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Zhang J, Lu V, Zhou AK, Stevenson A, Thahir A, Krkovic M. Predictors for infection severity for open tibial fractures: major trauma centre perspective. Arch Orthop Trauma Surg 2023; 143:6579-6587. [PMID: 37418004 PMCID: PMC10541339 DOI: 10.1007/s00402-023-04956-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION Open diaphyseal tibial fractures are the most common long-bone fractures and require a rapid approach to prevent devastating complications. Current literature reports the outcomes of open tibial fractures. However, there is no robust, up-to-date research on the predictive indicators of infection severity in a large open tibial fracture patient cohort. This study investigated the predictive factors of superficial infections and osteomyelitis in open tibial fractures. MATERIALS AND METHODS A retrospective analysis of the tibial fracture database was carried out from 2014 to 2020. Criteria for inclusion was any tibial fracture including tibial plateau, shaft, pilon or ankle, with an open wound at the fracture site. Exclusion criteria included patients with a follow-up period of less than 12 months and who are deceased. A total of 235 patients were included in our study, of which 154 (65.6%), 42 (17.9%), and 39 (16.6%) developed no infection, superficial infection, or osteomyelitis, respectively. Patient demographics, injury characteristics, fracture characteristics, infection status and management details were collected for all patients. RESULTS On multivariate modelling, patients with BMI > 30 (OR = 2.078, 95%CI [1.145-6.317], p = 0.025), Gustilo-Anderson (GA) type III (OR = 6.120, 95%CI [1.995-18.767], p = 0.001), longer time to soft tissue cover (p = 0.006) were more likely to develop a superficial infection, and patients with wound contamination (OR = 3.152, 95%CI [1.079-9.207], p = 0.036), GA-3 (OR = 3.387,95%CI [1.103-10.405], p = 0.026), longer to soft tissue cover (p = 0.007) were more likely to develop osteomyelitis. Univariate analysis also determined that risk factors for superficial infection were: BMI > 35 (OR = 6.107, 95%CI [2.283-16.332], p = 0.003) and wound contamination (OR = 2.249, 95%CI [1.015-5.135], p = 0.047); whilst currently smoking (OR = 2.298, 95%CI [1.087-4.856], p = 0.025), polytrauma (OR = 3.212, 95%CI [1.556-6.629], p = 0.001), longer time to definitive fixation (p = 0.023) were for osteomyelitis. However, none of these reached significance in multivariate analysis. CONCLUSION Higher GA classification is a significant risk factor for developing superficial infection and osteomyelitis, with a stronger association with osteomyelitis, especially GA 3C fractures. Predictors for superficial infection included BMI and time to soft tissue closure. Time to definitive fixation, time to soft tissue closure, and wound contamination were associated with osteomyelitis.
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Affiliation(s)
- James Zhang
- Department of Trauma and OrthopaedicsAddenbrooke’s Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP UK
| | - Victor Lu
- Department of Trauma and OrthopaedicsAddenbrooke’s Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP UK
| | - Andrew Kailin Zhou
- Department of Trauma and OrthopaedicsAddenbrooke’s Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP UK
| | - Anna Stevenson
- Department of Trauma and OrthopaedicsAddenbrooke’s Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP UK
| | - Azeem Thahir
- Department of Trauma and OrthopaedicsAddenbrooke’s Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
| | - Matija Krkovic
- Department of Trauma and OrthopaedicsAddenbrooke’s Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
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Mica L, Niggli C, Bak P, Yaeli A, McClain M, Lawrie CM, Pape HC. Development of a Visual Analytics Tool for Polytrauma Patients: Proof of Concept for a New Assessment Tool Using a Multiple Layer Sankey Diagram in a Single-Center Database. World J Surg 2020; 44:764-772. [PMID: 31712843 DOI: 10.1007/s00268-019-05267-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Early physiological assessment of multiple injured patients is crucial for decision making and has relied on personal experience of trauma experts. We have developed a new visual analytics tool (Sankey diagram, Watson Trauma Health care tool) that includes known prognostic parameters for polytrauma patients to help guide assessment and treatment decisions for physicians involved in trauma care. METHODS A prospectively collected trauma database of a single level I trauma center (3655 patients) was used. INCLUSION CRITERIA age >16 years, an injury severity score (ISS) >16 and presence of a