Nonoperative versus operative management of frail institutionalized older patients with a proximal femoral fracture: a cost-utility analysis alongside a multicenter prospective cohort study

Hip fractures are associated with significant healthcare costs. In frail institutionalized patients, the costs of nonoperative management are less than operative management with comparable short-term quality of life. Nonoperative management of hip fractures in patients at the end of life should be openly discussed with SDM.

PURPOSE

The aim was to describe healthcare use with associated costs and to determine cost-utility of nonoperative management (NOM) versus operative management (OM) of frail institutionalized older patients with a proximal femoral fracture.

METHODS

This study included institutionalized patients with a limited life expectancy aged ≥ 70 years who sustained a proximal femoral fracture in the Netherlands. Costs of hospital- and nursing home care were calculated. Quality adjusted life years (QALY) were calculated based on EuroQol-5D-5L utility scores at day 7, 14, and 30 and at 3 and 6 months. The incremental cost-effectiveness ratio (ICER) was calculated from a societal perspective.

RESULTS

Of the 172 enrolled patients, 88 (51%) patients opted for NOM and 84 (49%) for OM. NOM was associated with lower healthcare costs at 6 months (NOM; €2425 (SD 1.030), OM; €9325 (SD 4242), p < 0.001). The main cost driver was hospital stay (NOM; €738 (SD 841) and OM; €3140 (SD 2636)). The ICER per QALY gained in the OM versus NOM was €76,912 and exceeded the threshold of €20,000 per QALY. The gained QALY were minimal in the OM group in patients who died within 14- and 30-day post-injury, but OM resulted in more than triple the costs.

CONCLUSION

OM results in significant higher healthcare costs, mainly due to the length of hospital stay. For frail patients at the end of life, NOM of proximal femoral fractures should be openly discussed in SDM conversations due to the limited gain in QoL.

TRIAL REGISTRATION

Netherlands Trial Register (NTR7245; date 10-06-2018).

Trauma care during the COVID-19 pandemic in the Netherlands: a level 1 trauma multicenter cohort study

PURPOSE

The coronavirus (COVID-19) pandemic has caused major healthcare challenges worldwide resulting in an exponential increase in the need for hospital- and intensive care support for COVID-19 patients. As a result, surgical care was restricted to urgent cases of surgery. However, the care for trauma patients is not suitable for reduction or delayed treatment. The influence of the pandemic on the burden of disease of trauma care remains to be elucidated.

METHODS

All patients with traumatic injuries that were presented to the emergency departments (ED) of the Amsterdam University Medical Center, Location Academic Medical Center (AMC) and VU medical center (VUMC) and the Northwest Clinics (NWC) between March 10, 2019 and May 10, 2019 (non-COVID) and March 10, 2020 and May 10, 2020 (COVID-19 period) were included. The primary outcome was the difference in ED admissions for trauma patients between the non-COVID and COVID-19 study period. Additionally, patient- and injury characteristics, health care consumption, and 30-day mortality were evaluated.

RESULTS

A 37% reduction of ED admissions for trauma patients was seen during the COVID-19 pandemic (non-COVID n = 2423 and COVID cohort n = 1531). Hospital admission was reduced by 1.6 trauma patients per day. Fewer patients sustained car- and sports-related injuries. Injuries after high energetic trauma were more severe in the COVID-19 period (Injury Severity Score 17.3 vs. 12.0, p = 0.006). Relatively more patients were treated operatively (21.4% vs. 16.6%, p < 0.001) during the COVID-19 period. Upper-(17.6 vs. 12.5%, p = 0.002) and lower extremity injuries (30.7 vs. 23.0%, p = 0.002) mainly accounted for this difference. The 30-day mortality rate was higher during the pandemic (1.0 vs. 2.3%, p = 0.001).

CONCLUSION

The burden of disease and healthcare consumption of trauma patients remained high during the COVID-19 pandemic. Results of this study can be used to optimize the use of hospital capacity and anticipate health care planning in future outbreaks.

