Symptom cluster profiles following traumatic orthopaedic injuries

BackgroundMillions of Americans experience traumatic orthopaedic injuries (TOIs) annually. Post-injury symptoms of acute stress disorder (ASD), anxiety, depression, pain, and sleep disturbance are common. Symptoms often present in clusters. Symptom cluster profiles phenotypically characterize TOI survivors’ experiences with clustered symptoms. Expression of brain-derived neurotrophic factor (BDNF) may contribute to the biological underpinnings of symptom cluster profile membership.MethodsWe recruited hospitalized TOI survivors within 72 hours of injury. We measured symptoms of ASD with the Acute Stress Disorder Scale and symptoms of anxiety, depression, pain, and sleep disturbance with Patient-Reported Outcomes Measurement Information System (PROMIS) short forms. We measured serum BDNF concentrations with enzyme-linked immunosorbent assay (ELISA) and identified rs6265 genotypes with TaqMan real-time PCR. We performed latent profile analysis to identify the symptom cluster profiles. We identified the variables associated with symptom cluster profile membership with unadjusted and adjusted multinomial logistic regression.ResultsWe identified 4 symptom cluster profiles characterized by symptom severity that we labelled Physical Symptoms Only, and Mild, Moderate, and Severe Psychological Distress. Age, self-identified Black race, resilience, and serum BDNF concentrations were associated with lower odds, and female sex with higher odds, of being in the Psychological Distress clusters. Clinical characteristics and rs6265 genotypes were not associated with symptom cluster profile membership.ConclusionTOI survivors experience distinct symptom cluster profiles. Sociodemographic characteristics and serum BDNF concentrations, not clinical characteristics, were associated with symptom cluster profile membership. These findings support comprehensive symptom screening and treatment for all TOI survivors and further evaluating BDNF as a biomarker of post-injury symptom burden.     

Subacute and delayed period microsurgical management of traumatic extremity injuries in pediatric population

The purpose of the present report is to evaluate the outcome of subacute and delayed period microsurgical reconstructions of traumatic extremity defects of the pediatric patients. Eighteen free tissue transfers had been performed in 18 patients. Patients ranged in age from 5 to 17 years of age and had a median age of 12.05 years. The time between trauma and free flap transfer varied between 8 and 86 days (mean, 30.8 days). Hospital stay ranged from 8 to 90 days, with a mean stay of 38.7 days. Postoperative complications were seen in 8 of 18 patients (44.4%). Re-exploration for venous thrombosis was necessary in two patients, and total flap loss occurred in one case. The average follow-up time was 34 months. One could conclude from our report and the reference literature that the frequently quoted dogma of a definitive defect closure within 7 days may have lost much of its justification. The final results obtained after delayed definitive soft tissue reconstruction compare favorably with results previously reported in the literature from patient groups whose wounds could be closed in the early period within 7 days.     

Class C firework injuries in a pediatric population

Class C fireworks are those which can be readily purchased by the public. Between July 1971 and August 1988, 23 patients were admitted to our institution with firework injuries. Fourteen patients (60.9%) sustained injuries related to Class C fireworks. All patients were males with a mean age of 9.0 +/- 3.6 years, with a total body surface area (TBSA) burn of 18 +/- 20% with 10 +/- 15% being full thickness. Thirteen of the 14 patients required hospitalization. Five patients were admitted acutely and eight patients were referred to our institution at least 3 days postinjury. All patients required operative intervention in order to obtain wound closure. Patients admitted acutely showed a decrease in length of hospital stay and patient morbidity when compared to referral patients. Our data suggest that class C firework injuries, although small in terms of TBSA burned, result in full-thickness wounds that warrant aggressive surgical management.     

Traumatic aortic injuries in the pediatric population

Background/Purpose

Blunt trauma is the leading cause of pediatric injury, but pediatric aortic injuries are rare. We undertook this study to investigate the demographics, treatment, and outcomes of children with blunt aortic injuries and report our experience over a 10-year period.

Methods

After Institutional Review Board approval, a 10-year retrospective review of all pediatric patients admitted with blunt aortic injury was performed. Patient demographics, injury details and severity score (Injury Severity Score), treatment, and outcomes were recorded.

