Estudio observacional retrospectivo correlacionando las fracturas traumáticas de pelvis y sus lesiones asociadas según la clasificación de Tile

IntroductionPelvic fractures due to high energy trauma present a high risk of associated injuries that compromise the functional and vital prognosis of the patients. The objective of this study was to analyze the relationship between traumatic pelvic fractures and their associated injuries according to the Tile classification.MethodsRetrospective observational study of patients who suffered traumatic pelvic fractures (Type A, B or C of the Tile classification) with concomitant associated injuries, analyzing hemoglobin levels, between 6/2013 and 1/2016.ResultsA total of 42 patients were included; of those 69% (n = 29) were males, mean age was 48 years. 45% (n = 19) suffered traffic accidents and 26.2% (n = 11) falls. There was a different proportion in pelvic injuries: Tile A (n = 15, 35.7%), B (n = 20, 47.6%), and C (n = 7, 16.6%) of cases. 54.8% (n = 23) underwent surgery, 21.4% (n = 9) needed temporary or definitive external fixation. Significant differences were found between Tile A type and scapula fractures (P=.032), and Tile B with sacral fractures (P=.033) and visceral injuries (P=.049), while there is a tendency without a statistical significal between Tile C and costal fractures. 61.9% (n = 26) needed blood transfusion; 9.5% (n = 4) presented hypovolemic shock.ConclusionsTile A pelvic fractures were associated with scapular fractures, and Tile B with transforaminal fractures of the sacrum and with visceral injuries (lungs, liver and genitourinary). The small number of Tile C prevent us to confirm an association with any pathology, although they are the ones which presnt more hemodynamically instability and thoracic injuries.     

Combat-related acetabular fractures: Outcomes of open versus closed injuries

IntroductionSince the onset of the Global War on Terror close to 50,000 United States service members have been injured in combat, many of these injuries would have previously been fatal. Among these injuries, open acetabular fractures are at an increased number due to the high percentage of penetrating injuries such as high velocity gunshot wounds and blast injuries. These injuries lead to a greater degree of contamination, and more severe associated injuries. There is a significantly smaller proportion of the classic blunt trauma mechanism typically seen in civilian trauma.MethodsWe performed a retrospective review of the Department of Defense Trauma Registry into which all US combat-injured patients are enrolled, as well as reviewed local patient medical records, and radiologic studies from March 2003 to April 2012. Eighty seven (87) acetabular fractures were identified with 32 classified as open fractures. Information regarding mechanism of injury, fracture pattern, transfusion requirements, Injury Severity Score (ISS), and presence of lower extremity amputations was analyzed.ResultsThe mechanism of injury was an explosive device in 59% (n = 19) of patients with an open acetabular fracture; the remaining 40% (n = 13) were secondary to ballistic injury. In contrast, in the closed acetabular fracture cohort 38% (21/55) of fractures were due to explosive devices, and all remaining (n = 34) were secondary to blunt trauma such as falls, motor vehicle collisions, or aircraft crashes. Patients with open acetabular fractures required a median of 17units of PRBC within the first 24 h after injury. The mean ISS was 32 in the open group compared with 22 in the closed group (p = 0.003). In the open fracture group nine patients (28%) sustained bilateral lower extremity amputations, and 10 patients (31%) ultimately underwent a hip disarticulation or hemi-pelvectomy as their final amputation level.DiscussionOpen acetabular fractures represent a significant challenge in the management of combat-related injuries. High ISS and massive transfusion requirements are common in these injuries. This is one of the largest series reported of open acetabular fractures. Open acetabular fractures require immediate damage control surgery and resuscitation as well as prolonged rehabilitation due to their severity. The dramatic number of open acetabular fractures (37%) in this review highlights the challenge in treatment of combat related acetabular fractures.     

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.     

