The risk of local infective complications after damage control procedures for femoral shaft fracture

OBJECTIVES: To determine infection rates after damage control orthopaedics (DCO) and primary intramedullary nailing (1' IMN) in multiply injured patients with femoral shaft fracture. DESIGN: Retrospective case analysis. SETTING: Level I trauma center. PATIENTS: All patients with New Injury Severity Score (NISS) >20 and femoral shaft fracture (AO 32-) treated in our unit between 1996 and 2002. INTERVENTION: Damage control orthopaedics, defined as primary external fixation of the femoral shaft fracture and subsequent conversion to an intramedullary nail, or primary IMN. MAIN OUTCOME MEASUREMENTS: Rates of infection classified as contamination (positive swabs with no clinical change), superficial, deep (requiring surgery), and removal of hardware (those requiring removal of femoral instrumentation or amputation). RESULTS: A total of 173 patients with 192 fractures were included; 111 fractures were treated by DCO and 81 by primary IMN. Mean follow-up was 19.1 months [median, 16.7, range, 1 (patient died)-67 months]. DCO patients had a significantly higher NISS and more grade III open fractures (P<0.001). IMN procedures took a median of 150 minutes compared with 85 minutes for DCO (P<0.0001). Although wound contamination (including contaminated pin sites) was more common in the DCO group (P<0.05), the risk of infectious complications was equivalent (P=0.86). Contamination was significantly more likely when conversion to IMN occurred after more than 14 days (P<0.05); however, this did not lead to more clinically relevant infections. Logistic regression analysis showed that although a DCO approach was not associated with infection, delay before conversion in the DCO group might be [P=0.002 for contamination and removal of hardware, P=0.065 for serious infection (deep or worse), not significant for other infection outcomes]. Grade III open injury also was significantly associated with serious infection in all patients (P<0.05). CONCLUSIONS: Infection rates after DCO for femoral fractures are comparable to those after primary IMN. We see no contraindication to the implementation of a damage control approach for severely injured patients with femoral shaft fracture where appropriate. Pin-site contamination was more common where the fixator was in place for more than 2 weeks. For patients treated by using a DCO approach, conversion to definitive fixation should be performed in a timely fashion.     

Early intramedullary nailing for femoral fractures in patients with severe thoracic trauma: A systemic review and meta-analysis

Purpose: Early intramedullary nailing (IMN) within the first 24 h for multiply injured patients with femoral fracture and concomitant thoracic trauma is controversial. Previously published studies have been limited in size and their outcomes have been inconclusive. A meta-analysis was conducted to evaluate the available data in order to guide care and help improve the outcomes for these patients. Methods: We searched the literature up to December 2011 in the main medical search engines and identified 6 retrospective cohort studies that explored the safety of early IMN in patients with both femoral fracture and chest injury. Our primary outcome was the rates of pulmonary complication (pneumonia, adult respiratory distress syndrome, fat embolism syndrome), multiple organ failure (MOF) and mortality. Results: We found no statistically significant difference in the rate of pulmonary complications, MOF or mortality in the patients treated with early IMN. Conclusion: Early IMN for femoral fractures does not increase the mortality and morbidity in chestinjured patients in the studies analyzed.     

Humeral shaft fractures as predictors of intra-abdominal injury in motor vehicle collision victims

To assess the utility of humeral shaft fractures as predictors of organ injuries and skeletal injuries in multiply injured patients involved in motor vehicle collisions (MVCs). A prospectively collected database of multiply injured motor vehicle occupants with an Injury Severity Score (ISS) greater than 12 admitted to a level I regional trauma centre during a 102-month period (January 1992 to June 2000) was reviewed to assess skeletal and organ injuries associated with a humeral shaft fracture. The effect of occupant location within the vehicle, the point of collision, and the use of a seat belt restraint was also examined to identify trends in injury patterns. Data from 1070 motor vehicle occupants - 65 with concomitant humeral shaft fractures and 1005 without humeral shaft fractures - revealed that 63% of motor vehicle occupants who sustained humeral fractures were drivers, compared with 77% in the non-humeral fracture group. Those patients who sustained a humeral shaft fracture had a significantly greater number of liver injuries (p = 0.022), forearm/hand fractures (p < 0.001), tibial fractures (p < 0.01) and femoral fractures (p < 0.01) compared with controls. A lateral collision impact showed a trend towards increased splenic and hepatic injuries within the humeral shaft fracture group. The presence of a humeral shaft fracture in a multiply injured patient involved in a MVC is significantly associated with an increased incidence of both upper and lower extremity fractures and liver injury. Moreover, humeral shaft fractures may serve as a predictor of potential intra-abdominal pathology in multiply injured trauma patients involved in MVCs.     

Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients

BACKGROUND: Recently, there has been a move away from early total care in patients with severe, multiple injuries to damage control orthopedics (DCO) in an attempt to limit the physiologic insult resulting from operative treatment after trauma. For femoral shaft fracture, this entails initial external fixation and subsequent conversion to an intramedullary nail (IMN). We sought to quantify the inflammatory response to initial surgery and conversion and link this to subsequent organ dysfunction and complications. METHODS: Patients with femoral shaft fracture and a New Injury Severity Score of 20 or more were included. Data were retrospectively collected for 4 days at admission and at exchange procedure (external fixation to intramedullary nail), and the Systemic Inflammatory Response Syndrome (SIRS) score and the Marshall multiorgan dysfunction score were calculated. RESULTS: One hundred seventy-four patients met the inclusion criteria. The DCO group had significantly more severe injuries (New Injury Severity Score of 25.4 vs. 36.2, p < 0.0001) and significantly more head and thoracic injuries (both p < 0.0001). The mean SIRS score was significantly higher in the IMN group, from 12 hours until 72 hours postoperatively (p < 0.05). The mean peak postoperative SIRS score was significantly higher in the IMN group than in the DCO group, at the primary procedure and at conversion, as was the time with an SIRS score greater than 1. At conversion in the DCO group, the preoperative SIRS score correlated with magnitude and duration of elevation in the SIRS and multiorgan dysfunction scores (p < 0.0001). CONCLUSION: It would appear that despite more severe injuries in the DCO group, patients had a smaller, shorter postoperative SIRS and did not suffer significantly more pronounced organ failure than the IMN group. DCO patients undergoing conversion while their SIRS score was raised suffered the most pronounced subsequent inflammatory response and organ failure. According to these data, DCO treatment was associated with a lesser systemic inflammatory response than early total care for femur fractures. The inflammatory status of the patient may be a useful adjunct in clinical decision making regarding the timing of conversion to an intramedullary device.     

Wirbelsäulenfrakturen bei Mehrfachverletzten

OBJECTIVE: Spinal trauma is frequently found in multiply injured patients. To gain more insight into the epidemiology and the clinical course of this entity, we analyzed the relevant data held in the German Trauma Registry (German Trauma Society, DGU). The Registry provides prospective, standardized and anonymous documentation on severely injured patients at different predetermined time points from the site of the accident until they are discharged from hospital. METHODS: Out of 8,057 patients whose details are recorded in the German Trauma Registry, 772 (approximately 10%) with severe spine trauma (AIS>/=3) patients were identified. Far more men (72%) than women (28%) had such spinal injuries. The mean age of the patients with severe spine injury was 37+/-17 years; their mean Injury Severity Score (ISS) was 29+/-15 (range 9-75) points. RESULTS: The age group 15-54 years was the largest (80%). Motor vehicle accidents (MVA) were the most frequent cause of severe spine trauma (49%), followed by falls from a great height (20%). About half of all severe spine injuries were not suspected in the prehospital setting. Symptoms of incomplete paraplegia were found in 20% of the patients and symptoms of complete paraplegia, in 27%. Patients with injuries to the thoracic spine more often had a lengthy average stay in the intensive care unit, because they were accompanied by thoracic trauma significantly more often than were injuries to the other spinal segments (96% vs 37%). Patients who underwent spinal surgery at an early stage (70% operated on <72 h after their injuries were sustained) showed a tendency to shorter periods ventilatory support and did not remain in the intensive care unit or indeed in the hospital as long as the other patients. Seventy-eight percent of the patients had survived for 90 days after sustaining their injuries. CONCLUSION: Almost 10% of all documented cases of patients with severe injuries in the German Trauma Registry had severe spinal injuries. These injuries were frequently not recognized or their extent underestimated in the preclinical setting. About 70% underwent spine stabilization within 72 h after being injured. These results support previous findings suggesting that early stabilization of vertebral fractures might be beneficial in multiply injured patients.     