Health-Related Quality of Life Is Decreased After Necrotizing Soft-Tissue Infections

BACKGROUND

A necrotizing soft-tissue infection (NSTI) is a rare but severe infection with a high mortality rate of 12%-20%. Diagnosing is challenging and often delayed. Treatment consists of surgical debridement of all necrotic tissue and administration of antibiotics. Despite adequate treatment, survivors are often left with extensive wounds, resulting in mutilating scars and functional deficits. Both the disease and the subsequent scars can negatively influence the health-related quality of life (HRQoL). The present study was performed to contribute to the knowledge about HRQoL in patients after NSTI.

METHODS

We retrospectively identified patients treated for NSTI in a tertiary center in the Netherlands. Patient and treatment characteristics were collected and patients were asked to fill in a Short Form 36 questionnaire.

RESULTS

Forty-six patients with a diagnosis of NSTI were identified. Twenty-eight (61%) were male and mean age was 57 y. Thirty-nine patients (80%) survived. Thirty-one (84%) of the survivors returned the questionnaire after a median follow-up of 4.1 y (interquartile range [IQR], 2.4-5.9 y). Statistically significantly decreased scores when compared to the Dutch reference values were observed for the Short Form 36 domains, physical functioning, role-physical functioning, general health, and the combined Physical Component Score. No differences were observed for the other five domains or for the Mental Component Score.

CONCLUSIONS

This study confirms that NSTI negatively affects HRQoL as reported by the patient, especially on the physical domains. To learn more about HRQoL in patients after NSTI, studies in larger groups with a more disease-specific questionnaire should be performed.

LEVEL OF EVIDENCE

Level 3, prognostic and epidemiological.

[A man with a painful right shoulder]

Posterior sternoclavicular luxations are uncommon and potentially life threatening. When clinically suspected, a computed tomography angiography is the gold standard to investigate whether important structures located in the mediastinum are at risk. A fast reduction should be performed to reduce pain and prevent acute and late complications.

Emergency Endovascular Treatment of Thoracic Aortic Rupture in Three Accident Victims with Multiple Injuries

Purpose:

To report an experience with emergency endovascular treatment of traumatic thoracic aortic ruptures in multi-injured patients.

Case Reports:

Three victims of motor vehicle accidents with multiple head, chest, and abdominal injuries in addition to fractures were treated urgently for thoracic aortic lacerations with transluminal placement of an endovascular graft during the initial emergent laparotomy. In all cases, ruptured visceral organs were treated first and the abdomen closed. Femoral artery access was gained through a cutdown, and the endografts were delivered with no systemic heparinization. The endovascular component of the surgical session took ∼50 minutes. All patients survived to discharge. Two patients are alive at 5 and 12 months with sustained endovascular exclusion of the pseudoaneurysm, but one patient with severe brain damage died 9 months after treatment from respiratory insufficiency.

Conclusions:

Acute endovascular treatment of thoracic aortic ruptures is feasible and has the advantage of avoiding thoracotomy in otherwise severely injured patients.

[Falling from a height: Psychiatric comorbidity and complications]

OBJECTIVE

To investigate whether a mental disorder increases the occurrence of complications in patients after 'a fall from a height'.

DESIGN

Retrospective descriptive study.

METHODS

Data on all patients admitted following a 'fall from a height' in the period 2004-2012 was retrieved from the trauma registry of the Academic Medical Center (AMC) in Amsterdam, the Netherlands. This was combined with data from the National Surgical Complications Registry (LHCR). A chart review was conducted to determine the presence of mental disorders in these patients. Corrected risk ratio for the risk of complications in patients with a psychological disorder was calculated using the Mantel-Haenszel method.

RESULTS

A total of 507 patients presented to the emergency department at the AMC following a fall from a height; 147 patients (29%) experienced 1 or more complications and 131 patients (25.8%) had a mental disorder. Complications arose in 60 patients with a mental disorder (45.8%) and in 87 patients (23.1%) without a mental disorder. The corrected risk ratio showed that a mental disorder is a statistically significant independent predictor of complications (risk ratio: 1.58; 95% confidence interval: 1.21-2.06).

CONCLUSION

The risk of complications following a fall from a height in patients with a mental disorder is one and a half times higher than in patients without a mental disorder. This mental disorder is a significant independent predictor of a medical complication following a fall from a height.

