Comparing the outcomes between Chopart,Lisfranc and multiple metatarsal shaft fractures

Objectives

Complex midfoot injuries could lead to severe functional impairment of mobility and quality of daily living. Aim of this study was to compare the clinical and functional outcomes of Chopart, Lisfranc fractures and multiple metatarsal shaft fractures.

Design

Retrospective case series.

Setting

Level one trauma center.

Intervention

Open or closed reduction and internal fixation with screws, K-wires, plates, external fixation or combination of different technics.

Main outcome measurements

The American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score and the Maryland Foot Score were used to assess pain and functional outcome. 3D gait analysis, pedobarographic analysis and radiologic examinations were performed. The activity level was measured by a step counting accelerometer. All results were compared to an age-matched healthy control group.

Results

24 patients with a median age of 44 years (16–72) were included: 12 patients with multiple metatarsal shaft fractures, 6 patients with Chopart and 6 patients with Lisfranc fractures. The median follow-up was 2.6 years. The pedobarographic analysis reports reduced contact time of the total foot (p = 0.08), the forefoot (p = 0.008) and the hallux (p = 0.015) for the injured foot. A median score of 64 for the SF-36, 64 for the AOFAS Midfoot Score and 73 for the Maryland Foot Score indicated a poor restoration of foot function. Multiple metatarsal shaft fractures presented a significantly lower walking speed (p = 0.03) and cadence (p = 0.04).

Conclusion

The worst results were reported for multiple metatarsal shaft fractures on outcome scores, pedobarography, gait analysis and activity. Metatarsal serial fractures should not be underestimated as well as Chopart and Lisfranc fractures.

Level of evidence

Level IV.     

Validity and internal consistency of the American Orthopaedic Foot and Ankle Society Midfoot Scale in patients with Lisfranc injury

BackgroundThe American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale is an extensively used outcome measure instrument for evaluating outcomes after foot and ankle surgery or trauma.MethodsIn total, 117 patients with Lisfranc injury completed the AOFAS Midfoot Scale and the Visual Analogue Scale Foot and Ankle (VAS-FA) instruments. Internal consistency (correlation between different items), floor and ceiling values, convergent validity, item threshold distribution, and the coverage (item difficulty) of the AOFAS Midfoot scale were tested.ResultsAOFAS Midfoot Scale had high convergent validity and acceptable internal consistency (Cronbach’s alpha >0.70). The ceiling effect was confirmed. The person-item distribution indicated that the scale had a lack of coverage and targeting in our sample.ConclusionsOur data suggests that the AOFAS Midfoot Scale has acceptable validity and internal consistency. However, due to the lack of coverage and targeting, it should not be the primary outcome measure to be used to evaluate the outcomes after Lisfranc injury in the future studies.     

Do columns or sagittal displacement matter in the assessment and management of Lisfranc fracture dislocation? An alternate approach to classification of the Lisfranc injury

AimThe classification of a Lisfranc injury has conventionally been based around Myerson's system. The aims of this study were to review whether a novel classification system based on sagittal displacement of the tarsometatarsal joint and breadth of injury as determined by a columnar theory was associated with functional outcomes and thus had a greater utility.PatientsWe retrospectively reviewed 54 Lisfranc injuries with a minimum follow up of two years at our Level One Trauma Centre. Each fracture was sub-classified based on our novel classification system which assessed for evidence of sagittal displacement and involvement of columns of the midfoot. Our primary outcome measures were the FFI and AOFAS midfoot scores.ResultsInjuries involving all three of the columns of the midfoot were associated with significantly worse functional outcome scores (FFI p = 0.004, AOFAS p = 0.036). Conversely, sagittal displacement, whether dorsal or plantar, had no significance (FFI p = 0.147, AOFAS p = 0.312). The best predictor of outcome was the quality of anatomical reduction (FFI p = 0.008, AOFAS p = 0.02).ConclusionColumn involvement and not sagittal displacement is the most significant factor in considering the severity Lisfranc injury and long term functional outcomes. This classification system has greater clinical utility than those currently proposed.     