Reamed versus nonreamed anterograde femoral nailing

OBJECTIVE: To compare reamed femoral nailing with unreamed femoral nailing. DESIGN: Prospective, randomized. SETTING: Two Level One trauma centers. PATIENTS: One hundred seventy patients with 172 femur fractures were randomized to an unreamed or reamed group. MAIN OOUTCOME MEASURES: Data included demographics, Injury Severity Score (ISS), operative time, blood loss, blood and fluid requirements, technical complications, time to callus formation, time to union, and complications. RESULTS: There was no statistical difference in operative time, transfusion requirements, or hypoxic episodes between the groups. Intraoperative blood loss was greater in the reamed group. The time to union was 80 +/- 35 days for the reamed group and 109 +/- 62 days for the unreamed group (p = 0.002). This difference was most dramatic in the distal femur, with union in the reamed group occurring in 80 days compared with 158 days in the unreamed group (p = 0.012). There were more technical complications and delayed unions in the unreamed group. CONCLUSIONS: There is no advantage to the routine use of nailing without reamed insertion. Fractures treated with reamed nails heal faster than those treated with unreamed nails, especially distal fractures.     

Treatment of humeral shaft fractures related to associated injuries. A retrospective study of 237 patients.

The results of treatment in 237 patients with humeral shaft fractures in relation to the severity of associated injuries were reviewed. Three groups were defined with the Injury Severity Score: multiply injured (ISS greater than or equal to 18; n 58), moderately injured (4 less than ISS less than 18; n 52), and singly injured patients (ISS = 4; n 127). Three basic forms of therapy were evaluated: operative stabilization, traction, and bracing. In singly injured patients the best results were obtained by bracing, and no cases of delayed union were observed. In multiply injured patients, the incidence of delayed union was low after operative stabilization. In moderately injured patients who had to remain in bed, traction therapy was warranted. The majority of 21 primary and 19 secondary radial nerve injuries showed good recovery, independent of surgical exploration.     

Risk factors for respiratory failure following operative stabilization of thoracic and lumbar spine fractures

BACKGROUND: Respiratory failure is a serious complication that can adversely affect the hospital course and survival of multiply injured patients. Some studies have suggested that delayed surgical stabilization of spine fractures may increase the incidence of respiratory complications. However, the authors of these studies analyzed small sets of patients and did not assess the independent effects of multiple risk factors. METHODS: A retrospective cohort study was conducted at a regional level-I trauma center to identify risk factors for respiratory failure in patients with surgically treated thoracic and lumbar spine fractures. Demographic, diagnostic, and procedural variables were identified. The incidence of respiratory failure was determined in an adult respiratory distress syndrome registry maintained concurrently at the same institution. Univariate and multivariate analyses were used to determine independent risk factors for respiratory failure. An algorithm was formulated to predict respiratory failure. RESULTS: Respiratory failure developed in 140 of the 1032 patients in the study cohort. Patients with respiratory failure were older; had a higher mean Injury Severity Score (ISS) and Charlson Comorbidity Index Score; had greater incidences of pneumothorax, pulmonary contusion, and thoracic level injury; had a lower mean Glasgow Coma Score (GCS); were more likely to have had a posterior surgical approach; and had a longer mean time from admission to surgical stabilization than the patients without respiratory failure (p < 0.05). Multivariate analysis identified five independent risk factors for respiratory failure: an age of more than thirty-five years, an ISS of > 25 points, a GCS of < or = 12 points, blunt chest injury, and surgical stabilization performed more than two days after admission. An algorithm was created to determine, on the basis of the number of preoperative predictors present, the relative risk of respiratory failure when surgery was delayed for more than two days. CONCLUSIONS: Independent risk factors for respiratory failure were identified in an analysis of a large cohort of patients who had undergone operative stabilization of thoracic and lumbar spine fractures. Early operative stabilization of these fractures, the only risk factor that can be controlled by the physician, may decrease the risk of respiratory failure in multiply injured patients.     