Results

There were 11 children, with ages ranging from 7 to 19 years. The most common mechanism of injury was motor vehicle crashes (8). Initial computed tomography demonstrated all 11 injuries: 7 thoracic aortic (TA) and 4 abdominal aortic (AA) injuries. Associated injuries were common. The TA injuries included 4 transections, 2 intimal flaps, and 1 pseudoaneurysm. Three of these were managed nonoperatively. The AA injuries included 3 intimal flaps and 1 dissection. Three of these were also managed nonoperatively. There were no complications in the 4 children with AA or in the 3 children with TA managed nonoperatively. Complications in the 4 children undergoing operative repair of the TA included paraplegia, renal failure, recurrent laryngeal nerve injury, and pulmonary embolus. The mean hospital stay was 8 days. All children survived, with all but one discharged directly to home.

Conclusions

Blunt aortic injury in children is uncommon and is primarily associated with motor vehicle crashes. Injuries to the abdominal aorta were seen with restrained children vs those to the thoracic aorta that were seen in children who were unrestrained.     

Predicting inpatient mortality for pediatric trauma patients with blunt injuries: a better alternative

PURPOSE: The aim of this study was to identify significant independent predictors of inpatient mortality rates for pediatric victims of blunt trauma and to develop a formula for predicting the probability of inpatient mortality for these patients. METHODS: Emergency department and inpatient data from 2,923 pediatric victims of blunt injury in the New York State Trauma Registry in 1994 and 1995 were used to explore the relationship between patient risk factors and mortality rate. A stepwise logistic regression model with P<.05 was developed using survival status asthe dependent variable. Independent variables included are elements of the Pediatric Trauma Score (PTS), additional elements from the Revised Trauma Score (RTS), the motor response and eye opening components of the Glasgow Coma Scale (GCS), age-specific systolic blood pressure, the AVPU score, and 2 measures of anatomic injury severity (the Injury Severity Score [ISS] and the International Classification of Disease, Ninth Revision-based Injury Severity Score [ICISS]). RESULTS: The only significant independent predictors of severity that emerged were the ICISS, no motor response (best motor response = 1) from the GCS, and the unresponsive component from the AVPU score. The statistical model exhibited an excellent fit (C statistic = .964). The specificity associated with the prediction of inpatient mortality rate based on the presence of 1 or more of these risk factors was .926, and the sensitivity was .944. CONCLUSION: The best independent predictors of inpatient mortality rate for pediatric trauma patients with blunt injuries include variables not specifically contained in the PTS or the RTS: ICISS, no motor response (best motor response = 1) from the GCS, and the unresponsive component of the AVPU score.     

The risk of carcinogenesis from radiographs to pediatric orthopaedic patients

This study set out to determine whether cumulative radiograph exposure of children significantly increases their risk of radiation-induced carcinogenesis or hereditary defects. Records of children treated for idiopathic scoliosis, hip dysplasia, or leg-length discrepancy between 1980 and 1993 at the Shriners Hospital in Spokane, WA, were retrospectively reviewed. Total radiation and organ dose exposures were calculated using information from individual radiology reports. Surgically treated idiopathic scoliosis patients had the largest total radiation skin entrance and organ dose exposures. This group's risks for developing leukemia, breast cancer, or a heritable defect, respectively, were 0.8%, 2.1%, and 3.0% higher than baseline risks. The other treatment groups had increased carcinogenic risks of <1%. The use of serial radiographs during the treatment of idiopathic scoliosis, hip dysplasia, and leg-length discrepancy appears relatively safe. The increased risk of carcinogenesis or hereditary defects in these patients is minimal.     

Frailty predicts mortality and complications in chronologically young patients with traumatic orthopaedic injuries

BackgroundAs morbidity and mortality from traumatic orthopaedic injuries continues to rise, increased research is being conducted on how to best predict complications in at risk patients. Recently, frailty indices have been validated in a variety of surgical subspecialties as predictors of morbidity and mortality. However, the vast majority of research has been conducted on geriatric patient populations, with little evidence on patients who are chronologically young. The purpose of this study was to evaluate the role of a modified frailty index (mFI) in predicting mortality and complications after pelvis, acetabulum, and lower extremity trauma in patients of all ages.MethodsThe American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2014 for all patients who underwent surgery for pelvis, acetabulum, and lower extremity trauma. The sample size was divided into geriatric (age ≥ 60) and young (age < 60) cohorts. The mFI score was calculated for each patient. Bivariate analysis was performed using logistic regression and a chi-square test to determine the relationship between mFI and both primary and secondary outcomes while adjusting for age. Univariate analysis and multivariate analyses were performed. All analyses were done using SAS 9.4 (Cary, NC) and a p < 0.05 was considered significant.Results56,241 patients were identified to have undergone surgery for pelvis, acetabulum, or lower extremity trauma. 28% of patients were identified under the age of 60. In the young cohort, mFI was a strong predictor of thirty-day mortality (OR 11.02, 95% CI 6.26–19.39, p < 0.001). With regards to Clavien-Dindo grade IV complications, MFI is also a strong predictor in the young cohort (OR 28.82, 95% CI 16.05–51.77, p < 0.001).Conclusion and relevanceThe mFI score was a significant predictor of morbidity and mortality in chronologically young orthopaedic trauma patients. The use of the mFI score can provide an individualized risk assessment to interdisciplinary teams for perioperative counseling and to improve outcomes.     

