The impact of helmet use on outcomes after a motorcycle crash

BackgroundHelmet use in a motorcycle collision has been shown to reduce head injury and death. Its protective effect on the cervical spine (C-spine), however, remains unclear. The objective of this study was to explore the relationship between helmet use and C-spine injuries.MethodRetrospective National Trauma Data Bank (NTDB) study. All motorcycle collisions between 2007 and 2014 involving either a driver or passenger were included. Data collected included demographics, vital signs, Abbreviated Injury Scale (AIS), Injury Severity Score (ISS) and specific injuries. The primary outcome was the prevalence of C-spine injuries. Secondary outcomes included were overall mortality, ventilation days, intensive care unit length of stay (LOS), total hospital LOS, and in-hospital complications.ResultsA total of 270,525 patients were included. Helmets were worn by 57.6% of motorcyclists. The non-helmeted group was found to have a higher incidence of head injury with head AIS > 2 (27.6% vs 14.8%, p < 0.001). Univariate analysis showed a higher prevalence of C-spine injuries in the non-helmeted group (10.4% vs 9.4%, p < 0.001), with a higher proportion of severe C-spine injuries with AIS > 2 (3.2% vs 2.6%, p < 0.001). Additionally, traumatic brain injury (TBI) was found to be two times higher in the non-helmeted group (20.7% vs 10.9%, p < 0.001). Multiple logistic regression showed helmet use to be an independent protective factor against mortality (OR = 0.832, 95% CI 0.781–0.887, p < 0.001). Although statistically significant in univariate analysis, helmet use was not associated with C-spine injuries after adjusting for relevant covariates. However, helmet use reduced the risk of severe head injuries by almost 50% (OR = 0.488, 95% CI 0.475–0.500, p < 0.001).ConclusionsHelmet use reduces the risk of head injury and death among motorcyclists; however, no association with C-spine injuries could be detected.     

Computed tomography findings in young children with minor head injury presenting to the emergency department greater than 24 h post injury

BackgroundLarge studies which developed decision rules for the use of Computed tomography (CT) in children with minor head trauma excluded children with late presentation (more than 24 h).ObjectiveTo assess the prevalence of significant traumatic brain injury (TBI) on CT in infants with head trauma presenting to the emergency department (ED) more than 24 h from the injury.MethodsA retrospective chart review of infants less than 24 months old referred for head CT because of traumatic brain injury from January 2004 to December 2014 in Assaf-Harofeh medical center was conducted. We used the PECARN definitions of TBI on CT to define significant CT findings.Results344 cases were analyzed, 68 with late presentation.There was no significant difference in the age between children with late and early presentation (mean 11.4 (SD 5.6) month vs 10. 5 (SD 7.0) month, P = 0.27). There was no significant difference between the groups in the incidence of significant TBI (22% vs 19%, p = 0.61). Any TBI on CT (e.g. fracture) was found in 43 (63%) patients with late presentation compared with 116 (42%) patients with early presentation (p = 0.002, OR 2.37, 95% CI 1.37–4.1).ConclusionA similar rate of CT-identified traumatic brain injury was detected in both groups.‏ There was no significant difference in the incidence of significant TBI on CT between the groups.‏ Young children presenting to the ED more than 24 hours after the injury may have abnormal findings on CT.     

Three-year outcomes of intracapsular femoral neck fractures fixed with sliding hip screws in adults aged under sixty-five years

IntroductionIntracapsular femoral neck fractures remain associated with high rates of post-traumatic femoral head necrosis, non-union, and revision surgery.AimOur aim was to identify factors associated with revision surgery in intracapsular femoral neck fractures treated with sliding hip screws (SHS) in adults aged <65 years.Patients and methodsConsecutive admissions were identified retrospectively from the Royal Victoria Hospital, Belfast, which was the largest volume hospital on the National Hip Fracture Database. Of 2201 hip fractures between 1st August 2008 and 31st December 2010, 97 (4%) intracapsular fractures treated with SHS in adults <65 years were followed for a mean of 2.9 years (range 0–6.6).ResultsTwenty-one (22%) hips were revised to arthroplasty. Avascular necrosis developed in 28 (29%) femoral heads. Eight (8%) fractures proceeded to non-union. Displaced fractures (p < 0.001, Fisher’s exact [FE]), posterior comminution (p = 0.049, FE), chronic respiratory disease (p = 0.006, FE) and residual distraction (p = 0.011, χ²) were associated with revision to arthroplasty. Multiple regression found displaced fractures (p = 0.006) and chronic respiratory disease (p = 0.017) significant; in the latter 4 of 6 were revised (67%), including all four patients with chronic obstructive pulmonary disease (COPD). Eleven (11%) individuals required walking aids before injury, which rose to 34 (35%) at one year (p < 0.0001, χ²). Eighty-nine (92%) individuals could walk alone outdoors before injury, but only 76 (78%) at one year (p = 0.009, χ²).ConclusionsDisplaced fractures in individuals with chronic respiratory disease should be considered high risk for revision to arthroplasty. Posterior cortex deficiency should be evaluated prior to choice of operation. Fracture biology and revascularisation play a greater role than operation timing. A significant proportion of individuals do not recovery pre-morbid mobility by one year.     