Trauma to the medial ray of the foot: A classification of patterns of injury and their management

AimsFractures and dislocations of the midfoot are relatively uncommon but can be life changing injuries. Within the literature, there has been scant specific reference to the identification and management of medial ray injuries in midfoot trauma. Moreover, it is appreciated that these injuries are associated with poor outcomes. We aim to clearly define these injury characteristics and demonstrate fixation techniques.Patients and methodsA retrospective review of the case notes and imaging was conducted for operatively treated midfoot injuries between January 2013 and January 2018.Results161 patients were identified, 31 of these with imaging and operative diagnosis suggestive of medial ray injury. Studying these 31 injuries revealed five patterns of injury.ConclusionWhen treating midfoot trauma, it is important to fully understand the injury pattern as this dictates the principles and techniques of fixation. Identification and knowledge of these five injury patterns will aid surgeons in future management of these injuries and may improve treatment outcomes.     

Functional outcomes and quality of life in patients with subtalar arthrodesis for posttraumatic arthritis

IntroductionSubtalar arthrodesis is a common salvage operation for posttraumatic subtalar arthritis, a condition frequently seen in patients who suffered major trauma. Functional outcomes in trauma patients may be influenced by concomitant injuries and the severity of the initial trauma. The aim of this study was to evaluate quality of life and functional outcomes of subtalar arthrodesis for posttraumatic arthritis in patients with severe or complex foot injuries.Materials and methodsThis is a retrospective single center study with prospective follow-up. Patients who underwent subtalar arthrodesis for posttraumatic arthritis between 2000 and 2016 were included and invited to complete a Maryland Foot Score (MFS), a EuroQol five-dimensional (EQ-5D™) and Visual Analog Scale (EQ-VAS™) questionnaire, and four additional questions.ResultsForty patients were included in the study, functional outcome scores were available for 30 patients (response rate 75%). Additional surgery of the fused foot was performed in 29 patients and 15 suffered multiple lower extremity injuries. Six patients were polytraumatized. Ninety percent of all patients would recommend the procedure to others, walking abilities improved in 69% and less pain was experienced in 76%. Median MFS score was 61 (IQR 53–72). Quality of life was significantly lower when compared to a reference population (p < 0.001).ConclusionSatisfaction was high, as 90% of all patients would recommend subtalar fusion to others, even though the relatively poor outcome measures would suggest differently. Existing functional outcomes measures were influenced by concomitant injuries and additional procedures. This demands development of instruments suitable for severely injured patients with multiple or complex injuries.     

A single surgeon's experience of treatment of Lisfranc joint injuries

This paper assesses the outcomes and complications of Lisfranc joint injuries treated at a regional trauma centre under the care of a single surgeon. We performed a retrospective study of all patients that underwent ORIF of a Lisfranc joint injury over a 5-year period. Case note review, radiology review, and questionnaire assessment were performed. We analysed for correlations between outcome and injury type, mechanism of injury, and presence of other ipsilateral limb injury and pure ligamentous injury. All injuries were classified according to a system described by Myerson et al. (Types A, B1, B2, C1, C2). Radiographs were also assessed for the presence of pure ligamentous injury. Outcome was measured using the American Orthopaedic Foot and Ankle society (AOFAS) midfoot score. Twenty-five injuries (24 patients) were identified and 16 injuries (15 patients) were available for follow. The mean duration of follow up was 42.6 months (11-69). The mean outcome score was 78.3 (38-100). The outcome scores for pure ligamentous injury (74.9) and for mixed bony and ligamentous injury (80.9) had no significant difference (p=0.61). High-energy trauma accounted for 50% of cases, and scored significantly less than low energy trauma (69.1 versus 87.4, p<0.05). There was an associated injury in the ipsilateral limb in 31% of cases and this group had a poorer outcome (63.0 versus 85.3, p<0.035). The most common injury type was B2 (38%). Type C2 injuries (divergent with total displacement) had a worse outcome than the mean outcome of all other categories (60.5 versus 84.4, p<0.01). Our mean outcome from ORIF of Lisfranc joint injuries is comparable to internationally quoted figures. Pure ligamentous injuries did no worse statistically than mixed bony and ligamentous injuries. Poorer outcome was associated with high-energy trauma, associated injury on the ipsilateral limb, and Type C2 injuries.     