complete data set in the database. Data collected included admission values of patient age, injury scoring, shock classification, temperature, acid-base and hemostasis parameters. All of these parameters were collected daily as longitudinal parameters. Endpoints of the clinical course we considered were sepsis, SIRS and early in hospital mortality (<72 h). A proof of concept of the visualization was developed over a 2-year period in a cooperation between physicians and engineers. Statistically, the most predictive parameters were selected by binary logistic regression and ROC analysis. RESULTS A dynamic interactive multilayer Sankey diagram, based on cohort similarities, was developed in a collaboration between the University Hospital of Zurich, Department of Trauma and IBM, from August 2017 until January 2018. It is a modular tool and allows any user to add a new patient, or work with an existing case. The visualization used the data-driven documents (D3) interactive visualization library to create a responsive graphic. CONCLUSIONS This application summarizes the experience of 3655 polytrauma patients and might serve as a guide for clinical decisions and educative purposes, as well as new scientific questions for the polytrauma patient. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ladislav Mica
- Department of Trauma Surgery, University Hospital of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
| | - Cedric Niggli
- Department of Trauma Surgery, University Hospital of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Peter Bak
- IBM Haifa University Campus, 3498825, Mount Carmel Haifa, Israel
| | - Avi Yaeli
- IBM Haifa University Campus, 3498825, Mount Carmel Haifa, Israel
| | - Margaret McClain
- Gettysburg College, Durham University, 281 Canterwood Ln, Wexford, PA, 15090, USA
| | - Charles M Lawrie
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO, 63130, USA
| | - Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
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Weber CD, Hildebrand F, Kobbe P, Lefering R, Sellei RM, Pape HC. Epidemiology of open tibia fractures in a population-based database: update on current risk factors and clinical implications. Eur J Trauma Emerg Surg 2018; 45:445-453. [PMID: 29396757 DOI: 10.1007/s00068-018-0916-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/31/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Open tibia fractures usually occur in high-energy mechanisms and are commonly associated with multiple traumas. The purposes of this study were to define the epidemiology of open tibia fractures in severely injured patients and to evaluate risk factors for major complications. METHODS A cohort from a nationwide population-based prospective database was analyzed (TraumaRegister DGU®). Inclusion criteria were: (1) open or closed tibia fracture, (2) Injury Severity Score (ISS) ≥ 16 points, (3) age ≥ 16 years, and (4) survival until primary admission. According to the soft tissue status, patients were divided either in the closed (CTF) or into the open fracture (OTF) group. The OTF group was subdivided according to the Gustilo/Anderson classification. Demographic data, injury mechanisms, injury severity, surgical fracture management, hospital and ICU length of stay and systemic complications (e.g., multiple organ failure (MOF), sepsis, mortality) were collected and analyzed by SPSS (Version 23, IBM Inc., NY, USA). RESULTS Out of 148.498 registered patients between 1/2002 and 12/2013; a total of 4.940 met the inclusion criteria (mean age 46.2 ± 19.4 years, ISS 30.4 ± 12.6 points). The CTF group included 2000 patients (40.5%), whereas 2940 patients (59.5%) sustained open tibia fractures (I°: 49.3%, II°: 27.5%, III°: 23.2%). High-energy trauma was the leading mechanism in case of open fractures. Despite comparable ISS and NISS values in patients with closed and open tibia fractures, open fractures were significantly associated with higher volume resuscitation (p < 0.001), more blood (p < 0.001), and mass transfusions (p = 0.006). While the rate of external fixation increased with the severity of soft tissue injury (37.6 to 76.5%), no major effect on mortality and other major complications was observed. CONCLUSION Open tibia fractures are common in multiple trauma patients and are therefore associated with increased resuscitation requirements, more surgical procedures and increased in-hospital length of stay. However, increased systemic complications are not observed if a soft tissue adapted surgical protocol is applied.
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Affiliation(s)
- Christian David Weber
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Pauwels Street 30, 52074, Aachen, Germany.
