Injury. 2025 Jun 25;56(8):112557. doi: 10.1016/j.injury.2025.112557. Online ahead of print.

ABSTRACT

The global rise in total knee arthroplasty (TKA), driven by an aging population, has led to an increased incidence of periprosthetic fractures (PPFs). Dual implants for distal femur periprosthetic fractures (PDFFs) are a growing area of interest for these challenging fractures with dual plating (DP) and plate-retrograde femoral intramedullary nail (PN) emerging as viable constructs for these injuries. However, dual implants have inherent limitations. Herein we focus on describing a modified PN fixation-retrograde tibial intramedullary nail (RTN) combined with a less invasive stabilization system (LISS) for PDFFs following TKA in elderly patients and providing the technical trick of this modified PN fixation.

PMID:40602036 | DOI:10.1016/j.injury.2025.112557

Injury. 2025 Jun 21:112542. doi: 10.1016/j.injury.2025.112542. Online ahead of print.

ABSTRACT

BACKGROUND: Suicide in older people is increasing. We know less about serious deliberate self-harm in this population or the impact of this on Major Trauma Centres (MTC).

OBJECTIVES: Investigate demographics, injury mechanism and outcomes in older people admitted with self-inflicted injury.

DESIGN: Retrospective service evaluation.

SETTING: Single MTC in London, UK.

SUBJECTS: 60 people aged 65 years and over admitted to a MTC with self-inflicted injury.

METHODS: Retrospective analysis of trauma registry data (February 2015-2022).

VARIABLES: age, sex, past medical and psychiatric history, home and marital status, injury type and narrative, injury severity score (ISS), critical care admission, length of stay, discharge status and destination.

RESULTS: Self-inflicted injury represented 1.5 % of trauma admissions aged 65 and over (80 % male, median age 73 years). Most females and over half of men had a psychiatric history (females n = 11, 91.7 %; males n = 28, 58.3 %). Depression was the most common psychiatric comorbidity (n = 15). Males were more likely to suffer penetrating injury (males n = 37, 77.1 %; females n = 4, 33.3 %). The most common injury mechanism was self-stabbing amongst males (n = 37, 77.1 %) and a jump from height amongst females (n = 6, 50.0 %). Median ISS (8.5) and mortality (n = 8, 13.3 %) was low across the cohort. The most common discharge destination was psychiatric admission (males n = 28, 58.3 %; females n = 6, 50.0 %).

CONCLUSION: Older people who present with traumatic self-inflicted injury are predominantly male, utilise violent methods, have significant psychiatric comorbidity and require psychiatric admissions.

PMID:40592662 | DOI:10.1016/j.injury.2025.112542

Injury. 2025 Jun 23;56(8):112543. doi: 10.1016/j.injury.2025.112543. Online ahead of print.

ABSTRACT

BACKGROUND: Tibial plateau fractures (TPFs) are complex injuries associated with significant postoperative complications including infection, deformity and wound healing disorders. Limited data exist on risk factors for complications following surgical treatment, particularly in large multicenter cohorts.

METHODS: This retrospective study analyzed 1027 patients with intra-articular TPFs treated surgically at two level-I trauma centers in Germany (2011-2020). Preoperative CT imaging and follow-up data were required for inclusion. Complications were categorized into seven groups (infection, deformity, wound healing disorders, postoperative compartment syndrome, range of motion deficit and others). Statistical analyses assessed associations with fracture type (Schatzker classification), surgical approach, duration, and patient factors (BMI, age, smoking).

RESULTS: Nineteen percent of patients required surgical revision, with deformity (5.7 %), infection (5.4 %), and wound healing disorders (3.3 %) being the most common complications. Complex fractures (Schatzker V-VI) and prolonged or multi-approach surgeries were associated with higher complication rates. Elevated BMI increased overall complication risk, while smoking was linked to wound healing disorders.

CONCLUSION: The 19 % revision rate highlights the challenges of managing TPFs. Surgical factors, including operative duration and approach, play a critical role in the occurrence of complications, emphasizing the need for tailored strategies based on fracture complexity and surgical considerations.

PMID:40577996 | DOI:10.1016/j.injury.2025.112543

Injury. 2025 Jun 23;56(8):112550. doi: 10.1016/j.injury.2025.112550. Online ahead of print.