Percutaneous reduction and fixation of low energy Lisfranc injuries results in better outcome compared to open reduction and internal fixation: Results from a matched case-control study with minimum 12 months follow up

Background: Percutaneous fixation of Lisfranc injuries is potentially less invasive to traditional open techniques but evidence of any clinical benefit is lacking. The aim of this study is to compare the clinical outcomes of percutaneous reduction and internal fixation (PRIF) of low energy Lisfranc injuries with a matched, control group of patients treated with ORIF.Methods: Over a seven-year period (2012-2019), 16 consecutive patients with a low energy Lisfranc injury (Myerson B2-type) were treated with PRIF. Patient demographics, injury mechanism and radiological outcomes were recorded within a prospectively maintained database at the institution. This study sample was matched for age, sex and mechanism of injury to a control group of 16 patients with similar low energy Lisfranc injuries (Myerson B2-type) treated with ORIF. Clinical outcome was compared using the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Manchester Oxford Foot Questionnaire (MOXFQ).Results: At a mean follow up of 43 months (95% CI 35.6 – 50.4), both the AOFAS and MOXFQ scores were significantly higher in the PRIF group compared to the control ORIF group (AOFAS 89.1vs 76.4, p=0.03; MOXFQ 10.0 vs 27.6, p=0.03). There were no immediate postoperative complications in either group. There was no radiological evidence of midfoot osteoarthritis in the PRIF group, three patients in the ORIF group developed midfoot osteoarthritis (p=0.2).Conclusions: PRIF of low energy Lisfranc injures is a safe, minimally invasive technique and is associated with better mid-term clinical outcomes compared to ORIF.     

The association of hand and wrist injuries with other injuries in multiple trauma patients. A retrospective study in a UK Major Trauma Centre

BackgroundApproximately 20,000 major trauma cases occur in England every year. However, the association with concomitant upper limb injuries is unknown. This study aims to determine the incidence, injury pattern and association of hand and wrist injuries with other body injuries and the Injury Severity Score (ISS) in multiply injured trauma patients.MethodsSingle centre retrospective study was performed at a level-one UK Major Trauma Centre (MTC). Trauma Audit and Research Network (TARN) eligible multiply injured trauma patients that were admitted to the hospital between January 2014 and December 2018 were analysed. TARN is the national trauma registry. Eligible patients were: a trauma patient of any age who was admitted for 72 h or more, or was admitted to intensive care, or died at the hospital, was transferred into the hospital for specialist care, was transferred to another hospital for specialist care or for an intensive care bed and whose isolated injuries met a set of criteria. Data extracted included: age, gender, mode of arrival, location of injuries including: hand and/or wrist and mechanism of injury. We performed a logistic regression analysis to assess the association between hand/wrist injury to ISS score of 15 points or above/below and to the presentation of other injuries.Results107 patients were analysed. Hand and wrist injuries were the second most common injury (26.2%), after thoracic injuries. Distal radial injuries were found in 5.6%, carpal/carpometacarpal in 6.5%, concurrent distal radius and carpometacarpal in 0.9%, phalangeal injuries in 4.7%, tendon injuries in 0.9% and concurrent hand and wrist injuries in 7.5% cases. There was a significant association between hand or wrist injuries and lower limb injuries (Odds Ratio (OR): 3.84; 95% confidence intervals (CI): 1.09 to 13.50; p = 0.04) and pelvic injuries (OR: 4.78; 95% CI: 1.31 to 17.44; p = 0.02). There was no statistical association between hand and wrist injuries and ISS score (OR: 0.80; 95% CI: 0.11 to 5.79; p = 0.82).ConclusionsHand and wrist injuries are prevalent in trauma patients admitted to MTCs. They should not be under-estimated but routinely screened for in multiply injured patients particularly those with a pelvic or lower limb injury.     