| | - Frank Hildebrand
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Pauwels Street 30, 52074, Aachen, Germany
| | - Philipp Kobbe
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Pauwels Street 30, 52074, Aachen, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - Richard M Sellei
- Department of Trauma Surgery and Orthopaedics, Sana Klinikum, Offenbach, Germany
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Classification of soft-tissue injuries in open femur fractures: Relevant for systemic complications? J Trauma Acute Care Surg 2017; 81:824-833. [PMID: 27533903 DOI: 10.1097/ta.0000000000001216] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A broad range of systemic complications has been described to occur in patients with open major fractures. Various causes have been claimed to play a role. We therefore surveyed a nationwide trauma registry to assess risk factors associated with closed and various types of open femur fractures. METHODS This was a cohort study in a nationwide population-based prospective database. Inclusion criteria for selection from database are as follows: individuals with femur fracture, age 16 years or older, and survival until primary admission. Main groups included closed and open femur fracture. Patient demographics, injury severity (New Injury Severity Score), surgical fracture management, length of stay, and systemic complications (e.g., multiple organ failure [MOF], sepsis, mortality) were collected and statistically analyzed using SPSS statistics. Multivariate regression analysis was performed to stratify subgroups for the degree of open soft-tissue injury according to Gustilo and Anderson. RESULTS Among 32,582 documented trauma victims (January 1, 2002, to December 31, 2010), a total of 5,761 met the inclusion criteria. Main groups: 4,423 closed (76.8%) and 1,338 open femur fractures (23.2%). Open fractures subgroups were divided into I° (334, 28.1%), II° (526, 44.3%), and III° (328, 27.6%). Open fractures were associated with an increased risk of prehospital hemorrhagic shock (p = 0.01), higher resuscitation requirements (p < 0.001), MOF (p = 0.001), and longer in-hospital (p < 0.001) and intensive care stay (p = 0.001). While New Injury Severity Score values showed a minor increase per subgroup, the prevalence of MOF, sepsis, and mortality multiplied with the degree of open soft-tissue injury. Especially patients with Type III open femur fractures received mass transfusions (28.2%, p < 0.001), and mass transfusions were identified as independent predictor for sepsis (odds ratio [OR], 2.393; 95% confidence interval [CI], 1.821-3.143; p < 0.001) and MOF (OR, 2.966; 95% CI, 2.409-3.651; p < 0.001). Our data also indicate an increased mortality in patients with open femur managed outside Level I trauma centers (OR, 1.358; 95% CI, 1.018-1.812; p = 0.037). CONCLUSION Open femur fractures are associated with higher in-hospital complications related to incidence of MOF, associated intensive care unit stay, and hospital days when compared with closed femur fractures. For prevention of in-hospital complications, prompt hemorrhage control, surgical fracture fixation, cautious blood management, and triage to a Level I trauma center must be considered. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level II.
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Dei Giudici L, Giampaolini N, Panfighi A, Marinelli M, Procaccini R, Gigante A. Orthopaedic Timing in Polytrauma in a Second Level Emergency Hospital. An Overrated Problem? Open Orthop J 2015; 9:296-302. [PMID: 26312113 PMCID: PMC4541330 DOI: 10.2174/1874325001509010296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 04/26/2015] [Accepted: 05/18/2015] [Indexed: 11/22/2022] Open
Abstract
The main concern for orthopaedic treatment in polytrauma has always been the same for almost forty years, which also regards "where" and "when" to proceed; correct surgical timing and correct interpretation of the DCO concept are still being debated. In the last few years, several attempts have been made to classify patients based on their clinical presentation and by trying to figure out which vital parameters are able to predict the patient's outcome. This study evaluated all patients who presented with code red at the Emergency Department of our Hospital, a level II trauma center. For every patient, the following characteristics were noted: sex, age, day of hospitalization, orthopaedic trauma, time to surgery, presence of an associated surgical condition in the fields of general surgery, thoracic surgery, neurosurgery and vascular surgery, cardiac frequency, blood pressure, oxygen saturation, Glasgow Coma Scale and laboratory data. All patients included were divided into subgroups based on orthopaedic surgical timing. Two other subgroups were also identified and analyzed in detail: deceased and weekend traumas. A total of 208 patients were included. Our primary goal was to identify a correlation between the mortality and surgical timing of the orthopaedic procedures; our secondary goal was to recognize, if present, a statistically relevant association between historical, clinical and laboratory data, and mortality rate, defining any possible risk factor. A correlation between mortality and orthopaedic surgical timing was not found. Analyzing laboratory data revealed an interesting correlation between mortality and: blood pressure, platelet count, cardiac frequency, hematocrit, hemoglobin and age.
