Injury. 2025 Jan 19;56(3):112165. doi: 10.1016/j.injury.2025.112165. Online ahead of print.

ABSTRACT

PURPOSE: Standard operating procedures aim to achieve a standardized and assumedly high-quality therapy. However, in orthopaedic surgery, the aspect of temporal urgency is often based on surgical tradition and experience. At a time of evidence-based medicine, it is necessary to question these temporal guidelines. The following review will therefore address the most important temporal guidelines in orthopaedic surgery and discuss their practical relevance and potential need for optimization.

METHODS: The systematic review features a literature review by database search in "PubMed" (https://pubmed.ncbi.nlm.nih.gov) for time to surgery in terms of (1) "proximal femoral fractures", (2) "femoral neck fractures", (3) "proximal humeral fractures", (4) "ligament and tendon injuries", (5) "spinal cord injuries", (6) "open fractures" and (7) "fracture-related infections". For every diagnosis, hypotheses on timing were set up and checked for evidence.

RESULTS: There is solid clinical evidence supporting the initiation of treatment within 24 h for specific conditions like the surgical treatment of proximal femur fractures and prompt decompression of spinal cord injuries. However, for other scenarios such as the 6-hour rule for open fractures, joint-preserving femoral neck fractures, timing of ligament injuries, humeral head fractures and fracture-related infections there is currently no reliable evidence to guide prompt surgical treatment.

CONCLUSION: Based on the current data, resource-adapted surgical planning seems reasonable. Further research in these areas is necessary to determine the best timing of treatment and address existing doubts.

PMID:39879862 | DOI:10.1016/j.injury.2025.112165

Injury. 2025 Jan 25;56(3):112183. doi: 10.1016/j.injury.2025.112183. Online ahead of print.

ABSTRACT

PURPOSE: Reduction and intraoperative maintenance of fracture fragments during minimally invasive plate osteosynthesis (MIPO) pose technical difficulties, particularly when the interposed fragment is angulated, prompting surgeons to attempt reduction due to concerns about nonunion or malunion. We aimed to compare the clinical and radiological outcomes of MIPO for mid-shaft clavicular fractures based on the reduced status of the interposed fragments.

METHOD: Fifty-seven patients who underwent MIPO for acute mid-shaft Robinson type 2B clavicular fractures were divided into two groups based on the alignment of the interposed fracture fragment. A vertical fracture fragment was defined as one tilted by >45° relative to the long axis of the proximal clavicular shaft. Radiological outcomes were evaluated using time to union, clavicle thickness, and length ratio after union compared with the healthy side. Clinical outcomes were assessed using the visual analog scale (VAS); the Korean Shoulder Score (KSS); Disability of the Arm, Shoulder, and Hand (DASH) score; and shoulder range of motion (ROM). Continuous variables were analyzed using Student's t-test or Mann-Whitney U test, based on data distribution.

RESULT: The vertical fragment group comprised 21 patients, and the nonvertical fragment group comprised 36. The mean time to union was similar between the vertical (4.48 ± 1.20 months) and nonvertical group (4.64 ± 1.17 months, p = 0.162). The groups showed comparable clavicular length and thickness ratios: 0.992 ± 0.040 vs. 1.076 ± 0.045 (p = 0.175), 1.189 ± 0.102 vs. 1.186 ± 0.271 (AP view, p = 0.165), and 1.121 ± 0.238 vs. 1.112 ± 0.230 (Lordotic view, p = 0.655), respectively. At 12 months, no significant differences were observed in VAS (0.3 ± 0.7 vs. 0.8 ± 0.8, p = 0.667), KSS (97.10 ± 6.30 vs. 96.75 ± 6.77, p = 0.940), and DASH (1.44 ± 3.64 vs. 2.00 ± 4.05, p = 0.501), or in ROM forward flexion (165.24 ± 9.28 vs. 162.78 ± 12.56, p = 0.464) and external rotation (60.95 ± 13.00 vs. 60.00 ± 13.47, p = 0.965).

CONCLUSION: Favorable radiological and clinical outcomes were achieved in all patients who underwent MIPO for mid-shaft clavicular fractures, regardless of whether the interposed fracture fragment after reduction was vertical.

PMID:39879861 | DOI:10.1016/j.injury.2025.112183

Injury. 2025 Jan 21;56(3):112178. doi: 10.1016/j.injury.2025.112178. Online ahead of print.

ABSTRACT

INTRODUCTION: Severe open lower limb fractures are complex and costly injuries. Studies reporting the costs associated with these injuries, the economic impact of complications, and the clinical benefit of adherence to national guidelines have been previously reported. However, the economic benefits of national guidelines and their relationship with length of inpatient stay have not been described.

