Management of Traumatic Femur Fractures: A Focus on the Time to Intramedullary Nailing and Clinical Outcomes.

BACKGROUND: Femur shaft factures (FSF) are common injuries following high-energy mechanisms mainly involving motor vehicle crashes (MVC). We evaluated the timings of nailing management and analyzed the pattern of fracture union and outcome in a level 1 trauma center. METHODS: This was a retrospective observational study of all the admitted trauma patients who sustained femoral fractures between January 2016 and September 2020. Data were analyzed and compared based on time to Intramedullary Nailing (IMN) (<12 h, 12-24 h and >24 h) and outcomes of FSF (union, delayed union and nonunion). RESULTS: A total of 668 eligible patients were included in the study, of which the majority were males (90.9%) with a mean age of 34.5 ± 15.8, and 54% of the injuries were due to MVCs. The chest (35.8%) was the most commonly associated injured body region, followed by the pelvis (25.9%) and spine (25.4%). Most of femur fractures (93.3%) were unilateral, and 84.4% were closed fractures. The complete union of fractures was observed in 76.8% of cases, whereas only 4.2% and 3.3% cases had delayed union and nonunion, respectively, on the clinical follow-up. Patients in the delayed IMN (>24 h) were severely injured, had bilateral femur fracture (p = 0.001) and had higher rate of external fixation, blood transfusion, pulmonary complications and prolonged hospitalization. Non-union proportion was greater in those who had IMN <24 h, whereas a delayed union was greater in IMN done after 24 h (p = 0.5). Those with a nonunion femur fracture were more likely to have bilateral fracture (p = 0.003), frequently had retrograde nailing (p = 0.01), and high-grade femur fracture (AO type C; p = 0.04). CONCLUSION: This study showed that femur fracture is not uncommon (8.9%), which is manifested with the variety of clinical characteristics, depending on the mechanism, management and outcome in our center. Bilateral fracture, retrograde nailing and AO classification type C were the significant risk factors of non-union in patients with diaphyseal fractures. The timing of IMN has an impact on the fracture union; however, it is not a statistically significant difference. Therefore, the treating physicians should consider the potential risk factors for a better outcome by careful selection of treatment in sub-groups of patients.

Initial Serum Levels of Magnesium and Calcium as Predictors of Mortality in Traumatic Brain Injury Patients: A Retrospective Study.

Background: We sought to evaluate the predictor role of the initial serum level of calcium and magnesium in hospitalized traumatic brain injury (TBI) patients. Materials and methods: A retrospective analysis of all TBI patients admitted to the Hamad Trauma Center (HTC), between June 2016 and May 2021 was conducted. Initial serum electrolyte levels of TBI patients were obtained. A comparative analysis of clinical variables between patients with abnormal and normal serum electrolyte level was performed. Logistic regression analysis with the variables that showed a significant difference (p < 0.05) in the bivariate analysis was performed to calculate the odds ratios (OR) for mortality. Results: There was a total of 922 patients with clinical records of serum electrolyte levels at admission. Of these, 757 (82.1%) had hypocalcemia, 158 (17.1%) had normal calcium level, and 7 (0.8%) had hypercalcemia. On the other hand, 616 (66.8%) patients had normal magnesium level, 285 (30.9%) had hypomagnesemia, and 12 (1.3%) had hypermagnesemia. The mortality rate in hypocalcemia group was 24% while in patients with normal calcium level it was 12%, p = 0.001. Proportionate mortality rates in hypomagnesemia and normal magnesium groups were 15% and 23% (p = 0.006), respectively. On the other hand, 7 out of 12 (58%) hypermagnesemia patients died during the index hospitalization. The regression model including GCS, ISS, PT, aPTT, INR, Hemoglobin, Bicarbonate, Lactate, Sodium, Potassium, Calcium, Magnesium, and Phosphate showed that hypocalcemia was not a significant predictor [OR 0.59 (CI 95%: 0.20-1.35)] of mortality after TBI. However, hypermagnesemia was a significant predictor [OR 16 (CI 95%: 2.1-111)] in addition to the GCS, ISS, aPTT, Bicarbonate, and Lactate values on admission. Conclusion: Although hypocalcemia and hypomagnesemia are common in hospitalized TBI patients, hypocalcemia was not a significant predictor of mortality, while hypermagnesemia was an independent predictor. Further studies with larger sample size and with prospective design are required to support these findings and their importance.

Trouble in Tiger country: isolated traumatic pancreatic transection - a case report.