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Affiliation(s)
- L Dei Giudici
- Clinical Orthopaedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Italy
| | - N Giampaolini
- Clinical Orthopaedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Italy
| | - A Panfighi
- Clinical Orthopaedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Italy
| | - M Marinelli
- Clinical Orthopaedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Italy
| | - R Procaccini
- Clinical Orthopaedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Italy
| | - A Gigante
- Clinical Orthopaedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Italy
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Abstract
BACKGROUND Development of trauma systems is a demanding process. The United States and Germany both have sophisticated trauma systems. This manuscript is a summary of political, economic, and medical changes that have led to the development of both trauma systems and the current high-quality standards. QUESTIONS/PURPOSES We specifically asked three questions: (1) What tasks are involved in developing a modern trauma system? (2) What is the approach to achieve this task? (3) Do these systems work? METHODS We conducted a systematic review of relevant articles by searching electronic databases (PubMed, Embase, Cochrane library) using the following search terms: "trauma system", "polytrauma", "trauma networks", and "trauma registry". Of 2573 retrieved manuscripts, the authors made a personal selection of studies. A personal study selection from our experiences was added when their contribution to the topic was judged important. RESULTS Worldwide, similar tasks concerning trauma care have to be addressed. In most societies, traffic accidents and firearm-related injuries contribute to a high number of trauma victims. The German approach has been to decrease the number of accidents through injury prevention and to provide better care by establishing an emergency medical system. For in-hospital treatment, clinical care has constantly improved and a close interaction with members from the American Association for the Surgery of Trauma and the Orthopaedic Trauma Association has helped a great deal to achieve these improvements. The German healthcare system was developed as a powerful healthcare tool covering patients from injury to rehabilitation. In addition, trauma and injury research has been strengthened to deal with various questions of trauma care. CONCLUSIONS Organized injury prevention programs and systematized professional patient care can address the issues associated with the global burden of trauma. These trauma systems require constant monitoring and improvement.
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Physician involvement in the care of multiply injured patients: the role of guidelines and subspecialties. Eur J Trauma Emerg Surg 2012; 38:209-10. [PMID: 26815951 DOI: 10.1007/s00068-012-0193-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 04/16/2012] [Indexed: 10/28/2022]
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Schreiber VM, Tarkin IS, Hildebrand F, Darwiche S, Pfeifer R, Chelly J, Giannoudis P, Pape HC. The timing of definitive fixation for major fractures in polytrauma--a matched-pair comparison between a US and European level I centres: analysis of current fracture management practice in polytrauma. Injury 2011; 42:650-4. [PMID: 20701910 DOI: 10.1016/j.injury.2010.07.248] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 06/14/2010] [Accepted: 07/12/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE Early definitive stabilisation is usually the treatment of choice for major fractures in polytrauma patients. Modifications may be made when patients are in critical condition, or when associated injuries dictate the timing of surgery. The current study investigates whether the timing of fracture treatment is different in different trauma systems. MATERIALS AND METHODS Consecutive patients treated a Level I trauma centre were documented (Group US) and a matched-pair group was gathered from the German Trauma Registry (Group GTR). INCLUSION CRITERIA New Injury Severity Score (NISS)>16, >2 major fractures and >1 organ/soft tissue injury. The timing and type of surgery for major fractures was recorded, as were major complications. RESULTS 114 patients were included, n=57 Group US (35.1% F, 64.9% M, mean age: 44.1 yrs±16.49, mean NISS: 27.4±8.65, mean ICU stay: 10±7.49) and n=57 Group GTR (36.8% F, 63.1% M, mean age: 41.2 yrs±15.35, mean NISS: 29.4±6.88, mean ICU stay: 15.6±18.25). 44 (57.1%) out of 77 fractures in Group US received primary definitive fracture fixation compared to 61 (65.5%) out of 93 fractures in Group GTR (n.s.). The average duration until definitive treatment was comparable in all major extremity fractures (pelvis: 5 days±2.8 Group US, 7.1 days±9.6 Group GTR (n.s.), femur: 7.9 days±8.3 Group US, 5.5 days±7.9 (n.s.), tibia: 6.2 days±5.6 Group US, 6.2 days±9.1 Group GTR (n.s.), humerus: 5 days±3.7 Group US, 6.6 days±6.1 Group GTR (n.s.), radius: 6 days±4.7 Group US, 6.1 days±8.7 Group GTR (n.s.). CONCLUSION The current matched-pair analysis demonstrates that the timing of initial definitive fixation of major fractures is comparable between the US and Europe. Certain fractures are stabilised internally in a staged fashion regardless the trauma system, thus discounting previous apparent contradictions.
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Affiliation(s)
- Verena M Schreiber
- Department of Orthopaedic Surgery, Division of Trauma, University of Pittsburgh, Pittsburgh, USA.