ABSTRACT

Introduction Geriatric fractures are a major contributor of morbidity and mortality in elderly patients and represent a large resource burden on healthcare institutions across the United States. Elderly populations are predicted to increase in the coming decades, motivating epidemiological studies that may inform more effective and targeted prevention measures for these injuries. Methods Data analyzed in this study was extracted from the National Electronic Injury Surveillance System (NEISS), a public database representing approximately 100 US EDs to provide national injury estimates. NEISS was queried for all fracture ED admissions among patients age 65 and older. Fracture events were restricted to injuries from January 1, 2019 to December 31, 2023. Results A geriatric fracture NEISS query resulted in 82,953 ED visits, extrapolating to a total national estimate of 3852,261 fractures presenting to US EDs across the study period. The overall hospitalization rate was 54.8 %, increasing to 74.5 % by age 99. Linear regression of fractures rates by year demonstrated a significant increase in male fractures over time (p = 0.047, β = 7688). Compared to females, males were also more likely to sustain trunk fractures and become injured at sporting facilities. Older patients also saw higher rates of trunk fractures (including upper and lower trunk), while rates of extremity fractures (upper and lower extremities) decreased with age. Fractures in the home also decreased with age, while those occurring on public property (including assisted living facilities) increased with age. Conclusion Increasing fracture rates among males indicates an opportunity for improved prevention measures among men 65 and older. Males were also more likely to sustain fractures while participating in sports, and may therefore benefit from education programs on fracture risk. Geriatric fractures were more likely to occur on public property such as sidewalks and assisted living facilities as patients aged, demonstrating the need for improved precautionary measures such as low-floor beds, hip protectors, fall alarms, and wearable devices.

PMID:40577995 | DOI:10.1016/j.injury.2025.112550

Injury. 2025 Jun 17:112521. doi: 10.1016/j.injury.2025.112521. Online ahead of print.

ABSTRACT

INTRODUCTION: Over the past two decades, damage control laparotomy and resuscitation (DCL and DCR, respectively) have become the dominant paradigms for the management of exsanguinating trauma. Fascial complications are common after DCL. Minimizing crystalloid administration is a key component of DCR, but there is little direct evidence that it reduces fascial complications. This study was designed to test the hypothesis that lower crystalloid administration volume during the perioperative period for DCL is associated with an increase in fascial closure rates and a decreased rate of fascial dehiscence.

METHODS: This was a retrospective observational study at a single urban trauma center. Adult trauma patients who underwent emergent DCL between March 2019 - December 2022 were included. Patients who died within 7 days of definitive closure or underwent additional intracavitary operations (e.g., thoracotomy) before or concurrent with laparotomy were excluded. Risk factors for fascial dehiscence and planned ventral hernia (PVH) were evaluated using univariate and multiple logistic regression analysis.

RESULTS: Among 287 included patients, median age was 32 (IQR 23-44), median injury severity score (ISS) 25 (17-34), median base deficit 6 (2-9), and 56.1 % had penetrating mechanism. The median crystalloid intravenous fluid (IVF) received from prehospital period to 48 h after index operation was 16.3 L (13.0-20.1 L). ISS, base deficit, and vital signs (systolic blood pressure, heart rate, and respiratory rate) did not differ between patients discharged with PVH or primary fascial closure, nor between patients who experienced a documented dehiscence event versus those who did not. Crystalloid volume was statistically different across both comparisons (primary fascial closure vs PVH at discharge: 15.6 vs 20.5 L, p < 0.001; no dehiscence vs any dehiscence 15.0 vs 18.1 L, p < 0.001). By multiple logistic regression, early IVF administration was associated with both PVH at discharge (odds ratio (OR) 1.14, 95 %CI 1.07-1.23) and fascial dehiscence (OR 1.17, 95 %CI 1.04-1.20).

CONCLUSION: Increased volume of perioperative crystalloid is associated with higher risk of fascial complications among patients requiring DCL for trauma. The DCR paradigm may reduce surgical complications as well as mortality among patients with severe trauma requiring laparotomy.

PMID:40571541 | DOI:10.1016/j.injury.2025.112521

Injury. 2025 Jun 17;56(8):112528. doi: 10.1016/j.injury.2025.112528. Online ahead of print.

