Validation of the International Classification of Functioning, Disability and Health Core Sets for traumatic brain injury from Australian community patient perspectives.

OBJECTIVE: To examine the validity of the Comprehensive and Brief International Classification of Functioning, Disability and Health (ICF) Core Sets for Traumatic Brain Injury for patients with traumatic brain injury living in the community in Australia. DESIGN: Qualitative methodology using focus groups and individual interviews. PATIENTS: Community-dwelling adult persons with traumatic brain injury. METHODS: Patients sustaining traumatic brain injury with post-traumatic amnesia between September 2009 and August 2013, selected from the Royal Melbourne Hospital Trauma Registry, were invited to participate in the study. Participants were asked structured questions based on the ICF framework. Digital recordings of the discussions were transcribed in full for linking to the ICF categories. RESULTS: Saturation of data was reached after 5 groups involving 21 participants. Participants identified as relevant 77.7% (n = 108/139) and 100% (n = 23/23) of the Comprehensive and Brief ICF Core Sets for traumatic brain injury, respectively. Additional ICF categories identified in 2 or more groups were: b180 "experience of self and time functions"; b250 "taste function"; b265 "touch function"; b530 "weight maintenance function"; b780 "sensation related to muscles and movement"; and d650 "caring for household objects". CONCLUSION: The study found additional ICF categories to consider and supports the use of the ICF Core Sets for traumatic brain injury in Australian adults in the community.

Finger thoracostomy in patients with chest trauma performed by paramedics on a helicopter emergency medical service.

OBJECTIVE: To determine the frequency of finger thoracostomy performed by intensive care flight paramedics after the introduction of a training programme in this procedure and complications of the procedure that were diagnosed after hospital arrival. METHODS: This was a retrospective cohort study of adult and paediatric trauma patients undergoing finger thoracostomy performed by paramedics on a helicopter emergency medical service between June 2015 and May 2018. Hospital data were obtained through a manual search of the medical records at each of the three receiving major trauma services. Additional data were sourced from the Victorian State Trauma Registry. RESULTS: The final analysis included 103 cases, of which 73.8% underwent bilateral procedures with a total of 179 finger thoracostomies performed. The mean age of patients was 42.8 (standard deviation 21.4) years and 73.8% were male. Motor vehicle collision was the most common mechanism of injury accounting for 54.4% of cases. The median Injury Severity Score was 41 (interquartile range 29-54). There were 30 patients who died pre-hospital, with most (n = 25) having finger thoracostomy performed in the setting of a traumatic cardiac arrest. A supine chest X-ray was performed prior to intercostal catheter insertion in 38 of 73 patients arriving at hospital; of these, none demonstrated a tension pneumothorax. There were three cases of potential complications related to the finger thoracostomy. CONCLUSION: Finger thoracostomy was frequently performed by intensive care flight paramedics. It was associated with a low rate of major complications and given the deficiencies of needle thoracostomy, should be the preferred approach for chest decompression.

Applicability of traumatic brain injury rehabilitation interventions in natural disaster settings.

Objective: To evaluate published traumatic brain injury (TBI) clinical practice guidelines (CPGs) and assess rehabilitation intervention recommendations for applicability in disaster settings. Methods: Recommendations for rehabilitation interventions were synthesized from currently published TBI CPGs, developed by the Department of Labor and Employment (DLE); Scottish Intercollegiate Guidelines Network (SIGN); Department of Veterans Affairs/Department of Defence (DVA/DOD); and American Occupational Therapy Association (AOTA). Three authors independently extracted, compared, and categorized evidence-based rehabilitation intervention recommendations from these CPGs for applicability in disaster settings. Results: The key recommendations from a rehabilitation perspective for TBI survivors in disaster settings included patient/carer education, general physical therapy, practice in daily living activities and safe equipment use, direct cognitive/behavioral feedback, basic compensatory memory/visual strategies, basic swallowing/communication, and psychological input. More advanced interventions are generally not applicable following disasters due to limited access to services, trained staff/resources, equipment, funding, and operational issues. Conclusions: Many recommendations for TBI care are challenging to implement in disaster settings due to complexities related to the environment, resources, service provision, workforce, and other reasons. Further research is needed to identify and address barriers for implementation.