Management of blunt renal injury in a level 1 trauma centre in view of the European guidelines

BACKGROUND

Debate continues about the optimal management strategy for patients with renal injury.

PURPOSE

To report the diagnostics and treatment applied in a level 1 trauma centre and to compare it to the recommendations of the European Association of Urology guidelines concerning blunt renal injury.

METHODS

The management of all patients with blunt renal injury, admitted to the level 1 trauma centre of the Academic Medical Centre, between January 2005 and December 2009 was reviewed retrospectively.

RESULTS

Median age and ISS of the 186 included patients were 40 and 17 years respectively. All but one haemodynamically stable patients with microscopic haematuria received nonoperative management. Sixty percent of the haemodynamically stable patients with gross haematuria underwent CT scanning. Patients with grade 1-4 renal injury received nonoperative management. Additionally, two patients with grade 3-4 renal injury received angiography and embolization (A&E). One patient with grade 5 injury underwent renal exploration and two A&E. Seven of the 8 haemodynamically unstable patients underwent emergency laparotomy and in 2 patients, haemodynamically unstable because of renal injury, A&E was performed as an adjunct to surgical intervention.

CONCLUSIONS

In the present study, violation of the guidelines increased with injury severity. A&E can provide both a useful adjunct to nonoperative management and alternative to surgical intervention in specialised centres with appropriate equipment and expertise, even in patients with high grade renal injury. We advocate an update of the guidelines with a more prominent role of A&E.

Preventability of trauma deaths in a Dutch Level-1 trauma centre

BACKGROUND

Monitoring the quality of trauma care is frequently done by analysing the preventability of trauma deaths and errors during trauma care. In the Academic Medical Center trauma deaths are discussed during a monthly Morbidity and Mortality meeting. In this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a Dutch Level-1 trauma centre for (potential) preventability.

METHODS

All patients who died during or after presentation in the trauma resuscitation room in a 2-year period were eligible for review. All information on trauma evaluation and management was summarised by an independent research fellow. An external multidisciplinary panel individually evaluated the cases for preventability of death. Potential errors or mismanagements during the admission were classified for type, phase and domain. Overall agreement on (potential) preventability was compared between the external panel and the internal M&M consensus.

RESULTS

Of the 62 evaluated trauma deaths one was judged as preventable and 17 were judged as potentially preventable by the review panel. Overall agreement on preventability between the review panel and the internal consensus was moderate (Kappa 0.51). The external panel judged one death as preventable compared with three from the internal consensus. The interobserver agreement between the external panel members was also moderate (Kappa 0.43). The panel judged 31 errors to have occurred in the (potential) preventable death group and 23 errors in the non-preventable death group. Such errors included choice or sequence of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies.

CONCLUSIONS

The preventable death rate in the present study was comparable to data in the available literature. Compared to internal review, the external, multidisciplinary review did not find a higher preventable death rate, although it provided several insights to optimise trauma care.

Impact of splenic artery embolization on the success rate of nonoperative management for blunt splenic injury

Introduction

Nonoperative management (NOM) has become the treatment of choice for hemodynamically stable patients with blunt splenic injury. Results of outcome after NOM are predominantly based on large-volume studies from level 1 trauma centers in the United States. This study was designed to assess the results of NOM in a relatively low-volume Dutch level 1 trauma center.

Methods

An analysis of a prospective trauma registry was performed for a 6-year period before (period 1) and after the introduction and implementation of splenic artery embolization (SAE) (period 2). Primary outcome was the failure rate of initial treatment.

Results

A total of 151 patients were reviewed. An increased use of SAE and a reduction of splenic operations during the second period was observed. Compared with period 1, the failure rate after observation in period 2 decreased from 25% to 10%. The failure rate after SAE in period 2 was 18%. The splenic salvage rate (SSR) after observation increased from 79% in the first period to 100% in the second period. During the second period, all patients with failure after observation were successfully treated with SAE. The SSR after SAE in periods 1 and 2 was respectively 100% and 86%.

Conclusions

SAE of patients with blunt splenic injuries is associated with a reduction in splenic operations. The failure and splenic salvage rates in this current study were comparable with the results from large-volume studies of level 1 trauma centers. Nonoperative management also is feasible in a relatively low-volume level 1 trauma center outside the United States.