Outcome after nonoperative treatment of stable Lisfranc injuries. A prospective cohort study

BackgroundThe aim of this study was to evaluate the outcome after nondisplaced and stable Lisfranc injuries.Methods26 patients with injuries to the Lisfranc joint complex detected on CT scans, but without displacement were tested to be stable using a fluoroscopic stress test. The patients were immobilized in a non-weightbearing short leg cast for 6 weeks. The final follow-up was 55 (IQR 53–60) months after injury.ResultsAll the Lisfranc injuries were confirmed to be stable on follow-up weightbearing radiographs at a minimum of 3 months after injury. Median American Foot and Ankle Society (AOFAS) midfoot score at 1-year follow-up was 89 (IQR 84–97) and at final follow-up 100 (IQR 90–100); The AOFAS score continued to improve after 1-year (P=.005). The median visual analog scale (VAS) for pain was 0 (IQR 0–0) at the final follow-up. One patient had radiological signs of osteoarthritis at 1-year follow-up.ConclusionStable Lisfranc injuries treated nonoperatively had an excellent outcome in this study with a median follow-up of 55 months. The AOFAS score continued to improve after 1 year.     

Long-term outcome in operatively and non-operatively treated isolated type B fibula fractures

PurposeType B fibula fractures are the most common type of ankle fractures. Generally, surgical repair is advised for unstable fractures and non-operative treatment for stable fractures. However, evidence on long-term functional outcome of both treatment regimens is lacking.Aim of this study is to compare the long-term outcome in function and pain between patients with an isolated type B fibula fracture treated non-operatively and surgically.Material & methodsIn this retrospective cohort study, all consecutive patients aged between 18 and 75 years, treated non-operatively or surgically between January 2008 and December 2015 for a distal fibula fracture at the level of the syndesmosis without an additional medial or posterior fracture and with a medial clear space ≤6 mm were included. All eligible patients received a questionnaire, composed of the Olerud-Molander Ankle Score (OMAS), the American Orthopaedic Foot and Ankle Society ankle-hindfoot score (AOFAS), the Euroqol-5D (EQ-5D) for quality of life and the Visual Analogue Scale (VAS) for pain sensation.With a mean follow-up of 5.3 years, 229 patients were included. For all aspects of the questionnaire, there was no significant difference between non-operative and operative treatment in outcome of function and pain: the EQ-5D score was respectively 0.8 vs. 0.9 (p = 0.72), mean VAS score 0.8 vs. 1.3 (p = 0.09), OMA score 84 vs. 84 (p = 0.98) and for the AOFAS 93 vs. 90 (p = 0.28). 33% of the patients who had surgery had revision surgery for implant removal because of persistent pain complaints. In 3% of the surgically treated patients, a wound infection required intravenous antibiotic treatment. In the non-operatively treated cohort, one patient developed a deep venous thrombosis in the fractured leg.ConclusionAccording to results of this study, in adult patients with an isolated distal fibula and medial clear space ≤6 mm, without proven instability these fractures can safely be treated non-operatively, while avoiding risks and costs of surgery and preserving good long-term outcome in terms of pain and function.     

Long-term results after isolated iliac wing fractures

IntroductionIsolated iliac wing fracture is a rare pelvic fracture that is considered benign in the literature. As there is a complete lack of information on function and quality of life in patients with this injury, the primary aim of this study was to evaluate the long-term functional results, and secondly to evaluate the patients’ clinical function and fracture healing.Patients and MethodsAll patients treated in Oslo University Hospital, Ullevaal (OUH-U), the Norwegian National Pelvic Service, in the time period 2006–2016 were included. Nine of 13 eligible patients (69%) were evaluated by the Patient Reported Outcome Measures (PROM); EQ-5D-3L and Majeed Score. For the secondary outcomes, the patients were clinically examined for Range of Motion (ROM) in the hips, pain, muscular function and nerve deficiencies. Finally, the patients underwent X-rays (AP-view and iliac and obturator oblique views).ResultsAll patients were injured in high-energy trauma with severe associated injuries. Five patients were operated and four received conservative treatment. At the time of follow-up (median seven years after injury), the mean EQ-5D VAS was 84, and the mean Majeed score was 87. Two out of nine reported moderate level of pain, three reported mild pain, and the rest reported no pain. Six patients were still working, two were retired, and the last one was receiving disability benefit of other reasons than the iliac fracture. One patient had difference in range of external rotation of >10° between the hips, while the rest had no differences in ROM. The follow-up X-rays showed healed fractures in all the patients.ConclusionPatients with isolated iliac wing fractures seem to have a good general state of health, scoring high on the PROMs, with minor and insignificant clinical sequela. This original finding is in accordance with the general assumption amongst pelvic surgeons that the injury is a benign one.     