Intracranial pressure monitoring in severe traumatic brain injuries: a closer look at level 1 trauma centers in the United States

IntroductionThe Brain Trauma Foundation (BTF) recently updated recommendations for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). The effect of ICP monitoring on outcomes is controversial, and compliance with BTF guidelines is variable. The purpose of this study was to assess both compliance and outcomes at level I trauma centers.Materials and methodsThe American College of Surgeons Trauma Quality Improvement Program database was queried for all patients admitted to level I trauma centers with isolated blunt severe TBI (AIS > 3, GCS < 9) who met criteria for ICP monitoring. Patients who had severe extracranial injuries, craniectomy, or death in the first 24 h were excluded. Comparison between groups with and without ICP monitoring was made, analyzing demographics, comorbidities, mechanism of injury, head Abbreviated Injury Scale (AIS), vital signs on admission, head CT scan findings. Outcomes included in-hospital mortality, mechanical ventilation days, intensive care unit (ICU) length of stay, hospital length of stay, systemic complications, and functional independence at discharge. Multivariable analysis was used to identify independent risk factors for each of the outcomes.ResultsOverall, 4880 patients were included. ICP monitoring was used in 529 patients (10.8%). Stepwise logistic regression analysis identified ICP monitor placement as an independent risk factor for mortality (OR 1.63; 95% CI 1.28–2.07; p < 0.001), mechanical ventilation (OR 5.74 95% CI 4.42–7.46; p < 0.001), ICU length of stay (OR 4.03; 95% CI 2.94–5.52; p < 0.001), systemic complications (OR 2.78; 95% CI 2.29–3.37; p < 0.001), and decreased functional independence at discharge (OR 1.71 95% CI 1.29–2.26; p < 0.001). Subgroup analysis of patients with head AIS 3, 4, and 5 confirmed that ICP monitors remained an independent risk factor for mortality in both head AIS 4 and 5.ConclusionsCompliance with BTF guidelines for ICP monitoring is low, even at level I trauma centers. In this study, ICP monitoring was associated with poor outcomes, and was found to be an independent risk factor for mortality. Further studies are needed to determine the optimal role of ICP monitoring in the management of severe TBI.     

Orthopaedic injuries among electric bicycle users

IntroductionThe use of electric bicycles (E-bike) has dramatically increased. E-bikes offer convenient, environmental-friendly, and less expensive alternative to other forms of transport. However, E-bikes provide a new public health challenge in terms of safety and injury prevention.This study is the first to specifically investigate the E-bike related orthopaedic injuries, based on a national trauma registry.MethodsData from a National Trauma Registry were reviewed for patients hospitalized following E-bike related injuries. Between Jan 2014 to Dec 2015, a total of 549 patients were reviewed. Data were analyzed according to demography, type of orthopaedic injury, associated injuries and severity, injury mechanism and treatment in the operating room.ResultsA total of 360 (65%) patients sustained orthopaedic injuries, out of them 230 (63.8%) sustained limb/pelvis/spine fractures. Lower extremity fractures were more prevalent than upper extremity fractures (p < 0.001). The tibia was the most fractured bone (19.2%). Patients over the age of 50 years were at the highest risk for spine (20. 5%, p = 0.0001), pelvis (15.9%, p = 0.0001) and femoral neck (15.9%, p = 0.0172) fractures relative to other age groups. Approximately 42% of patients sustained associated injuries, with head/neck/face injuries being the most prevalent (30.3%). followed by chest (11.9%) and abdominal injury (13.3%). A collision between E-bike and a motorized vehicle was the mechanism of injury in 35% of cases. In this mechanism of injury, patients had 1.7 times the risk for associated injuries (p < 0.0001) and the risk for major trauma (ISS score ≥16) was more than the double (p = 0.03).One third of patients with orthopaedic injuries required treatment in the operating room.Treatment varied depending on the type of fracture.ConclusionsThis study provides unique information on epidemiological characteristics of orthpaedic injuries caused be E-bikes, pertinent both to medical care providers, as well as to health policy-makers allocating resources and formulating prevention strategies.     