METHODS: An international retrospective cohort study, using length of stay as a proxy for in-hospital economic impact, comparing the duration of inpatient stay in countries with national guidelines and those without.

RESULTS: In a cohort of 2641 patients from 16 countries, length of stay was 17 % lower in countries with national guidelines, equivalent to 2-3 fewer inpatient days per patient. This difference was primarily driven by a lower incidence of deep infection observed in countries with national clinical guidelines.

CONCLUSION: The presence of national guidelines for the management of severe lower limb injuries is associated with both improved clinical outcomes and reduced length of stay and therefore healthcare burden. Whilst application and adoption of national guidelines is not without challenges, their implementation is associated with significant clinical and economic benefits.

PMID:39879860 | DOI:10.1016/j.injury.2025.112178

Injury. 2025 Jan 20;56(3):112174. doi: 10.1016/j.injury.2025.112174. Online ahead of print.

ABSTRACT

OBJECTIVES: Long bone fractures with concomitant vascular injury have the potential to be life and limb threatening injuries, with increased risk for limb loss. There is currently no established surgical order of operations for orthopaedic and vascular intervention. This study compares injury classification, warm ischemia time and patient outcomes in patients with long bone fractures and associated vascular injury after orthopaedic versus vascular primary intervention.

METHODS: Design: Retrospective review Setting: Level 1 Trauma Center Patient Selection Criteria: Included were patients treated between 2016 and 2021 with fractures of the femur, tibia, fibula, or knee dislocation (OTA/AO 32, 33, 41, 42 and 43) with associated vascular injury necessitating vascular repair. Outcome Measures and Comparisons: Warm ischemia time, intraoperative transfusion requirements, readmission, definitive amputation, fasciotomy, infection, need for vascular revision, and return to weight bearing were compared between the two groups (primary vascular intervention (VP) and primary orthopaedic intervention (OP)).

RESULTS: 35 patients were included with 29 patients in the VP group and 6 patients in the OP group. There was no significant difference in the warm ischemia time between groups (p = 0.52) or total operative time (p = 0.13). 3/29 patients in the VP group required definitive amputation and 0/6 patients in the OP group required amputation (p = 1.00). There were no statistically significant differences in rates of infection, fasciotomy, readmission, length of stay, vascular revision, or time to weight bearing between groups.

CONCLUSIONS: This study demonstrates collaborative care between surgical teams to minimize warm ischemia time is crucial in patients with lower extremity fractures associated with vascular injury. There is no significant difference in patient outcomes including definitive intraoperative transfusion requirements, amputation, time to weight bearing or infection when comparing primary orthopaedic versus vascular intervention.

PMID:39874867 | DOI:10.1016/j.injury.2025.112174

Injury. 2025 Jan 23;56(3):112182. doi: 10.1016/j.injury.2025.112182. Online ahead of print.

ABSTRACT

INTRODUCTION: Blunt chest trauma represents a major risk factor for complications in polytrauma patients. Various scoring systems have emerged, but their impact is not fully appreciated. This review evaluates changes in chest trauma scoring over time and potential shifts in complication rates linked to modified surgical approaches in long bone fractures.

METHODS: A systematic review was performed utilizing Medline and EMBASE. Included studies analyzed the clinical course following blunt chest trauma with orthopedic injuries requiring surgical fixation. Quantification of chest injury severity was assessed based on the utilized scores in the respective publication such as the Abbreviated Injury Scale, Injury Severity Score, Thoracic Trauma Score (TTS) or the Chest Trauma Score (CTS). The studies were categorized into two groups: "ante-millenium" (AM) (<31.12.2000) and "post-millenium" (PM) (>01.01.2000). Endpoint analysis focused on chest-injury-related complications, including acute respiratory distress syndrome (ARDS), pneumonia, multiple organ failure (MOF), and pulmonary embolism. A meta-analysis examined the influence of surgical timing (early vs. late) on clinical outcomes.

RESULTS: Of 9,682 studies on chest trauma, 20 (4,079 patients) met the inclusion criteria. Most studies in both AM and PM reported the thoracic AIS scale for severity assessment. In group PM more clinical parameters were included in the decision making. Incidences of pooled and weighted mortality were higher in AM (5.1 %) compared to PM (2.3 %, p = 0.003), and ARDS incidence was also greater in AM (12.1 %) versus PM (8.9 %, p = 0.045), though these findings were not confirmed through indirect meta-analysis. Early fracture fixation (<24 h) displayed a non-significant trend toward lower ARDS (OR: 0.60; 95 % CI, 0.23-1.52) and mortality (OR: 0.66; 95 % CI, 0.28-1.55), but significantly reduced pneumonia risk (OR, 0.53; 95 % CI, 0.40-0.71).