How to evaluate the quality of fracture reduction and fixation of the wrist and ankle in clinical practice: a Delphi consensus

METHOD

A Delphi study was conducted to obtain consensus on the most important criteria for the radiological evaluation of the reduction and fixation of the wrist and ankle. The Delphi study consisted of a bipartite online questionnaire, focusing on the interpretation of radiographs and CT scans of the wrist and the ankle. Questions addressed imaging techniques, aspects of the anatomy and fracture reduction and fixation. Agreement was expressed as the percentage of respondents with similar answers. Consensus was defined as an agreement of at least 90%.

RESULTS

In three Delphi rounds, respectively, 64, 74 and 62 specialists, consisting of radiologists, trauma and orthopaedic surgeons from the Netherlands responded. After three Delphi rounds, consensus was reached for three out of 14 (21%) imaging techniques proposed, 11 out of the 13 (85%) anatomical aspects and 13 of the 22 (59%) items for the fracture reduction and fixation. This Delphi consensus differs from existing scoring protocols in terms of the greater number of anatomical aspects and aspects of fracture fixation requiring evaluation and is more suitable in clinical practice due to a lower emphasis on measurements.

Functional treatment versus plaster for simple elbow dislocations (FuncSiE): a randomized trial

BACKGROUND

Elbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures. After reduction of a simple dislocation, treatment options include immobilization in a static plaster for different periods of time or so-called functional treatment. Functional treatment is characterized by early active motion within the limits of pain with or without the use of a sling or hinged brace. Theoretically, functional treatment should prevent stiffness without introducing increased joint instability. The primary aim of this randomized controlled trial is to compare early functional treatment versus plaster immobilization following simple dislocations of the elbow.

METHODS/DESIGN

The design of the study will be a multicenter randomized controlled trial of 100 patients who have sustained a simple elbow dislocation. After reduction of the dislocation, patients are randomized between a pressure bandage for 5-7 days and early functional treatment or a plaster in 90 degrees flexion, neutral position for pro-supination for a period of three weeks. In the functional group, treatment is started with early active motion within the limits of pain. Function, pain, and radiographic recovery will be evaluated at regular intervals over the subsequent 12 months. The primary outcome measure is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford elbow score, pain level at both sides, range of motion of the elbow joint at both sides, rate of secondary interventions and complication rates in both groups (secondary dislocation, instability, relaxation), health-related quality of life (Short-Form 36 and EuroQol-5D), radiographic appearance of the elbow joint (degenerative changes and heterotopic ossifications), costs, and cost-effectiveness.

DISCUSSION

The successful completion of this trial will provide evidence on the effectiveness of a functional treatment for the management of simple elbow dislocations.

TRIAL REGISTRATION

The trial is registered at the Netherlands Trial Register (NTR2025).

Are routine repeat chest x-rays before leaving the trauma room useful?

BACKGROUND

Several guidelines advocate multiple chest x-rays during primary resuscitation of trauma patients. Some local hospital protocols include a repeat x-ray before leaving the trauma resuscitation room (TR). The purpose of this study was to determine the value of routine repeat x-rays.

METHODS

One-year data of all radiological imaging in the TR were prospectively collected for all patients presenting to the TR of the hospital. The x-rays were counted and assessed and the findings were classified as either 'new injury detected', 'presence of intervention devices' or 'deterioration of previously detected injury'.

RESULTS

A total of 674 patients were included. More than 75% had two x-rays. Eight (2.1%) new injuries without clinical relevance were found on the repeat x-ray after an initial normal x-ray. 61 patients (9%) had a repeat x-ray to verify the effect of an intervention or position of devices. In 28 patients (22%) with two abnormal x-rays, newly diagnosed injuries (n=9) or deterioration of known injuries (n=19) were found. In 411 patients (81%) the results of the repeat x-ray had no clinical consequences.

CONCLUSION

This study indicates that routine repeat chest x-rays can be omitted in trauma patients whose initial chest x-ray is normal.