External validation of the clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures

IntroductionOn evaluation of the clinical indications of computed tomography (CT) scan of head in the patients with low-energy geriatric hip fractures, Maniar et al. identified physical evidence of head injury, new onset confusion, and Glasgow Coma Scale (GCS) < 15 as predictive risk factors for acute findings on CT scan. The goal of the present study was to validate these three criteria as predictive risk factors for a larger population in a wider geographical distribution.Patients and methodsPatients ≥65 years of age with low-energy hip fractures from 6 trauma centers in a wide geographical distribution in the United States were included in this study. In addition to the relevant patient demographic findings, the above mentioned three criteria and acute findings on head CT scan were gathered as categorical variables.ResultsIn total 799 patients from 6 centers were included in the study. There were 67 patients (8.3%) with positive acute findings on head CT scan. All of these patients (100%) had at least one criteria positive. There were 732 patients who had negative acute findings on head CT scan with 376 patients (51%) having at least one criteria positive and 356 patients (49%) having no criteria positive. Sensitivity of 100% and negative predictive value of 100% was observed to predict negative acute findings on head CT scan when all the three criteria were negative.ConclusionWith the observed 100% sensitivity and 100% negative predictive value, physical evidence of acute head injury, acute retrograde amnesia, and GCS < 15 can be recommended as a clinical decision guide for the selective use of head CT scans in geriatric patients with low energy hip fractures. All the patients with positive acute head CT findings can be predicted in the presence of at least one positive criterion. In addition, if these criteria are used as a pre-requisite to order the head CT, around 50% of the unnecessary head CT scans can be avoided.     

Diagnostic performance of isolated orbital CT scan for assessment of globe rupture in acute blunt facial trauma

ObjectivesWe determine the diagnostic performance of emergent orbital computed tomography (CT) scans for assessing globe rupture in patients with blunt facial trauma.MethodsWe performed a retrospective cohort study based on prospectively collected trauma registry and acute care surveillance data in a tertiary-care hospital. Patients aged at least 18 years who underwent isolated orbital CT scanning for assessing potential ocular trauma were examined. Analyses were performed to evaluate the magnitude of agreement between diagnosis by CT scanning and ophthalmic assessment, including globe rupture.ResultsOur study cohort comprised 136 patients, 30% of whom (41 patients) sustained orbital wall fractures. Concordance for orbital CT diagnosis and the ophthalmic assessment of globe rupture was substantial (k = 0.708). The relative risk of globe rupture was 0.692 (95% confidence interval (CI): 0.054–8.849) for superior wall fractures, 0.459 (95% CI: 0.152–1.389) for inferior wall fractures, 2.286 (95% CI: 1.062–4.919) for lateral wall fractures, and 0.637 (95% CI: 0.215–1.886) for medial wall fractures. According to multivariate analysis, lateral wall fractures were an independent risk factor for globe ruptures (adjusted odds ratio (OR) = 12.01, P = 0.011), and medial or inferior wall fracture was a protective factor (adjusted OR = 0.14, P = 0.012). In the stratified analysis of diagnostic performance of CT scan, specificity was highest among patients with orbital wall fractures (97.2%), followed by negative predictive volume (NPV, 97%), and accuracy (95.1%).ConclusionAmong patients with blunt facial trauma who underwent isolated orbital CT scanning as part of ocular trauma assessment, the diagnostic performance of CT in detecting globe rupture is more accurate in patients with orbital wall fractures. Nevertheless, isolated orbital CT alone does not have a sufficiently high diagnostic performance to be reliable to rule out all globe ruptures. Lateral orbital wall fractures in blunt facial trauma patients, in particular, should prompt thorough evaluation by an ophthalmologist.     