Epidemiology of abdominal trauma: An age- and sex-adjusted incidence analysis with mortality patterns

PurposeAbdominal injuries may occur in up to one-third of all patients who suffer severe trauma, but little is known about epidemiological trends and characteristics in a Northern European setting. This study investigated injury demographics, and epidemiological trends in trauma patients admitted with abdominal injuries.MethodsThis was an observational cohort study of all consecutive patients admitted to Stavanger University Hospital (SUH) with a documented abdominal injury between January 2004 and December 2018. Injury demographics, age- and sex-adjusted incidence, and mortality patterns are analyzed across three time periods.ResultsAmong 7202 admitted trauma patients, 449 (6.2%) suffered abdominal injuries. The median age was 31 years, and the age increased significantly over time (from a median of 25 years to a median of 38.5 years; p = 0.020). Patients with ASA 2 and 3 increased significantly over time. Men accounted for 70% (316/449). The injury mechanism was blunt in 91% (409/449). Transport-related accidents were the most frequent cause of injury in 57% (257/449). The median Injury Severity Score (ISS) was 21, and the median New Injury Severity Score (NISS) was 25. The annual adjusted incidence of all abdominal injuries was 7.2 per 100,000. Solid-organ injuries showed an annual adjusted incidence of 5.7 per 100,000. The most frequent organ injury was liver injury, found in 38% (169/449). Multiple abdominal injuries were recorded in 44% (197/449) and polytrauma in 51% (231/449) of the patients. Overall 30-day mortality was 12.5% (56/449) and 90-day mortality 13.6% (61/449).ConclusionThe overall adjusted incidence rate of abdominal injuries remained stable. Age at presentation increased by over a decade, more often presenting with pre-existing comorbidities (ASA 2 and 3). The proportion of polytrauma patients was significantly reduced over time. Mortality rates were declining, although not statistically significant.     

Survival and health related quality of life after severe trauma − a 15 years follow up study

IntroductionAs the primary treatment of patients with severe trauma continues to improve, increasing interest has been directed towards long-term survival and Health Related Quality of Life (HRQoL). In trauma patients, there are few studies describing long-term outcome using tools specifically directed at HRQoL.HypothesisHRQoL measured with EQ-5D is significantly reduced compared to the Danish norm score 15 years after severe injury.Materials and methodsAll patients more than 18 years of age, admitted to a level 1 trauma center from March 1996 to September 1997 were prospectively included and scored with Injury Severity Score (ISS). Survival status was recorded in May 2012 and EQ-5D questionnaires were sent out.Results95 of the original 154 trauma patients were eligible for participation. The response rate was 66%. The average EQ-5D index score in the trauma population was significantly reduced compared to the index score in the Danish norm population (P = 0.00, one-sample t-test). In addition, ISS is associated with HRQoL and ISS ≥ 16 predicts poorer HRQoL.ConclusionEQ-5D is significantly reduced 15 years after severe trauma High ISS was associated with low HRQoL. Knowledge of the distribution and predictors of long-term disability can be used to develop more efficient prevention policies and to improve trauma care in general.     

