Injury. 2025 Jan 12;56(2):112160. doi: 10.1016/j.injury.2025.112160. Online ahead of print.

ABSTRACT

BACKGROUND: Femoral neck fractures, particularly Pauwels type II and III, pose significant challenges due to their vertical instability and susceptibility to complications such as non-union and avascular necrosis (AVN). Medial buttress plates (MBPs) have emerged as a promising adjunct in fixation, offering biomechanical advantages by neutralizing shearing forces and enhancing stability. However, the clinical efficacy of MBPs across different fixation techniques, plate configurations, and positioning remains unclear.

PURPOSE: This study aimed to (1) analyse outcomes of femoral neck fracture fixations augmented with MBPs, focusing on Pauwels type 2 and 3 fractures, and (2) analyse the impact of plate size, positioning, and the use of MBPs in different fixation techniques.

STUDY DESIGN: Systematic review; Level of evidence, 4.

METHODS: Two independent reviewers performed a literature search based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using PubMed, MEDLINE, EMBASE, and Cochrane databases. Studies published from 2010 onwards, focusing on MBPs in Pauwels type II and III femoral neck fractures, were included. Clinical outcomes and plate details were recorded.

RESULTS: Data from 21 studies, including 11 derived from meta-analyses, encompassing 642 patients were analysed. MBP-augmented fixations demonstrated a non-union rate of 6 %, an AVN rate of 4 %, and an overall failure rate of 17.3 %. The mean time to union was 3.9 ± 1.2 months, and the average HHS was 89.5 ± 5.5 at the final follow-up. Multiple cannulated screws (MCS) combined with a MBP showed a lower failure rate (14.6 %) compared to dynamic hip screw combined with a MBP (26.8 %), though not statistically significant (p = 0.164). Medial or anteromedial plate positioning yielded better outcomes, while anterior placement was associated with high failure rates. No studies examined the outcomes of femoral neck system fixation combined with a MBP.

CONCLUSION: MBPs are a valuable adjunct in managing Pauwels type II and III femoral neck fractures, providing favourable outcomes with low rates of failure and complications. The combination of MBPs with various fixation techniques has shown promising results, highlighting the potential for improved stability and outcomes. Further research is needed to optimize plate size, screw type, positioning, and the role of MBPs in augmenting fixation techniques for these challenging fractures.

PMID:39827529 | DOI:10.1016/j.injury.2025.112160

Injury. 2025 Jan 12;56(2):112158. doi: 10.1016/j.injury.2025.112158. Online ahead of print.

ABSTRACT

The repair of critical-sized bone defects represents significant clinical challenge. An alternative approach is the use of 3D composite scaffolds to support bone regeneration. Hydroxyapatite (HA) and tri-calcium phosphate (β-TCP), combined with polycaprolactone (PCL), offer promising mechanical resistance and biocompatibility. Bioelectrical stimulation (ES) at physiological levels is proposed to reestablishes tissue bioeletrocity and modulates cell signaling communication, such as the BMP/TGF-β and the RANK/RANK-L/OPG pathways. This study aimed to evaluate the use HA/TCP scaffolds and ES therapy for bone regeneration and their impact on the TGF-β/BMP pathway, alongside their relationship with the RANK/RANKL/OPG pathway in critical bone defects. The scaffolds were implanted at the bone defect in animal model (calvarial bone) and the area was subjected to ES application twice a week at 10 µA intensity of current for 5 min each session. Samples were collected for histomorphometry, immunohistochemistry, and molecular analysis. The TGF-β/BMP pathway study showed the HA/TCP+ES group increased BMP-7 gene expression at 30 and 60 days, and also greater endothelial vascular formation. Moreover, the HA/TCP and HA/TCP+ES groups exhibited a bone remodeling profile, indicated by RANKL/OPG ratio. HA/TCP scaffolds with ES enhanced vascular formation and mineralization initially, while modulation of the BMP/TGF pathway maintained bone homeostasis, controlling resorption via ES with HA/TCP.

PMID:39826405 | DOI:10.1016/j.injury.2025.112158

Injury. 2025 Jan 13;56(2):112154. doi: 10.1016/j.injury.2025.112154. Online ahead of print.

ABSTRACT

BACKGROUND: Boxing is a sport well-known for the risk of injury. However, the epidemiology of boxing-associated fractures has not been well studied. This study aims to report the characteristics of boxing fractures that lead to presentation to the emergency room and evaluate the demographics and practices of the patients to prevent these injuries.

METHODS: This cross-sectional study analyzed boxing-associated fractures over a decade (2013-2022) using the National Electronic Injury Surveillance System (NEISS) database. Patients presenting to U.S. emergency departments with boxing-related injuries were categorized by age, gender, and injury location. Descriptive statistics, chi-square tests, and ANOVA were employed to assess temporal trends and associations between injury occurrence and demographic variables.