Isolated pancreatic transection is a rare surgical condition that occurs more commonly following blunt abdominal trauma. It carries a high degree of morbidity and mortality, and the management remains a source of debate as universally accepted guidelines are not well established owing to the paucity in clinical experience and large series. We presented a case of an isolated pancreatic transection following blunt abdominal trauma. The surgical management of pancreatic transection has evolved over the decades from aggressive approaches to more conservative measures. Given the lack of large series and clinical experience, no universal consensus exists, except for applying damage control surgery and resuscitation principles in critically unstable patients. For transections of the main pancreatic duct, most recommend excision of the distal pancreas. Concerns over the iatrogenic complications of wide excisions, particularly diabetes mellitus, have led to reconsideration and more conservative approaches, but it may fail in some cases.

Patterns, Management, and Outcome of Traumatic Femur Fracture: Exploring the Experience of the Only Level 1 Trauma Center in Qatar.

BACKGROUND: Femur is the most fractured long bone in the body that often necessitates surgical fixation; however, data on the impact of the mechanism of injury (MOI), age, and timing of intervention are lacking in our region of the Arab Middle East. We aimed to describe the patterns, management, and outcome of traumatic femoral shaft fractures. METHODS: A retrospective descriptive observational study was conducted for all trauma patients admitted with femoral shaft fractures between January 2012 and December 2015 at the only level 1 trauma center and tertiary hospital in the country. Data were analyzed and compared according to the time to intervention (intramedullary nailing; IMN), MOI, and age groups. Main outcomes included in-hospital complications and mortality. RESULTS: A total of 605 hospitalized cases with femur fractures were reviewed. The mean age was 30.7 ± 16.2 years. The majority of fractures were unilateral (96.7%) and 91% were closed fractures. Three-fourths of fractures were treated by reamed intramedullary nailing (rIMN), antegrade in 80%. The pyriform fossa nails were used in 71.6% while trochanteric entry nails were used in 28.4%. Forty-five (8.9%) fractures were treated with an external fixator, 37 (6.1%) had conservative management. Traffic-related injuries occurred more in patients aged 14-30 years, whereas fall-related injuries were significantly higher in patients aged 31-59. Thirty-one patients (7.8%) had rIMN in less than 6 h post-injury, 106 (25.5%) had rIMN after 6-12 h and 267 (66.8%) had rIMN after more than 12 h. The implant type, duration of surgery, DVT prophylaxis, in-hospital complications, and mortality were comparable among the three treatment groups. CONCLUSIONS: In our center, the frequency of femoral fracture was 11%, and it mainly affected severely injured young males due to traffic-related collisions or falls. Further multicenter studies are needed to set a consensus for an appropriate management of femur fracture based on the MOI, location, and timing of injury.

Patterns and Effects of Admission Hyperglycemia and Inflammatory Response in Trauma Patients: A Prospective Clinical Study.

BACKGROUND: The constellation of the initial hyperglycemia, proinflammatory cytokines and severity of injury among trauma patients is understudied. We aimed to evaluate the patterns and effects of on-admission hyperglycemia and inflammatory response in a level 1 trauma center. We hypothesized that higher initial readings of blood glucose and cytokines are associated with severe injuries and worse in-hospital outcomes in trauma patients. METHODS: A prospective, observational study was conducted for adult trauma patients who were admitted and tested for on-admission blood glucose, hemoglobin A1c, interleukin (IL)-6, IL-18 and hs-CRP. Patients were categorized into four groups [non-diabetic normoglycemic, diabetic normoglycemic, diabetic hyperglycemic (DH) and stress-induced hyperglycemic (SIH)]. The inflammatory markers were measured on three time points (admission, 24 h and 48 h). Generalized estimating equations (GEE) were used to account for the correlation for the inflammatory markers. Pearson's correlation test and logistic regression analysis were also performed. RESULTS: During the study period, 250 adult trauma patients were enrolled. Almost 13% of patients presented with hyperglycemia (50% had SIH and 50% had DH). Patients with SIH were younger, had significantly higher Injury Severity Score (ISS), higher IL-6 readings, prolonged hospital length of stay and higher mortality. The SIH group had lower Revised Trauma Score (p = 0.005), lower Trauma Injury Severity Score (p = 0.01) and lower GCS (p = 0.001). Patients with hyperglycemia had higher in-hospital mortality than the normoglycemia group (12.5% vs 3.7%; p = 0.02). A significant correlation was identified between the initial blood glucose level and serum lactate, IL-6, ISS and hospital length of stay. Overall rate of change in slope 88.54 (95% CI:-143.39-33.68) points was found more in hyperglycemia than normoglycemia group (p = 0.002) for IL-6 values, whereas there was no statistical significant change in slopes of age, gender and their interaction. The initial IL-6 levels correlated with ISS (r = 0.40, p = 0.001). On-admission hyperglycemia had an adjusted odds ratio 2.42 (95% CI: 1.076-5.447, p = 0.03) for severe injury (ISS > 12) after adjusting for age, shock index and blood transfusion. CONCLUSIONS: In trauma patients, on-admission hyperglycemia correlates well with the initial serum IL-6 level and is associated with more severe injuries. Therefore, it could be a simple marker of injury severity and useful tool for patient triage and risk assessment. TRIAL REGISTRATION: This study was registered at the ClinicalTrials.gov (Identifier: NCT02999386), retrospectively Registered on December 21, 2016. https://clinicaltrials.gov/ct2/show/NCT02999386 .