The epidemiology of fractures of the proximal ulna

IntroductionThe aim of our study was to report the epidemiological characteristics of fractures of the proximal ulna.MethodsFrom our prospective trauma database of 6872 fractures, we identified all acute fractures of the proximal ulna from a 1-year period between July 2007 and June 2008. Age, gender, mode of injury, fracture classifications, associated injuries and treatment were the factors documented and analysed.ResultsThere were 78 fractures of the proximal ulna with a mean age of 57 years (15–97). Males (n = 35) sustained their fracture at a significantly younger age than females (p = 0.041), with no gender predominance seen (p = 0.365). The overall fracture distribution was a unimodal older male and unimodal older female type-F curve. The most common mode of injury was a simple fall from standing height (n = 52, 67%), with younger patients more likely to sustain their injuries following a high-energy mechanism such as sports or a motor vehicle collision (p < 0.001). Seventeen (22%) patients sustained associated injuries to the ipsilateral limb, with an associated proximal radial fracture most frequent (n = 13, 17%). Open fractures were seen in five (6.4%) patients. A total of 64 patients had a fracture of the olecranon, with the Mayo 2A most frequently seen (n = 47, 60%).ConclusionsFractures of the proximal ulna are fragility fractures that predominantly occur in elderly patients. Given the number of elderly patients sustaining these injuries, research is needed to determine the role of non-operative treatment for these fractures, particularly in patients with multiple co-morbidities and low functional demands.     

The acute compartment syndrome following fractures of the lower leg in children

IntroductionThe acute compartment syndrome (ACS) of the lower leg is a rare but serious complication following either fractures or soft tissue injuries. An acute intervention consisting of fasciotomy is indicated as ACS may cause muscle and nerve damage. The aim of the present study was to evaluate the cause, the incidence, the time to fasciotomy and the outcome of ACS of the lower leg following fractures in a paediatric population.Patients and methodsA retrospective analysis of all patients with ACS following a fracture of the lower leg treated from 1998 to 2010 was performed. The time from admission to occurrence of the ACS, the kind of fracture and surgical treatment was evaluated. Accident mechanisms were recorded.ResultsA total of 1028 fractures of the lower leg were treated. 31 patients (3%) with a median age of 14.6 years (range 7.3–17.1 years) developed an ACS. In the group of patients younger than 12 years the incidence was even lower (1.3%). 81% of injuries leading to ACS were caused by high-energy trauma, with motorcycle accidents being the most common (45%). External fixation was used in 45%, including all open fractures. The diagnosis of an ACS was primarily based on clinical symptoms. In 23 cases an intracompartmental pressure of median 55 mmHg (range 40–100 mmHg) were measured. ACS was diagnosed after 19 h mean (range: 1.5–65 h). There was a tendency that the ACS occurred earlier after high-energy trauma than after low energy trauma (mean 16.9 vs. mean 28 h). No complications linked to the compartment syndrome were observed.DiscussionACS can occur up to 65 h after an accident and therefore clinical monitoring is fundamental in order to be able to surgically intervene as soon as possible when needed. With early decompression complications can be prevented.     

Spinal and pelvic injuries in airborne sports: A retrospective analysis from a major Swiss trauma centre