RESULTS: Analysis of 959 boxing-associated fractures (BAFs) showed that hand fractures were most common (53.64%), followed by phalanx (12.73%) and facial fractures (10.91%). Significant differences were observed across body parts (χ2 = 9.74, P < .001). Associated soft tissue injuries included lacerations, contusions, sprains, strains, and hematomas, with no significant differences among these categories (χ2 = 1.47, P = 0.832). Males experienced more BAFs than females overall, but females had a significant increase over time (F(1,9) = 4.308, p = 0.032). Most fractures occurred in recreational or sports settings (34.5%), followed by home (19.1%) and school (13.24%). The highest BAF incidence was in individuals aged 21-30 (32.18%), while the lowest was in those aged 41-50 (5.47%). From 2020 to 2022, BAFs decreased in recreational settings and increased at home during 2020-2022.

CONCLUSION: Hand fractures were the most common type of BAF. Males had significantly more BAFs, although the incidence of BAFs in females increased significantly since 2013. Fractures mainly occurred in recreational places, but from 2020-2022, most occurred at home. This shift coincided with the COVID-19 pandemic, suggesting increased home sparring. These findings emphasize the need for further research into protective measures and injury prevention in boxing.

PMID:39823921 | DOI:10.1016/j.injury.2025.112154

Injury. 2025 Jan 11;56(2):112156. doi: 10.1016/j.injury.2025.112156. Online ahead of print.

ABSTRACT

BACKGROUND: Determining trauma as an act of Self-directed violence (SDV) or from high risk or unclear behaviours is challenging for trauma clinicians and may be affected by patient sex and mechanism of injury. The aim of this study was to examine the differences in characteristics and outcomes between those who have intentionally directed violence towards themselves with those of unclear intent, within a regional trauma system.

METHODS: Data was collected between January 2018 and December 2021 in patients who had been identified as a result of either self-directed violence (SDV) defined as any intentional act that can cause injury to one's self, including death or participated in high-risk behaviours, where the intent was unclear (UI). Differences between female and male patients presenting with SDV and unclear intent were explored.

RESULTS: Overall, 2760 patients were identified, with a median age of 39 years (IQR 28-54) and just over a quarter of females (28 %). Falls from height were the most common mechanism of injury in all groups. SDV was recorded in 45 % of patients, and previous mental health diagnoses were almost three times as prevalent in this group compared to those of unclear intent (SDV: 42 % vs UI: 13 %). In the sex-based analysis females were more likely than males to have a history of depression (49 % vs 31 %, p < 0.0001). There were few sex differences in the SDV group but women of unclear intent were older, with a quarter being aged 65 years or over (Females: 26 % vs. Males: 11 %, p < 0.0001). Females of unclear intent were also more likely to have sustained a high level fall (Females: 29 % vs. Males:11 %, p < 0.001).

CONCLUSION: Previous mental health co-morbidity was associated with self-directed violence in our cohort. Yet the determinants of intent for over half of the patients were unclear. Trauma clinicians should actively enquire regarding intent of injury and escalate to clinical psychology or psychiatry teams as indicated. Those with mental health comorbidities, previous depression and older women may all have an increased risk where intent is unclear and warrants further investigation. Understanding the predictors and characteristics of unclear intent and high-risk behaviours are key to implementation of public health strategies around prevention of self-directed violence and suicide.

PMID:39823920 | DOI:10.1016/j.injury.2025.112156

Injury. 2025 Jan 9;56(2):112148. doi: 10.1016/j.injury.2025.112148. Online ahead of print.

ABSTRACT

BACKGROUND: Ballistic fractures of the femoral neck, rare injuries that overwhelmingly affect younger adults, pose significant challenges to the treating surgeon. However, there is limited literature that the treating surgeon can leverage to guide their treatment decisions. The goal of this study is to describe the demographics, associated injuries, outcomes, and complications associated with ballistic femoral neck fractures.

PATIENTS AND METHODS: This retrospective case series, performed at a single, academic, urban, level-one trauma center, evaluated patients with a ballistic fracture of the femoral neck (AO/OTA 31B) between 2003 and 2022. International Classification of Disease codes were utilized to identify patients in the electronic medical record. Chart review was performed to assess patient demographics, associated injuries, success rate of operative and nonoperative intervention, and post-operative complication rate and types.

RESULTS: Seventeen patients were included (94 % male; median age 22.5 years). Median follow up was 12.2 months (range 1-84 months). Five patients (29 %) sustained a concomitant vascular injury. Eight patients (47 %) sustained an additional osseous injury. The median injury severity score was 9 (interquartile range 4-17). Thirteen patients were treated with operative reduction and fixation, 3 patients with incomplete fractures were treated nonoperatively, and one was treated with acute total hip arthroplasty (THA). Overall, 12 of 17 patients (71 %) healed their fracture or had an uncomplicated recovery after acute THA. Of the 13 patients treated with operative reduction and fixation, 8 (62 %) healed their fracture and 5 (38 %) developed one or more post-operative complications.