ABSTRACT

This study reported the development of a novel mouse model for full-thickness articular cartilage defects. A total of 120 C57BL/6 mice were assigned to a sham group and three defect groups. The defect groups included D0.1, D0.2, and D0.3 groups, with 0.1, 0.2, and 0.3 mm wide full-thickness defects in the femoral trochlear grooves, respectively. The reproducibility and consistency of full-thickness defects and cartilage repair were evaluated by histological examination. The mRNA and protein expression levels of cAMP response element binding protein (CREB), phosphorylated CREB (p-CREB), parathyroid receptor 1 (PTH1R), Sonic hedgehog (Shh), Smoothened (Smo), and Gli 1 were assessed by immunohistochemistry and qRT-PCR. The results showed that the full-thickness defects displayed good reproducibility and consistency. Injury widths of 0.1 and 0.2 mm presented superior repair abilities than 0.3 mm (p < 0.05). During cartilage repair, the expression levels of PTH1R, CREB, p-CREB, Shh, Smo, and Gli 1 in the three defect groups were significantly higher than in the sham group (p < 0.05). In addition, the PTH/PTHrP and Hh signaling pathways were activated. In conclusion, we successfully established a novel mouse model for full-thickness articular cartilage defects, which enables deeper exploration of the biological mechanisms involved in cartilage repair in mice.

PMID:40570648 | DOI:10.1016/j.injury.2025.112528

Injury. 2025 Jun 6;56(8):112440. doi: 10.1016/j.injury.2025.112440. Online ahead of print.

ABSTRACT

INTRODUCTION: Controversy surrounds the optimal surgical management of proximal humerus fractures (PHFs). The aim of this study was to evaluate and compare the anatomic and clinical outcomes of open reduction internal fixation (ORIF) of PHFs using FA or VA locking plates.

METHODS: This was a retrospective study of 85 patients (19 male, mean age 60.5 ± 14 years) with displaced surgical neck PHFs treated with VA (44 patients) or FA (41 patients) locking plates. Inclusion criteria were a minimum of 1 year postoperative follow up (mean 3.1 years) or earlier revision surgery. Outcome measures included active range of motion, American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), Single Assessment Numeric Evaluation (SANE), EuroQol-5D (EQ-5D), Visual Analog Scale Pain score (VAS pain) and radiographic assessments of reduction quality, screw position, avascular necrosis (AVN) and failure of fixation.

RESULTS: The initial reduction was anatomic in 47 (55 %), acceptable in 29 (34 %), and malreduced in 9 (11 %). 69 (81 %) met inclusion criteria with no differences in reduction quality between the VA and FA plates (p=.16). VA plating was associated with significantly greater plate height compared to FA plating (B = 4.94; p<.001). Additionally, VA plating was associated with better calcar screw placement in terms of both shorter calcar distance (difference in means =1.8 mm, p=.009) and head distance (difference in means=2.4 mm, p=.007). Reoperation was required in 15 (22 %) patients while AVN occurred in 13 (19 %) patients. Neither reoperation nor AVN differed by plate type (p=.75 and p=.99, respectively). Finally, there were no significant differences in PROMs or ROM at final follow up between groups (difference in mean ASES: 1.1, p=.69; OSS: 1.4, p=.76; SANE: 6.5, p=.07; VAS Pain: 0.1, p=.35; EQ-5D: 0.02, p=.68; Active Forward Flexion: 2.3 degrees, p=.77; Active External Rotation: 6.7 degrees; Active Internal Rotation: 0.8, p=.55).

CONCLUSIONS: ORIF of PHFs with VA locking plates yields comparable outcomes to FA plates while facilitating plate positioning and calcar screw placement. Optimizing fracture reduction and fixation when performing ORIF of displaced PHFs is crucial to reducing the incidence of AVN and reoperation.

LEVEL OF EVIDENCE: Level III, Comparative Cohort Series, Treatment Study.

PMID:40570647 | DOI:10.1016/j.injury.2025.112440

Injury. 2025 Jun 18:112527. doi: 10.1016/j.injury.2025.112527. Online ahead of print.

ABSTRACT

BACKGROUND: Evidence-based clinical practice guidelines play a crucial role in supporting clinical decision-making among healthcare providers, policymakers, and administrators by offering structured, research-informed recommendations. Globally, numerous guidelines have been developed for the management of burn injuries, but they vary considerably in terms of quality, structure, and methodological rigor. This study aimed to critically evaluate the quality of existing burn care guidelines from an interprofessional perspective and assess their adaptability for use in low- and middle-income countries (LMICs).

METHODS: This appraisal study, conducted between 2024 and 2025, employed the AGREE II instrument to evaluate guideline quality through the lens of an interprofessional burn care team. The methodology involved a systematic search to identify relevant guidelines, the formation of a multidisciplinary panel of burn care professionals, and a final quality appraisal of the selected guidelines using the AGREE II framework.