Clinical practice guidelines for rehabilitation in traumatic brain injury: a critical appraisal.

This review aim to provide an overview of recommendations and quality of existing clinical practice guidelines (CPGs) for the management of traumatic brain injury (TBI) from the rehabilitation perspective. Comprehensive literature search, including health databases, CPG clearinghouse/developer websites, and grey literature using Internet search engines up to September 2017. All TBI CPGs published in the last decade were selected if their scope included management of TBI, systematic methods for evidence search, clear defined recommendations, and supporting evidence for rehabilitation interventions. Three authors independently critically appraised the quality of included CPGs using the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) Instrument. Four of 13 potential CPGs met the inclusion criteria. Despite variation in scope, target population, size, and guideline development processes, all four CPGs assessed were good quality (AGREE score of 5-7/7). Key rehabilitation recommendations included education, physical rehabilitation, integrated computer-based management, repetitive task-specific practice in daily living activities, safe equipment usage, cognitive/behavioral feedback, compensatory memory/visual strategies, swallowing/communication, and psychological input for TBI survivors. In conclusion, although rehabilitation is an integral component in TBI management, many published CPGs do not include rehabilitation. These CPGs, however, recommend comprehensive, flexible coordinated multidisciplinary care and appropriate follow-up, education, and support for patients with TBI (and carers).

Comparing the outcomes of isolated, serious traumatic brain injury in older adults managed at major trauma centres and neurosurgical services: A registry-based cohort study.

BACKGROUND: The incidence of older adult traumatic brain injury (TBI) is increasing in both high and middle to low-income countries. It is unknown whether older adults with isolated, serious TBI can be safely managed outside of major trauma centres. This registry based cohort study aimed to compare mortality and functional outcomes of older adults with isolated, serious TBI who were managed at specialised Major Trauma Services (MTS) and Metropolitan Neurosurgical Services (MNS). METHOD: Older adults (65 years and over) who sustained an isolated, serious TBI following a low fall (from standing or ≤ 1 m) were extracted from the Victorian State Trauma Registry from 2007 to 2016. Multivariable models were fitted to assess the association between hospital designation (MTS vs. MNS) and the two outcomes of interest: in-hospital mortality and functional outcome, adjusting for potential confounders. Functional outcomes were measured using the Glasgow Outcome Scale Extended at six months post-injury. RESULTS: From 2007-2016, there were 1904 older adults who sustained an isolated, serious TBI from a low fall who received definitive care at an MTS (n = 1124) or an MNS (n = 780). After adjusting for confounders, there was no mortality benefit for patients managed at an MTS over an MNS (OR = 0.84; 95% CI: 0.65, 1.08; P = 0.17) or improvement in functional outcome six months post-injury (OR = 1.13; 95% CI: 0.94, 1.36; P = 0.21). CONCLUSION: For older adults with isolated, serious TBI following a low fall, there was no difference in mortality or functional outcome based on definitive management at an MTS or an MNS. This confirms that MNS without the added designation of a major trauma centre are a suitable destination for the management of isolated, serious TBI in older adults.

Traumatic spinal cord injury in Victoria, 2007-2016.

OBJECTIVE: To investigate trends in the incidence and causes of traumatic spinal cord injury (TSCI) in Victoria over a 10-year period. DESIGN, SETTING, PARTICIPANTS: Retrospective cohort study: analysis of Victorian State Trauma Registry (VSTR) data for people who sustained TSCIs during 2007-2016. MAIN OUTCOMES AND MEASURES: Temporal trends in population-based incidence rates of TSCI (injury to the spinal cord with an Abbreviated Injury Scale [AIS] score of 4 or more). RESULTS: There were 706 cases of TSCI, most the result of transport events (269 cases, 38%) or low falls (197 cases, 28%). The overall crude incidence of TSCI was 1.26 cases per 100 000 population (95% CI, 1.17-1.36 per 100 000 population), and did not change over the study period (incidence rate ratio [IRR], 1.01; 95% CI, 0.99-1.04). However, the incidence of TSCI resulting from low falls increased by 9% per year (95% CI, 4-15%). The proportion of TSCI cases classified as incomplete tetraplegia increased from 41% in 2007 to 55% in 2016 (P < 0.001). Overall in-hospital mortality was 15% (104 deaths), and was highest among people aged 65 years or more (31%, 70 deaths). CONCLUSIONS: Given the devastating consequences of TSCI, improved primary prevention strategies are needed, particularly as the incidence of TSCI did not decline over the study period. The epidemiologic profile of TSCI has shifted, with an increasing number of TSCI events in older adults. This change has implications for prevention, acute and post-discharge care, and support.