Incidence rate of mild traumatic brain injury among patients who have suffered from an isolated limb fracture: Upper limb fracture patients are more at risk

ObjectivesThis study compares the incidence rate of mild traumatic brain injury (mild TBI) detected at follow-up visits (retrospective diagnosis) in patients suffering from an isolated limb trauma, with the incidence rate held by the hospital records (prospective diagnosis) of the sampled cohort. This study also seeks to determine which types of fractures present with the highest incidence of mild TBI.Patients and methodsRetrospective assessment of mild TBI among orthopaedic monotrauma patients, randomly selected for participation in an Orthopaedic clinic of a Level I Trauma Hospital. Patients in the remission phase of a limb fracture were recruited between August 2014 and May 2015. No intervention was done (observational study). Main outcome measurements: Standardized semi-structured interviews were conducted with all patients to retrospectively assess for mild TBI at the time of the fracture. Emergency room related medical records of all patients were carefully analyzed to determine whether a prospective mild TBI diagnosis was made following the accident.ResultsA total of 251 patients were recruited (54% females, Mean age = 49). Study interview revealed a 23.5% incidence rate of mild TBI compared to an incidence rate of 8.8% for prospective diagnosis (χ² = 78.47; p < 0.0001). Patients suffering from an upper limb monotrauma (29.6%; n = 42/142) are significantly more at risk of sustaining a mild TBI compared to lower limb fractures (15.6%; n = 17/109) (χ² = 6.70; p = 0.010). More specifically, patients with a proximal upper limb injury were significantly more at risk of sustaining concomitant mild TBI (40.6%; 26/64) compared to distal upper limb fractures (20.25%; 16/79) (χ² = 7.07; p = 0.008).ConclusionsResults suggest an important concomitance of mild TBI among orthopaedic trauma patients, the majority of which go undetected during acute care. Patients treated for an upper limb fracture are particularly at risk of sustaining concomitant mild TBI.     

Predictors of osteoarthritis following operative treatment of medial tibial plateau fractures

PurposeTo determine factors influencing the development of posttraumatic osteoarthritis (OA) following medial tibial plateau fractures and to evaluate concomitant injuries associated with these fractures.Materials and methodsA chart review of patients with operatively treated medial tibial plateau fractures admitted to our Level I trauma centre from 2002 to 2008 was performed. Of 63 patients, 41 participated in a clinical and radiographic examination. The mean age was 47 years (range 16–78) and the mean follow-up time was 7.6 (range 4.7–11.7) years. All patients had preoperative computed tomography (CT) scans and postoperative radiographs. At the end of follow-up, standing radiographs, mechanical axis, and CT scans were evaluated.ResultsOf the 41 patients, 24 had no or mild (Kellgren-Lawrence grade 0–2) OA and 17 had severe (grade 3–4) OA. Initial articular depression measured from preoperative CT scans was a significant predictor of OA (median 1.8 mm vs 4.5 mm, p = 0.009). Fracture line extension to the lateral plateau (p = 0.68) or fracture comminution (p = 0.21) had no effect on the development of posttraumatic OA, nor did articular depression at the end of follow-up (p = 0.68) measured from CT scans. Mechanical axis >4° of varus and ≥2 mm articular depression or step-off were associated with worse WOMAC pain scores, but did not affect other functional outcome scores. Six patients (10%) had permanent peroneal nerve dysfunction. Ten patients (16%) required LCL reconstruction and nine (14%) ACL avulsions were treated at the time of fracture stabilisation.ConclusionsThe amount of articular depression measured from preoperative CT scans seems to predict the development of posttraumatic OA, probably reflecting the severity of chondral injury at the time of fracture. Restoration of mechanical axis and articular congruence are important in achieving a good clinical outcome.     

The older they are the harder they fall: Injury patterns and outcomes by age after ground level falls

BackgroundTrauma centers are seeing an increasing number of geriatric patients that are more susceptible to injuries even from relatively minor insults such as a ground level fall (GLF). As life expectancy increases, people are living in the geriatric age bracket for decades and often use anticoagulation agents for various comorbidities. We hypothesize that this patient population is not homogenous and we investigated the injury patterns and outcomes after GLF as a function of age and anticoagulation use. We also sought to identify injury patterns and patient characteristics of GLF patients.MethodsA retrospective review of a Level I trauma center’s database identified all adult (age > 18) trauma patients admitted after GLFs between 1/2003 and 12/2013. Demographics, injury patterns, antiplatelet use, anticoagulation use (including warfarin, enoxaparin, and rivaroxaban) and outcomes were abstracted.ResultsThe cohort included 5088 patients. 3990 patients were >60 years and 38.2% were male. With each decade, although the mean ISS did not considerably change (range 7.0–8.6), mortality increased (0.9% at <60 years vs. 5.5% at >90 years), and the likelihood of home discharge decreased dramatically (73.7% at <60 years vs. 18.2% at >90 years). Abdominal solid organ injuries were rare (0.8%). Age was associated with an increased incidence of cervical spine (p = 0.002), rib (p = 0.009) and pelvic fractures (p < 0.001). Only aspirin use was significantly associated with intracranial bleed (p = 0.001). Aspirin (p = 0.049) or warfarin (p < 0.001) use was associated with increased overall mortality.ConclusionGLF patients are not homogenous as certain injury patterns change with increasing age. Aspirin use was associated with an increased incidence of intracranial bleeds, whereas other antiplatelet or anticoagulation agents were not. GLF is also associated with significant morbidity and mortality that increases dramatically with age. Both aspirin and warfarin are independently associated with increased mortality. These patient differences have implications for their evaluation and management.Level of evidenceEpidemiological/prognostic study level IV.     