CONCLUSION: Prior to 2000, chest injuries were quantified using the AIS alone, while afterwards multiple scoring systems that incorporated pathophysiologic response were utilized. Possibly related to changes in timing of surgery, fixation techniques, or general improvements in-patient care seems to have improved in patients with concomitant thoracic trauma regarding mortality and ARDS. Overall, polytrauma patients with concomitant thoracic injuries might benefit from early definitive fracture care if their physiology and overall injury pattern allows it.

LEVEL OF EVIDENCE: Systematic Review; Level IV.

PMID:39874866 | DOI:10.1016/j.injury.2025.112182

Injury. 2024 Dec 18;56(2):112045. doi: 10.1016/j.injury.2024.112045. Online ahead of print.

ABSTRACT

Frame configuration for the management of complex tibial fractures is highly variable and is dependent upon both fracture pattern and surgeon preference. The optimal number of rings to use when designing a frame remains uncertain. Traditionally larger, multi-ring-per-segment constructs have been assumed to offer optimal stability and therefore favourable conditions for fracture healing but there is little in-vivo evidence for this and the recent concept of reverse dynamisation challenges this approach. We compared the clinical outcomes in 302 consecutive patients with tibial fractures treated in our unit with either a stable two-ring circular frame or a three-or-more-ring (3+) frame. The primary outcome measure was time spent in frame. Secondary outcomes were the incidence of malunion and the need for further surgical procedures to achieve bone union. The mean time in frame was 168 days for the 2-ring group and 202 days for the 3+ rings group (p = 0.003). No significant differences were found in the rate of malunion or the requirement for secondary surgical intervention to achieve union. The groups were evenly matched for age, co-morbidities, energy of injury mechanism, post-treatment alignment and presence of an open fracture. This study finds that 2-ring frame constructs are a reliable option associated with shorter duration of treatment and no increase in rates of adverse outcomes compared with larger, more complex frame configurations.

PMID:39870047 | DOI:10.1016/j.injury.2024.112045

Injury. 2025 Jan 17;56(3):112162. doi: 10.1016/j.injury.2025.112162. Online ahead of print.

ABSTRACT

INTRODUCTION: Clinical data on osseointegration (OI) for limb replacement indicates a concerning increase in mechanical complications after five years post-implantation. Since adequate bone-implant contact and proper implant alignment are critical factors for successful osseointegration, it is essential to identify the factors influencing these outcomes. This study aimed to assess the effects of residual femur length and implant sizing on bone-implant contact and implant alignment.

METHODS: Three-dimensional models of eight cadaveric femora were reconstructed from CT scans, and transfemoral amputations were simulated for each femur at three levels: short (ST: 1/3 L), medium (MD: 1/2 L), and long (LG: 2/3 L). Virtual OI surgeries were then performed using computer-aided design (CAD) models, and implant sizes were recorded. Subsequently, the effect of implant sizing was assessed by adjusting the implant size by ±1 mm. Contact length and implant alignment were compared between the groups using repeated measures analysis of variance with Bonferroni correction.

RESULTS: The contact in the ST group (65.2 ± 7.3 %) was significantly less compared to the MD (96.1 ± 4.1 %, p < 0.001) and LG (96.8 ± 3.2 %, p < 0.001) groups. Upsizing increased contact in the ST group by 7.0 ± 2.6 % (p < 0.001), though it did not reach levels comparable to the MD and LG groups (p > 0.05). Additionally, sagittal implant misalignment was larger in the ST group (10.1 ± 2.0°) than in the MD (7.9 ± 1.5°) and LG (3.5 ± 1.6°) groups (p < 0.001), while no difference was observed in coronal implant alignment.

CONCLUSION: These findings highlight the factors influencing mechanical complications of osseointegration implants and provide a basis for refined implant designs and surgical techniques for patients with short residual limbs.

PMID:39869959 | DOI:10.1016/j.injury.2025.112162

Injury. 2025 Jan 11:112149. doi: 10.1016/j.injury.2025.112149. Online ahead of print.

ABSTRACT

INTRODUCTION: Optimizing treatment strategies in polytrauma patients is a key focus in trauma research and timing of major fracture care remains one of the most actively discussed topics. Besides physiologic factors, associated injuries, and injury patterns also require consideration. For instance, the exact impact and relevance of traumatic brain injury on the timing of fracture care have not yet been fully investigated.

METHODS: In this retrospectively cohort study at a level one trauma center, patients requiring trauma team activations from 2015 to 2020 were screened. Patients with an injury severity score >16 and at least one body region requiring operative fixation were included. Patients who underwent their first definitive surgery <24 h were stratified as group SDS (Safe Definitive Surgery) and >24 h as group DFC (Delayed Fracture Care). Outcomes were early mortality (<72 h), SIRS and sepsis, timing to first definitive surgery and completed reconstruction, total number of surgeries, and factors influencing the surgical strategy (e.g., unstable physiology). Odds ratios for treatment strategies and influencing factors were calculated using the Fisher`s exact test with conditional maximum likelihood estimate.