BackgroundAdrenalin-seeking airborne sports like BASE-jumping, paragliding, parachuting, delta-gliding, speedflying, and skysurfing are now firmly with us as outdoor lifestyle activities and are associated with a high frequency of severe injuries, especially to the spine.MethodsRetrospective analysis of all airborne sports-associated spinal and pelvic injuries admitted to a Level I trauma centre in the Swiss Alps between 1st March 2000 and 31st October 2009. Spinal injuries were classified by the Magerl system and pelvic injuries by the AO/OTA scheme modified by Isler and Ganz. Spino-pelvic dissociation fractures in airborne sports were compared to similar injuries in the general trauma population using multiple logistic regression analysis.Results181 patients (11 BASE-jumpers, 144 paragliders, 19 parachuters, 1 speedflyer, 4 deltagliders, 2 skysurfer) were included. 161 (89%) were male. Median age was 37.0 years (IQR = 29.0–47.0) and ISS 8 (IQR = 4–13). 89 (49.2%) patients sustained spinal fractures. Type A fractures were predominant (91.5%), followed by Type C (5.3%) and Type B (3.2%). The level L1 was most often affected (35.1%). 17 patients (9.4%) had pelvic ring fractures. Most frequent were Type C fractures (41.2%), followed by Types A and B (29.4% each). 8 paragliders (4.4%) suffered spino-pelvic dissociation injuries. The odds ratio for sustaining such fractures in paragliders was 21-fold higher (OR 21.04, 95% CI 7.83–56.57, p < 0.001) than in the general trauma population.ConclusionsSerious spinal and pelvic injuries account for most injuries sustained during airborne sporting activities. The thoracolumbar region was most often affected, but the lumbopelvic junction is also especially vulnerable as high impact forces from vertical and horizontal deceleration need to be absorbed. The frequency of spino-pelvic dissociation was very high in paragliding injuries, with a 21-fold higher odds ratio than in the general trauma population.     

Natural history of medial clavicle fractures

BackgroundFractures of the medial third of the clavicle comprise less than 3% of all clavicle fractures. The natural history and optimal management of these rare injuries are unknown. The aim of our study is to describe the demographics, management and outcomes of patients with medial clavicle fractures treated at a Level 1 Trauma Centre.MethodsA retrospective review was conducted of patients presenting to our institution between January 2008 and March 2013 with a medial third clavicle fracture. Clinical and radiographic data were recorded including mechanism of injury, fracture pattern and displacement, associated injuries, management and complications. Functional outcomes were assessed using the Glasgow Outcome Scale Extended (GOS-E) scores from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Shoulder outcomes were assessed using two patient reported outcomes scores, the American Shoulder and Elbow Society Score (ASES) and the Subjective Shoulder Value (SSV).ResultsSixty eight medial clavicle fractures in 68 patients were evaluated. The majority of patients were male (n = 53), with a median age of 53.5 years (interquartile range (IQR) 37.5–74.5 years). The most common mechanism of injury was motor vehicle accident (n = 28). The in-hospital mortality rate was 4.4%.The fracture pattern was almost equally distributed between extra articular (n = 35) and intra-articular (n = 33). Fifty-five fractures (80.9%) had minimal or no displacement. Associated injuries were predominantly thoracic (n = 31). All fractures were initially managed non-operatively, with a broad arm sling.Delayed operative fixation was performed for painful atrophic delayed union in two patients (2.9%). Both patients were under 65 years of age and had a severely displaced fracture of the medial clavicle. One intra-operative vascular complication was seen, with no adverse long-term outcome.Follow-up was obtained in 85.0% of the surviving cohort at an average of three years post injury (range 1–6 years). The mean ASES score was 80.3 (SD 24.8, range 10–100,), and the mean SSV score was 77.0 (SD 24.6, range 10–100).ConclusionSixty eight patients with medial clavicle fractures were identified over a 5 year period, with excellent functional results seen following conservative management.     

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.     

Injury factors associated with discharge status from emergency room at two major trauma hospitals in The Gambia,Africa

IntroductionInjuries are the leading cause of disability across all ages and gender. In this study, we identified predictors of discharge status and disability at discharge among patients who seek emergency room treatment.Materials and methodsThe study was conducted in two major trauma hospitals in urban Gambia. 1905 patients participated in the study. 74.9% were males, and 25.1% were females. The study includes injured patients from all mechanisms. However, patients’ records without age, gender, injury mechanism, and deposition from the emergency room were considered incomplete and excluded. We examined distributions of injury by age, gender, mechanism, place of occurrence, intent, primary body part injured, and primary nature of injury. We identified demographic and injury characteristics associated with hospital admission (compared to emergency department discharge) and discharge disability (any level of disability compared with none).ResultsThe leading mechanisms of injury were road traffic (26.1%), struck by objects (22.1%), cut/pierce (19.2%), falls (19.2%), and burns (5.4%). Injuries most commonly occurred in the home (36.7%) and on the road (33.2%). For those aged 19–44, the proportion of injuries due to assault was higher for females (35.9%) than males (29.7%). Males had increased odds for admission (aOR = 1.48 95% CI = 1.15–1.91) and for disability (aOR = 1.45; 95% CI = 1.06–1.99). Increased odds for admission were found for brain injuries, fractures, large system injuries, and musculoskeletal injuries when compared with soft tissue injuries. The highest odds for any level of discharge disability were found for brain injuries, fractures, injuries from falls, burns, and road traffic.ConclusionsEpidemiology of injuries in The Gambia is similar to other low-income countries. However, the magnitude of cases and issues uncovered highlights the need for a formal registry.     