Traumatic sternal injury in patients with rib fracture: A single-center experience.

PURPOSE: We aimed to assess the pattern and impact of sternal injury with rib fracture in a Level 1 trauma center. PATIENTS AND METHODS: We conducted a retrospective review of trauma registry data to identify patients who presented with sternal fracture between 2010 and 2017. Data were analyzed and compared in patients with and without rib fracture. RESULTS: We identified 212 patients with traumatic sternal injury, of them 119 (56%) had associated rib fractures. In comparison to those who had no rib fracture, patients with rib fractures were older (40.1 ± 13.6 vs. 37.8 ± 14.5), were frequently involved in traffic accidents (75% vs. 71%), had higher chest abbreviated injury scale (AIS 2.8 ± 0.6 vs. 2.2 ± 0.5) and Injury Severity Score ( ISS 17.5 ± 8.6 vs. 13.3 ± 9.6), were more likely to be intubated (33% vs. 19%), required chest tube insertion (13.4% vs. 4.3%), and received blood transfusion (29% vs. 17%). Rates of spine fracture, head injury, and solid organ injury were comparable in the two groups. Manubrium, clavicular and scapular fractures, lung contusion, hemothorax, and pneumothorax were significantly more evident in those who had rib fractures. Hospital length of stay was prolonged in patients with rib fractures (P = 0.008). The overall mortality was higher but not statistically significant in patients with rib fractures (5.0% vs. 3.2%). CONCLUSIONS: Sternal fractures are rare, and detection of associated injuries requires a high index of suspicion. Combined sternal and rib fractures are more evident in relatively older patients after chest trauma. This combination has certain clinical implications that necessitate further prospective studies.

Clinical and Radiological Presentations and Management of Blunt Splenic Trauma: A Single Tertiary Hospital Experience.

BACKGROUND Splenic injury is the leading cause of major bleeding after blunt abdominal trauma. We examined the clinical and radiological presentations, management, and outcome of blunt splenic injuries (BSI) in our institution. MATERIAL AND METHODS A retrospective study of BSI patients between 2011 and 2014 was conducted. We analyzed and compared management and outcome of different splenic injury grades in trauma patients. RESULTS A total of 191 BSI patients were identified with a mean (SD) age of 26.9 years (13.1); 164 (85.9%) were males. Traffic-related accident was the main mechanism of injury. Splenic contusion and hematoma (77.2%) was the most frequent finding on initial computerized tomography (CT) scans, followed by shattered spleen (11.1%), blush (11.1%), and devascularization (0.6%). Repeated CT scan revealed 3 patients with pseudoaneurysm who underwent angioembolization. Nearly a quarter of patients were managed surgically. Non-operative management failed in 1 patient who underwent splenectomy. Patients with grade V injury presented with higher mean ISS and abdominal AIS, required frequent blood transfusion, and were more likely to be FAST-positive (p=0.001). The majority of low-grade (I-III) splenic injuries were treated conservatively, while patients with high-grade (IV and V) BSI frequently required splenectomy (p=0.001). Adults were more likely to have grade I, II, and V BSI, blood transfusion, and prolonged ICU stay as compared to pediatric BSI patients. The overall mortality rate was 7.9%, which is mainly association with traumatic brain injury and hemorrhagic shock; half of the deaths occurred within the first day after injury. CONCLUSIONS Most BSI patients had grade I-III injuries that were successfully treated non-operatively, with a low failure rate. The severity of injury and presence of associated lesions should be carefully considered in developing the management plan. Thorough clinical assessment and CT scan evaluation are crucial for appropriate management of BSI.