CONCLUSIONS: Nearly 1 in 3 patients with ballistic femoral neck fractures sustain concomitant vascular injury and almost half sustain another osseous injury. In this series, only 62 % of patients who underwent operative reduction and fixation healed their fractures, and nearly 40 % of patients treated with operative reduction and fixation developed a post-operative complication. Given the poor outcomes and high complication rates associated with these injuries, surgeons should counsel patients with ballistic femoral neck fractures accordingly. Further research into the optimal treatment of ballistic femoral neck fractures is needed.

PMID:39813950 | DOI:10.1016/j.injury.2025.112148

Injury. 2024 Dec 31;56(2):112139. doi: 10.1016/j.injury.2024.112139. Online ahead of print.

ABSTRACT

INTRODUCTION: During revision surgery for the management of patients presenting with long-bone upper extremity nonunion, it is crucial to rule out fracture-related infection (FRI). This is especially true if there are clinical signs suggestive of FRI, or if there is a history of prior FRI, open wound fracture, or surgery. This study aimed to determine the efficacy of frozen section analysis (FSA) in providing real-time diagnosis of FRI in patients with upper-limb long-bone nonunion undergoing revision surgery.

PATIENTS AND METHODS: We included previously surgically treated patients who underwent revision surgery for chronic/late-onset nonunion of the long bones of the upper limbs over a 9-year period. We retrospectively applied the FRI criteria to identify eligible patients and recorded their clinical features and demographic characteristics. In all included patients, samples for microbiological analysis and FSA were collected simultaneously during revision surgery. Patients were categorized according to intraoperative culture results as having aseptic or infected nonunion. The sensitivity, specificity, positive and negative predictive values, and accuracy of FSA test were calculated and compared using microbiological analysis as the reference standard test. The concordance rate between FSA and definitive histopathology was also determined.

RESULTS: Sixty-two patients who were surgically treated for nonunion of the arm or forearm were included in this study. Septic nonunion was diagnosed intraoperatively in 9 patients based on FSA findings, while microbiological analysis confirmed septic nonunion in 8 patients. The sensitivity and specificity of FSA were 88 % (95 % confidence interval [CI] [47, 100]) and 96 % (95 % CI [87, 100]), respectively. Positive and negative predictive values were 78 % (95 % CI [47, 93]) and 98 % (95 % CI [89, 100]), respectively, with an overall test accuracy of 95 % (95 % CI [87, 99]). Cohen's Kappa coefficient between FSA and definitive histopathology was 0.74 (95 % CI [0.5, 1]).

CONCLUSIONS: FSA showed high sensitivity and specificity for the detection of active infection during revision surgery for nonunion of the upper limb. Owing to its high negative predictive value, it can reliably rule out active infections during revision surgery. Since the results are obtained immediately during revision surgery, this approach offers the significant advantage of enabling real-time decision-making.

PMID:39809066 | DOI:10.1016/j.injury.2024.112139

Injury. 2025 Jan 11;56(2):112155. doi: 10.1016/j.injury.2025.112155. Online ahead of print.

ABSTRACT

BACKGROUND: Paediatric upper limb fractures are commonly treated with Kirschner (K) wire fixation, which can be buried or left exposed. Although both techniques are widely used, controversy remains regarding infection risk, complications, and other clinical outcomes between buried and exposed K-wires. This systematic review and meta-analysis aimed to compare infection rates and secondary outcomes between buried and exposed K-wires in paediatric upper limb fractures located distal to and including the elbow, and proximal to the carpus.

METHODS: A systematic review of the literature was conducted according to PRISMA guidelines, with searches performed across Medline, EMBASE, and the Cochrane Library up to July 2023. Studies were included if they directly compared buried and exposed K-wires in paediatric patients (under 18 years old) and reported on infection rates. Meta-analysis was conducted to compare overall infection rates. Pooled means were used to compare secondary outcomes. Bias was assessed using the ROBINS-I and RoB2 tools.

RESULTS: Fifteen studies involving 1,854 participants were included. The meta-analysis showed that buried K-wires were associated with a significantly lower risk of overall postoperative infection compared to exposed K-wires (RR 0.33; 95 % CI 0.22 to 0.50; p< 0.001). The risk of deep infection requiring further surgery was 1.74 % in buried K-wires (95 % CI: 0.72 % to 2.75 %) and 2.07 % in exposed K-wires (95 % CI: 0.55 % to 3.59 %). Skin erosion was a common complication of buried K-wires, with a pooled mean rate of 13.0 %. Buried K-wires were associated with a higher likelihood of requiring removal in theatre (84.4 % vs. 4.2 %). Time to K-wire removal was longer in the buried group (10.9 weeks vs. 5.3 weeks). Re-operation and bone union failure rates were similar between groups.