Correlation of parameters on preoperative CT images with intra-articular soft-tissue injuries in acute tibial plateau fractures: A review of 132 patients receiving ARIF

IntroductionTibial plateau fractures often occur in conjunction with soft-tissue injuries of knees. The hypothesis of this study is that parameters of CT imaging can predict intra-articular soft-tissue injuries.Patients and methodsPatients who underwent arthroscopically assisted reduction and internal fixation (ARIF) for acute tibial plateau fractures performed by a single orthopedic surgeon between 2005 and 2015 were included in this retrospective study. Patients with concomitant ipsilateral femoral fractures, who had received revision surgery or who had undergone index surgery more than 30 days from the event were excluded. We measured lateral plateau depression and widening, medial plateau depression and displacement, and column involvement observed on preoperative CT scans. Intra-articular soft-tissue injuries were diagnosed based on findings from knee arthroscopy. The correlation of imaging parameters with soft-tissue injuries was analyzed by the area under a receiver operating characteristic (AUROC) curve and multivariate logistic regression.ResultsOne-hundred and thirty-two patients were enrolled in the study. The average age was 45.7 ± 13.1 years (range: 18–75 years). Lateral tibial plateau depressions >11 mm were significantly associated with increased risk of lateral meniscus tears (p = 0.001). However, there was no significant threshold of lateral tibial plateau widening that could be used to predict lateral meniscus tear. Greater risk of anterior cruciate ligament (ACL) avulsion fracture was observed in younger patients, patients with high-energy-pattern tibial plateau fractures, patients with fractures involving anteromedial or posterolateral columns, and patients with medial tibial plateau displacement >3 mm (p < 0.05).ConclusionMeasuring lateral tibial plateau depression and column involvement on preoperative CT scans can help predict a higher risk of lateral meniscus tear and ACL avulsion fracture respectively in patients with acute tibial plateau fractures.     

Predictors of amputation in high-energy forefoot and midfoot injuries

IntroductionHigh energy injuries to the midfoot and forefoot are highly morbid injury groups that are relatively unstudied in the literature. Patients sustaining injuries of this region are challenging to counsel at the time of injury because so little is known about the short and long term results of these injuries. The purpose of this study was to investigate injury specific factors that were predictive of amputation in patients sustaining high energy midfoot and forefoot injuries.Patients and methods137 patients with 146 injured feet [minimum of two fractures located in the forefoot and midfoot, excluding phalanges, talus, calcaneus, with a high energy mechanism].Results121 of 146 feet (83%) were treated operatively; 27 patients sustained 34 total surgical amputation events. 30-day amputation rate was 13.9% and 1-year amputation rate was 18.9%; 27 of 146 feet ultimately sustained amputation with 23 of 27 sustaining a below the knee amputation (BKA) and 17 of 23 (73.9%) received a BKA as their first amputation. Statistically significant predictors of amputation included the number of bones fractured in the foot (p = 0.015), open injury to the plantar or dorsal surfaces of the foot, Gustilo grade, vascular injury, and complete loss of sensation to any surface of the foot (all p < 0.001). Specific fracture patterns predictive of any amputation were fracture of all five metatarsals (p < 0.001) and fracture of the first metatarsal (p = 0.003). Presence of a dislocation or fracture of the distal tibia were not predictive of amputation. Midterm patient-reported-outcomes (N = 51) demonstrated no difference in physical function for patients with and without amputations.ConclusionsHigh-energy forefoot and midfoot injuries are associated with a high degree of morbidity; 1/5th of patients sustaining these injuries proceeded to amputation within 1 year. Injury characteristics can be used to counsel patients regarding severity and amputation risk.     