Heterotopic Ossification following acetabular fixation: Incidence and risk factors: 10-year experience of a tertiary centre

BackgroundHeterotopic Ossification (HO) is a well-recognized complication following acetabular fracture fixation and its presence is prognostic for suboptimal clinical outcome. There are many controversies pertaining to its aetiology, including surgical approach, associated injuries and the use of HO prophylaxis. Long term data from high volume centres is necessary to address these issues.AimTo determine the incidence of HO post open reduction and internal fixation (ORIF) of acetabular fractures and to examine the associated risk and prognostic factors.MethodWe studied a cohort of 369 consecutive acetabular fractures that underwent ORIF at our institution over a 10 year period. Data was analyzed using univariate and multivariate logistic regression.ResultsThe existence of HO was evident in 65 patients (17.62%), of these 39 (60.0%) were Class I, 16 (24.6%) were Class II, 8 (12.3%) were Class III, and 2 (3.1%) were Class IV according to Brooker Classification. We found a significant association between admission to an Intensive Care Unit (ICU) (P-value = 0.039), chest injury (P-value = 0.013), multiple fractures (P-value = 0.005), and the time lapse between injury and operation (P-value = 0.025), and some statistical significance with surgical approach, ipsilateral fractures, open fractures, tibial and patellar fractures. Age over 30 years as the only prognostic factor for severe HO. Prophylaxis with Indomethacin did not appear to confer any benefit in our patient group.ConclusionThe risk factors for developing HO following acetabular fracture fixation are multifactorial and include admission to ICU, associated chest injuries, multiple fractures and delay between injury and surgery. Surgical approach, ipsilateral fractures and tibia and patellar fractures may also play a role. Age over thirty years was the only prognostic factor for developing severe HO.     

Epidemiology and mortality of glacier crevasse accidents

IntroductionCrevasse accidents can lead to severe injuries and even death, but little is known about their epidemiology and mortality.MethodsWe retrospectively reviewed helicopter-based emergency services rescue missions for crevasse victims in Switzerland between 2000 and 2010. Demographic and epidemiological data were collected. Injury severity was graded according to the National Advisory Committee for Aeronautics (NACA) score.ResultsA total of 415 victims of crevasse falls were included in the study. The mean victim age was 40 years (SD 13) (range 6–75), 84% were male, and 67% were foreigners. The absolute number of victims was much higher during the months of March, April, July, and August, amounting to 73% of all victims; 77% of victims were practicing mountaineering or ski touring. The mean depth of fall was 16.5 m (SD 9.0) (range 1–35). Overall on-site mortality was 11%, and it was higher during the ski season than the ski offseason (14% vs. 7%; P = 0.01), for foreigners (14% vs. 5%; P = 0.01), and with higher mean depth of fall (22 vs. 15 m; P = 0.01). The NACA score was ≥4 for 22% of the victims, indicating potential or overt vital threatening injuries, but 24% of the victims were uninjured (NACA 0). Multivariable analyses revealed that depth of the fall, summer season, and snowshoeing were associated with higher NACA scores, whereas depth of the fall, snowshoeing, and foreigners but not season were associated with higher risk of death.ConclusionThe clinical spectrum of injuries sustained by the 415 patients in this study ranged from benign to life-threatening. Death occurred in 11% of victims and seems to be determined primarily by the depth of the fall.     