Ageing population has changed the nature of major thoracic injury.

INTRODUCTION: An increasing proportion of the major trauma population are older persons. The pattern of injury is different in this age group and serious chest injuries represent a significant subgroup, with implications for trauma system design. The aim of this study was to examine trends in thoracic injuries among major trauma patients in an inclusive trauma system. METHODS: This was a retrospective review of all adult cases of major trauma with thoracic injuries of Abbreviated Injury Scale score of 3 or more, using data from the Victorian State Trauma Registry from 2007 to 2016. Prevalence and pattern of thoracic injury was compared between patients with multitrauma and patients with isolated thoracic injury. Poisson regression was used to determine whether population-based incidence had changed over the study period. RESULTS: There were 8805 cases of hospitalised major trauma with serious thoracic injuries. Over a 10-year period, the population-adjusted incidence of thoracic injury increased by 8% per year (incidence rate ratio [IRR] 1.08, 95% CI 1.07 to 1.09). This trend was observed across all age groups and mechanisms of injury. The greatest increase in incidence of thoracic injuries, 14% per year, was observed in people aged 85 years and older (IRR 1.14, 95% CI 1.09 to 1.18). CONCLUSIONS: Admissions for thoracic injuries in the major trauma population are increasing. Older patients are contributing to an increase in major thoracic trauma. This is likely to have important implications for trauma system design, as well as morbidity, mortality and use of healthcare resources.

Potentially preventable trauma deaths: A retrospective review.

BACKGROUND: Reviewing prehospital trauma deaths provides an opportunity to identify system improvements that may reduce trauma mortality. The objective of this study was to identify the number and rate of potentially preventable trauma deaths through expert panel reviews of prehospital and early in-hospital trauma deaths. METHODS: We conducted a retrospective review of prehospital and early in-hospital (<24 h) trauma deaths following a traumatic out-of-hospital cardiac arrest that were attended by Ambulance Victoria (AV) in the state of Victoria, Australia, between 2008 and 2014. Expert panels were used to review cases that had resuscitation attempted by paramedics and underwent a full autopsy. Patients with a mechanism of hanging, drowning or those with anatomical injuries deemed to be unsurvivable were excluded. RESULTS: Of the 1183 cases that underwent full autopsies, resuscitation was attempted by paramedics in 336 (28%) cases. Of these, 113 cases (34%) were deemed to have potentially survivable injuries and underwent expert panel review. There were 90 (80%) deaths that were not preventable, 19 (17%) potentially preventable deaths and 4 (3%) preventable deaths. Potentially preventable or preventable deaths represented 20% of those cases that underwent review and 7% of cases that had attempted resuscitation. CONCLUSIONS: The number of potentially preventable or preventable trauma deaths in the pre-hospital and early in-hospital resuscitation phase was low. Specific circumstances were identified in which the trauma system could be further improved.

Level of agreement between medical record and ICD-10-AM coding of mental health, alcohol and drug conditions in trauma patients.