RESULTS: From a total of 901 patients screened, 239 were included in the analyzes (Group DFC: 151, Groups SDS: 88). Groups did not significantly differ regarding early mortality, SIRS and sepsis. Group SDS had a significantly lower mean number of operations (4.3 vs. 5.3; p = 0.037) and a significantly shorter mean time until completion of reconstructive operations (10 days vs. 15 days; p = 0.013). Unstable physiology and intracranial trauma sequelae with the necessity for neurosurgical interventions (NSI) were identified as most significant factors for delaying definitive fracture care (OR: 2.85; 95 % CIs: 1.56 to 5.33 and OR: 5.59; 95 % CIs: 1.63 to 29.85), while the presence of intracranial bleeding (IB) without NSI did not have a significant influence (OR: 1.21; 95 % CIs: 0.63 to 2.34).

CONCLUSION: The necessity of NSI and unstable physiology are highly relevant factors for delaying definitive fracture care in polytrauma patients, while the presence of IB without NSI had less impact. In this cohort, early definitive fracture care in physiologically stable patients without NSI, was not associated with increased patient morbidity.

PMID:39864965 | DOI:10.1016/j.injury.2025.112149

Injury. 2025 Jan 22;56(3):112180. doi: 10.1016/j.injury.2025.112180. Online ahead of print.

ABSTRACT

INTRODUCTION: External fixators are utilized to temporarily stabilize bicondylar tibial plateau fractures. They can be prepped during definitive surgery to help maintain fracture length and alignment. However, there is a potential for increased infection by leaving the external fixator on during the surgery. We hypothesize that maintaining the external fixator during surgery will result in no difference in rates of deep infection but improve reduction quality.

METHODS: We performed a retrospective cohort study of all bicondylar tibial plateau fractures treated at an academic, level one trauma center over a 10-year period. The primary outcome analyzed was the rate of deep infection. Secondary outcomes analyzed included reduction quality by comparing the medial proximal tibia angle (MPTA) and posterior proximal tibia angle (PPTA), complication rate, and reoperation rate.

RESULTS: One hundred and thirty-nine fractures in 133 patients met the inclusion criteria. There was no difference between the external fixator removed and prepped groups in terms of baseline patient characteristics except for more motor vehicle collisions in the removed group (42 % vs 22.99 %, p = 0.0193) and more open fractures in the prepped group (6 % vs 18.39 %). Operative characteristics were also not statistically different except for more patients in the prepped group underwent preoperative skin shaving (22 % vs 48.28 %, p = 0.0023) and more patients in the removed group had fixation constructs with plate and pin site overlap (46 % vs 24.14 %, p = 0.0083). There was no difference in deep infection between the groups (16.00 % vs 8.05 %, p = 0.1511). There was no difference in reduction quality when comparing the MPTA (87.64° vs 87.40°, p = 0.6607) and PPTA (83.18° vs 83.97°, p = 0.3592). The rates of superficial infection (20 % vs 29.89 %, p = 0.2056), unplanned reoperation (30 % vs 18.39 %, p = 0.1179), complications (58 % vs 44.83 %, p = 0.1376), and nonunion (8 % vs 6.89 %, p = 0.8111) were also similar.

CONCLUSIONS: Bicondylar tibial plateau fractures are challenging injuries with a high complication profile. Our findings suggest that maintaining the external fixator is not associated with increased rates of deep infection or complications. However, maintaining the external fixator during surgery did not lead to differences in final coronal or sagittal alignment reduction quality.

PMID:39864400 | DOI:10.1016/j.injury.2025.112180

Injury. 2025 Jan 17;56(3):112163. doi: 10.1016/j.injury.2025.112163. Online ahead of print.

ABSTRACT

BACKGROUND: Older adults make up an increasing portion of orthopedic trauma care. Proxy reports are particularly valuable when patients face difficulties formulating answers due to pre-existing or temporary cognitive impairment, and provide critical insights into patient well-being.

QUESTIONS/PURPOSES: This study examines the agreement between patient- and proxy-reported outcome measures across various health domains of older adult orthopedic trauma patients, including those with mild cognitive impairment.

PATIENTS AND METHODS: A prospective cohort study was conducted in the Orthopedic trauma clinic of two Level 1 trauma centers, involving 108 patients aged 70 years or older, with or without mild cognitive impairment, and a self-identified discernible proxy. Participants were evaluated using PROMIS measures for physical function, pain intensity, anxiety, depression, fatigue, and social roles and (instrumental) activities of daily living questionnaires. Agreement between patient and proxy assessments was analyzed using Intraclass Correlation Coefficient and Bland-Altman analyses. Subgroup comparison was made using confidence intervals.