CONCLUSION: Our systematic review and meta-analysis suggest that, while buried K-wires are associated with lower overall infection rates, the risk of deep infection is comparable between buried and exposed K-wires. Buried K-wires show higher rates of skin erosion and increased need for removal in theatre. Given these findings, exposed K-wires offer a safe and more cost-effective option for paediatric upper limb fracture fixation. Further studies are needed to assess patient-reported outcomes and environmental impacts.

PMID:39809065 | DOI:10.1016/j.injury.2025.112155

Injury. 2025 Jan 12;56(2):112150. doi: 10.1016/j.injury.2025.112150. Online ahead of print.

ABSTRACT

INTRODUCTION: Injuries and violence are among the most prominent public health problems in the world. As well as being a leading cause of mortality - particularly among children and young adults - many of the millions of non-fatal injuries result in life-long disabilities and health consequences. The aim of this study was to estimate the prevalence of unintentional injuries and violence, and their associated factors among high school students.

METHODS: This cross-sectional study included a total of 1218 high-school students in Turkey. Data were collected through a facilitated self-administered questionnaire with questions adapted from the Global School-based Student Health Survey instrument. Data were analyzed in IBM SPSS Statistics 28.0 using chi-square test to find statistical significance if any. The significant variables from the chi-square test were selected for multiple logistic regression analysis.

RESULTS: The overall prevalence of physical attack, physical fighting, and serious injuries were 8.3 %, 14.8 %, and 11.7 %, respectively. In a multiple regression analysis, student truancy and lateness, worry, suicide attempts, and not having close friends were found to be associated with physically attacked, physical fight, and serious injuries.

CONCLUSION: This study demonstrated that the prevalence of unintentional injuries and violence among high school students is a major public health problem in Turkey. This study results can have important implications for school administration, parents, and policymakers alike to plan appropriate anti-violence strategies and interventions.

PMID:39805210 | DOI:10.1016/j.injury.2025.112150

Injury. 2025 Jan 5:112144. doi: 10.1016/j.injury.2025.112144. Online ahead of print.

ABSTRACT

BACKGROUND: Older adults with rib fractures pose an increasing clinical and financial burden on healthcare. Identifying and addressing the increased risk of adverse outcomes has been a key objective in geriatric co-management of surgical patients. The Comprehensive Geriatric Assessment-based Frailty Index (FI-CGA) is a useful predictor of complications and mortality in older adults, but its value in rib fracture management remains unclear. This study investigates the association between FI-CGA and short- and long-term outcomes of older adults with rib fractures.

METHODS: Rib fracture patients ≥65 years, with a FI-CGA score available, were retrospectively identified from a single level-I trauma center between 2018 and 2022. FI-CGA scores were categorized as pre-frail (<0.20), mild frailty (0.20-0.29), moderate frailty (0.30-0.39), and severe frailty (≥0.40). Outcome measures included mortality up to two years, length of stay (LOS), complications, and 30-day readmission.

RESULTS: 288 patients were included for analysis (57 pre-frail; 66 mildly frail; 61 moderately frail; 104 severely frail). Compared to the pre-frail group, only severely frail patients were at higher risk of 90-day (OR 5.71 [CI 1.29 - 52.67]) and 1-year mortality (OR 6.66 [CI 2.18 - 27.37]), while 2-year mortality was higher in mild (OR 3.77 [CI 1.30 - 12.57]), moderate (OR 4.28 [CI 1.46 - 14.51]) and severe (OR 6.42 [CI 2.43 - 20.11]) frailty groups. Hospital (p=0.183) and ICU LOS (p=0.131) was similar across groups. Severely frail patients were at risk of pneumonia (OR 3.50 [CI 0.95 - 19.48]) and delirium (OR 4.16 [CI 1.33 - 17.40]), while other complications were similar between groups (p=0.679). Adjusted proportional hazard ratios for mortality were significantly higher for moderate frailty (HR 1.99 [CI 1.02 - 3.89]) and severe frailty (HR 2.66 [CI 1.10 - 3.73]). FI-CGA was also a significant predictor if used per 0.01 point (HR 1.03 [CI 1.01 - 1.04)]) and per 0.1 point (HR 1.29 [CI 1.12 - 1.47]).

CONCLUSION: FI-CGA can identify vulnerable rib fracture patients at risk of in-hospital complications, and short- and long-term mortality. Continuous FI-CGA scores provide a granular and individualized risk assessment. In severely frail patients with rib fractures, FI-CGA may assist in aligning treatment with individual patients' needs and goals of care.

PMID:39800638 | DOI:10.1016/j.injury.2025.112144

Injury. 2025 Jan 8;56(2):112146. doi: 10.1016/j.injury.2025.112146. Online ahead of print.