Appraisal of early evaluation of blunt chest trauma: development of a standardized scoring system for initial clinical decision making

BACKGROUND: Current techniques for assessment of chest trauma rely on clinical diagnoses or scoring systems. However, there is no generally accepted standard for early judgement of the severity of these injuries, especially in regards to related complications. This drawback may have a significant impact on the management of skeletal injuries, which are frequently associated with chest trauma. However, no convincing conclusions can be determined until standardization of the degrees of chest trauma is achieved. We investigated the role of early clinical and radiologic assessment techniques on outcome in patients with blunt multiple trauma and thoracic injuries and developed a new scoring system for early evaluation of chest trauma. METHODS: A retrospective investigation was performed on the basis of 4,571 blunt polytrauma (Injury Severity Score [ISS] > or = 18) patients admitted to our unit. Inclusion criteria were treatment of thoracic injury that required intensive care therapy, initial Glasgow Coma Scale score greater than 8 points, and no local or systemic infection. Patients with thoracic trauma and multiple associated injuries (ISS > or = 18) were included. In all patients, the association between various parameters of the thoracic injuries and subsequent mortality and morbidity was investigated. RESULTS: A total of 1,495 patients fulfilled the inclusion criteria. Patients' medical records and chest radiographs were reevaluated between May 1, 1998, and June 1, 1999. The association between rib fractures and chest-related death was low (> three ribs unilateral, mortality 17.3%, odds ratio 1.01) unless bilateral involvement was present (> three ribs bilateral, mortality 40.9%, odds ratio 3.43). Injuries to the lung parenchyma, as determined by plain radiography, were associated with chest-related death, especially if the injuries were bilateral or associated with hemopneumothorax (lung contusion unilateral, mortality 25.2%, odds ratio 1.82; lung contusion bilateral + hemopneumothorax, mortality 53.3%, odds ratio 5.1). When plain anteroposterior chest radiographs were used, the diagnostic rate of rib fractures (< or = three ribs) increased slightly, from 77.1% to 97.3% during the first 24 hours of admission. In contrast, pulmonary contusions were often not diagnosed until 24 hours after admission (47.3% at admission, 92.4% at 24 h, p = 0.002). A new composite scoring system (thoracic trauma severity score) was developed that combines several variables: injuries to the chest wall, intrathoracic lesions, injuries involving the pleura, admission PaO2/FIO2 ratio, and patient age. The receiver operating characteristic curve demonstrated an adequate discrimination, as demonstrated by a value of 0.924 for the development set and 0.916 for the validation set. The score was also superior to the ISS (0.881) or the thorax Abbreviated Injury Score (0.693). CONCLUSION: Radiographically determined injuries to the lung parenchyma have a closer association with adverse outcome than chest-wall injuries but are often not diagnosed until 24 hours after injury. Therefore, clinical decision making, such as about the choice of surgery for long bone fractures, may be flawed if this information is used alone. A new thoracic trauma severity score may serve as an additional tool to improve the accuracy of the prediction of thoracic trauma-related complications.     

Incidence and management of occult hemothoraces

BACKGROUND: Little is known about the incidence of and associated management outcomes of occult hemothorax in blunt trauma patients. The increased use of computed thoracic tomography for the evaluation of the multiply injured blunt trauma patient has led to an increase in the identification of these hemothoraces and management dilemmas. METHODS: A retrospective review of blunt trauma patients with occult hemothoraces was performed. Patients were divided into 2 groups: chest tube versus no chest tube. Outcomes and complications for the 2 groups were defined. Data included demographics, Injury Severity Score, length of stay, need for mechanical ventilation and thoracic consult, pneumonia, and empyema. The size of the occult hemothorax was measured on the computed thoracic tomography. RESULTS: Eighty-eight patients (21.4%) had a total of 107 occult hemothoraces. Patients in the chest tube group were more likely to have a higher Injury Severity Score and an associated occult pneumothorax and to have smaller hemothoraces. CONCLUSIONS: Occult pneumothoraces occur in a significant proportion of the multiply injured blunt trauma population. Small, isolated, occult hemothoraces can be managed safely in the stable patient.     