RESULTS: Most patients were married women with a mean age of 78 years (SD 6.2), 61 % had higher education, 67 % were walking independently, and 53 % had fractures of the pelvic ring or femur. Proxies were younger (mean age 64 years, SD 15), with 41 % being children and 40 % spouses. Significant correlations were found between patient and proxy assessments in physical function (ICC 0.74, 95 % CI 0.61-0.82), pain intensity (ICC 0.83, 95 % CI 0.74-0.89), (instrumental) activities of daily living (both ICC 0.86, 95 % CI 0.80-0.91). Moderate correlations were observed in anxiety, depression, fatigue, and participation in social roles (ICCs ranging from 0.56 to 0.66). Bland-Altman analyses confirmed good agreement with none to minimal systematic bias across all these domains.

CONCLUSION: Proxy-reported outcomes are valuable for evaluating health domains in older adult orthopedic trauma patients, including those with cognitive impairments. While proxies reliably assess physical and pain-related domains, additional strategies are needed to improve accuracy in more subjective domains. Future research should explore longitudinal agreements to better understand recovery perceptions over time and mitigate bias proxy-reporting, ultimately enhancing both patient care and outcomes research in geriatric orthopedic trauma patients.

PMID:39864399 | DOI:10.1016/j.injury.2025.112163

Injury. 2025 Jan 20;56(3):112176. doi: 10.1016/j.injury.2025.112176. Online ahead of print.

ABSTRACT

BACKGROUND: Proximal femoral fractures has been associated with high mortality risk, while little is known about more distal lower extremity fractures. The aim was to report 30- and 365-days mortality in surgically treated lower extremity fractures in individuals above 65 years.

MATERIALS AND METHODS: We extracted data from the Danish National Patient Register on all surgically treated lower extremity fracture in the period 1998-2017. The primary outcome was mortality reported by fracture site defined by ICD-10 codes (femur S72*, tibia S82*, foot/ankle S92*S825-8). The secondary outcomes were mortality divided on sex, age groups (5-year span), and comorbidity. This study was conducted using descriptive statistics.

RESULTS: We identified 182,013 operatively treated lower extremity fractures of which 73 % occurred in females. The 30-day mortality was 10 % for patients with femoral fractures, 2 % for tibia and 1 % for foot/ankle. The 30-day mortality were similar in femoral fractures regardless of location in the femur (8-11 %). The 365-day mortality was 29 % for femoral fractures, 8 % for tibia and 6 % for foot/ankle. Men with a femoral fracture had higher mortality (15 % at 30 days, 37 % at 356 days) in comparison to women (8.2 % at 30 days, 26 % at 356 days). For the above 85+ year age group, the fracture location was less important for 365-day mortality.

CONCLUSION: There was an observed high risk of mortality in surgically treated femoral fractures. The mortality risks seems to rapidly decline when the fractures are below the knee.

PMID:39862495 | DOI:10.1016/j.injury.2025.112176

Injury. 2025 Jan 20;56(3):112169. doi: 10.1016/j.injury.2025.112169. Online ahead of print.

ABSTRACT

BACKGROUND: Unstable posterior pelvic-ring fractures are rare and difficult to manage. There are many injury patterns, they are associated with high morbidity and mortality, and optimal surgical management remains contentions. This study aims to compare outcomes and complications for different surgical management of these injuries.

METHODS: This was a multi-centre observational study of patients with traumatic posterior pelvic-ring injuries that underwent operative management between 1st January 2010 and 1st January 2020 at three Australian MTS. Cases were identified using internal hospital databases and the Victorian State Trauma registry. Data was retrieved from medical records and included surgeries, fixation method, length of stay, and outcomes (revision surgery, infection, hardware breakage, screw misplacement and hardware removal), time to each outcome was also recorded. The extracted data was collated and then analysed using RStudio; generalised liner models and linear regression models were developed to calculate mean differences and odd ratios.

RESULTS: There were 439 cases (309 males and 130 females) in the cohort with a median age of 39 years. The overall prevalence of revision was 7.7 %; 4.8 % for infection, 1.8 % for hardware failure and 13.2 % for removal of hardware. Bulkier, more prominent fixation methods had higher rates of metalware removal. Numbers were too small in subgroups to detect a significant difference in complication rates between fixation method. However, bilateral injuries had a significant effect on revision with a calculated prevalence of 16.7 % vs 5.6 % for unilateral injuries. Cases managed with open-reduction had a calculated infection rate of 15.6 % vs 4.6 %. Length-of-stay was increased in patients managed with temporising external fixators, who had bilateral injuries, where infection occurred or were restricted to non-weight bearing postoperatively.