Cavovarus foot treated with combined calcaneus and metatarsal osteotomies

Twenty-one feet in fifteen patients underwent osteotomies of the calcaneus and one or more metatarsals for symptomatic cavovarus foot deformity. Seven (nine feet) were male, and eight (twelve feet) were female. The etiology included hereditary motor sensory neuropathy (HMSN) (fifteen feet), post-polio syndrome (two feet), sacral cord lipomeningocele (two feet), parietal lobe porencephalic cyst (one foot), and idiopathic peripheral neuropathy (one foot). Presenting complaints were metatarsalgia (fifteen feet), ankle instablility (five), and ulceration beneath the second metatarsal head (one foot). Eleven feet were assessed using the Maryland Foot Rating Score. Maryland Foot Rating Score (University of Maryland, Baltimore, MD) improved from 72.1 (avg.) preoperatively to 89.9 (avg.) post-operatively (follow-up 70.9 months avg.). Eight feet were assessed using the AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot and Midfoot Scores. The AOFAS Ankle-Hindfoot Score improved from 46.3 (avg.) pre-operatively to 89.1 (avg.) post-operatively, and the AOFAS Midfoot Score improved from 40.9 (avg.) pre-operatively to 88.8 (avg.) post-operatively (follow-up 20.8 months avg.). The postoperative AOFAS Ankle-Hindfoot Score for all nineteen feet was 90.8 (avg.) and the post-operative AOFAS Midfoot Score for all nineteen feet was 90.2 (avg.). Two patients were lost to follow-up and were not included in the study. Ankle, hindfoot, and midfoot motion was maintained or improved in sixteen feet. Complications included delayed union in two and nonunion in three of 66 metatarsal osteotomies. While three patients required an AFO (ankle-foot orthosis) for ambulation preoperatively, all patients were brace free postoperatively. All patients expressed willingness to undergo the same procedure again if it were necessary. Weight-bearing radiographs were available for 17 feet. Radiographic analysis revealed a decrease in forefoot adduction (9.6 degrees avg.) and a reduction in both hindfoot (9.1 degrees avg.) and forefoot cavus (10.6 degrees) leading to an overall 13 percent reduction in the height of the longitudinal arch. Lateral sliding elevating calcaneal osteotomy combined with dorsolateral closing wedge osteotomies of one or more metatarsal bases in the severe symptomatic cavovarus foot can provide a pain-free, plantigrade foot with a lowered longitudinal arch and a stable ankle without sacrificing motion.     

Early results of low-velocity ballistic femoral shaft fractures

IntroductionBallistic femur fractures are a common injury treated at United States civilian trauma centers. This study investigates the outcomes of these injuries by comparing the rates of infection, nonunion, secondary operations, and associated injuries from low-velocity gunshot (GSW) injuries with fractures sustained by blunt trauma.MethodsA retrospective cohort comparative study was performed at a Level 1 trauma center. 345 patients with closed blunt or GSW femoral shaft fractures over 10 years were included. All were treated with intramedullary nail fixation. Superficial and deep infection, vascular injury, compartment syndrome, nonunion, and secondary operations were identified.Results148 patients in the GSW group and 197 patients in the blunt trauma group had overall mean age 33.5 years and 80% were male. Deep infection rates were similar There were no nonunions in the GSW group, contrasted with 8 (4.4%) nonunions in the blunt trauma group (p = 0.02). The rate of compartment syndrome was higher in the GSW group (6.1% vs 0, p < 0.001). Arterial injury occurred in 9% following GSW (vs 0, p < 0.001). Overall, secondary unplanned procedure rates were the same: 8.1% for both groups.DiscussionBallistic femoral shaft fractures are often equated with open injuries; however, rates of infection and secondary operations closely mirror that of closed injuries resulting from blunt force trauma. Nonunions may be more common after blunt injury, and compartment syndrome and arterial injury are substantially more common following GSW, warranting careful clinical assessment.Level of evidencePrognostic, level III.     