Timing and duration of the initial pelvic stabilization after multiple trauma in patients from the German trauma registry: is there an influence on outcome?

BACKGROUND: There is an ongoing debate about the systemic burden of early definitive fracture stabilization in multiply injured patients. In patients with extremity fractures, the benefit of limited initial surgery has been examined. In this retrospective analysis, we assessed whether differences in outcome can be attributed to the degree of initial surgery in polytrauma patients with pelvic-ring fractures. METHODS: Multiply injured patients of the German Trauma Registry (Injury Severity Score [ISS] > or =16) with pelvic-ring fractures in need of surgery were analyzed for independent effects of the duration and the timing of the initial surgical stabilization of the pelvis. We compared three subgroups according to duration (D) [short (S): <1 hour; intermediate (I): 1-3 hours; and long (L): >3 hours] and timing (T) [early (E): day 0; intermediate (I): days 1-3; and late (L): day >3]. In addition, a subgroup analysis dependent on injury severity was performed. Statistics included analysis of variance, post-hoc Tukey test, chi test, Student's t test, with significance at p < 0.05. RESULTS: Demographic data and injury severity were comparable between the groups. The duration of surgery was associated with a higher rate of liver failure (group D-S: 6%; D-I: 17%; D-L: 28%; p = 0.028). The timing of surgery was associated with a higher rate of renal failure (T-E: 17%; T-I: 3%; T-L: 5%; p = 0.021), multiorgan failure (T-E: 27%; T-I: 23%; T-L: 13%; p = 0.024) and mortality (T-E: 18%; T-I: 19%; T-L: 4%; p = 0.019). There was improved mortality, lower rates of multiorgan failure, and sepsis in patients with higher ISS for procedures less than 3 hours. CONCLUSIONS: In our retrospective analysis, both initial short as well as delayed surgery were associated with a lower rate of organ failure and mortality in multiply injured patients (ISS > or =16). This is especially supported for patients with high ISS.     

Predictors of mortality in adult trauma patients: the physiologic trauma score is equivalent to the Trauma and Injury Severity Score

Background:

Several statistical models (Trauma and Injury Severity Score [TRISS], New Injury Severity Score [NISS], and the International Classification of Disease, Ninth Revision-based Injury Severity Score [ICISS]) have been developed over the recent decades in an attempt to accurately predict outcomes in trauma patients. The anatomic portion of these models makes them difficult to use when performing a rapid initial trauma assessment. We sought to determine if a Physiologic Trauma Score, using the systemic inflammatory response syndrome (SIRS) score in combination with other commonly used indices, could accurately predict mortality in trauma.

Study Design:

Prospective data were analyzed in 9,539 trauma patients evaluated at a Level I Trauma Center over a 30-month period (January 1997 to July 1999). A SIRS score (1 to 4) was calculated on admission (1 point for each: temperature >38°C or <36°C, heart rate >90 beats per minute, respiratory rate >20 breaths per minute, neutrophil count > 12,000 or < 4,000. SIRS score, Injury Severity Score (ISS), Revised Trauma Score (RTS), TRISS, Glasgow Coma Score, age, gender, and race were used in logistic regression models to predict trauma patients’ risk of death. The area under the receiver-operating characteristic curves of sensitivity versus 1-specificity was used to assess the predictive ability of the models.

Results:

The study cohort of 9,539 trauma patients (of which 7,602 patients had complete data for trauma score calculations) had a mean ISS of 9 ± 9 (SD) and mean age of 37 ± 17 years. SIRS (SIRS score ≥ 2) was present in 2,165 of 7,602 patients (28.5%). In single-variable models, TRISS and ISS were most predictive of outcomes. A multiple-variable model, Physiologic Trauma Score combining SIRS score with Glasgow Coma Score and age (Hosmer-Lemenshow CHI-SQUARE = 4.74) was similar to TRISS and superior to ISS in predicting mortality. The addition of ISS to this model did not significantly improve its predictive ability.