CONCLUSIONS: This study highlight bilateral posterior-pelvic ring injuries as a greater management challenge than unilateral injuries. It supports the use of percutaneous fixation with closed-reduction, decreased infection risk and decreased length-of-stay. It challenges the use of external fixators and supports less restrictive post-operative restrictions. This study also serves as a descriptive analysis for the current management of pelvic fractures in an Australian setting, shedding light on complication rates and profiles.

PMID:39862494 | DOI:10.1016/j.injury.2025.112169

Injury. 2025 Jan 16;56(3):112170. doi: 10.1016/j.injury.2025.112170. Online ahead of print.

ABSTRACT

OBJECTIVES: The purpose of this study is to determine what demographic and anatomical variables affect successful placement of a superior medullary ramus screw, and how they affect the maximal diameter of that screw.

METHODS: Design: Prognostic Level IV SETTING: Level I Trauma Center Patients/Participants: Two hundred consecutive patients underwent computed tomography (CT) of the pelvis. We included those patients aged 18 and older without osseous injury or abnormalities precluding measurement.

INTERVENTION: 3D reconstructions of the pelvis were created, and a virtual 3.5 mm cylindrical implant was placed from the pubic tubercle to the lateral cortex of the ilium. Success was defined as a bicortical virtual screw path from the ramus to the lateral ilium without cortical perforation. The cylinder was then expanded to model varying screw diameters. We then repeated this same process for unicortical retrograde screw insertion ending medial to the acetabular joint.

MAIN OUTCOME MEASURES: Successful screw placement and maximum screw diameter.

RESULTS: A 3.5 mm screw was successfully placed in 187 patients (93.5 %). One male (1/107, 0.9 %) and 12 females (12/93, 12.9 %) could not accommodate a 3.5 mm screw. All cases of perforation occurred lateral to the obturator foramen. Increasing height was associated with success, and male gender was associated with the ability to accommodate screws with a diameter 6.5 mm and larger.

CONCLUSIONS: Most patients can accommodate a 3.5 mm screw from the pubic tubercle to the ilium. Height and gender should be noted when planning medullary ramus fixation.

PMID:39862493 | DOI:10.1016/j.injury.2025.112170

Injury. 2025 Jan 23;56(3):112167. doi: 10.1016/j.injury.2025.112167. Online ahead of print.

ABSTRACT

OBJECTIVE: Our primary objective was to identify and describe demographic trends in head and neck injuries incurred while participating in horseback riding.

STUDY DESIGN: Cross-sectional analysis.

SETTING: National Database.

METHODS: Head and neck injuries related to horseback riding over a ten-year period (2014-2023) were analyzed using data from the National Electronic Injury Surveillance System (NEISS). A total of 3,177 cases were identified. Inclusion criteria encompassed injuries to the head, neck, face, mouth, or ear. Variables included age, gender, injury type, anatomical location, and patient disposition. Chi-squared analyses were employed to compare the aforementioned injury variables.

RESULTS: Among the 3,177 reported injuries of males and females, females (mean age 27.51 years, SD = 19.04) were more likely to be treated and released (83.29 %, n= 2023), while males (mean age 34.65 years, SD = 22.58) were more likely to be hospitalized. There was a significant association between gender and concussion diagnosis (p<.001), with females more likely to be diagnosed with concussions (n = 687) compared to males (n = 129). Females experienced more head and face injuries compared to males. Age distribution varied significantly across disposition categories, indicating different management practices for various age groups. The dataset indicates that the average age of females (27.51 years) is notably lower than that of males (34.65 years), suggesting a younger demographic among females overall.

CONCLUSIONS: The study highlights a significant gender disparity in horseback riding-related head and neck injuries, with females more likely to be treated and released and males more often requiring hospitalization.

PMID:39862492 | DOI:10.1016/j.injury.2025.112167

Injury. 2025 Jan 11;56(2):112161. doi: 10.1016/j.injury.2025.112161. Online ahead of print.

ABSTRACT

INTRODUCTION: The development of national registries from routinely collected health data has transformed the research landscape by improving access to large sample populations. This growing volume of data enables researchers to address critical questions but also challenges clinicians in conducting, evaluating, and applying the research. The National Trauma Data Bank (NTDB), the largest aggregate of deidentified trauma data in the world, is increasingly utilized for retrospective studies on trauma. This scoping review aimed to assess the quality of reporting of NTDB-based orthopedic trauma publications.

METHODS: We queried the Dimensions database for orthopedic studies using the NTDB. The quality of reporting was assessed by adherence to two international publication guidelines: the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement and the REporting of studies Conducted using Observational routinely collected data (RECORD).