RESULTS: Out of the 38 initially identified clinical guidelines, 31 were excluded due to failure to meet the preliminary thresholds for quality and methodological validity. The remaining seven guidelines were subjected to a comprehensive evaluation using the 23-item AGREE II instrument, encompassing six key quality domains. The appraisal revealed considerable variability across these domains, with particularly marked disparities in stakeholder involvement, methodological rigor, and practical applicability.

CONCLUSION: The findings revealed significant heterogeneity in both the structural and content quality of current burn care guidelines. Among the evaluated documents, the guideline developed by the International Society for Burn Injuries (ISBI) achieved the highest AGREE II scores, demonstrating a strong interprofessional focus and relevance to LMICs. The expert panel subsequently endorsed it as the most appropriate candidate for adaptation in resource-constrained settings. These results highlight the urgent need for more robust, interdisciplinary, and context-sensitive burn care guidelines to improve patient outcomes and healthcare delivery globally.

PMID:40562590 | DOI:10.1016/j.injury.2025.112527

Injury. 2025 Jun 18:112525. doi: 10.1016/j.injury.2025.112525. Online ahead of print.

ABSTRACT

BACKGROUND: Rib fractures are common after blunt chest trauma and are associated with significant morbidity, mortality, and prolonged hospital stays due to pulmonary complications. Effective pain management is crucial in preventing these complications. The 'STUdy of the Management of BLunt chest wall trauma' (STUMBL) score can identify patients with rib fractures at risk of complications and assist with Emergency Department (ED) disposition decisions. Its role in guiding Acute Pain Service (APS) and Intensive Care Unit (ICU) referrals was previously unexplored.

DESIGN AND OBJECTIVES: We conducted a retrospective cohort study on adults with radiologically confirmed rib fractures who presented to The Royal Melbourne Hospital between April 2021 and March 2022. We aimed to assess the association between STUMBL scores and advanced analgesia prescription or ICU admission. Participants were categorised into five STUMBL groups (<11, 11-20, 21-25, 26-30, ≥31). The primary outcome of interest was regional analgesia insertion. The secondary outcomes were patient-controlled analgesia (PCA) use, APS and ICU referrals, and medical emergency team (MET) calls within 48 h. Modified Poisson regression was used to analyse associations, with the <11 group used as the reference.

RESULTS: Among 344 participants, the median STUMBL score was 17 (interquartile range [IQR] 10-24). Higher STUMBL scores were strongly associated with regional analgesia insertion in the STUMBL 26-30 group (RR 15.3, 95 % CI 1.8-130.3, p = 0.013) and the STUMBL ≥31 group (RR 29.3, 95 % CI 4.0-212.5, p = 0.001). Significant associations were also observed for PCA prescription (RR 5.0, 95 % CI 2.6-9.7, p < 0.001), APS referral (RR 4.7, 95 % CI 2.7-8.1, p < 0.001), and ICU admission (RR 3.8, 95 % CI 2.0-6.9, p < 0.001) in the STUMBL ≥31 group.

CONCLUSION: The STUMBL score is a valuable tool for identifying patients likely to require advanced analgesia and APS input, with high scores strongly associated with regional analgesia insertion and PCA prescription. Additionally, patients with STUMBL scores ≥26 were more likely to require ICU admission. Incorporating STUMBL thresholds into rib fracture guidelines could facilitate early APS involvement, guide appropriate admission destinations, optimise hospital resource allocation and improve patient outcomes. Further studies should validate these findings in larger, multi centre cohorts and explore patient-reported outcomes.

PMID:40562589 | DOI:10.1016/j.injury.2025.112525

Injury. 2025 Jun 19;56(8):112538. doi: 10.1016/j.injury.2025.112538. Online ahead of print.

ABSTRACT

AIM: Friction burns are a common paediatric injury that can result in significant morbidity and long-term disability. This systematic review aimed to evaluate the management and outcomes of these injuries.

METHODS: A protocol was developed a priori and registered on the PROSPERO database (CRD42022376782). A comprehensive search of MEDLINE, EMBASE, CENTRAL, CINAHL and trial registries was conducted to identify studies evaluating the management and outcomes of paediatric upper limb friction injuries. Primary outcome measures were healing time, functional outcomes, and the need for surgical intervention. Secondary outcomes included complications such as problematic scarring and cost.