BACKGROUND: Despite the reliance on administrative data in epidemiological studies, there is little information on the completeness of co-morbidities in administrative data coded from medical records. OBJECTIVE: The aim of this study was to quantify the agreement between the International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) administrative coding of mental health, drug and alcohol co-morbidities and medical records in a severely injured patient population. METHOD: A random sample of patients (n = 500) captured by the Victorian State Trauma Registry and definitively managed at the state's adult major trauma services was selected for the study. Retrospective medical record review was conducted to collect data about documented co-morbidities. The agreement between ICD-10-AM data generated from routine hospital coding and medical record-based co-morbidities was determined using Cohen's κ and prevalence-adjusted bias-adjusted kappa (PABAK) statistics. RESULTS: The percentage of agreement between the medical record and ICD-10-AM coding for mental health, drug and alcohol co-morbidities was 72.8%, and the PABAK showed moderate agreement (PABAK = 0.46; 95% confidence interval (CI): 0.37, 0.54). There was no difference in agreement between unintentional injury patients (PABAK = 0.52; 95% CI: 0.42, 0.62) compared with intentional injury patients (PABAK = 0.36, 95% CI: 0.23, 0.49), and no change in agreement for patients admitted before (PABAK = 0.40; 95% CI: 0.30, 0.50) and after the introduction of mandatory co-morbidity coding (PABAK = 0.46; 95% CI: 0.37, 0.54). CONCLUSION: Despite documentation in the medical record, a large proportion of mental health, drug and alcohol conditions were not coded in ICD-10-AM. Acknowledgement of these limitations is needed when using ICD-10-AM coded co-morbidities in research studies and health policy development. IMPLICATIONS: This work has implications for researchers of drug and alcohol abuse; mental health; accidents and injuries; workers' compensation; health workforce; health services; and policy decisions for healthcare, emergency services, insurance industry, national productivity and welfare costings reliant on those research outcomes.

Comparison of the performance of mental health, drug and alcohol comorbidities based on ICD-10-AM and medical records for predicting 12-month outcomes in trauma patients.

BACKGROUND: Many outcome studies capture the presence of mental health, drug and alcohol comorbidities from administrative datasets and medical records. How these sources compare as predictors of patient outcomes has not been determined. The purpose of the present study was to compare mental health, drug and alcohol comorbidities based on ICD-10-AM coding and medical record documentation for predicting longer-term outcomes in injured patients. METHODS: A random sample of patients (n = 500) captured by the Victorian State Trauma Registry was selected for the study. Retrospective medical record reviews were conducted to collect data about documented mental health, drug and alcohol comorbidities while ICD-10-AM codes were obtained from routinely collected hospital data. Outcomes at 12-months post-injury were the Glasgow Outcome Scale - Extended (GOS-E), European Quality of Life Five Dimensions (EQ-5D-3L), and return to work. Linear and logistic regression models, adjusted for age and gender, using medical record derived comorbidity and ICD-10-AM were compared using measures of calibration (Hosmer-Lemeshow statistic) and discrimination (C-statistic and R2). RESULTS: There was no demonstrable difference in predictive performance between the medical record and ICD-10-AM models for predicting the GOS-E, EQ-5D-3L utility sore and EQ-5D-3L mobility, self-care, usual activities and pain/discomfort items. The area under the receiver operating characteristic (AUC) for models using medical record derived comorbidity (AUC 0.68, 95% CI: 0.63, 0.73) was higher than the model using ICD-10-AM data (AUC 0.62, 95% CI: 0.57, 0.67) for predicting the EQ-5D-3L anxiety/depression item. The discrimination of the model for predicting return to work was higher with inclusion of the medical record data (AUC 0.69, 95% CI: 0.63, 0.76) than the ICD-10-AM data (AUC 0.59, 95% CL: 0.52, 0.65). CONCLUSIONS: Mental health, drug and alcohol comorbidity information derived from medical record review was not clearly superior for predicting the majority of the outcomes assessed when compared to ICD-10-AM. While information available in medical records may be more comprehensive than in the ICD-10-AM, there appears to be little difference in the discriminative capacity of comorbidities coded in the two sources.

Patient-identified information and communication needs in the context of major trauma.

BACKGROUND: Navigating complex health care systems during the multiple phases of recovery following major trauma entails many challenges for injured patients. Patients' experiences communicating with health professionals are of particular importance in this context. The aim of this study was to explore seriously injured patients' perceptions of communication with and information provided by health professionals in their first 3-years following injury. METHODS: A qualitative study designed was used, nested within a population-based longitudinal cohort study. Semi-structured telephone interviews were undertaken with 65 major trauma patients, aged 17 years and older at the time of injury, identified through purposive sampling from the Victorian State Trauma Registry. A detailed thematic analysis was undertaken using a framework approach. RESULTS: Many seriously injured patients faced barriers to communication with health professionals in the hospital, rehabilitation and in the community settings. Key themes related to limited contact with health professionals, insufficient information provision, and challenges with information coordination. Communication difficulties were particularly apparent when many health professionals were involved in patient care, or when patients transitioned from hospital to rehabilitation or to the community. Difficulties in patient-health professional engagement compromised communication and exchange of information particularly at transitions of care, e.g., discharge from hospital. Conversely, positive attributes displayed by health professionals such as active discussion, clear language, listening and an empathetic manner, all facilitated effective communication. Most patients preferred communication consistent with patient-centred approaches, and the use of multiple modes to communicate information. CONCLUSIONS: The communication and information needs of seriously injured patients were inconsistently met over the course of their recovery continuum. To assist patients along their recovery trajectories, patient-centred communication approaches and considerations for environmental and patients' health literacy are recommended. Additionally, assistance with information coordination and comprehensive multimodal information provision should be available for injured patients.