RESULTS: From a total of 3,720 identified articles, 137 manuscripts were available for analysis. The median scores and interquartile ranges (IQR) for STROBE and RECORD were 19 (IQR 18-20) and 7 (IQR 7-8), respectively. For STROBE scoring, the lowest fulfilled items were handling missing data and potential sources of bias. For RECORD scoring, the lowest fulfilled items were accessibility to protocol, raw code and data, validation studies, and data cleaning. A greater proportion of high-scoring studies were published in high-impact journals versus low-impact journals and in journals that enforced guidelines versus those that did not.

CONCLUSION: This study highlights the methodological gaps in the NTDB-based orthopedic trauma publications and identifies areas for improvement, including the management of missing data, selection of the study population through data cleaning, identification of sources of bias, and transparency in data accessibility. Future work should test the reproducibility of these studies and evaluate adherence to established guidelines across a broader range of databases and disciplines.

PMID:39854810 | DOI:10.1016/j.injury.2025.112161

Injury. 2025 Jan 12;56(2):112145. doi: 10.1016/j.injury.2025.112145. Online ahead of print.

ABSTRACT

The term "fragility fractures of the pelvis" refers to the disruptions of the pelvic ring that are caused by low energy injuries (such as low-level falls or falls from the standing position) in the elderly population (age over 65 years) in the absence of metastatic bone disease. These fractures are increasing in numbers, due to the aging population, particularly in the developed countries, causing significant morbidity and mortality [1]. Although some fracture patterns are stable enough requiring only conservative treatment, other fracture types can cause significant pelvic instability, demanding a more insistent management protocol.

PMID:39847824 | DOI:10.1016/j.injury.2025.112145

Injury. 2025 Jan 17;56(3):112175. doi: 10.1016/j.injury.2025.112175. Online ahead of print.

ABSTRACT

BACKGROUND: Indications for, and usage of, anticoagulant (AC) and antiplatelet (AP) agents is increasing. In this context, it is important to understand the evidence base of the effect of pre-injury AC/AP agents on patient outcomes in the context of traumatic solid organ injury (SOI) to inform management protocols.

METHODS: A scoping review of the literature was undertaken with a systematic search strategy within the PubMed and Scopus databases. Study characteristics, clinical outcomes and outcome measures including mortality, hospital length of stay, admission to intensive care units, length of stay in intensive care and management details were extracted from included studies.

RESULTS: The search identified six eligible studies reporting results from a total of 26,960 patients. Patients on AC/AP are more likely to fail non-operative management (NOM) than their non-AC/AP counterparts; at the same time, they are less likely to be operated on as a first line of management. Clinical outcome measures (mortality, length of stay, admission to intensive care units, and length of intensive care unit stay) were heterogeneous across studies, but it is likely that AC/AP patients have poorer outcomes in SOI. Results on transfusion requirements were inconclusive.

CONCLUSION: Few studies have examined the effect of pre-injury anticoagulation on outcomes in trauma patients sustaining solid organ injuries. Future studies should more closely examine solid organ trauma within the elderly group, as well as the effect of newer AC/AP agents in current use.

PMID:39842106 | DOI:10.1016/j.injury.2025.112175

Injury. 2025 Jan 10;56(2):112157. doi: 10.1016/j.injury.2025.112157. Online ahead of print.

ABSTRACT

INTRODUCTION: Studies have demonstrated successful outcomes with early weightbearing following open reduction internal fixation (ORIF) of specific ankle fractures. The external validity of an early weightbearing protocol and its effects on patient-reported outcome information scores (PROMIS) has yet to be investigated. This study aimed to investigate the effects of an early weightbearing protocol for all operatively treated ankle fractures and its impact on clinical outcomes and complications.

METHODS: This retrospective cohort study included 229 patients (≥ 16 years) with OTA/AO 44 A-C fractures who underwent open reduction and internal fixation (ORIF). Patients were divided into groups based on early (2-3 weeks postoperative) or delayed (>6 weeks postoperative) weightbearing protocols. Primary outcomes included PROMIS score subsets including physical function, depression, and pain interference and ankle range of motion (ROM) at each follow up visit. Secondary outcomes included complications such as implant removal for pain, prominence, or surgical site infection, revision surgery for failure of fixation or loss of reduction, and post-operative sensory or motor deficits.

RESULTS: There were 96 patients in the early weightbearing cohort and 133 patients in the delayed weightbearing cohort. The median follow-up time of the early weightbearing cohort was 471.47 ± 389.69 days while the delayed cohort was 459.82 ± 358.21 days. Demographics and comorbidities were distributed equally between both groups, except the presence of peripheral neuropathy which was observed more frequently in the delayed weightbearing cohort (8 versus 0, p = 0.022). Results indicated no statistically significant differences in PROMIS scores at final follow up, ankle ROM, or post-operative complications between the early and delayed weightbearing cohorts. Multivariable regression analysis identified smoking as a factor associated with worse ankle ROM at final follow-up.