RESULTS: Twenty-two studies met the inclusion criteria, encompassing 842 paediatric patients with upper limb friction injuries, predominantly treadmill-related (95 %). Most injuries (58.7 %) were deep partial-thickness to full-thickness. Conservative management with dressings was the primary treatment in 70.4 % of cases, while 29.6 % underwent acute surgery, predominately full-thickness skin grafting followed by split-thickness skin grafting. Mean healing times ranged from 19.4 to 31.5 days. Problematic scarring affected 20.5 % of patients, with 38.3 % of this group undergoing further scar revision surgery. Functional outcomes were generally positive, with minimal long-term disability reported.

CONCLUSION: Paediatric upper limb friction injuries, particularly those caused by treadmills, have typically been managed conservatively, with good functional outcomes. However, deeper injuries and delayed healing increase the risk of problematic scarring and need for scar revision surgery. Further research is needed to standardise treatment protocols and minimise long-term complications.

PMID:40561811 | DOI:10.1016/j.injury.2025.112538

Injury. 2025 Jun 18;56(8):112526. doi: 10.1016/j.injury.2025.112526. Online ahead of print.

ABSTRACT

BACKGROUND: Displaced distal radial fractures are common among all age groups, but increasingly in older patients, and are frequently managed by emergency nurse practitioners. Most can be manipulated and reduced in the emergency department, often by procedural sedation and analgesia, which can be time consuming and often requiring multiple resources. Using haematoma blocks may offer advantages.

AIM: To examine the use and efficacy of haematoma blocks in managing close reduction of distal radial fractures by emergency nursing practitioners compared to procedural sedation.

DESIGN: Matched case-control study.

RESULTS: Compared to those who had procedural sedation and analgesia (n = 100), the haematoma block group (n = 100) had a shorter procedure time (0.4 hrs vs. 0.7 hrs, Z= -1.24, p < .001), time from reduction to discharge (1.5 hrs vs. 4.6 hrs, Z= -2.98, p < .001), overall ED length of stay (2.8 hrs vs. 4.9 hrs, Z= -3.49, p < .001) and minimal pain post reduction (0/10 vs. 4/10, Z= -2.6, p = .001). No adverse events were noted in the haematoma block group compared to 23 % in the procedural sedation and analgesia group.

CONCLUSION: Hematoma block is a safe, effective and efficient alternative to procedural sedation in the reduction of distal radial fractures by emergency nurse practitioners.

PMID:40561810 | DOI:10.1016/j.injury.2025.112526

Injury. 2025 Jun 11;56(8):112367. doi: 10.1016/j.injury.2025.112367. Online ahead of print.

ABSTRACT

INTRODUCTION: Hemorrhage causes 40 % of deaths from trauma. Low- and middle- income countries (LMICs) claim the majority of these deaths, in part due to lack of resources and organization in the prehospital and hospital arenas. Guatemala experiences a high burden of trauma-related injuries but does not have the resources nor the emergency response system to deal with it. In Guatemala, firefighters (bomberos) lead trauma responses, yet do not receive medical training. Recognizing these gaps in LMICs, we developed "CrashSavers", a low cost, openly accessible, self-training mobile phone-based platform to teach hemorrhage control techniques to first responders in Guatemala City. In this manuscript, we present the evaluation and outcomes of the bomberos who were trained with CrashSavers.

METHODS: Our self-administered educational program teaches first responders to train themselves in the decision making and psychomotor skills of tourniquet placement. This free platform, accessible via mobile phone, provides didactic material, virtual reality cases and instructions to construct a bleeding extremity simulator. Sixty-four bomberos were trained from July-August 2022. Eighteen months later they were retested to assess knowledge retention. Interviews were conducted with all bomberos to elicit feedback, which were then analyzed with narrative synthesis. We assessed medical knowledge, confidence, and surgical skills pre and post training.

RESULTS: After training, bomberos were able to apply the tourniquet more efficiently and more confidently. The time taken to stop a bleed on the simulator dropped from 58.5 s to 39.2 s, p < 0.003. Assessment of their skills 18 months after initial training showed that they were able to retain both confidence and psychomotor skill of tourniquet placement. Qualitative analysis showed overall positive experience with the course.

CONCLUSIONS: A low cost, easily accessible, self-taught course of didactics, VR cases and simulation successfully trained bomberos to control a bleeding extremity. This may be a solution for the large gaps in LMIC trauma response, as traditional programs designed for high income countries (HICs) are inaccessible, expensive and time intensive. With CrashSavers, learners became faster and more confident in stopping a bleed, and in a situation where time is blood and blood is life, efficiency is key.

PMID:40561809 | DOI:10.1016/j.injury.2025.112367

Injury. 2025 Jun 17:112532. doi: 10.1016/j.injury.2025.112532. Online ahead of print.