Comparing ICD-10 external cause codes for pedal cyclists with self-reported crash details.

Accurate coding of injury event information is critical in developing targeted injury prevention strategies. However, little is known about the validity of the most universally used coding system, the International Classification of Diseases (ICD-10), in characterising crash counterparts in pedal cycling events. This study aimed to determine the agreement between hospital-coded ICD-10-AM (Australian modification) external cause codes with self-reported crash characteristics in a sample of pedal cyclists admitted to hospital following bicycle crashes. Interview responses from 141 injured cyclists were mapped to a single ICD-10-AM external cause code for comparison with ICD-10-AM external cause codes from hospital administrative data. The percentage of agreement was 77.3% with a κ value of 0.68 (95% CI 0.61 to 0.77), indicating substantial agreement. Nevertheless, studies reliant on ICD-10 codes from administrative data should consider the 23% level of disagreement when characterising crash counterparts in cycling crashes.

Road safety: serious injuries remain a major unsolved problem.

OBJECTIVE: To investigate temporal trends in the incidence, mortality, disability-adjusted life-years (DALYs), and costs of health loss caused by serious road traffic injury. DESIGN, SETTING AND PARTICIPANTS: A retrospective review of data from the population-based Victorian State Trauma Registry and the National Coronial Information System on road traffic-related deaths (pre- and in-hospital) and major trauma (Injury Severity Score > 12) during 2007-2015.Main outcomes and measures: Temporal trends in the incidence of road traffic-related major trauma, mortality, DALYs, and costs of health loss, by road user type. RESULTS: There were 8066 hospitalised road traffic major trauma cases and 2588 road traffic fatalities in Victoria over the 9-year study period. There was no change in the incidence of hospitalised major trauma for motor vehicle occupants (incidence rate ratio [IRR] per year, 1.00; 95% CI, 0.99-1.01; P = 0.70), motorcyclists (IRR, 0.99; 95% CI, 0.97-1.01; P = 0.45) or pedestrians (IRR, 1.00; 95% CI, 0.97-1.02; P = 0.73), but the incidence for pedal cyclists increased 8% per year (IRR, 1.08; 95% CI; 1.05-1.10; P < 0.001). While DALYs declined for motor vehicle occupants (by 13% between 2007 and 2015), motorcyclists (32%), and pedestrians (5%), there was a 56% increase in DALYs for pedal cyclists. The estimated costs of health loss associated with road traffic injuries exceeded $14 billion during 2007-2015, although the cost per patient declined for all road user groups. CONCLUSIONS: As serious injury rates have not declined, current road safety targets will be difficult to meet. Greater attention to preventing serious injury is needed, as is further investment in road safety, particularly for pedal cyclists.

Predictors of recovery in cyclists hospitalised for orthopaedic trauma following an on-road crash.

BACKGROUND: As cycling-related injury rates are on the rise, there is a need to understand the long term outcomes of these patients in order to quantify the burden of injury and to inform injury prevention strategies. This study aimed to investigate predictors of return to work and functional recovery in a cohort of cyclists hospitalised for orthopaedic trauma from crashes occurring on-road. METHODS: A retrospective analysis of data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) was conducted for patients who were hospitalised for orthopaedic trauma following a cycling crash that occurred on-road between July 2007 and June 2015. RESULTS: There were 1787 injured cyclists admitted at the participating hospitals. Most cyclists were male (79%), resided in major cities (89%) and were in the highest socioeconomic quintile (52%). The majority of crashes were either non-collisions (41%) or collisions with a motor vehicle (35%). A smaller proportion of cyclists who collided with motor vehicles had returned to work and had returned to pre-injury functional levels at 12 months post-injury, when compared to collisions with other impact counterparts and non-collisions. Mixed effects logistic regression models revealed that compensable patients demonstrated lower odds of complete functional recovery and return to work when compared with non-compensable patients. CONCLUSION: Cyclists who collided with motor vehicles had worse outcomes compared to crashes with other impact counterparts and non-collision events. These findings provide support for reducing the potential for interaction between cyclists and motor vehicles.