ABSTRACT

INTRODUCTION: Intertrochanteric fractures are common in older adults and pose significant challenges in terms of morbidity and mortality. Accurate reduction and optimal implant positioning during operative stabilisation of these fractures reduce the rates of complications and reoperations while improving functional outcomes in this population. This study aimed to assess the effects of a structured educational intervention on the radiographic outcomes, reduction quality, and revision rates of intertrochanteric fractures.

METHODS: We initiated a training program that included an instructional video on interpreting intraoperative fluoroscopic views, as well as instructions and an algorithm for reducing and stabilising intertrochanteric fractures and mandated its implementation for all operating surgeons. We thus established an intervention cohort (n = 209) of patients who underwent surgery after the program's introduction, which we compared with a historical control cohort (n = 207) of patients who had undergone surgery before the program's implementation. The analysed postoperative radiographic parameters included the Baumgaertner reduction index, tip-apex distance (TAD), restoration of the caput-collum-diaphyseal angle, and calcar displacement. Mortality and the need for revision surgery were monitored for 2 years postoperatively.

RESULTS: We observed significant improvements in the intervention cohort, particularly among the less experienced surgeons. The TAD was reduced by 7 %, indicating improved implant positioning. Similarly, the Baumgaertner reduction index revealed an increase in 'good' reductions (40.2% vs. 37.2 %). Additionally, the rates of revision surgery (4.8% vs. 11.1 %) and mechanical complications (1.9% vs. 6.3 %) were lower in the intervention cohort than in the control cohort.

CONCLUSION: Implementation of the structured training program led to better radiographic outcomes for intertrochanteric fractures, especially among less experienced surgeons. The observed improvements in reduction quality and decrease in revision rates underscore the potential benefits of incorporating educational interventions in orthopaedic trauma treatment.

PMID:39799872 | DOI:10.1016/j.injury.2025.112146

Injury. 2025 Jan 9;56(2):112159. doi: 10.1016/j.injury.2025.112159. Online ahead of print.

ABSTRACT

Traumatic brain injury (TBI) remains a leading cause of morbidity and mortality among trauma patients. The care of these patients continues to be a complex endeavor with prevention of associated complications, often requiring as much attention as that of the treatment of the primary injury. Paramount among these are venous thromboembolic events (VTE) due to their high incidence, additive effect on the risk of morbidity and mortality, and the careful balance that must be utilized in their diagnosis and treatment to prevent progression of the brain injury itself. In this review, we have synthesized the most recent major studies detailing the ideal choice of chemoprophylactic agent, the timing of initiation, and continued monitoring and management strategies through the hospital course and beyond. Additional discussion is provided for subpopulations in which management can vary significantly, including the elderly, critically ill, and obese. Ultimately, current literature supports the use and safety of low molecular weight heparin over unfractionated heparin, especially when dosed using newer assays including anti-Xa levels. The timing of prophylaxis remains important, as the risk of VTE increases with each day that prophylaxis is held. Consensus findings favor initiation within 24-72 h, in the absence of documented progression, life threatening bleeding, or need for major surgical intervention. Despite available data, there continues to be significant variability in practice patterns which we hope to address with this review.

PMID:39799871 | DOI:10.1016/j.injury.2025.112159

Injury. 2025 Jan 5;56(2):112137. doi: 10.1016/j.injury.2024.112137. Online ahead of print.

ABSTRACT

Treatment algorithms for fracture nonunion depend on the presence or absence of bacterial infection. However, it is often impossible to identify infection preoperatively. While some infections may present with clinical signs of infection, low-grade infections lack infection signs and have a clinical presentation similar to aseptic nonunion. The clinical relevance of low-grade infection in nonunion is not entirely clear. Therefore, the aim of this study was to evaluate the role of low-grade infection in the development and management of lower extremity nonunion. A prospective multicenter clinical study enrolled patients with femoral or tibial shaft nonunion and regular healed fractures, scheduled for nonunion revision and routine implant removal, respectively. Preoperatively, serum markers including C-reactive protein (CRP), leukocytes, and procalcitonin were determined, clinical infection signs were recorded, and a suspected septic or aseptic diagnosis was made prior to surgery and further diagnostics. Tissue samples were collected for microbiology and histopathology, and osteosynthesis material for sonication. Nonunion patients were followed for twelve months, during which the definitive diagnosis of "septic" or "aseptic" nonunion was made according to diagnostic criteria for fracture-related infection. One hundred and ten patients with nonunion and 34 patients with regular healed fractures were included. Sixty-two nonunion patients were diagnosed as aseptic, 22 with expected and confirmed infection, and 23 with unexpected low-grade infection. Three patients had an unclear diagnosis. Low-grade infection was detected in 28 % of presumed aseptic nonunion patients. Sensitivity and specificity for the suspected diagnosis were 49 % and 95 %, respectively. The suspected diagnosis had a significant impact on revision strategy. All medians of the preoperative blood values were within the reference ranges except for CRP, which was slightly elevated in the expected and confirmed infected nonunion group. Expected and confirmed septic nonunion and unexpected low-grade infected nonunion demonstrated a similar bacterial spectrum. While 10 % of patients with aseptic nonunion required follow-up surgeries, re-operation rates were higher in patients with low-grade infection and expected and confirmed infection at 30 % and 64 %, respectively. Patients with low-grade infections were treated less frequently with systemic antibiotics and for a shorter duration than patients with expected and confirmed infections, with no significant difference in healing rate which was 83 % in low-grade and 62 % in expected and confirmed infections. The healing rate of aseptic nonunion was 90 %. A limitation of this study is the limited number of tissue samples for microbiological and histopathological diagnostics in the suspected aseptic nonunion cohort, which may have led to an underestimation of the low-grade infection rate. Our findings suggest that unexpected low-grade infection is frequently associated with nonunion. While expected and confirmed infected nonunion differs significantly from aseptic nonunion, low-grade infected nonunion is very similar to aseptic nonunion, except for intraoperative bacterial detection. In addition to antibiotic therapy, surgical nonunion revision with implant exchange and debridement appears to be highly effective in achieving consolidation of low-grade infected nonunion.