A snapshot of circulation failure following acute traumatic injury: The expansion of computed tomography beyond injury diagnosis

ObjectiveCT scans with a flat Inferior Vena Cava (IVC) suggest hypovolemia, and the presence of shock bowel implies hypoperfusion. The purpose of this study is to correlate injury severity, resuscitation needs, and clinical outcomes with CT indices of hypovolemia and hypoperfusion.DesignRetrospective cohort study.SettingLevel II trauma centre in Central California.PatientsAdult patients imaged with abdominal and pelvic CT scans, from January 2010–January 2011.InterventionsNone.Measurements and main resultsCirculatory derangements on CT scans were defined as an IVC (AP) diameter measurement of <9 mm, flat IVC (FIVC), hypovolemia. The presence of small intestine hypoperfusion was shock bowel (SB). The absence of these findings was a normal CT scan (NCT). Comparisons of acid-base status, fluids, morbidity and mortality were made based on CT findings. Subgroups were: FIVC (n = 20), FIVC + SB (n = 19), SB (n = 4) only versus normal CT scans, NCT (n = 47).ResultsOverall ISS was 19 (SD) 14. The lowest ISS was in NCT 14 (SD) 10 and there was an incremental increase in ISS based on circulatory derangements, p = 0.001. ICU admission was lowest in NCT and highest in the presence of hyovolemia and hypoperfusion, p = 0.03.Similarly ED crystalloid requirements and the activation of a massive transfusion protocol (MTP), was lowest in NCT group and gradually increased significantly as hypovolemia and hypoperfusion was demonstrated on CT scans. Additional parameters such as metabolic acidosis, nosocomial infections and mortality were associated with acute CT findings of circulatory failure.ConclusionsHypovolemia and hypoperfusion, markers of abnormal circulation, were demonstrated on CT scans for trauma evaluation. The presence of these findings alone or in combination showed strong correlation with high injury severity, and the need for aggressive resuscitation.     

Intentional injury against children in Sub-Saharan Africa: A tertiary trauma centre experience

BackgroundIntentional injuries are the result of violence. This is an important public health issue, particularly in children, and is an unaddressed problem in sub-Saharan Africa. This study sought to describe the characteristics of intentional injury, particularly physical abuse, in children presenting to our tertiary trauma centre in Lilongwe, Malawi and how they compare to children with unintentional injuries.MethodsA retrospective analysis of children (<18 years old) with traumatic injuries presenting to Kamuzu Central Hospital (KCH) in Lilongwe, Malawi from 2009 to 2013 was performed. Children with intentional and unintentional injuries were compared with bivariate analysis and multivariate logistic regression modelling.Results67,672 patients with traumatic injuries presented to KCH of which 24,365 were children. 1976 (8.1%) patients presented with intentional injury. Intentional injury patients had a higher mean age (11.1 ± 5.0 vs. 7.1 ± 4.6, p < 0.001), a greater male preponderance (72.5 vs. 63.6%, p < 0.001), were more often injured at night (38.3 vs. 20.7%, p < 0.001), and alcohol was more often involved (7.8 vs. 1.0%, p < 0.001). Multivariate logistic regression modelling showed that increasing age, male gender, and nighttime or urban setting for injury were associated with increased odds of intentional injury. Soft tissue injuries were more common in intentional injury patients (80.5 vs. 45.4%, p < 0.001) and fist punches were the most common weapon (25.6%). Most patients were discharged in both groups (89.2 vs 80.9%, p < 0.001) and overall mortality was lower for intentional injury patients (0.9 vs. 1.2%, p = 0.001). Head injury was the most common cause of death (43.8 vs. 32.2%, p < 0.001) in both groups.ConclusionsSub-Saharan African tertiary hospitals are uniquely positioned to play a pivotal role in the identification, clinical management, and alleviation of intentional injuries to children by facilitating access to social services and through prevention efforts.     