U-shaped sacral fractures: surgical treatment and quality of life

BACKGROUND

U-shaped sacral fractures are rare and highly unstable pelvic ring fractures. They are not recognised in the standard classification systems of these fractures. The fracture pattern is associated with significant neurological injury and can lead to progressive deformity and chronic pain if not diagnosed and treated properly. In recent years a variety of surgical strategies have been shown to facilitate early mobilisation and reduce early mortality as compared to non-operative strategies. Poor evidence, however, has hampered the development of a standard treatment algorithm. As for the long-term morbidity, the influence of operative treatment may be difficult to assess due to associated injury. However, evidence exists that there is a significant effect on the long-term morbidity.

OBJECTIVE

To assess the injury characteristics, choice of treatment and quality of life of U-shaped sacral fractures.

METHODS

Eight polytraumatised patients with U-shaped sacral fractures were identified over a 7-year period and evaluated retrospectively. They were analysed for fracture classification, associated injury, and injury severity. Clinical and Radiological results were evaluated. Neurological outcome was retrospectively classified by Gibbons' criteria. Long-term quality of life outcome was evaluated using the EuroQoL-6D questionnaire.

RESULTS

The study population consists of five women and three men; with a median age of 29 years. All patients sustained severe associated injury. The Injury Severity Score ranged from 17 to 45 (median 23). The median time between trauma and definitive internal fixation was 4 days (range, 2-22 days). Definitive fixation included either percutaneous iliosacral screws (n=2), transsacral plate osteosynthesis (n=1) or triangular osteosynthesis with (n=4) or without transsacral plating (n=1). Early postoperative mobilisation and early partial weight-bearing were encouraged when possible. Follow-up ranged from 5 to 65 months (median, 36 months). Pain, mood disorders and mobility problems mainly influenced patients' present general health status.

CONCLUSION

U-shaped sacral fractures present a rare and heterogeneous injury. Operative treatment depended mainly on fracture type, associated spinal fractures, and the surgeon's preference. Long-term quality of life is dominated by pain, mood disorders and moderate mobility problems.

The value of postmortem computed tomography as an alternative for autopsy in trauma victims: a systematic review

The aim of this study was to assess the role of postmortem computed tomography (PMCT) as an alternative for autopsy in determining the cause of death and the identification of specific injuries in trauma victims. A systematic review was performed by searching the EMBASE and MEDLINE databases. Articles were eligible if they reported both PMCT as well as autopsy findings and included more than one trauma victim. Two reviewers independently assessed the eligibility and quality of the articles. The outcomes were described in terms of the percentage agreement on causes of death and amount of injuries detected. The data extraction and analysis were performed together. Fifteen studies were included describing 244 victims. The median sample size was 13 (range 5–52). The percentage agreement on the cause of death between PMCT and autopsy varied between 46 and 100%. The overall amount of injuries detected on CT ranged from 53 to 100% compared with autopsy. Several studies suggested that PMCT was capable of identifying injuries not detected during normal autopsy. This systematic review provides inconsistent evidence as to whether PMCT is a reliable alternative for autopsy in trauma victims. PMCT has promising features in postmortem examination suggesting PMCT is a good alternative for a refused autopsy or a good adjunct to autopsy because it detects extra injuries overseen during autopsies. To examine the value of PMCT in trauma victims there is a need for well-designed and larger prospective studies.

Autopsies following death due to traumatic injuries in The Netherlands: an evaluation of current practice

INTRODUCTION

Because of a steady decline in the number of autopsies following death due to traumatic injuries, valuable information concerning possible missed injuries and potential improvements in management is lost. This retrospective study describes current practice in the Amsterdam region of the Netherlands regarding such autopsies, and their rates.

METHOD

The current protocols for autopsies were reviewed. Data from government databases and hospitals for the year 2005 were collected. For all patients included that died an unnatural death due to traumatic injury, causes of death and recommendations for autopsy were reviewed. The number of clinical and medico-legal autopsies was determined.

RESULTS

Of 872 registered unnatural deaths, 414 were due to traumatic injuries; 63% of these died before reaching hospital and 37% died in hospital. There were more male deaths, and average age was 54 years. In 23% an autopsy was advised by the medical examiners, more often for pre-hospital deaths. The rate of autopsies was 46% when advice was given for a medico-legal autopsy.