ABSTRACT

BACKGROUND: The frequent use of computed tomography (CT) scan in the evaluation of trauma patients has led to an increase in the diagnosis of hemothorax. This study aimed to assess whether a hemothorax volume of <300 ml, as determined by CT imaging, can be managed without tube thoracostomy and to identify the factors that recommend its use.

METHODS: A retrospective observational study was conducted at XXX Trauma Center, including all patients with traumatic hemothorax from June 2014 to January 2020. Patient demographics, injury mechanism, severity, associated chest injuries, indications for tube thoracostomy, mechanical ventilation, hospital length of stay, complications, and outcomes were reviewed. The study compared patients with hemothorax volumes < 300 ml and ≥300 ml and assessed the outcomes of conservative management without tube thoracostomy (conservative management) vs therapeutic management with tube thoracostomy placement (failed observation).

RESULTS: A total of 254 patients with hemothorax were included. Most patients (79 %) were successfully managed without tube thoracostomy insertion, while 53 patients (21 %) required tube thoracostomy after failure of conservative management. Patients with larger hemothorax volumes were significantly more likely to require tube thoracostomy (p = 0.001) and had significantly longer hospital stays (p = 0.021). Those with failed observation had higher injury severity scores (p = 0.001), more associated lung contusions (p = 0.015), pneumothorax (p = 0.024), and rib fractures (p = 0.001). They also had larger hemothorax volumes (p = 0.001), a greater need for mechanical ventilation (p = 0.001), and prolonged hospitalization (p = 0.001). Predictors of failed observation included high hemothorax volume (≥300 ml), ISS, and greater number of fractured ribs.

CONCLUSION: Conservative management (without tube thoracostomy) was adequate for most patients with <300 ml of hemothorax volumes. Quantitative assessment of hemothorax volume should be considered part of the clinical decision-making algorithm. Further research is needed to refine management strategies and improve outcomes for traumatic hemothorax.

PMID:40555636 | DOI:10.1016/j.injury.2025.112532

Injury. 2025 Jun 17;56(8):112529. doi: 10.1016/j.injury.2025.112529. Online ahead of print.

ABSTRACT

INTRODUCTION: Sternal fractures are uncommon but may result in significant morbidity when associated with respiratory compromise or severe pain. Conventional methods such as plate fixation are often invasive and technically challenging.

METHODS: We retrospectively reviewed eight cases of transverse sternal fractures treated using an intramedullary fixation technique with cannulated cancellous screws (CCS). Preoperative computed tomography with 3D reconstruction was used for surgical planning. Reduction was achieved percutaneously or through a limited incision, followed by guidewire insertion and screw fixation.

RESULTS: The minimally invasive procedure was completed in 18-35 min (mean, 22 min) with little blood loss (mean, 23 mL). Among six patients with ventilatory compromise, four were successfully extubated within three days postoperatively. There were no complications related to screw insertion, and bone union was confirmed in all cases.

CONCLUSION: Intramedullary screw fixation represents a safe, minimally invasive, and mechanically robust alternative for the management of sternal fractures, particularly in patients with flail chest or severe pain.

PMID:40554841 | DOI:10.1016/j.injury.2025.112529

Injury. 2025 Jun 18;56(8):112522. doi: 10.1016/j.injury.2025.112522. Online ahead of print.

ABSTRACT

OBJECTIVES: To determine (1) if early routine radiographic follow-up at 2-3 weeks for patients with operatively treated tibia, fibula or ankle fractures identified complications (i.e., complications only visible on radiographs and not associated with symptoms on history taking or clinical examination) and (2) if these complications were clinically relevant (i.e., led to treatment change).

METHODS: All adult patients who underwent operative treatment for a tibia, fibula or ankle fracture between January 2021 and January 2023 and who received early routine radiographic follow-up between 10 and 30 days postoperatively were included in this retrospective case series. Routine radiographs were defined as radiographs that were scheduled and obtained as part of the institution's standardized follow-up protocol. The primary outcome was the rate of complications detected on early routine radiographs, stratified by the presence of associated symptoms based on history taking or findings on physical examination. The secondary outcome was any documented treatment change for complications.

RESULTS: Six hundred and twenty-eight patients (median age of 47 years, 42 % male) were included. A total of 5 complications in 628 patients (0.8 %) were seen on early routine radiographs, of which 3 complications (0.5 %) were exclusively identified on radiographs (i.e., not associated with symptoms). None of these 3 complications led to a change in treatment strategy. The remaining 2 complications were visible on radiographs but were accompanied by symptoms on history taking or physical examination.