Clinical characteristics of 1653 injured motorcyclists and factors that predictmortality from motorcycle crashes in Malaysia

PurposeAmongst the ASEAN countries, Malaysia has the highest road fatality risk (>15 fatalities per 100 000 population) with 50% of these fatalities involving motorcyclist. This contributes greatly to ward admissions and poses a significant burden to the general surgery services. From mild rib fractures to severe intra-abdominal exsanguinations, the spectrum of cases managed by surgeons resulting from motorcycle accidents is extensive. The objective of this study is to report the clinical characteristics and identify predictors of death in motorcycle traumatic injuries from a Malaysian trauma surgery centre.MethodsThis is a prospective cross-sectional study of all injured motorcyclists and pillion riders that were admitted to Hospital Sultanah Aminah and treated by the trauma surgery team from May 2011 to February 2015. Only injured motorcyclists and pillion riders were included in this study. Patient demography and predictors leading to mortality were identified. Significant predictors on univariate analysis were further analysed with multivariate analysis.ResultsWe included 1653 patients with a mean age of (35 ± 16.17) years that were treated for traumatic injuries due to motorcycle accidents. The mortality rate was 8.6% (142) with equal amount of motorcycle riders (788) and pillion riders (865) that were injured. Amongst the injured were male predominant (1 537) and majority of ethnic groups were the Malays (897) and Chinese (350). Severity of injury was reflected with a mean Revised Trauma Score (RTS) of 7.31 ± 1.29, New Injury Severity Score (NISS) of 19.84 ± 13.84 and Trauma and Injury Severity Score (TRISS) of 0.91 ± 0.15. Univariate and multivariate analysis revealed that age≥35, lower GCS, head injuries, chest injuries, liver injuries, and small bowel injuries were significant predictors of motorcycle trauma related deaths with p < 0.05. Higher trauma severity represented by NISS, RTS and TRISS scores was also significant for death with p < 0.05.ConclusionAge, lower GCS, presence of head, chest, liver, small bowel injuries and higher severity on NISS, RTS and TRISS scores are predictive of death in patients involved with motorcycle accidents. This information is important for prognostic mortality risk prevention and counselling.     

Fractures and dislocations of the hand in polytrauma patients: Incidence,injury pattern and functional outcome

IntroductionInjuries of the hand can cause significant functional impairment, diminished quality of life and delayed return to work. However, the incidence and functional outcome of hand injuries in polytrauma patients is currently unknown. The aim of this study was to determine the incidence, distribution and functional outcome of fractures and dislocation of the hand in polytrauma patients.MethodsA single centre retrospective cohort study was performed at a level 1 trauma centre. Polytrauma was defined as patients with an Injury Severity Score of 16 or higher. Fractures and dislocations to the hand were determined. All eligible polytrauma patients with hand injuries were included and a Quick Disability of Arm, Shoulder and Hand questionnaire (QDASH) and Patient-Rated Wrist/Hand Evaluation (PRWHE) were administered. Patients were contacted 1–6 years after trauma.ResultsIn a cohort of 2046 polytrauma patients 72 patients (3.5%) suffered a hand injury. The functional outcome scores of 52 patients (72%) were obtained. The Metacarpal (48%) and carpal (33%) bones were the most frequently affected. The median QDASH score for all patients with hand injury was 17 (IQR 0–31) and the PRWHE 14 (IQR 0–41). Patients with a concomitant upper extremity injury (p = 0.002 for PRWHE, p0.006 for QDASH) and those with higher ISS scores (p = 0.034 for PRWHE, QDASH not significant) had worse functional outcome scores. As an example, of the 5 patients with the worst outcome scores 3 suffered an isolated phalangeal injury, all had concomitant upper extremity injury or neurological injuries (3 plexus injuries, 1 severe brain injury).ConclusionThe incidence of hand injuries in polytrauma patients is 3.5%, which is relatively low compared to a general trauma population. Metacarpal and carpal bones were most frequently affected. The functional extremity specific outcome scores are highly influenced by concomitant injuries (upper extremity injuries, neurological injuries and higher ISS).     