Conclusions:

A new statistical model (Physiologic Trauma Score), including only physiologic variables (admission SIRS score combined with Glasgow Coma Score and age) and easily calculated at the patient bedside, accurately predicts mortality in trauma patients. The predictive ability of this model is comparable to other complex models that use both anatomic and physiologic data (TRISS, ISS, and ICISS).     

The predictive qualities of four widely used scaling systems for multiply injured patients are not independent of the injury pattern. A method for identifying interfering variables is demonstrated

When comparing two populations of multiply injured patients differences in patient characteristics must be controlled for. To measure the overall severity of injury, scaling systems are used. If after adjustment for injury severity, the proportion of deaths in the two data sets are still different, the difference is to be considered as due to the quality of care. However, this conclusion is only valid after excluding the possibility that the scale in use fails to adequately reflect certain injuries. The scope of the study is to demonstrate a method for examining this potential interference. As an example, four widely used scales were applied to the data of 418 multiply injured patients. By means of multiple logistic regression analysis, variables were selected which have an influence on prognosis in addition to a scale, thus indicating a subgroup of patients who are underrepresented by the respective scoring system. For the scales examined, these additional variables were: Head and thoracic trauma for the Polytrauma score (Oestern), abdominal and thoracic trauma for the Trauma index (Schreinlechner), thoracic trauma and age for the Trauma score (Champion), head trauma and age for the Injury Severity Score (Baker). We conclude that each score analyzed had its characteristic weak points. Prognostic quality was affected by casemix. Therefore, comparisons between groups of polytraumatized patients may be invalidated. The method outlined here is a useful means for checking a scoring system for these types of interfering variables. Therefore, it is recommended to search routinely for potentially interfering variables before applying a scale. In a given data set of multiply injured patients, appropriate adjustments can then be made for the deficiencies of the scoring system.     

Timing of thoracic spine stabilization in trauma patients: impact on clinical course and outcome

BACKGROUND: Optimal timing of stabilization for thoracic spine injuries in multiply injured patients is still controversial because additional lung injury occurs frequently. Early operation might benefit clinical course and outcome in these patients. METHODS: We analyzed the German National Trauma Database (n = 8,057) and compared clinical parameters and outcome of patients with severe thoracic spine injuries (Abbreviated Injury Scale >2; n = 298) who underwent spine stabilization within 72 hours posttrauma (group I) or later (group II). RESULTS: In all, 95% of all patients had additional severe thoracic injuries such as lung contusion. In spite of comparable demographic data, patients in group I had a significant shorter intensive care unit (ICU) stay (median [range]: group I, 8 [0-237] days; group II, 16 [2-91] days; p = 0.001), shorter dependence on mechanical ventilation (group I: 2 [0-48] days; group II: 5 [0-91] days; p = 0.02), and shorter hospital stay (group I: 22 [1-255] days; group II: 31 [2-274] days; p = 0.048). Expected mortality calculated by Trauma and Injury Severity Score was significantly reduced in group I (calculated: 16%; documented: 6%; p < 0.05) but not in group II (19% versus 17%; p = NS). CONCLUSIONS: Almost 10% of all patients in the German National Trauma Registry had severe spine injuries. Severe thoracic injuries occurred in 95% of these patients with thoracic spine trauma. We provide further evidence that early stabilization of thoracic spine injuries in trauma patients reduces overall hospital and ICU stay and improves outcome. Thus early stabilization of thoracic spine injuries within 3 days after trauma appears to be favorable.     