PMID:39799870 | DOI:10.1016/j.injury.2024.112137

Injury. 2025 Jan 5;56(2):112143. doi: 10.1016/j.injury.2025.112143. Online ahead of print.

ABSTRACT

INTRODUCTION: In the United States, deep vein thrombosis (DVT) and pulmonary embolism (PE) ranked high in terms of possibly preventable hospital deaths. Victims of trauma were at a higher risk of developing thromboembolic complications, and thus various agents were used for prophylaxis. Multiple studies recommended holding these agents in the perioperative period to decrease the potential complications of additional bleeding, wound issues, hematoma etc. However, the data regarding the timing and duration of withholding these agents was not consistent and at times surgeon specific. The aim of this study was to compare the incidence of DVT/PE in trauma patients before and after a June 2022 policy intervention to operate through prophylactic anticoagulation at an academic trauma center.

METHODS: We compared DVT/PE rates in trauma patients requiring surgery prior to and following policy change at our institution. The query included charts from January 1, 2018, through December 31, 2023. Clinical information relating to trauma date, surgery date, injury type, anticoagulant administration, DVT/PE development, and death, if applicable, was obtained from patient charts. We conducted a chi-square post hoc analysis to evaluate the incidence of DVT or PE before and after a policy change. The analysis focused on two categories: the presence or absence of DVT/PE.

RESULTS: DVT/PE development was 14.553 times more likely pre-policy change when anticoagulation was held prior to surgery compared to post-policy change when anticoagulation was administered before surgery (X2 (3, N = 374) =14.553, p=.002). Mortality related to DVT/PE showed no significant difference between pre-policy and post-policy groups (X2 (1, N = 374) = 0.130, p = .718). After excluding patients over age 65, analysis of MVA blunt trauma charts showed no statistical difference in blood transfusions pre policy v. post policy (X2 (1, N = 174) = 0.2198, p = .639).

CONCLUSION: Findings suggested that DVT/PE rates have significantly decreased post policy change without a significant increase in mortality and bleeding risk.

PMID:39798393 | DOI:10.1016/j.injury.2025.112143

Injury. 2025 Jan 7;56(2):112153. doi: 10.1016/j.injury.2025.112153. Online ahead of print.

ABSTRACT

BACKGROUND: Falls are some of the most common childhood injuries. However, for vulnerable children in low- and middle-income countries (LMICs) such as India, mortality from a fall is nearly three times that of high-income countries. Despite fall being a leading cause of paediatric injury, detailed data from LMICs remain sparse. This study aims to assess fall-related patterns of injury and mortality in children in urban India.

METHODS: We conducted a retrospective analysis from the Towards Improved Trauma Care Outcomes (TITCO) database, comprising 16,000 trauma patients admitted to four tertiary centres in India, between July 2013 and December 2015. We analysed demographics, Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), and the pattern of injury sustained for patients under 18-years admitted with fall and assessed survival probability in different age groups using Kaplan-Meier survival analysis and log-rank tests.

RESULTS: Of 1281 children admitted after a fall, two-to-five-year-olds formed the majority (40 %). Nearly all children (99 %) had blunt trauma. The median ISS was 9 (IQR 9-11) and median GCS was 15. Overall in-hospital mortality was 7.8 % and isolated traumatic brain injury (TBI) was the most common (71 %) injury in those who died. Mortality was significantly higher in male children (9 %) than in female children (5 %) (p = 0.009). There was no significant difference in survival between age groups (p = 0.9).