Hepatic dysfunction: A common occurrence in severely injured patients

BackgroundHepatic dysfunction (HD) is a common finding in critically ill patients. The underlying pathophysiological process is one of either cholestasis or hypoxic liver injury (HLI). Using serum bilirubin, our study aimed to determine the incidence of HD in a critically ill trauma population, identify risk factors and analyse the impact on outcomes.MethodsA retrospective observational study was performed on all patients admitted to the Level 1 Trauma Unit ICU at Inkosi Albert Luthuli Central Hospital in Durban, South Africa (IALCH) from 01/01/2012 until 31/12/2012. HD was defined as a total bilirubin greater than 34.2 μmol/l (2 mg/dL). Additional demographic, physiological, biochemical, and pharmaceutical risk factors for hepatic dysfunction were identified and recorded.ResultsTwo hundred and twenty five patients were included in the study of whom 48 (21.3%) developed HD. An increased duration of ventilation (median 15 days [inter-quartile range 6–19] vs 6 days [IQR 3–11] p < 0.001), prolonged length of stay (median 19 days [IQR 8.5–31] vs 7 days [IQR 3–13] p < 0.001), and higher mortality rate (31.3% vs. 14.7% p = 0.01) were all significantly associated with HD. Shock on admission was twice as common in patients developing HD (p < 0.001). The only drugs associated with HD were piperacillin-tazobactam (p < 0.001) and enalapril (p = 0.04). On multivariable analysis however, HD was not associated with mortality.ConclusionHD was common in our study population, and was associated with other organ dysfunction, increased mortality and length of stay.     

Horse-related injuries in children – unmounted injuries are more severe: A retrospective review

IntroductionHorse-related injuries account for one quarter of all paediatric sports fatalities. It is not known whether the pattern of injury spectrum and severity differ between children injured whilst mounted, compared with those injured unmounted around horses. We aimed to identify any distinctions between the demographic features, spectrum and severity of injuries for mounted versus unmounted patients.Patients and methodsTrauma registry data were reviewed for 505 consecutive paediatric patients (aged < 16 years) admitted to a large paediatric trauma centre with horse-related injuries over a 16-year period. Patients were classified into mounted and unmounted groups, and demographics, injury spectrum, injury severity, and helmet usage compared using odds ratios and Wilcoxon rank-sum tests.ResultsMore patients (56%) were injured in a private setting than in a sporting or supervised context (23%). Overall, head injuries were the most common horse-related injury. Mounted patients comprised 77% of the cohort. Mounted patients were more likely to sustain upper limb fractures or spinal injuries, and more likely to wear helmets. Unmounted were more likely to be younger males, and more likely to sustain facial or abdominal injuries. Strikingly, unmounted children had significantly more severe and critical Injury Severity Scores (OR 2.6; 95% CI 1.5, 4.6) and longer hospital stay (2.0 days vs 1.1 days; p < 0.001). Unmounted patients were twice as likely to require intensive care or surgery, and eight times more likely to sustain a severe head injury.ConclusionsHorse-related injuries in children are serious. Unmounted patients are distinct from mounted patients in terms of gender, age, likelihood of personal protective equipment use, severity of injuries, and requirement for intensive or invasive care. This study highlights the importance of vigilance and other safety behaviours when unmounted and around horses, and proposes specific targets for future injury prevention campaigns, both in setting of organised and private equestrian activity.     

Plasma mitochondrial DNA levels were independently associated with lung injury in elderly hip fracture patients

IntroductionHip fracture in the elderly can induce systemic inflammatory response (SIRS) and lung injury which increases the risk of lung infection and death. Mitochondrial DNA (mtDNA) plays a role in SIRS and lung injury in patients with multi-trauma, and also in patients with hip fractures. This study evaluated the potential value of plasma mtDNA in the early prognosis of lung injury in elderly fracture patients.MethodsThis study enrolled 156 elderly patients with intertrochanteric fracture. Plasma mtDNA, IL-6, IL-10, prostaglandin E2 (PGE2) levels were measured at admission. Sixty-one and 31 patients were diagnosed with systemic inflammatory response syndrome (SIRS) and lung injury, respectively.ResultsPlasma mtDNA levels were higher in hip fracture patients compared to healthy controls (P < 0.001) and significantly higher in the lung injury subgroup compared to the lung injury absent subgroup (P < 0.001). MtDNA levels were correlated with the SIRS score (r = 0.446, P < 0.001), IL-6 (r = 0.506, P < 0.001), IL-10 (r = 0.523, P < 0.001), and PGE2 (r = 0.360, P < 0.001). Logistic regression analysis revealed that plasma mtDNA, IL-6, PGE2 and SIRS score were independent predictors of the risk of lung injury.ConclusionPlasma mtDNA release induced by hip fracture in elderly patients, might be an early predictor of lung injury in these patients.     