股骨干骨折髓内针固定术后出现全身炎性反应综合征的回顾研究

目的回顾股骨干骨折髓内针固定扩髓与非扩髓患者术后发生全身炎性反应综合征（SIRS）情况,探讨髓内针固定与发生SIRS的关系。方法1997年4月至2005年4月股骨干骨折患者324例,按伤情分为轻度创伤组（n=179）和中度创伤组（n=145）。治疗采取闭合复位带锁髓内针固定,其中轻度创伤组64例、中度创伤组51例予以扩髓。分别记录每名患者入院后每日的体温、心率、呼吸频率,术后每6h记录相关数据,任何一项出现异常的患者即行血细胞分类计数,记录SIRS发生的情况。检测数据按不同伤情、扩髓与否进行分组,计算SIRS在各组中的发生率,并对之进行组内分组资料的卡方检验。结果术后早期出现SIRS者124例（发生率38．3％）,其中轻度创伤组61例（24例扩髓,37例未扩髓）,中度创伤组63例（27例扩髓,36例未扩髓）。124例中的119例经严密观测及常规术后治疗顺利恢复,5例则出现并发症。统计结果显示SIRS的发生率各组间差异无显著性。结论股骨干髓内针固定术本身会对创伤后的机体产生一定影响,导致发生SIRS;扩髓或非扩髓并不会对患者术后SIRS的发生与否产生明显的影响。     

Influence of primary plate-osteosynthesis of femur fractures on complications in multiple trauma patients with or without thoracic injuries

Summary Primary intramedullary nailing of femoral fractures is well known to increase the risk of pulmonary complications, especially in multiple-trauma patients with severe thoracic injuries. Aim of this study was to investigate the influence of primary plate ostesynthesis of femur fractures on maior complications after trauma. This retrospective study based on the records of 325 multiple trauma patients (Injury severity score ISS > 18, no letal brain injury, age 16–65). According to the abbreviated injury scale of the Thorax (AIS T) patients were divided in groups without (AIS T < 3, “N”) or with relevant thoracic injury (AIS T > = 3, “T”). Both groups were additionally divided in subgroups without severe trauma to the extremities (AIS E< 3, “0”) or primary plate-osteosynthesis of femur fractures (< 24 h, “I”). 4 groups were performed: N0 (n = 39, ISS 25 ± 1, pneumonia 10 %, ARDS 5 %, lethality 10 %); NI (n = 55, ISS 27 ± 1, pneumonia 4 %, ARDS 5 %, lethality 4 %); T0 (n = 137, ISS 28 ± 1, pneumonia 21 %, ARDS 15 %, lethality 16 %); TI (n = 94, ISS 31 ± 1, pneumonia 21 %, ARDS 17 %, lethality 15 %). Primary plate-osteosynthesis of femur fractures did not increase lethality or incidence of pulmonary complications in patients with or without severe thoracic injuries. Also complication rate after primary plate-osteosynthesis was less compared to published results after intramedullary nailing. For this, primary plate-osteosynthesis is recommendable in case of multiple trauma with thoracic injuries.      

Elderly trauma patients with rib fractures are at greater risk of death and pneumonia

BACKGROUND: The purpose of this study was to show that elderly patients admitted with rib fractures after blunt trauma have increased mortality. METHODS: Demographic, injury severity, and outcome data on a cohort of consecutive adult trauma admissions with rib fractures to a tertiary care trauma center from April 1, 1993, to March 31, 2000, were extracted from our trauma registry. RESULTS: Among 4,325 blunt trauma admissions, there were 405 (9.4%) patients with rib fractures; 113 were aged > or = 65. Injuries were severe, with Injury Severity Score (ISS) > or = 16 in 54.8% of cases, a mean hospital stay of 26.8 +/- 43.7 days, and 28.6% of patients requiring mechanical ventilation. Mortality (19.5% vs. 9.3%; p < 0.05), presence of comorbidity (61.1% vs. 8.6%; p < 0.0001), and falls (14.6% vs. 0.7%; p < 0.0001) were significantly higher in patients aged > or = 65 despite significantly lower ISS (p = 0.031), higher Glasgow Coma Scale score (p = 0.0003), and higher Revised Trauma Score (p < 0.0001). After adjusting for severity (i.e., ISS and Revised Trauma Score), comorbidity, and multiple rib fractures, patients aged > or = 65 had five times the odds of dying when compared with those < 65 years old. CONCLUSION: Despite lower indices of injury severity, even after taking account of comorbidities, mortality was significantly increased in elderly patients admitted to a trauma center with rib fractures.     

