Shots fired: evaluation of vascular injury, compartment syndrome, and transfusion rates among civilian ballistic orthopaedic fracture patients presenting to two Level I trauma centres

PURPOSE

This study investigates baseline patient demographics and predictors of vascular injury, blood transfusion, and compartment syndrome in patients with orthopaedic fractures secondary to GSWs at two high-volume Level I trauma centres.

METHODS

A retrospective chart review of all GSW-related trauma patients at two Level I trauma centres between July 2019 and September 2021 was conducted. Chi-squared and two-tailed independent t tests were used for data analysis, and logistic regression with odds ratios (OR) determined predictors of primary outcomes.

RESULTS

Among 478 GSW patients, 94 (19.7%) sustained 130 orthopaedic fractures, most commonly at the lower extremity (77.7%). Orthopaedic fracture patients showed significantly higher rates of vascular injury (29.8 vs. 4.7%, p < 0.001), transfusion (27.7 vs. 12.8%, p = 0.006), and compartment syndrome (3.2 vs. 0.3%, p = 0.011) compared to non-orthopaedic injury patients. Univariable analysis identified ankle (OR = 47.50, p < 0.001) and hip/femur fractures (OR = 5.31, p < 0.001) as predictors of vascular injury. Multivariable logistic regression revealed lower extremity vascular injury (OR = 54.69, p = 0.006) and anatomic fracture sites of the humerus (OR = 15.17, p = 0.008), clavicle/scapula (OR = 11.30, p = 0.009), and acetabulum/pelvis (OR = 7.17, p = 0.025) as predictors of blood transfusion. Univariable analysis showed lower extremity vascular injury (OR = 30.14, p = 0.007) as a predictor of compartment syndrome.

CONCLUSION

These findings underscore the importance of diagnosing and managing vascular injuries and compartment syndrome in GSW-related orthopaedic fractures, emphasizing the necessity for targeted transfusion strategies in such cases.

Blood loss and transfusion risk in intramedullary nailing for subtrochanteric fractures

BACKGROUND

The incidence of hip fractures and subtrochanteric fractures in particular is increasing, along with the globally expanding aging population. Intramedullary nailing remains the 'gold standard' of their treatment. Blood loss can be a result of the original trauma, but also secondary to the subsequent surgical insult, especially during the reaming of the intramedullary canal.

OBJECTIVES

The aim of our study was to report on the blood loss and incidence of blood transfusion in patients presenting with a subtrochanteric fracture treated with intramedullary nailing. Most importantly, we aim to identify factors associated with the need for transfusion within the first 48 h post-operatively.

METHODS

Following institutional board approval, 431 consecutive patients (131 males; age: 79.03 years old, SD 13.68 years) presenting in a Level 1 Trauma Centre with a subtrochanteric fracture treated with an intramedullary nail were retrospectively identified, over an 8-year period. Exclusion criteria included patients with high energy injuries, pathological fractures, primary operations at other institutions and patients lost to follow-up. To identify risk factors leading to increased risk of transfusion, we first compared patients requiring intra-operative transfusion or transfusion during the first 48 h post-operatively against those who did not require transfusion. This was then followed by multivariate regression analysis adjusted for confounding factors to identify the most important risk factors associated with need for transfusion within the first 48 h post-operatively.

RESULTS

Incidence of blood transfusion was 6.0% pre-operatively, compared to 62.7% post-operatively. A total of 230 patients (52.3%) required either intra-operative transfusion or transfusion during the first 48 h following surgery. Patients having a transfusion within the first 48 h post-operatively had a higher incidence of escalation in their care (p = 0.050), LOS (p = 0.015), 30-day (p = 0.033) and one-year mortality (p = 0.004). Multivariate regression analysis adjusted for confounding factors identified that the most important association of a need for transfusion within the first 48 post-operative hours was a pre-operative Hb <100 g/L (OR 6.64); a nail/canal ratio <70% (OR 3.92), followed by need for open reduction (OR 2.66). Fracture involving the lesser trochanter was also implicated with an increased risk (OR 2.08). Additionally, pre-operative moderate/severe renal impairment (OR 4.56), as well as hypoalbuminaemia on admission (OR 2.10) were biochemical predictors of an increased risk of transfusion. Most importantly, the need for transfusion was associated with an increase in 30-day mortality (OR 12.07).

CONCLUSION

Several patient, fracture and surgery related factors are implicated with an increased risk for transfusion within the first 48-h post-operatively. Early identification, and where possible correction of these factors can potentially reduce blood loss and risk of transfusion, along with all the associated sequelae and mortality risk.

LEVEL OF EVIDENCE

III.

Traction Splinting for midshaft femoral fractures in the pre-hospital and Emergency Department environment-A systematic review

INTRODUCTION

Pain and hemorrhage are common in midshaft femoral fractures. Traction splints (TSs) can reduce pain and control hemorrhage, but evidence of their effectiveness in femoral fractures is still lacking. Through a systematic review, we aimed to analyze and discuss the potential role of TSs in the prehospital and emergency department (ED) setting.