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Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery. J Am Acad Orthop Surg 2009; 17:541-9. [PMID: 19726738 DOI: 10.5435/00124635-200909000-00001] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The optimal timing of surgical stabilization of fractures in the multitrauma patient is controversial. There are advantages to early definitive surgery for most patients. Early temporary fixation using external fixators, followed by definitive fixation (ie, the damage control approach), may increase the chance for survival in a subset of patients with severe multisystem injuries. Improved understanding of the pathophysiology of trauma has led to a greater ability to identify patients who would benefit from damage control surgery. A patient is classified as physiologically stable, unstable, borderline, or in extremis. The stable patient can undergo fracture surgery as necessary. An unstable patient should be resuscitated and adequately stabilized before receiving definitive orthopaedic care. The decision whether to perform initial temporary or definitive fixation in the borderline patient is individualized based on the clinical condition. In patients presenting in extremis, life-saving measures are pivotal, followed by a damage control approach to their injuries.
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The stress response to bilateral femoral fractures: a comparison of primary intramedullary nailing and external fixation. J Orthop Trauma 2009; 23:90-7; discussion 98-9. [PMID: 19169099 DOI: 10.1097/bot.0b013e31819194c6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Concern has recently been expressed with regard to the physiologic effects of primary intramedullary femoral nailing in seriously injured patients. "Damage control orthopaedics" techniques have been proposed, which comprise principally the use of primary external fixation. The aim of this study was to compare the physiologic effects of external femoral fixation with those of intramedullary stabilization over the first 24 hours after femoral fracture using an established large animal (ovine) trauma model. METHODS Under terminal anesthesia, bilateral high-energy femoral fractures and hypovolemic shock were produced using a pneumatic actuator. Twenty-four sheep were randomized into 4 groups and monitored for 24 hours. Group 1--control, group 2--trauma only, group 3--trauma and external fixation, and group 4--trauma and reamed intramedullary nailing. Outcome measures included the following: pulmonary embolic load (transesophageal echocardiography), metabolic base excess, plasma coagulation markers, and polymorphonuclear cell counts obtained from bronchoalveolar lavage samples. RESULTS The total embolic load was significantly higher (P < 0.001) in the intramedullary nailing group. All trauma groups had a significant increase (P < 0.05) in prothrombin times with a fall in antithrombin III and fibrinogen levels. However, the type of fracture stabilization used did not significantly affect any of the other outcome measurements. CONCLUSIONS A higher pulmonary embolic load can be expected during early intramedullary femoral fracture stabilization compared with primary external fixation. However, the degree of stimulation to systemic coagulation and pulmonary inflammation by each type of surgery was comparable.
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Optimal Timing of Fracture Fixation: Have We Learned Anything In the Past 20 Years? ACTA ACUST UNITED AC 2008; 65:253-60. [DOI: 10.1097/ta.0b013e31817fa475] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Søreide K, Krüger AJ, Vårdal AL, Ellingsen CL, Søreide E, Lossius HM. Epidemiology and contemporary patterns of trauma deaths: changing place, similar pace, older face. World J Surg 2008; 31:2092-103. [PMID: 17899256 DOI: 10.1007/s00268-007-9226-9] [Citation(s) in RCA: 148] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The epidemiology of trauma deaths in Europe is less than well investigated. Thus, our goal was to study the contemporary patterns of trauma deaths within a defined population with an exceptionally high trauma autopsy rate. METHODS This was a retrospective evaluation of 260 consecutive trauma autopsies for which we collected demographic, pre-hospital and in-hospital data. Patients were analyzed for injury severity by standard scoring systems (Abbreviated Injury Scale [AIS], Revised Trauma Score [RTS], and Injury Severity Score [ISS]), and the Trauma and Injury Severity Scale [TRISS] methodology. RESULTS The fatal trauma incidence was 10.0 per 100,000 inhabitants (17.4 per 100,000 age-adjusted > or = 55 years). Blunt mechanism (87%), male gender (75%), and pre-hospital deaths (52%) predominated. Median ISS was 38 (range: 4-75). Younger patients (<55 years) who died in the hospital were more often hypotensive (SBP < 90 mmHg; p = 0.001), in respiratory distress (RR < 10/min, or > 29/min; p < 0.0001), and had deranged neurology on admission (Glasgow Coma Score [GCS] < or = 8; p < 0.0001), compared to those > or = 55 years. Causes of death were central nervous system (CNS) injuries (67%), exsanguination (25%), and multiorgan failure (8%). The temporal death distribution is model-dependent and can be visualized in unimodal, bimodal, or trimodal patterns. Age increased (r = 0.43) and ISS decreased (r = -0.52) with longer time from injury to death (p < 0.001). Mean age of the trauma patients who died increased by almost a decade during the study period (from mean 41.7 +/- 24.2 years to mean 50.5 +/- 25.4 years; p = 0.04). The pre-hospital:in-hospital death ratio shifted from 1.5 to 0.75 (p < 0.007). CONCLUSIONS While pre-hospital and early deaths still predominate, an increasing proportion succumb after arrival in hospital. Focus on injury prevention is imperative, particularly for brain injuries. Although hemorrhage and multiorgan failure deaths have decreased, they do still occur. Redirected attention and focus on the geriatric trauma population is mandated.
