate the impact of perioperative opioid-related disorders on short- and long-term outcomes following open reduction and internal fixation (ORIF) of lower extremity fractures.

METHODS: This retrospective study utilized the multicenter database TriNetX to identify patients who underwent ORIF of the lower extremity between 2003-2023 and had a minimum of 2 years follow up. The exposure of interest was the diagnosis of OD within 3 months prior to and following surgery stratifying them into two cohorts: OD cohort and control. 3986 patients were identified in the OD cohort and 211,560 patients in the control cohort. 1:1 Propensity score matching was applied for cohorts based on demographics, BMI and comorbidities resulting in 3970 patients in each cohort. Outcomes were assessed at 90 days and 2 years postoperatively. Statistical analyses calculated risk ratios (RR), confidence intervals (CI) and p-values.

RESULTS: Within 90 days, patients with OD had increased rates of pulmonary embolism (RR: 1.74, p = 0.023), deep vein thrombosis (RR: 1.47, p = 0.018), transfusion (RR: 2.27, p < 0.001), wound complications (RR: 2.18, p < 0.001), and postoperative anemia (RR: 1.94, p < 0.001). At 2 years, they had higher rates of nonunion (RR: 1.4, p = 0.004), revisions/repairs (RR: 1.59, p < 0.001), implant-related infection (RR: 2.24, p < 0.001) and amputation (RR: 1.97, p = 0.001).

CONCLUSION: Perioperative opioid related disorders are associated with greater thromboembolic events, postoperative bleeding, and greater postoperative complications such as nonunion, wound complications, amputations and revisions. Further studies are needed to understand pathophysiologic and psychosocial effects of opioid disorders on fracture and wound healing.

LEVEL OF EVIDENCE: Level III, Retrospective Cohort.

PMID:41370960 | DOI:10.1016/j.injury.2025.112926

Injury. 2025 Dec 3;57(2):112922. doi: 10.1016/j.injury.2025.112922. Online ahead of print.

ABSTRACT

OBJECTIVES: The ankle fracture with both deltoid ligament (DL) rupture and syndesmotic diastasis was treated by fixing syndesmosis after open reduction and plate fixation of the fibular fracture. The present study aimed to evaluate the effect of deltoid ligament augmentation (DLA) replacing syndesmosis fixation for the treatment of such a fracture.

METHODS: This randomized controlled trial recruited acute ankle fracture patients with syndesmotic instability and DL rupture. Patients were randomized into DLA and trans-syndesmotic screw fixation (TSSF) groups. The primary outcome measure was the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale at 1 year post-surgery. The secondary outcome measures included Philips and Schwartz clinical scoring system of the ankle, the short-form (SF-36) questionnaire for quality of life, the range of ankle motion, the time to partial weight-bearing, the time to full weight-bearing, the time to return to previous work, the time to preinjury-level play, radiographic parameters, and complications. The analyses followed the intention-to-treat principle.

RESULTS: A total of 60 patients were randomized, and 59 were included for analysis: 30 in the DLA group and 29 in the TSSF group. The AOFAS scores at 1 year after surgery showed no statistical significance between the two groups. However, clinical scores at 3 months after surgery, including AOFAS score, Philips and Schwartz score, and subscales of SF-36 (physical function, general health, and social function), were significantly better in the DLA group than the TSSF group. Time to partial-weight-bearing, full-weight-bearing, return to work, and return to preinjury-level play were significantly reduced in the DLA group. No major complications were observed in both groups, and no difference was detected in the radiographic parameters immediately after surgery and at 1-year follow-up.

CONCLUSION: DLA achieved satisfactory clinical and radiographic outcomes at 1-year follow-up with rapid recovery post-surgery. This treatment method should be considered as an alternative option in ankle fractures associated with deltoid ligament rupture and syndesmotic diastasis.

PMID:41370959 | DOI:10.1016/j.injury.2025.112922

Injury. 2025 Dec 4;57(2):112929. doi: 10.1016/j.injury.2025.112929. Online ahead of print.

ABSTRACT

BACKGROUND: Musculoskeletal injuries occur in various school-based settings. However, no information describes musculoskeletal injury risk in school-aged populations relative to age, race, season, body part, and injury classification. We sought to perform an epidemiological analysis and create estimated multinomial logistic regression (MLR) models to profile school-based musculoskeletal injuries seen and treated at United States emergency departments from 2019 through 2023.

METHODS: We retrospectively searched the National Electronic Injury Surveillance System (NEISS) database from the United States Consumer Product Safety Commission (CPSC) between 2019 and 2023 for all school-based injuries in patients between 5 and 18 years of age. Through relative risk ratio calculations and MLR modeling, we created a comprehensive epidemiological analysis and predictive risk assessment profile of school-based musculoskeletal injuries between 2019 and 2023.

RESULTS: School-based musculoskeletal injuries declined during the 3-year COVID-19 timeframe and returned to above pre-COVID levels during 2023. Middle school-aged students experienced the most injuries, with high school students experiencing the least. A total of 54.6 % of injuries were to the upper extremity, with 38.5 % of injuries occurring in the lower extremity and 6.9 % in the trunk. Our estimated MLR models indicated that the most at-risk males for school-based musculoskeletal injuries were elementary students for upper and lower arm, wrist, and finger fractures during the summer, while middle and high school females demonstrated the highest risk of sustaining strains/sprains to the wrist and ankle during the summer and winter months.

CONCLUSIONS: From the NEISS database, we described the prevalence estimations of school-based musculoskeletal injuries reported to and treated by the United States emergency departments from 2019 through 2023. With our estimated MLR models, teachers, staff, school districts, administrators, healthcare providers, and other school leaders could create education and supervision initiatives to help prevent musculoskeletal injuries sustained in school settings.

PMID:41370958 | DOI:10.1016/j.injury.2025.112929

Injury. 2025 Dec 4;57(2):112946. doi: 10.1016/j.injury.2025.112946. Online ahead of print.

ABSTRACT

OBJECTIVES: This study aimed to evaluate the association between hospital arrival time/day and mortality in pediatric patients with severe trauma.

METHODS: This retrospective observational study was conducted using data retrieved from the Japan Trauma Data Bank from January 2004 to May 2019. Patients younger than 18 years and with an Injury Severity Score of 16 or higher were included. Patients' hospital arrival time was categorized into daytime (9:00 am to 4:59 pm) and nighttime (5:00 pm to 8:59 am), and hospital arrival day was categorized into weekdays (Monday to Friday, except for national holidays) and weekends/holidays (Saturday, Sunday, and national holidays). The main outcome was in-hospital mortality. Multiple imputation was used to address missing values. Subsequently, inverse probability of treatment weighting was applied to compare in-hospital mortality rates between the two sets of groups: (1) nighttime and daytime arrival groups and (2) weekend/holiday and weekday arrival groups.

RESULTS: Overall, 6562 patients were included in this study, and the crude in-hospital mortality rate was 6.8%. The odds of in-hospital mortality were significantly higher in the nighttime arrival group than in the daytime arrival group (adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 1.09-1.68). In contrast, no significant difference was observed between the weekend/holiday arrival group and the weekday arrival group (aOR, 0.95; 95% CI, 0.79-1.13).

CONCLUSIONS: Nighttime hospital arrival was associated with higher odds of in-hospital mortality in pediatric patients with severe trauma but weekend/holiday arrival was not.

PMID:41365281 | DOI:10.1016/j.injury.2025.112946