The use of a microcomputer for inpatient audit in an orthopaedic department.

A microcomputer has been used to assist in the inpatient audit of an orthopaedic unit in a district general hospital. The aims were to provide a more detailed, accurate audit, more rapidly than previous manual methods had allowed. The clinical details of 609 patients treated over a 9-month period were fed into the computer and various statistical analyses performed. The results of the audit are presented. The extent to which our aims have been achieved is discussed together with the specific problems encountered with computer hardware, software and organisation of the system.     

Spinal fractures resulting from traumatic injuries

Objective： To illustrate mechanisms of spine fractures and the pattern of spinal injuries characterized by the major mechanisms in urban population of Iran. Methods： Data regarding spinal injuries including demographics, mechanism and level of spinal injury, abbreviated injury score, associated injuries and final fate of the patients were extracted from the Iranian national trauma registry database from 1999 to 2004. Results： A total of 619 patients with traumatic spine fractures were identified, of whom 68.5% were males. The peak frequency of these injuries occurred in the 21-40 year age-group. Accidental falls and road traffic crashes （RTCs） were the most common mechanisms of spinal fractures （47.2% and 44.1%, respectively）. RTCs tended to occur in younger patients compared with accidental falls. The most common spinal region for spinal fracture was the lumbar spine （53.63%）. Cervical spine fractures were significantly more common in RTCs, while lumbar spine fractures were more common in accidental falls （P〈0.001）. A total of 171 （27.6%）patients had associated non-spinal injuries, of whom 127 had associated extremity injuries, and 55 had head injuries. Thirty-six （5.6%） patients had spinal cord injury （SCI）.The injury severity score of the RTC group was significantly higher than that of accidental falls （P=-0.002）. Fifteen （4%） patients died of traumatic injuries. The rate of death was significantly higher in RTCs compared with accidental falls （5.1% vs 2.1%, P=0.039）. Conclusions： The patterns of spinal fractures are similar to those reported from developed countries. RTCs tend to affect the younger age population and are associated with a higher degree of associated injuries and mortality than accidental falls. Therefore preventive strategies should be based on reduction of the number and severity of RTCs.     

The most frequent kinds of self-mutilation of the extremities

We describe the characteristic symptoms and the progress of self-inflicted injuries to the limbs on the basis of 4 out of 15 cases. Glove-like edemas (which can lead to the misdiagnosis Sudeck's disease) are the most frequent. Chronic tapping and scratching of soft tissues induces local swelling which suggests a sarcoma. Contractures are especially difficult to diagnose. Development resulting from self-manipulation should always be considered when the disease manifestations persist for an incredibly long time (even after an adequate trauma), when the cause cannot be explained by mechanical or neurological findings and when the symptoms do not match the imitated disease in all details. Mostly the patient own to the self-inflicted injury, when he clearly feels to be sized up.     

Endograft stenting in the adolescent population for traumatic aortic injuries

Traumatic thoracic aortic transections are uncommon in the pediatric population. These injuries are currently treated by open operative repair via thoracotomies. We present 2 adolescent patients with traumatic thoracic aortic transections who were repaired by endovascular techniques. Both adolescents, aged 16 and 17 years, were in high-speed motor vehicle collisions and presented with multisystem trauma. Patient 1 had a transection of the descending aorta and was repaired with two 23-mm (diameter), 3-cm-long endograft cuffs at 48 hours after injury because of her multiple organ injuries. She was hospitalized for 40 days. Patient 2 had a thoracic aortic transection just distal to the aortic arch. He was repaired within 12 hours of injury with a 24-mm and two 22-mm AneuRx endograft cuffs. He was hospitalized for 8 days. Both patients have recovered without complications at 13 and 21 months, respectively. Endovascular stenting, especially in critically ill patients, allows for definitive treatment of the vascular injury without the need for bypass and reduces the recovery time that is associated with thoracotomies. Short-term recovery and follow-up are encouraging for endovascular stenting in the adolescent population; however, further long-term follow-up is required.