CONCLUSION: The majority of paediatric patients admitted to urban hospitals in India after a fall were between the ages of two-to-five years, with isolated TBI and male sex associated with greater mortality. These findings have the potential to aid age-specific fall prevention strategies and resource allocation towards targeted initiatives to improve access to care, and consequently, mortality from fall in urban India.

PMID:39793303 | DOI:10.1016/j.injury.2025.112153

Injury. 2024 Dec 31;56(2):112091. doi: 10.1016/j.injury.2024.112091. Online ahead of print.

ABSTRACT

BACKGROUND: Severe metaphyseal comminution and sizable bone defect of the distal femur are high risks of fixation failure. To date, no exact magnitude of comminution and bone loss is determined as an indication for augmentation of fixation construct. The present study aimed to investigate the influence of metaphyseal gap width, working length, and screw distribution on the stability of the fixation construct.

METHODS: A finite element model of a fractured femur with 0-80 mm metaphyseal gap width stabilized by an 11-hole distal femur locking compression plate (LCP-DF) was generated. The different working length and screw distribution were created by three different screw configurations: 9-10-11 (long working length, cluster screw), 8-10-11, and 7-9-11 (short working length, spreading screw). Physiological loading conditions were applied to evaluate biomechanical performance including equivalent von Mises (EQV) stress, bone stress, and fracture strain.

RESULTS: The EQV stress increased accordingly to a metaphyseal gap width of 0-20 mm. The EQV stress values were at the same levels for 30-mm metaphyseal gap width and higher, particularly in screw configuration 9-10-11. Screw configuration 7-9-11 produced the lowest elastic strain. A 0-mm metaphyseal gap width presented the lowest bone stress. Bone stress values were in a similar magnitude across a 10-80 mm metaphyseal gap.

CONCLUSION: The 30-mm and wider metaphyseal gap width with a long working length presented a risk of varus collapse and fixation failure. Short working length with spreading screw provided low EQV stress, low bone stress, and high fracture stability.

PMID:39787783 | DOI:10.1016/j.injury.2024.112091

Injury. 2025 Jan 6;56(2):112134. doi: 10.1016/j.injury.2024.112134. Online ahead of print.

ABSTRACT

BACKGROUND: Medical training therapy (MTT) is an advanced, individualized rehabilitation approach that integrates multiple methods to improve physical function. It is widely applied to rehabilitate sports injuries. This randomized study evaluated MTT's effects on physical injury rehabilitation, mental function, and athletic performance in elite rock climbers.

METHODS: Thirty elite climbers (mean age 19.5 ± 2.9 years) from the Chinese National Climbing Team were randomly assigned to either an intervention group (MTT, n = 15) or a control group (CON, n = 15) for 16 weeks (May 6 to August 25, 2024). Both groups had access to the same rehabilitation facilities and physiotherapy. The CON group followed routine training, while the MTT group received additional exercises. The primary outcome was the incidence of climbing-related injuries across 19 body regions. Secondary outcomes included specialized abilities, Functional Movement Screen (FMS) scores, Self-Rating Anxiety Scale (SAS), and Pittsburgh Sleep Quality Index (PSQI).

RESULTS: The total number of injuries (375, 4.74) and the duration of discomfort (weeks) in the MTT group were lower than those in the CON group (492, 7.26). The MTT group demonstrated significant improvements in outcomes at six sites including the shoulder, forearm, hand, wrist, upper back, and hip (10 % and 21.25 %, 6.67 % and 19.17 %, 27.08 % and 56.67 %, 10.42 % and 3.75 %, 17.08 % and 27.08 %, and 2.08 % and 4.58 % for the MTT and CON groups, respectively, p < 0.05). In tests of sports-specific performance and psychological functioning in rock climbing, time and between-group interaction effects were observed (p < 0.01) for the Finger Strip Endurance Test, Hanging L-Lift Leg Test, FMS, and SAS. After the intervention, the MTT group exhibited a relative increase in injuries to the neck, upper back, and knees (6.25 % and 1.25 %, 6.67 % and 13.33 %, and 13.75 % and 7.08 % for the MTT and CON groups, respectively, p < 0.05).

CONCLUSION: MTT is an ideal method for the rehabilitation of injuries in elite rock climbers and for facilitating their early return to sport. It addresses the majority of athletes' physical injuries and reduces the concentration of injuries in high-risk areas. Additionally, it specifically improves athletes' performance in specialized tests to alleviate the symptom of anxiety.

PMID:39787782 | DOI:10.1016/j.injury.2024.112134

Injury. 2025 Jan 3;56(2):112142. doi: 10.1016/j.injury.2025.112142. Online ahead of print.

NO ABSTRACT

PMID:39778264 | DOI:10.1016/j.injury.2025.112142

Injury. 2025 Jan 3;56(2):112141. doi: 10.1016/j.injury.2025.112141. Online ahead of print.