Long-term health status and trajectories of seriously injured patients: A population-based longitudinal study.

BACKGROUND: Improved understanding of the quality of survival of patients is crucial in evaluating trauma care, understanding recovery patterns and timeframes, and informing healthcare, social, and disability service provision. We aimed to describe the longer-term health status of seriously injured patients, identify predictors of outcome, and establish recovery trajectories by population characteristics. METHODS AND FINDINGS: A population-based, prospective cohort study using the Victorian State Trauma Registry (VSTR) was undertaken. We followed up 2,757 adult patients, injured between July 2011 and June 2012, through deaths registry linkage and telephone interview at 6-, 12-, 24-, and 36-months postinjury. The 3-level EuroQol 5 dimensions questionnaire (EQ-5D-3L) was collected, and mixed-effects regression modelling was used to identify predictors of outcome, and recovery trajectories, for the EQ-5D-3L items and summary score. Mean (SD) age of participants was 50.8 (21.6) years, and 72% were male. Twelve percent (n = 333) died during their hospital stay, 8.1% (n = 222) of patients died postdischarge, and 155 (7.0%) were known to have survived to 36-months postinjury but were lost to follow-up at all time points. The prevalence of reporting problems at 36-months postinjury was 37% for mobility, 21% for self-care, 47% for usual activities, 50% for pain/discomfort, and 41% for anxiety/depression. Continued improvement to 36-months postinjury was only present for the usual activities item; the adjusted relative risk (ARR) of reporting problems decreased from 6 to 12 (ARR 0.87, 95% CI: 0.83-0.90), 12 to 24 (ARR 0.94, 95% CI: 0.90-0.98), and 24 to 36 months (ARR 0.95, 95% CI: 0.95-0.99). The risk of reporting problems with pain or discomfort increased from 24- to 36-months postinjury (ARR 1.06, 95% CI: 1.01, 1.12). While loss to follow-up was low, there was responder bias with patients injured in intentional events, younger, and less seriously injured patients less likely to participate; therefore, these patient subgroups were underrepresented in the study findings. CONCLUSIONS: The prevalence of ongoing problems at 3-years postinjury is high, confirming that serious injury is frequently a chronic disorder. These findings have implications for trauma system design. Investment in interventions to reduce the longer-term impact of injuries is needed, and greater investment in primary prevention is needed.

Massive bilateral chylothorax post blunt trauma.

Chylothorax caused by blunt trauma is extremely rare. We present a case of bilateral massive chylothorax post blunt trauma and a review of the literature regarding the identification and management of this rare diagnosis. An eighteen-year-old male was involved in a motor vehicle crash where he sustained multiple injuries including a right, moderate to large, haemopneumothorax, a small left haemopneumothorax, left T8, T9, L1 and L2 acute transverse process fractures and fractures of bilateral 11th ribs. An intercostal catheter was inserted on the right side which initially drained blood-stained fluid however milky colour fluid was noted to be draining 11 h post insertion. Further imaging revealed a left pleural effusion causing a mediastinal shift where, once drained, also revealed a chylothorax. The patient was managed conservatively with bilateral intercostal catheters and a no fat/low-fat diet. The patient was discharged day seven post removal of bilateral intercostal catheters.

A prospective case series for a minimally invasive internal fixation device for anterior pelvic ring fractures.