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Affiliation(s)
- Kjetil Søreide
- Acute Care Medicine Research Network, Institute of Health Studies, University of Stavanger, 8100, N-4068 Stavanger, Norway.
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Dhar SA, Bhat MI, Mustafa A, Mir MR, Butt MF, Halwai MA, Tabish A, Ali MA, Hamid A. 'Damage control orthopaedics' in patients with delayed referral to a tertiary care center: experience from a place where Composite Trauma Centers do not exist. J Trauma Manag Outcomes 2008; 2:2. [PMID: 18271951 PMCID: PMC2253507 DOI: 10.1186/1752-2897-2-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Accepted: 01/29/2008] [Indexed: 11/10/2022]
Abstract
BACKGROUND Management of orthopaedic injuries in polytrauma cases continues to challenge the orthopaedic traumatologist. Mass disasters compound this challenge further due to delayed referral. Recently there has been increasing evidence showing that damage control surgery has advantages that are absent in the early total care modality. We studied the damage control modality in the management of polytrauma cases with orthopaedic injuries who had been referred to our hospital after more than 24 hours of sustaining their injuries in an earthquake. This study was conducted on 51 cases after reviewing their records and complete management one year after the trauma. RESULTS At one year, out of the 62 fractures, 3 were still under treatment, while the others had united. As per the radiological and functional scoring there were 20 excellent, 29 good, 5 fair and 5 poor results. In spite of the delayed referral there was no mortality. CONCLUSION In situations of delayed referral in areas where composite trauma centers do not exist the damage control modality provides an acceptable method of treatment in the management of polytrauma cases.
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Affiliation(s)
- Shabir Ahmed Dhar
- Department of Orthopaedics, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Masood Iqbal Bhat
- Department of Surgery, Sheri Kashmir institute of medical sciences, Srinagar, Jammu and Kashmir, India
| | - Ajaz Mustafa
- Department of Hospital Administration, Sheri Kashmir institute of medical sciences, Srinagar, Jammu and Kashmir, India
| | - Mohammed Ramzan Mir
- Department of Orthopaedics, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Mohammed Farooq Butt
- Department of Orthopaedics, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Manzoor Ahmed Halwai
- Department of Orthopaedics, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Amin Tabish
- Department of Hospital Administration, Sheri Kashmir institute of medical sciences, Srinagar, Jammu and Kashmir, India
| | - Murtaza Asif Ali
- Department of Orthopaedics, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Arshiya Hamid
- Department of Anaesthesia and critical care, Sheri Kashmir institute of medical sciences, Srinagar, Jammu and Kashmir, India
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Affiliation(s)
- Hans-Christoph Pape
- Department of Orthopaedic Surgery, Division Chief-Traumatology, Suite 911, Kaufmann Med. Building, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA.
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Abstract
There were 329 trauma related deaths in Diyarbakir in 1997. Of these 226 were male (69%) and 103 were female (31%). The median age was 20 years old (range 1-82 years). Of the deaths, 30.5% were under 10, 51% were under 20 and 67% were under 30 years old. Two hundred and eleven deaths occurred in the hospital while 118 deaths occurred prehospital. Seventy-seven percent of hospital deaths (191) occurred in the first day. The most common cause of death was multiple injuries (151, 46%). Head injuries were the main reason for 128 deaths (46%). The most common mechanism of death was motor vehicle accident (131, 40%). The second was falls from a residential building (117, 33.7%).
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Affiliation(s)
- Y Yagmur
- Department of Accident and Emergency, Dicle University School of Medicine, Diyarbakir, Turkey.
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