The impact of the Major Trauma Network: will trauma units continue to treat complex foot and ankle injuries?

IntroductionApril 1st 2012 saw the introduction of National Trauma Networks in England. The aim to optimise the management of major trauma. Patients with an ISS ≥ 16 would be transferred to the regional Major Trauma Centre (level 1). Our premise was that trauma units (level 2) would no longer manage complex foot and ankle injuries thereby obviating the need for a foot and ankle specialist service.MethodsRetrospective analysis of the epidemiology of foot and ankle injuries, using the Gloucestershire trauma database, from a trauma unit with a population of 750,000. Rates of open fractures, complex foot and ankle injuries and requirement for stabilisation with external fixation were reviewed before and after the introduction of the regional Trauma Network. Secondly, using the Trauma Audit & Research Network (TARN) database, all foot and ankle injuries triaged to the regional Major Trauma Centre (MTC) were reviewed.ResultsIncidence of open foot and ankle injuries was 2.9 per 100,000 per year. There were 5.1% open injuries before the network and 3.2% after (p > 0.05). Frequency of complex foot and ankle injuries was 4.2% before and 7.5% after the network commenced, showing no significant change. There was no statistically significant change in the numbers of patients with complex foot and ankle injuries treated by application of external fixators. Analysis of TARN data revealed that only 18% of patients with foot and ankle injuries taken to the MTC had an ISS ≥ 16. The majority of these patients were identified as requiring plastic surgical intervention for open fractures (69%) or were polytrauma patients (43%). Only 4.5% of patients had isolated, closed foot and ankle injuries.ConclusionWe found that at the trauma unit there was no decrease in the numbers of complex foot and ankle injuries, open fractures, or the applications of external fixators, following the introduction of the Trauma Network. These patients will continue to attend trauma units as they usually have an ISS < 16. Our findings suggest that there is still a need for foot and ankle specialists at trauma units, in order to manage patients with complex foot and ankle injuries.     

The influence of foot and ankle injury patterns and treatment delays on outcomes in a tertiary hospital; a one-year prospective observation

BackgroundAnkle and foot fractures are amongst the most common injuries, and patterns may vary from primary care set up to tertiary hospitals. Severe foot injuries are projected to have significantly worse outcomes and surgical delays are thought to alter prognosis.MethodsAll patients with foot and ankle trauma were prospectively evaluated at a Tertiary trauma centre over one year. The incidence, fracture patterns, risk factors, and outcomes were evaluated, and cases were divided into simple foot injuries (FASS ≤ 3) and severe foot injuries (FASS > 3). Injury mechanisms, associated injuries, and delays in treatment were evaluated, and outcomes were analyzed using Visual–Analogue Scale Foot and Ankle (VASFA), Maryland Foot Score (MFS) and Foot and ankle disability index (FADI).Results294 Foot and Ankle injuries (51 females, 243 males) were encountered in 2919 trauma cases (incidence of 10%). 80 patients (27.2%) had simple foot injuries and 214 (72.8%) had severe foot injuries. 29 patients (9.9%) were below 18years; most (65.3%) patients were between 18 and 45 years age. Road traffic accident was most commonest mode of injury, with ankle fractures (30.6%) the most common. Metatarsal fractures (27.9%) and calcaneal fractures (21.4%) were 2nd and 3rd most common injuries in the foot. Surgical delay averaged 1 day in both severe and simple injuries. Injury led to 32 (10.9%) below knee amputations. Outcome evaluation in 127 (91 severe, 36 simple injuries) patients showed mean Maryland foot score of 89.30 in simple injury group and 84.87 in severe injury group. Mean VASFA score was 82.87 (simple) and 81.87 in severe injury, and mean FADI score was 93.13 (simple) and 91.05 (severe injury). More detailed analysis revealed that more good scores (64.4%) were documented in severe injuries group, and more excellent scores (52.8%) in simple injuries group.ConclusionFoot injuries constitute 10% of all orthopaedic trauma at tertiary hospitals; Majority of them are severe foot injuries, with 68.7% being open injuries. Surgical delay was similar in simple and severe foot and ankle injuries. Outcomes of severe injuries were similar to simple foot and ankle injuries, reflecting on the quality of care that could be administered to them when they present to tertiary hospitals.     