Outcomes of simultaneous versus staged intramedullary nailing fixation of multiple long bone lower extremity fractures

IntroductionRepair of multiple lower extremity long bone fractures with intramedullary nail (IMN) fixation is associated with significant cardiopulmonary burden and may result in mortality. These patients are at an increased risk for fat embolism syndrome, pulmonary embolism, Acute Respiratory Distress Syndrome (ARDS), and pneumonia. No standardized guidelines exist to guide treatment of these patients. Further, there is a paucity of data regarding the risk of simultaneous versus staged fixation of multiple long bone fractures that includes both tibial and femoral injuries, as patients with multiple concomitant fractures are often excluded from relevant analyses. Our level one trauma center aimed to identify whether simultaneous fixation, defined by definitive fixation of multiple lower extremity long bone fractures during one operative event, led to increased cardiopulmonary complications as compared to a staged approach, defined as multiple operations to reach definitive fixation.Patients and methodsThe Michigan Trauma Quality Improvement Program (MTQIP) database from 35 Level I and II trauma centers was queried to identify patients from January 2016 - December 2019. The primary outcome was incidence of cardiopulmonary complications for staged and simultaneous IMN fixation.ResultsWe identified 11,427 patients with tibial and/or femoral fractures during the study period. 146 patients met the inclusion criteria of two or more fractures treated with IMN fixation. 118 patients underwent simultaneous IMN fixation, and 28 patients received staged IMN fixation. There were no significant differences in injury severity score (ISS), demographics, pre-existing conditions, and cardiopulmonary complications between the two groups. There was a statistically significant difference in hospital length of stay (LOS) (p = 0.0012). The median hospital LOS for simultaneous fixation was 8.3 days versus 15.8 days for the staged cohort, a difference of 7.5 days.ConclusionThis is the largest retrospective study to date examining simultaneous versus staged IMN fixation in patients with multiple long bone lower extremity fractures. In contrast to previous studies, we found no difference in cardiopulmonary complications. Given these findings, patients with multiple long bone lower extremity fractures should be considered for simultaneous IMN, an approach which may decrease hospital LOS.     

Dutch trauma system performance: Are injured patients treated at the right place?

BackgroundThe goal of trauma systems is to match patient care needs to the capabilities of the receiving centre. Severely injured patients have shown better outcomes if treated in a major trauma centre (MTC). We aimed to evaluate patient distribution in the Dutch trauma system. Furthermore, we sought to identify factors associated with the undertriage and transport of severely injured patients (Injury Severity Score (ISS) >15) to the MTC by emergency medical services (EMS).MethodsData on all acute trauma admissions in the Netherlands (2015-2016) were extracted from the Dutch national trauma registry. An ambulance driving time model was applied to calculate MTC transport times and transport times of ISS >15 patients to the closest MTC and non-MTC. A multivariable logistic regression analysis was performed to identify factors associated with ISS >15 patients’ EMS undertriage to an MTC.ResultsOf the annual average of 78,123 acute trauma admissions, 4.9% had an ISS >15. The nonseverely injured patients were predominantly treated at non-MTCs (79.2%), and 65.4% of patients with an ISS >15 received primary MTC care. This rate varied across the eleven Dutch trauma networks (36.8%-88.4%) and was correlated with the transport times to an MTC (Pearson correlation -0.753, p=0.007). The trauma networks also differed in the rates of secondary transfers of ISS >15 patients to MTC hospitals (7.8% - 59.3%) and definitive MTC care (43.6% - 93.2%). Factors associated with EMS undertriage of ISS >15 patients to the MTC were female sex, older age, severe thoracic and abdominal injury, and longer additional EMS transport times.ConclusionsApproximately one-third of all severely injured patients in the Netherlands are not initially treated at an MTC. Special attention needs to be directed to identifying patient groups with a high risk of undertriage. Furthermore, resources to overcome longer transport times to an MTC, including the availability of ambulance and helicopter services, may improve direct MTC care and result in a decrease in the variation of the undertriage of severely injured patients to MTCs among the Dutch trauma networks. Furthermore, attention needs to be directed to improving primary triage guidelines and instituting uniform interfacility transfer agreements.