CONCLUSION

The rates of both medico-legal and clinically desirable autopsies are very low. Currently, the system in Amsterdam focuses mainly on the former, and the latter with its attendant educational aspects is largely ignored. The role of the government should be expanded to optimise the autopsy system in unnatural deaths following traumatic injuries.

Significant forefoot varus deformity resulting in progressive stress fractures of all lesser metatarsal bones

Stress fractures may occur in any bone, but appear most frequently in the metatarsal bones. Consecutive stress fractures of all lesser metatarsals in a short period are rare, and only a few cases have been described in the literature. We report an unusual case of a young man with consecutive stress fractures of four adjacent lesser metatarsal bones. The etiology was in all probability the fixed forefoot varus deformity. This foot deformity may impose increased mechanical loads across the lateral aspect of the foot that, in turn, may result in stress fractures involving the lesser metatarsals. In our patient conservative treatment finally resulted in a satisfactory outcome.

The results of 163 Achilles tendon ruptures treated by a minimally invasive surgical technique and functional aftertreatment

BACKGROUND

There is still controversy regarding the optimal surgical technique and post-operative treatment of acute Achilles tendon ruptures. We evaluated a treatment protocol for Achilles tendon ruptures consisting of a minimally invasive Achilles tendon repair combined with early full weight bearing.

METHODS

A consecutive group of 163 patients was prospectively followed during a 6 year period (1998-2004) in one university hospital and five teaching hospitals. Data were collected during the outpatient department visits at 1, 3, 5, and 7 weeks, 4 months and 12 months after the intervention. Outcome parameters were the incidence of re-rupture, other complications, the functional outcome and the period of sick leave concerning work and sport.

RESULTS

The patient group consisted of 128 men (79%) and 35 women (21%). The mean operating time was 41 min. In 9 patients (5.5%) a major complication occurred, necessitating 5 surgical re-interventions (2 for re-ruptures, 2 for infections and 1 for tendon necrosis). Fifteen patients (9.2%) suffered from dysfunction of the sural nerve. The median time of returning to work was 28 days (range 1-368) and the median time of returning to sport was 167 days (range 31-489). The majority of patients (150; 92%) were satisfied with the results.

CONCLUSION

Minimally invasive Achilles tendon repair in combination with a functional rehabilitation program is a safe and quick procedure with a low rate of re-rupture and a high level of patient satisfaction.

Endovascular treatment of anterior tibial artery pseudoaneurysm following locking compression plating of the tibia

Less invasive surgery and interventional radiology are relatively new techniques. This case report describes a patient with a distal tibial fracture that was stabilized using minimally invasive osteosynthesis consisting of a precontoured metaphyseal Locking Compression Plate (LCP). Postoperative radiographs showed good alignment of the bone, and the initial postoperative course was uneventful. At the sixth-week follow-up visit after surgery, the patient presented with a pulsating and tender mass on the lower leg that was palpable subcutaneously. Arteriography showed a pseudoaneurysm of the anterior tibial artery. At the same procedure an endovascular stent was placed, thereby excluding the pseudoaneurysm from the main circulation while keeping the vessel lumen patent. At the time of the last visit, 6 months after the operation, the patient was fully weightbearing with normal function of the ankle but with a nonhealing fracture on the x-ray. The dorsalis pedis pulse was equally strong as on the right side. Endovascular treatment with a covered stent proved to be an effective treatment for the described posttraumatic pseudoaneurysm of the anterior tibial artery. This case illustrates a risk of less invasive fracture surgery and at the same time underlines the value of a multidisciplinary approach to complications in trauma surgery.

[Prevention of thrombosis in traumatology]

Venous thromboembolism is frequent in trauma patients and often runs an asymptomatic course. Prophylaxis in these patients, who often have an increased risk of bleeding, deserves extra attention. After injuries to the lower extremities, low molecular weight heparin is advised during the period of immobilisation. Following hip-fracture surgery, fondaparinux is indicated for 4 weeks. In polytrauma and neurotrauma patients, low molecular weight heparin has shown the best results. Thrombosis prophylaxis also seems to be indicated in burn patients.