The epidemiology of fractures in infants – Which accidents are preventable?

IntroductionIn children, fractures have a huge impact on the health care system. In order to develop effective prevention strategies exact knowledge about the epidemiology of fractures is mandatory. This study aims to describe clinical and epidemiological data of fractures diagnosed in infants.MethodsA retrospective analysis of all infants (children < 1 year of age) presenting with fractures in an 11 years period (2001–2011) was performed. Information was obtained regarding the location of the fractures, sites of the accident, circumstances and mechanisms of injury and post-injury care.Results248 infants (54% male, 46% female) with a mean age of 7 months presented with 253 fractures. In more than half of the cases skull fractures were diagnosed (n = 151, 61%). Most frequently the accidents causing fractures happened at home (67%). Falls from the changing table, from the arm of the care-giver and out of bed were most commonly encountered (n = 92, 37%). While the majority of skull fractures was caused from falls out of different heights, external impacts tended to lead to fractures of the extremities. 6 patients (2%) were victims of maltreatment and sustained 10 fractures (2 skull fractures, 4 proximal humeral fractures, 2 rib fractures, and 2 tibial fractures).ConclusionFalls from the changing table, the arms of the caregivers and out of bed caused the majority of fractures (especially skull fracture) in infants. Therefore, awareness campaigns and prevention strategies should focus on these mechanisms of accident in order to decrease the rate of fractures in infants.     

The effect of Helicopter Emergency Medical Services on trauma patient mortality in the Netherlands

IntroductionObject of this study was to evaluate the effect of the Helicopter Emergency Medical Services (HEMS) on trauma patient mortality and the effect of prehospital time on the association between HEMS and mortality.Materials and methodsTrauma patients admitted to a level 1 trauma centre and treated on-scene by the HEMS and Emergency Medical Services (EMS) between 2003 and 2008 were included (n = 186). A control group treated by EMS only (n = 186) was created by matching on ISS, age and severe traumatic brain injury (TBI). Mortality was compared by calculating odds ratios (OR) and numbers needed to treat (NNT), with adjustment for prehospital coded Revised Trauma Score. The effect of prehospital time mortality was tested by a logistic regression. Analyses were made for patients with and without TBI.ResultsThe OR of early trauma fatality for the HEMS/EMS versus EMS-only groups was 0.8 for patients both with TBI (95% CI 0.4–1.7; NNT: 22) and without TBI (95% CI 0.2–3.3; NNT: 273). The risk of in-hospital mortality was non-significantly higher for patients with TBI in the HEMS/EMS group (OR = 1.3; 95% CI 0.6–2.7; NNT: ?15) compared to the EMS-only group and non-significantly lower for patients without TBI (OR = 0.9; 95% CI 0.3–2.5; NNT: 129). After adjustment for prehospital time, the risk of early trauma fatality for patients with TBI treated by the HEMS decreased (OR = 0.6; 95% CI 0.3–1.6). The risk of in-hospital mortality for these patients decreased from 1.3 to 0.8 (95% CI 0.4–2.0). The effect of the HEMS on patients without TBI did not change after adjustment for prehospital time.DiscussionHEMS treatment is associated with a non-significantly higher risk of in-hospital mortality for patients with TBI and a non-significantly lower risk for patients without TBI. This increased risk of mortality in TBI patients is attributable to the increased prehospital time. These results indicate that HEMS does not have a positive impact on survival.     