CONCLUSIONS: This study found that early weightbearing after ORIF of unstable ankle fractures leads to similar PROMIS scores and ankle ROM without increased complications. In addition, smokers were found to have worse ankle ROM when compared to nonsmokers at final follow-up.

PMID:39837099 | DOI:10.1016/j.injury.2025.112157

Injury. 2025 Jan 16;56(2):112171. doi: 10.1016/j.injury.2025.112171. Online ahead of print.

ABSTRACT

BACKGROUND: Fragility fractures of the pelvis are becoming increasingly important in an ageing society. However, they are under-represented in the current research literature. In particular, unstable bilateral fragility fractures of the sacrum (FFP IVb) benefit from surgical treatment, but individual fracture patterns need to be considered in the surgical decision. This study describes the sacral anatomy in patients with FFP IVb pelvic fractures, with particular emphasis on the identification and evaluation of possible trans-sacral screw corridors, with particular emphasis on the transverse fracture components.

METHODS: Design: Retrospective clinical study.

SETTING: Level 1 trauma center. Patient Selection Criteria: The study reviewed 100 patients admitted for bilateral FFP with a transverse fracture between 01 / 2013 and 11 / 2023 that had a preoperative computed tomography (CT) of the pelvis including the fifth vertebra, treated with FFP IVb using preoperative multiplanar CT scans to analyze sacral anatomy. Outcome Measures and Comparisons: Sacral types and transitional abnormalities were classified, and corridor dimensions for S1 and S2 were measured, including estimated bone density using Hounsfield units. Bone corridors ≥ 8 mm were considered adequate. In addition, possible trans-sacral screw corridors were evaluated, taking into account the transverse fracture component.

RESULTS: While large trans-sacral screw corridors (≥ 8 mm) for S1 and S2 were identifiable in most cases, the actual feasibility for screw placement was limited due to the transverse fracture component's location, resulting in meaningful corridors in only 80 % for S1 and 47 % for S2. Additionally, in 4 % of patients without an S1 corridor, trans-sacral screw fixation was deemed inadequate due to the fracture line passing through S2.

CONCLUSIONS: These results indicate that not all FFP IVb fractures can be effectively stabilized using trans-sacral screw or bar fixation, necessitating alternative techniques for some cases. Furthermore, precise preoperative planning is essential for the management of these fractures due to complexity of anatomy. To identify the most suitable treatment approaches, further clinical studies are required.

LEVEL OF EVIDENCE: III.

PMID:39827531 | DOI:10.1016/j.injury.2025.112171

Injury. 2025 Jan 9;56(2):112152. doi: 10.1016/j.injury.2025.112152. Online ahead of print.

ABSTRACT

INTRODUCTION: Concentration of trauma care in trauma network has resulted in different trauma populations across designated levels of trauma care.

OBJECTIVE: Describing psychological health status, by means of the impact event scale (IES) and the hospital anxiety and depression scale (HADS), of major trauma patients one and two years post-trauma across different levels of trauma care in trauma networks.

METHODS: A multicentre retrospective cohort study was conducted.

INCLUSION CRITERIA: aged ≥ 18 and an Injury Severity Score (ISS) > 15, surviving their injuries one year after trauma. Psychological health status was self-reported with HADS and IES. Subgroup analysis, univariate, and multivariable analysis were done on level of trauma care and trauma region for HADS and IES as outcome measures.

RESULTS: Psychological health issues were frequently reported (likely depressed n = 31, 14.7 %); likely anxious n = 32, 15.2 %; indication of a post-traumatic stress disorder n = 46, 18.0 %). Respondents admitted to a level I trauma centre reported more symptoms of anxiety (3, P25-P75 1-6 vs. 5, P25-P75 2-9, p = 0.002), depression (2, P25-P75 1-5 vs. 5, P25-P75 2-9, p < 0.001), and post-traumatic stress (6, P25-P75 0-15 vs. 13, P25-P75 3-33, p = 0.001), than patients admitted to a non-level I trauma centre. Differences across trauma regions were reported for depression (3, P25-P75 1-6 vs. 4, P25-P75 2-10, p = 0.030) and post-traumatic stress (7, P25-P75 0-18 vs. 15, P25-P75 4-34, p < 0.001).

CONCLUSIONS: Major trauma patients admitted to a level I trauma centre have more depressive, anxious, and post-traumatic stress symptoms than when admitted to a non-level I trauma centre. These symptoms differed across trauma regions, indicating populations differences. Level of trauma care and trauma region are important when analysing psychological health status.

PMID:39827530 | DOI:10.1016/j.injury.2025.112152