Evaluation of the necessity of clinical observation of high-energy trauma patients without significant injury after standardized emergency room stabilization

BACKGROUND

Patients involved in a high-energy trauma (HET) are usually admitted for clinical observation, even when no significant injury is found after standard care in the emergency room (ER). The necessity of this observation period is not evidence based. The goal of this study was to identify patients who revealed an initially undiagnosed injury during the observation period.

METHODS

A retrospective study of consecutive HET patients was conducted in two Level I trauma centers. Patients after a HET with two minor injuries or less, diagnosed during the standard ER care, were included. Data were abstracted from patients' medical records.

RESULTS

Five hundred three patients were included. None of the patients developed any complications during the clinical observation period or were readmitted to their own hospital within a week after the trauma.

CONCLUSION

There is no evidence for the necessity of clinical observation of HET patients with minimal or no injuries diagnosed after standard ER stabilization and evaluation.

In-hospital downgrading of the trauma team: Validation of the Academic Medical Center downgrading criteria

BACKGROUND

To reduce overtriage of trauma patients while at the same time minimising undertriage, an in-hospital triage tool was developed with the purpose of reducing the initial full trauma team (downgrading) in a structured and evidence-based manner. This study evaluated the effect on overtriage rates by the AMC downgrading protocol (AMCDP) consisting of 24 criteria scored during the primary survey.

PATIENTS AND METHODS

We prospectively investigated if any of the patients treated by the downgraded trauma team (DTT) were undertriaged by the protocol. All patients fulfilling the definition of severely injured (SI) patients but treated by the DTT were deemed undertriaged patients. Overtriage was measured by the percentage of patients treated by a full trauma team (FTT) while not classified as an SI patient.

RESULTS

A total of 220 patients were eligible and triaged by the AMCDP. After triage, 95 patients (43%) were treated by the DTT while 125 patients (57%) were treated by the FTT. A total of 66 patients (30%) met one or more of the criteria for an SI patient. None of these patients were treated by the DTT. Of the 125 patients treated by the FTT, 59 patients were not defined as SI.

CONCLUSION

For the entire study population no undertriage was found, while implementation of the AMCDP reduced overtriage in the entire study population from 70% to 26.8%. Similar trauma centres can benefit from implementing the AMC downgrading protocol.

M-study; arguments for regional trauma databases

BACKGROUND

The TRISS methodology, in combination with coefficients derived from the Major Trauma Outcome Study (MTOS), is the most widely used outcome prediction model for the care of trauma patients. Utilizing the M-statistic, different populations of trauma patients can be compared with the population originally enrolled in the MTOS.

PURPOSE

We hypothesized that databases outside of North-America would not be well matched to the MTOS study and thus the TRISS methodology would not accurately predict outcome in these different populations.

METHODS

All trauma studies utilizing TRISS methodology that were published between 1990-2003 were reviewed and M-statistics calculated based on the population described in the study. The populations were grouped by the following geographic locations: Europe, Asia/Africa and North-America.

RESULTS

The median M-statistic for Europe was 0.65, compared with 0.88 for Asian/African databases, and 0.90 for North-American studies. There was a significant difference between European and North-American studies (p < 0.05).

CONCLUSION

The trauma populations described in European studies differ significantly from the MTOS with respect to injury severity match, indicating the need for the development of regional trauma databases and modified TRISS coefficients based on the geographic location of the injured population included.

External fixators for pelvic fractures: comparison of the stiffness of current systems

We evaluated the stiffness of external fixation (EF) systems with a reproducible, standardized human pelvic replica of aluminum and perspex in which a type C pelvic ring injury was created. 12 EF systems were analyzed in 2 situations that necessarily occur during a walking cycle. Endpoints were defined as 15 mm of dislocation or tolerance of the maximum load in each situation. In the no weightbearing situation, all except 2 fixators failed; in the weightbearing situation, all fixators failed. Single bar systems performed better than frame configurations. Stability provided by any external fixator is low, and in the case of a type C pelvic ring injury, it is insufficient for patient mobilization and weightbearing. Single bar systems provide more stability than frames.