NO ABSTRACT

PMID:39778263 | DOI:10.1016/j.injury.2025.112141

Injury. 2024 Dec 27;56(2):112087. doi: 10.1016/j.injury.2024.112087. Online ahead of print.

ABSTRACT

PURPOSE: Several concerns regarding gender equality in orthopedic surgery do exists. The aim of this study was to (1) compare operative times, (2) compare mortality rates, (3) investigate gender disparities in hip fracture surgeries, and (4) analyze gender distribution among attending and resident surgeons performing Closed Reduction Internal Fixation (CRIF) and Hemiarthroplasty (HA) METHODS: All patients >75 years old treated for proximal femur fractures in a level-one trauma center in a four-year timeframe were retrospectively enrolled. Exclusion criteria were follow-up <3 years, incomplete data, active patients treated with total hip arthroplasty (THA) and other surgeries performed during the same anesthesia. Patients were grouped according to procedure: 1) Closed Reduction Internal Fixation (CRIF) and 2) Hemiarthroplasty (HA). Gender and level of expertise (residents or attending surgeon) of leading surgeons (male (M), female (F) and non-binary (NB)) was extracted from medical records. Operative time, mortality rates, and the likelihood of performing either CRIF or HA were compared across genders.

RESULTS: A total of 172 leading surgeons (M: 141 (82%); F: 31 (18%); NB: 0 (0%)) performed 1916 surgical procedures (CRIF: 1425 (74.4%); HA: 491 (25.6%)). 14.7% were performed by female surgeons (group 1: 15.5%; group 2: 12.2%; p = 0.076). No gender disparities were observed in the mean operating times for either group 1 (p = 0.759) or group 2 (p = 0.981). Similarly, there were no significant differences in mortality rates between genders in group 1 (p = 0.5779) or group 2 (p = 0.069). Additionally, no significant gender disparities were found in the performance of CRIF (p = 0.636) or HA (p = 0.141). Finally, analysis of gender distribution among attending and resident surgeons across various procedures, including CRIF and HA, revealed no significant differences in gender distribution (CRIF: p = 0.133, HA: p = 0.468, all procedures: p = 0.122).

CONCLUSIONS: Despite orthopedics still being a male-dominated field, gender does not affect surgical outcomes or the likelihood of performing CRIF or HA. However, the focus should shift towards improving inclusivity in surgical education and practice by providing equal opportunities and removing social and educational barriers based on gender.

PMID:39756148 | DOI:10.1016/j.injury.2024.112087

Injury. 2025 Jan 1;56(2):112135. doi: 10.1016/j.injury.2024.112135. Online ahead of print.

ABSTRACT

INTRODUCTION: In city hospitals, subway-related traumatic amputations are a frequent pattern of injury, however there is a paucity of literature on this specific injury pattern. The purpose of this study was to describe the epidemiology of subway-related traumatic amputations, as well as compare them to non-subway traumatic amputations.

PATIENTS AND METHODS: Retrospective review was performed at a single Level-1 trauma center in a metropolitan area. All patients who sustained a traumatic lower-extremity amputation over a seven-year period were included. Demographics, injury, treatment-related information, and complications were collected. Subway and non-subway traumatic amputations were statistically compared. Cohorts were further subdivided into above-knee amputations (AKAs) and below-knee amputations (BKAs) for statistical comparison.

RESULTS: Fifty-seven patients sustained 72 traumatic lower-extremity amputations, including 64 subway-related amputations. Fifteen patients with bilateral lower-extremity amputations all had subway-related injuries. Patients with subway-related injuries were more likely to have a history of alcohol use disorder (58.1 % vs. 0 %; P = 0.002), and experienced longer stays in the intensive care unit (ICU) (8.9 vs. 3.6 days; P = 0.006). Twenty-four amputations (33.3 %) were complicated by wound infection during the initial hospitalization, with wound cultures growing a variety of organisms, most frequently Enterococcus species and Enterobacter cloacae. When subway injuries were separated by AKAs and BKAs, patients with AKAs underwent more irrigation and debridement procedures on average (10.3 vs. 5.8; P = 0.006), had a higher rate of wound infections (58.8 % vs. 25.0 %; P = 0.018), and had longer hospital stays (50.4 vs. 32.2 days; P = 0.047).

CONCLUSION: Subway-related amputations are associated with longer ICU stays and a history of alcohol use disorder compared to non-subway traumatic amputations. Approximately 1/3 of these patients are expected to develop a wound infection, with Enterococcus and Enterobacter species being the most commonly identified organisms. Further research into high-energy, traumatic amputations, including subway injuries, may help improve prognostication of patient outcomes, identify potential in-hospital complications, and proactively direct differences in care compared to the standard for non-subway-related amputations.

LEVEL OF EVIDENCE: Prognostic Level III.

PMID:39754898 | DOI:10.1016/j.injury.2024.112135