CONCLUSION: The results of the current study suggest that radiographs at 2-3 weeks following operative treatment of tibia, fibula or ankle fractures may not need to be ordered routinely. Obtaining radiographs should be guided by clinical indication or by patient and surgeon preference (e.g., for reasons beyond complications). These findings should be considered in light of increasing healthcare expenditures and the time investment required of patients and healthcare professionals.

PMID:40554111 | DOI:10.1016/j.injury.2025.112522

Injury. 2025 May 22;56(8):112449. doi: 10.1016/j.injury.2025.112449. Online ahead of print.

NO ABSTRACT

PMID:40544747 | DOI:10.1016/j.injury.2025.112449

Injury. 2025 Jun 12:112524. doi: 10.1016/j.injury.2025.112524. Online ahead of print.

ABSTRACT

BACKGROUND: Patients with blunt solid organ injury (BSOI) face heightened thromboembolic risks, prompting scrutiny of early versus late venous thromboembolic (VTE) prophylaxis effects.

METHODS: Analyzing TQIP data (2017-2019) for adults (≥18 years) with severe BSOI under non-operative management and VTE prophylaxis, we classified patients into early (≤48 h) and late (>48 h) prophylaxis groups. We conducted a propensity score matching (PSM) to balance the population based on demographics, organ injury severity, vital signs and need for blood transfusion. Data were compared post-PSM.

RESULTS: Among 23,668 patients, mortality was 3.1 %, with 42.2 % receiving early and 57.8 % late VTE prophylaxis. Early prophylaxis correlated with lower mortality (2.1 % vs. 3.9 %), lower rates of failure of non-operative management (12.4 % vs. 16.6 %), stroke (0.7 % vs. 1.2 %), DVT (2.1 % vs. 4.9 %) and PE (1.4 % vs. 2.3 %) (p < 0.001 for all). Late prophylaxis associated with longer hospitalization and ICU stays (p < 0.001 for both). Post-match data showed that compared to early VTE prophylaxis, patients that received late VTE prophylaxis had higher mortality rates (2.5 % vs. 1.9 %), failure of non-operative management (14.6 % vs. 11.8 %), longer hospital (15.8 (8.7) vs. 12.4 (6.7) days) and ICU (8.9 (4.7) vs. 6.8 (3.4) days) LOS, and higher rates of developing thrombotic complications during hospital stay (p < 0.05, for all).

CONCLUSION: Early VTE prophylaxis not only proves safe for isolated solid organ injury patients but also is associated with lower mortality, mitigating thromboembolic risks and shortening hospital and ICU stays.

LEVEL OF EVIDENCE: Level III retrospective study.

PMID:40544037 | DOI:10.1016/j.injury.2025.112524

Injury. 2025 Jun 11:112523. doi: 10.1016/j.injury.2025.112523. Online ahead of print.

ABSTRACT

INTRODUCTION: Traumatic brain injury (TBI) is a major contributor to emergency department (ED) visits worldwide, with older adults being particularly susceptible due to fall-related injuries. The widespread use of anticoagulants, including direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs), raises concerns about the risk of delayed intracranial haemorrhage (dICH), even in cases where the initial head computed tomography (CT) scan shows no abnormalities. The optimal strategies for managing and monitoring these patients remain a subject of ongoing debate.

MATERIALS AND METHODS: We conducted a monocentric retrospective observational study at Santa Croce e Carle Hospital, Cuneo, Italy, from January 2019 to August 2024. We included patients aged ≥18 years, on chronic anticoagulant therapy, presenting with mild TBI (GCS ≥13) and a negative initial CT scan. All patients underwent a second CT after 24 h of observation, regardless of clinical changes. The primary outcome was the incidence of dICH. Secondary outcomes included neurosurgical interventions and 30-day mortality.

RESULTS: The study included 596 patients (median age 83 years; 46.5 % male). Most patients were on DOACs (74.5 %), and falls were the most common trauma mechanism (90.4 %). dICH was diagnosed in 2 % of patients (n = 12), with subarachnoid haemorrhage and subdural hematoma being the most frequent findings (5 patients each). None of the dICH cases required neurosurgical intervention or resulted in mortality at 30 days. Patients with dICH were more likely to have a GCS <15 upon arrival (16.7 % vs. 3.9 %; p = 0.17) and experienced high-energy trauma mechanism, (16.7 % vs. 1.7 %; p = 0.044); among patients with dICH, 41.7 % were on VKA therapy, compared to 25.2 % of patients without dICH (p = 0,33). Complications during hospitalization, primarily nosocomial infections and delirium, occurred in 66 % of patients hospitalized for dICH.