Trans-Atlantic hospital agreement in reading first day radiographs of clinically suspected scaphoid fractures

The purpose of this study was to describe the agreement between two hospitals on either side of the Atlantic Ocean in reading first day plain radiographs of suspected scaphoid fractures. Two groups of observers, one North American and one European, consisting of observers at various levels of training were compared. Kappa statistics were used to determine inter- and intra-observer agreement. The receiver-operating characteristics (ROC) curves and area under this curve (AUC) for each observer were calculated to determine test performance. Scaphoid radiographs of 80 consecutive patients seen with clinically suspected scaphoid fracture were included in the study. The results of the bone scan were used as the reference standard. There is an acceptable agreement between the USA and Europe for both radiologists and orthopaedic surgeons at various levels of training (kappa 0.45-0.88). Intra-observer agreement is acceptable as well (kappa 0.46-0.86). Considering all normal or equivocal radiographs, there is slight to moderate agreement at all levels of training in and between both centres and specialities (kappa 0-0.64). Overall test performance was acceptable for all consecutive radiographs (AUC 0.65-0.82) and poor for the normal radiographs (AUC 0.46-0.65). We could not detect differences in performance due to location of the readers' hospital or institution of training. The use of more sensitive techniques should be restricted to patients with negative or equivocal radiographs in clinically suspected scaphoid fractures.

Emergency endovascular treatment of thoracic aortic rupture in three accident victims with multiple injuries

PURPOSE

To report an experience with emergency endovascular treatment of traumatic thoracic aortic ruptures in multi-injured patients.

CASE REPORTS

Three victims of motor vehicle accidents with multiple head, chest, and abdominal injuries in addition to fractures were treated urgently for thoracic aortic lacerations with transluminal placement of an endovascular graft during the initial emergent laparotomy. In all cases, ruptured visceral organs were treated first and the abdomen closed. Femoral artery access was gained through a cutdown, and the endografts were delivered with no systemic heparinization. The endovascular component of the surgical session took approximately 50 minutes. All patients survived to discharge. Two patients are alive at 5 and 12 months with sustained endovascular exclusion of the pseudoaneurysm, but one patient with severe brain damage died 9 months after treatment from respiratory insufficiency.

CONCLUSIONS

Acute endovascular treatment of thoracic aortic ruptures is feasible and has the advantage of avoiding thoracotomy in otherwise severely injured patients.

Trauma outcome analysis of a Jakarta University Hospital using the TRISS method: validation and limitation in comparison with the major trauma outcome study. Trauma and Injury Severity Score

BACKGROUND

In this prospective study, the TRISS methodology is used to compare trauma care at a University Hospital in Jakarta, Indonesia, with the standards reported in the Major Trauma Outcome Study (MTOS).

METHODS

Between February 24, 1999, and July 1, 1999, all consecutive patients with multiple and severe trauma were included in the study (n = 105). Survival analysis was completed for 97 (92%) patients.

RESULTS

The majority of patients were men (81%), and the average age was 28 years. Ninety-five patients (98%) sustained blunt trauma, with motor vehicle crashes being the most common (68%). The predicted mortality was 14% and the observed mortality was 29%. The Z and M statistics were 7.87 and 0.843, respectively.

CONCLUSION

We conclude that in developing countries both institution-bound factors and specific limitations in the TRISS methodology are responsible for the difference between predicted and observed mortality, indicating the need for a regional database.

Fracture of the pancreas in two patients after a go-kart accident

BACKGROUND

After blunt abdominal trauma, an isolated injury to the pancreatic duct is uncommon. Physical signs and laboratory parameters are often inaccurate, and missing this diagnosis can cause serious clinical problems.

CASE OUTLINES

Two young women (aged 18 and 20 years) are reported who sustained isolated trauma to the pancreatic duct in go-kart accidents. Each patient sustained a fracture of the pancreas.This injury was diagnosed only after a period of clinical observation with repeated laboratory parameters, ultrasound and CT scan. Pancreatic tissue was conserved by performing a pancreaticojejunostomy.

DISCUSSION

After any episode of blunt abdominal trauma, isolated injury to the pancreatic duct should be considered. Serum analysis, ultrasonography and CT scanning can be helpful in early diagnosis. Preservation of pancreatic tissue can be achieved with a good clinical outcome.