Does the mechanism matter? Comparing thrombelastography between blunt and penetrating pediatric trauma patients

Background/PurposeThe utility of thrombelastography (TEG) in pediatric trauma remains unknown, and differences in coagulopathy between blunt and penetrating mechanisms are not established. We aimed to compare TEG patterns in pediatric trauma patients with blunt solid organ injuries (BSOI) and penetrating injuries to determine the role of mechanism in coagulopathy.MethodsHighest-level pediatric trauma activations with BSOI or penetrating injuries and admission TEG at two pediatric trauma centers were included. TEG abnormalities were defined by each institution's normative values and compared separately by injury mechanism and evidence of shock (elevated SIPA) using Kruskal-Wallis or Fisher's exact tests.ResultsOf 118 patients included, 64 had BSOI and 54 had penetrating injuries. There were no significant differences in TEG abnormalities between the BSOI and penetrating injury groups. Patients with shock were more likely to have decreased alpha-angles (30.9% vs. 8.0%, p = 0.01) and decreased maximum amplitude (MA) (44.1% vs. 8.0%, p < 0.001) compared to those without shock, regardless of mechanism of injury.ConclusionsTEG abnormalities were not significantly different between the BSOI and penetrating groups, but there were significant differences in alpha-angle and MA in those with shock, independent of mechanism. Hemodynamic status, rather than mechanism of injury, may be more predictive of coagulopathy in pediatric trauma patients.Level of evidence/study typeLevel III, retrospective     

Epidemiology of foot injury in a high-income developing country

Objectives

To study the epidemiology of foot injuries and factors predicting their severity in a high-income developing country so as to define prevention priorities.

Patients and Methods

All patients admitted to Al-Ain Hospital with foot injury between March 2003 and March 2006 were identified from a prospectively collected Trauma Registry. Injuries were scored using foot and ankle severity scale (FASS). Bilateral, multiple or segmental injuries, open fractures or those with FASS score higher than 3 were included in severe foot injury group and compared with simple foot injury group regarding patients’ demography, co-morbidities, trauma mechanism and energy, incident location, number of associated injuries, Injury Severity Score (ISS) and hospital stay using a univariate analysis. A logistic regression model was then used to study factors predicting severity of foot injury.

Results

171 patients (156 males) were studied. The average (range) age was 34 (2-75). 95 had right foot injury, 66 had left, and 10 had both. Fall from height was the most common mechanism. 105 (61%) had work-related injuries. 130 (76%) had isolated foot injury. 151 (88%) had 212 foot fractures. 20 (12%) had soft tissue injuries. 70 (41%) had severe injuries while 101 (59%) had simple ones. The multiple logistic model was highly significant (p = 0.002). Number of associated injuries (p = 0.025) and location of trauma (p = 0.044) were significant while the amount of energy (p = 0.054) showed a strong trend to predict severity.

Conclusions

Fall from height is the most common mechanism of foot injury in United Arab Emirates. The number of associated injuries, high-energy trauma, and being work related are predictors of foot injury severity. Prevention priorities include counteractions against falling from height and falling heavy objects as occupational hazards.     

Impaired quality of life after bicycle trauma

IntroductionBicycle crashes often affect individuals in working age, and can impair quality of life (QoL) as a consequence. The aim of this study was to investigate QoL in bicycle trauma patients and to identify those at risk of impaired QoL.Patients and methods173 bicycle trauma patients who attended a level I trauma centre from 2010 to 2012 received Hadorn's QoL questionnaire six months after their crash. Medical data was collected from the patient's records. Univariate ordinal logistic regression was used to investigate the association between QoL and other factors.Results148 patients returned the questionnaire (85.5%). The majority had only mild or minor injuries (85.1%; n = 126). However, 72.1% (n = 106) still suffered from pain or other physical symptoms more than six months after their bicycle crash. Patients with a Glasgow Coma Scale (GCS) ≤13 or an Injury Severity Score (ISS) >15 experienced impaired emotions/outlook on life (p-values 0.003 and 0.045, respectively). Physical suffering was reported by patients with a GCS ≤13 and in those with injuries to the cervical spine (p-values 0.02 and 0.025, respectively). Patients with an ISS >15 or facial fractures experienced limitations in daily activities (p-values 0.031 and 0.025, respectively).ConclusionsMore than 70% of bicycle trauma patients suffered physically more than six months after their crash, even though only 15% were severely injured. Risk factors for an impaired QoL were cervical spine injuries or facial fractures, a GCS ≤13 and an ISS >15.