CONCLUSION: Our findings confirm that dICH after TBI in anticoagulated patients with a negative initial CT is rare and typically benign. Routine prolonged observation and repeat CTs may not be necessary for all patients, particularly those without high-risk factors; individualized management based on clinical risk factors could minimize unnecessary hospitalizations, reduce complications, and optimize healthcare resources.

PMID:40537351 | DOI:10.1016/j.injury.2025.112523

Injury. 2025 Jun 5;56(8):112471. doi: 10.1016/j.injury.2025.112471. Online ahead of print.

ABSTRACT

INTRODUCTION: Tibial shaft fractures are common injuries seen particularly because of high velocity trauma. Considerable debate exists between the suprapatellar and infrapatellar approach for nailing of tibial shaft fractures. The aim of this study was to compare the clinical, radiological and functional outcomes and intra-operative fluoroscopy time, total blood loss and operative time between supra-patellar and infra-patellar insertion techniques in the treatment of extra-articular tibial shaft fractures.

METHODS: Sixty patients aged between 18-45 years who presented to our Level I trauma-centre with AO/OTA type 42 fractures were randomized into Suprapatellar (SP) and Infrapatellar (IP) groups. Operative time, intra-operative blood loss and radiation exposure was recorded. Severity of knee pain by VAS score and knee range of motion were documented at 2 weeks, 6 weeks, 3 months, 6 months, 12 months, 18 months and 24 months follow-up. Functional outcomes were measured using Knee Society Score, Lysholm Knee Score and KOOS-PF score and radiological union assessed with radiograph done at 6 weeks, 3 months, 6 months, 12 months, 18 months and 24 months post-operatively.

RESULTS: Thirty patients each underwent nailing by suprapatellar and infrapatellar approach. A statistically significant difference favouring the suprapatellar group was noted in the operative time (p-value 0.003) and mean intra-operative blood loss (p-value 0.027). There was no difference between the two groups in terms of knee pain or knee range of motion and the mean functional scores.

CONCLUSION: Suprapatellar nailing of tibial shaft fractures may help to reduce operative time and intra-operative blood loss with similar intra-operative radiation exposure, clinical and functional outcomes compared to infrapatellar nailing.

PMID:40532333 | DOI:10.1016/j.injury.2025.112471

Injury. 2025 May 28;56(8):112456. doi: 10.1016/j.injury.2025.112456. Online ahead of print.

ABSTRACT

BACKGROUND: Preoperative planning is a helpful tool for orthopaedic trauma cases, but clinical experience dictates that its use remains inconsistent. The primary aim of this cross-sectional survey study was to investigate practices and applications of preoperative planning for orthopaedic trauma cases and to identify factors influencing its use.

METHODS: A cross-sectional 26-item survey was distributed to members of the Orthopaedic Trauma Association and The Netherlands Orthopaedic Trauma Association between April 2024 and August 2024. Four key areas of interest were assessed: (1) general preoperative planning practices; (2) features of the preoperative plan; (3) use of preoperative planning for resident training; and (4) factors influencing the decision to make a preoperative plan. General preoperative planning practices were compared between attendings and residents or fellows.

RESULTS: Two-hundred-eleven orthopaedic surgeons, fellows, or residents completed the survey (84 % male, 74 % attending, 55 % of attendings trauma-fellowship-trained). Overall, 84 % of respondents considered preoperative planning very or extremely important. Formal preoperative planning was performed on average for 50 % of cases. Residents or fellows planned significantly more often than attendings (76 % vs. 30 %, p < 0.001) and used digital templating more often (59 % vs. 38 %, p= 0.006). The most common features of the plan were tactical, including positioning of implants and specific steps of approach and reduction. Residents reported that preoperative plans were discussed preoperatively in 75 % of cases and postoperatively evaluated in 40 %. Case complexity was the most influential factor in deciding to plan.

CONCLUSION: Respondents considered preoperative planning to be very or extremely important for orthopaedic trauma cases but made a formal preoperative plan on average in only half of cases. Residents or fellows made a preoperative plan twice as often. Complexity of the case was the most important factor in deciding to make a preoperative plan. Benefits of preoperative planning such as improving resident teaching and learning, efficiency, and teamwork should be considered more often in the decision to make a preoperative plan.

PMID:40532332 | DOI:10.1016/j.injury.2025.112456