METHODS

The Embase, CINAHL, Cochrane, and PubMed databases were searched up to January 2022. All studies on femoral fractures in the prehospital or ED setting that compared TSs with immobilization or no intervention were included. Articles not written in English, German, or Dutch were excluded. Two authors screened all articles, assessed their quality, and included them if both agreed on their inclusion. The risk of bias was assessed using the modified Methodological Index for Non-Randomized Studies (MINORS). The primary outcome measures were pain and hemorrhage control, while the secondary outcome measures were survivability, morbidity, and complications.

RESULTS

A total of 1,248 articles matched the search strategy, 24 articles were assessed for eligibility based on their abstracts, resulting in 20 articles being included in the synthesis. Ten articles reviewed the effects of TSs on pain, while five reported that the use of a TS was appropriate. All five articles that reviewed blood loss found benefits from the use of a TS. One study found significantly fewer pulmonary complications in patients who were splinted earlier at the scene of injury (level III). No difference was found in complications or mortality between prehospital patients receiving a TS or no TS (level III). None of the studies noted that TSs were a necessity in the ED setting; however, some argued that a TS is a necessary and useful prehospital tool in rural or military areas.

CONCLUSION

TS use is associated with a decreased necessity for blood transfusions and fewer pulmonary complications. No favorable effects were found in terms of pain relief. We recommend the use of TSs in situations where one is likely to encounter a femoral fracture as well as when the time to definitive treatment is long. Further well-designed studies are required to validate these recommendations.

Antegrade versus retrograde nailing of proximal femur fractures: A cortical diameter based study

Background

Retrograde nailing of proximal femoral shaft fractures is controversial. The purpose of this study was to compare patients with proximal femur fractures undergoing antegrade versus retrograde intramedullary nailing (AIMN vs RIMN) and determine the safety and efficacy of RIMN.

Methods

A retrospective review was performed on 54 patients undergoing femoral IMN for proximal femoral shaft fractures at an urban level one trauma institution between January 2016 and July 2021.Fracture distance from the lesser trochanter (LT) was recorded and used to calculate the number of cortical diameters (NCD) from the LT. Proximal femur fractures were defined as < 3 NCD. AIMN and RIMN fixation was utilized in 31 (57.4%) and 23 (42.6%) patients, respectively. Outcomes measures included pre-/postoperative true translational and angular displacement (TTD and TAD), operative time, estimated blood loss (EBL), union rate, time to union, complications, and reoperations.

Results

AIMN and RIMN groups were similar in terms of age, sex, BMI, tobacco use, diabetes, ASA classification >2, AO/OTA classification, preoperative TTD or TAD, open fractures, or ballistic fractures. The AIMN group, had a shorter measured distance from the LT (47.0 vs. 66.1 mm, p = 0.04) but the difference in NCD was not significant (1.4 vs. 2.0, p = 0.07). Among patients with isolated IMN procedures, the RIMN group had shorter operative times (142.3 vs. 178.5 min, p = 0.01) and less EBL (100 vs. 250 mL, p = 0.008). There was no observed intergroup difference in terms of postoperative TTD/TAD, union rate, time to union, complications, or reoperations.

Conclusion

RIMN is a viable treatment option for proximal femoral shaft fractures that results in less operative time, less blood loss, and no detectable differences in union, reoperations, or complications.

Level of evidence

Level III, Retrospective cohort study.

Fractures of the femur and blood transfusions

BACKGROUND

Blood loss estimation after trauma (i.e. physical injury) and early identification of potential sources of bleeding are important for planning of investigation and management of trauma. Long bone fractures have been reported to be associated with substantial volumes of blood loss requiring blood transfusion. The aim of this study was to assess rates and amounts of blood transfusion in the setting of isolated extra capsular femur fractures and to determine variables associated with the need for transfusion within the first 48 h of admission.

METHODS

A retrospective cohort study was conducted of patients in The Alfred Trauma Registry with isolated extra capsular femur fractures over a 7-year period. We compared patients with a femoral shaft fracture (FSF) to patients with either distal femur or proximal femur fractures (i.e. extremity fracture). We collected data potentially associated with blood transfusion within 48 h as well as operation details and patient outcomes.

RESULTS

There were 293 patients included, of which 121 had FSF and 172 extremity fracture. 105 (36%) patients received a blood transfusion during their admission. Admission haemoglobin (AOR 0.92; 95%CI 0.89-0.94, p < 0.01) was the only independently associated variable with blood transfusion within the first 48 h of hospital admission.

CONCLUSION

Volume of blood transfused to patients with extra-capsular femoral fractures was low and usually in the post-operative period. FSF, compared to femoral extremity fractures, were not more likely to receive blood transfusion within the first 48 h of admission, and did not receive a higher volume of blood overall. In the setting of major trauma with haemorrhagic shock, alternate sources of bleeding should be sought.