Physician staffed helicopter emergency medical systems can provide advanced trauma life support in mountainous and remote areas

IntroductionIn remote and mountainous areas, helicopter emergency medical systems (HEMS) are used to expedite evacuation and provide pre-hospital advanced trauma life support (ATLS) in major trauma victims. Aim of the study was to investigate feasibility of ATLS in HEMS mountain rescue missions and its influence on patient condition at hospital admission.Patients58 major trauma victims (Injury Severity Score ≥16), evacuated by physician staffed HEMS from remote and mountainous areas in the State of Tyrol, Austria between 1.1.2011 and 31.12.2013.ResultsPre-hospital time exceeded 90 min in 24 (44%) cases. 31 (53%) patients suffered critical impairment of at least one vital function (systolic blood pressure <90 mmHg, GCS <10, or respiratory rate <10 or >30). 4 (6.9%) of 58 patients died prior to hospital admission. Volume resuscitation was restrictive: 18 (72%) of 25 hypotensive patients received ≤500 ml fluids and blood pressure was increased >90 mmHg at hospital admission in only 9 (36%) of these 25 patients. 8 (50%) of 16 brain trauma patients with a blood pressure <90 mmHg remained hypotensive at hospital admission. Endotracheal intubation was accomplished without major complications in 15 (79%) of 19 patients with a Glasgow Coma Scale score <10. Rope operations were necessary in 40 (69%) of 58 cases and ATLS was started before hoist evacuation in 30 (75%) of them.ConclusionsThe frequent combination of prolonged pre-hospital times, with critical impairment of vital functions, supports the need for early ATLS in HEMS mountain rescue missions. Pre-hospital endotracheal intubation is possible with a high success and low complication rate also in a mountain rescue scenario. Pre-hospital volume resuscitation is restrictive and hypotension is reversed at hospital admission in only one third of patients. Prolonged pre-hospital hypotension remains an unresolved problem in half of all brain trauma patients and indicates the difficulties to increase blood pressure to a desired level in a mountain rescue scenario. Despite technical considerations, on-site ATLS is feasible for an experienced emergency physician in the majority of rope rescue operations.     

Pediatric pelvic ring injuries: How benign are they?

IntroductionWith an incidence of less than 0.2% of all pediatric fractures, pelvic ring injuries are rare. Historically they were conservatively treated, but because malunion and long-term morbidity are associated with unstable injuries, a trend towards operative treatment can be observed. The purpose was to determine clinical and radiographic outcomes following these complex pediatric pelvic ring injuries.Patients and methodsThis Level IV retrospective analysis was completed at a private orthopaedic practice in association with a Level One teaching trauma center. There were 33 children with pelvic ring injuries with a mean age of 12.6 years (4–16) and an average follow up of 28.6 months (range 6–101). Injuries were 2 A2, 3 B1, 16 B2, 10 B3, and 2 C2 according to OTA/AO classification. Group 1 had 16 unstable, operatively treated injuries and Group 2 had 17 stable, non-operatively treated injuries. Radiographic deformity, leg length discrepancy, low back, and SI joint pain were evaluated.ResultsFor Group 1, 10 of 15 patients (67%) had a permanent ischial height difference >5 mm compared to Group 2, in which 5 of 12 (42%) had an ischial height difference of >5 mm. Group 1 had more pelvic asymmetry (12.3 mm vs. 6.6 mm) and ring width difference (6.9 mm vs. 3.9 mm) on final X-rays as compared to Group 2. Children with 5–10 mm posterior sacral displacement had significantly more pain than children with 0–4 mm displacement (p = 0.034). Thirteen children (39%) had residual low back/SI joint pain; the rate was significantly higher in the Group 1 (3/17 vs. 10/16, p = 0.008). In three (9%) children with 2 B2 and 1 B3 injury, leg length discrepancy between 5 mm to 15 mm occurred.Discussion and conclusionIn pediatric patients with pelvic ring injuries, radiographic deformity persisted and did not remodel. Pelvic ring deformity occurred more commonly with complex unstable ring injuries. The complex displaced injuries have higher rates of operative intervention, residual deformity, and low back and SI joint pain.     