Traumatic skull fractures in children and adolescents: A retrospective observational study

ObjectiveTo investigate the epidemiological features of child and adolescent (≤18 years old) patients managed for traumatic skull fractures (TSKFs) and associated traumatic brain injury (TBI).Design393 Patients who were children and adolescent who had TSKFs admitted to our university affiliated hospitals between January 2003 and December 2010. The incidence and patterns were summarized with respect to different age group, admission time and etiology.SettingTwo university-affiliated hospitals from January 2003 to May 2010.ResultsThe most common etiologies were motor vehicle collisions (MVCs) (166, 42.2%) and high fall (101, 25.7%). The most common skull fracture sites were parietal fractures (n = 111, 28.2%) and basilar skull fracture (n = 111, 28.2%). A total of 300 (76.3%) patients suffered TBI and 23 (5.9%) patients suffered OCI. The most common intracranial hemorrhage was epidural hemorrhage (n = 94, 23.9%). The frequencies of emergency admission, medical insurance and associated injuries were 56.2% (n = 221), 22.4% (n = 88) and 37.2% (n = 146). The frequencies of TBI and associated injuries were significantly increased from 53.45% to 76.3% and from 6.9% to 41.6% with age, respectively.ConclusionsMVCs were the most common etiologies. Parietal and basilar skull fractures, epidural hemorrhages were the most common fracture sites and intracranial hemorrhage.     

Osteonecrosis of the distal tibia after pilon fractures

BackgroundPilon fractures are devastating injuries with high complication rates. Osteonecrosis has been previously described after Weber C fracture-dislocations but has not been reported following fixation of pilon fractures.MethodsAll AO/OTA 43-C pilon fractures from 2007 to 2018 were reviewed. Injury factors and demographics were recorded. Computed tomography (CT) scans of the fracture pattern were analyzed to determine risk factors for ON.Results71 pilon fractures in 69 patients were included. Mean follow-up was 21.6 months. 18 patients demonstrated ON at a mean 7.3 months’ post-injury. Regression analysis demonstrated no differences between cohorts with respect to smoking status, open injury, or diabetic status. ON was associated with small anterolateral fragment less than 2.0 cm² (OR = 19.47, p = 0.012), higher comminution (OR = 3.00, p = 0.005), use of calcium phosphate bone substitute (OR = 20.72, p = 0.013).ConclusionsON of the distal tibia was not associated with patient factors but was associated with fracture characteristics.     

Aggressive operative neurosurgical management in patients with extra-axial mass lesion and Glasgow Coma Scale of 3 is associated with survival benefit: A propensity matched analysis

IntroductionPrognosis in patients with traumatic brain injury (TBI) and Glasgow Coma Scale (GCS) score of 3 is poor, raising concern regarding the utility of aggressive operative neurosurgical management. Our purpose was to describe outcomes in a propensity matched population with TBI and GCS3 treated with operative neurosurgical procedures of craniotomy or craniectomy (CRANI).MethodsWe conducted a five-year, multicenter retrospective cohort study of patients with an ED GCS 3 and a positive head CT identified by ICD-9CM diagnosis codes. Two populations were examined: (1) patients with extra-axial mass lesion (subdural or epidural haematoma), (2) patients without mass lesion (subarachnoid and intraparenchymal haemorrhage including contusion, other intracerebral haemorrhage or intracranial injury including diffuse axonal injury). In patients with extra-axial mass lesion, propensity score techniques were used to match patients 1:1 by CRANI, and the following outcomes were analysed with conditional logistic regression: survival, favourable hospital disposition to home or rehabilitation, and development of complications.ResultsThere were 541 patients with TBI and GCS3; 19% had a CRANI, 83% were initiated within 4 h. In those with mass lesion, 27% (91/338) had a CRANI; after matching, a significant survival benefit was observed with CRANI vs. without CRANI (65% vs. 34% survival, OR: 3.9 (1.6–10.5) p < 0.001). There was borderline increased odds of favourable disposition (43% vs. 26%, OR: 2.4 (0.99–6.3, p = 0.052) with CRANI vs. without CRANI, and no difference in developing a complication (58% vs. 48%, OR: 1.5 (0.7–3.4), p = 0.30).ConclusionsSurvival was achieved in 65% of patients that underwent surgical intervention for subdural and epidural haematoma, despite a presenting GCS of 3. These results demonstrate prompt operative neurosurgical management of mass lesion is warranted for selected patients with a GCS of 3, contributing to a significant 4-fold survival benefit. In the absence of mass lesion the effect of immediate neurosurgery on outcomes is inconclusive.