Elastic stockings or Tubigrip for ankle sprain: a randomised clinical trial

BackgroundAnkle sprains are common and generally believed to be benign and self-limiting. However, a significant proportion of patients with ankle sprains have persistent symptoms for months or even years.AimsThe study aimed to evaluate whether elastic stockings improve recovery following ankle sprain.MethodologyAll patients within 72 h of ankle sprain were identified in Accident &; Emergency or the Fracture Clinic. Consenting patients, stratified for sex, were randomised to either: (i) Tubigrip or (ii) class II below knee elastic stockings (ESs, Medi UK Ltd.) which were fitted immediately and worn until the patient was pain-free and fully mobile. The deep veins of the injured legs were imaged by duplex Doppler for deep vein thrombosis (DVT) at 4 weeks. Outcome was compared using the American Orthopaedic Foot and Ankle Score (AOFAS) and SF12v2 for quality of life.ResultsIn the 36 randomised patients, the mean (95% confidence interval (CI)) circumference of the injured ankle treated by ES was 23.5 (23–24) cm initially and 22 (22–23) and 22 (21–22.5) cm at 4 and 8 weeks (p < 0.001) compared with 24 (23–25) cm initially and 24 (23–25) and 24 (23–24.5) cm using Tubigrip (p < 0.001). By 8 weeks, the mean AOFAS and SF12v2 scores were significantly improved by ES at 99 (8.1) and 119 (118–121) compared with 88 (11) and 102 (99–107) with Tubigrip (p < 0.001). Of the 34 duplex images at 4 weeks, none had a DVT.ConclusionElastic compression improves recovery following ankle sprain.     

A national survey of acute hospitals in England on their current practice in the use of femoral nerve blocks when splinting femoral fractures

IntroductionMissed compartment syndrome can have devastating long-term impact on a patient's function. Femoral fracture has been reported in 52–58% of acute thigh compartment syndromes in the existing literature. Time to diagnosis of compartment syndrome is cited as a key determinant of outcome. Use of femoral nerve blocks in splinting of femoral fractures may mask signs of early compartment syndrome. We present the attitudes of emergency department and orthopaedic staff in NHS trusts in England with regard to this issue.Methods and materialsSurvey of all 171 acute hospitals in the United Kingdom accepting trauma admissions. On-call middle grade doctors in emergency and orthopaedic department completed a telephone survey into departmental protocol and their experience of femoral nerve blocks for lower limb fractures.ResultsMiddle grades from all 171 trusts completed the survey (100% response rate). 54 emergency departments (30.8%) had a protocol for the use of femoral nerve blocks. Middle grades in the ED reported using a nerve block routinely in 95 hospitals (54%) with 63 using a long-acting and 32 a short-acting agent. Of those that did not 70% (n = 53) felt they were unnecessary, 21% (n = 16) were not confident in the technique and 9% (n = 7) had worries over compartment syndrome. 68% would be worried about compartment syndrome in high-energy injuries. Orthopaedic departmental protocols for nerve block use were reported in 16 trusts (9%). 45 orthopaedic middle grades (26%) indicated that they would use them routinely with 17 using long-acting and 28 using short-acting agents. 59.5% (n = 75) of orthopaedic middle grades felt nerve blocks were unnecessary, whilst 22% (n = 28) had worries about compartment syndrome and 18% (n = 23) were not confident with the technique. 77% orthopaedic middle grades would be more worried about compartment syndrome in high energy injuries.ConclusionFemoral nerve block is an under-utilised, effective mode of analgesia following femoral fractures. There is a low risk of associated compartment syndrome, but clinicians should be especially vigilant in high-energy injuries. We recommend that all acute trusts receiving trauma should have a protocol for the use of femoral nerve blocks agreed by the emergency and orthopaedic departments.