BACKGROUND: External fixation is commonly used as a means of definitive fixation of pelvic fractures. Pin site infection is common, with some cases of osteomyelitis and inpatient nursing can be challenging. The aim of this study is to report the outcomes and complications of an alternative minimally invasive technique, known as INFIX, utilising spinal pedicle screws inserted into the supra-acetabular bone and connected by a subcutaneous rod. METHODS: A single-centre prospective case series was performed. The primary outcome measures were fracture stability and displacement at time of implant removal and intra- and post-operative complications. RESULTS: Twenty-one patients were recruited, with 85.7 % of fractures being lateral compression type. Mean follow-up was 342 days. Mean application time was 51 min (range 44-65). Nineteen were removed electively, with mean time to removal 109 days. All cases were stable with no displacement. Two cases were removed emergently, one due to wound infection and the other due to lateral femoral cutaneous nerve neuropathic pain. Twelve patients sustained a lateral femoral cutaneous nerve palsy, with 20/42 nerves being affected. Improvement in all lateral femoral cutaneous nerve symptoms were reported with removal. Nine patients developed asymptomatic heterotopic ossification, and there were three deep infections and one symptomatic due to the bar. CONCLUSIONS: Minimally invasive internal fixation with the INFIX for anterior pelvic ring fractures is an alternative to anterior external fixation. However, a higher rate of lateral femoral cutaneous nerve palsy is noted, and the implant is not well tolerated by all patients. Further studies are required to define fracture types and patients best suited to the technique and how LFCN complications may be minimised. TRIAL REGISTRATION: ACTRN12616001421426 . Registered 12 October 2016. Retrospectively registered.

Bicycling crash characteristics: An in-depth crash investigation study.

The aim of this study was to describe the crash characteristics and patient outcomes of a sample of patients admitted to hospital following bicycle crashes. Injured cyclists were recruited from the two major trauma services for the state of Victoria, Australia. Enrolled cyclists completed a structured interview, and injury details and patient outcomes were extracted from the Victorian State Trauma Registry (VSTR) and the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). 186 cyclists consented to participate in the study. Crashes commonly occurred during daylight hours and in clear weather conditions. Two-thirds of crashes occurred on-road (69%) and were a combination of single cyclist-only events (56%) and multi-vehicle crashes (44%). Of the multi-vehicle crashes, a motor vehicle was the most common impact partner (72%) and distinct pre-crash directional interactions were observed between the cyclist and motor vehicle. Nearly a quarter of on-road crashes occurred when the cyclist was in a marked bicycle lane. Of the 31% of crashes that were not on-road, 28 (15%) occurred on bicycle paths and 29 (16%) occurred in other locations. Crashes on bicycle paths commonly occurred on shared bicycle and pedestrian paths (83%) and did not involve another person or vehicle. Other crash locations included mountain bike trails (39%), BMX parks (21%) and footpaths (18%). While differences in impact partners and crash characteristics were observed between crashes occurring on-road, on bicycle paths and in other locations, injury patterns and severity were similar. Most cyclists had returned to work at 6 months post-injury, however only a third of participants reported a complete functional recovery. Further research is required to develop targeted countermeasures to address the risk factors identified in this study.

Factors associated with long-term functional and psychological outcomes in persons with moderate to severe traumatic brain injury.

OBJECTIVE: To examine factors impacting long-term functional and psychological outcomes in persons with moderate-severe traumatic brain injury. METHODS: A prospective cross-sectional study (n = 103) assessed the long-term (up to 5 years) impact of traumatic brain injury on participants' current activity and restriction in participation using validated questionnaires. RESULTS: Participants' median age was 49.5 years (interquartile range (IQR) 20.4-23.8), the majority were male (77%), and 49% had some form of previous rehabilitation. The common causes of traumatic brain injury were falls (42%) and motor vehicle accidents (27%). Traumatic brain injury-related symptoms were: pain/headache (47%), dizziness (36%), bladder/bowel impairment (34%), and sensory-perceptual deficits (34%). Participants reported minimal change in their physical function and cognition (Functional Assessment Measure: motor (median 102, IQR 93-111) and cognition (median 89, IQR 78-95)). Participants were well-adjusted to community-living; however, they reported high levels of depression. Factors significantly associated with poorer current level of functioning/well-being included: older age (≥ 60 years), presence of traumatic brain injury-related symptoms, a lack of previous rehabilitation and those classified in "severe disability categories" at admission. Caregivers reported high levels of strain and burden (55%). CONCLUSION: Cognitive and psychosocial problems are more commonly reported than physical disability in the longer-term. A greater focus on participation and ageing with disability in these persons is needed.

Return to Work and Functional Outcomes After Major Trauma: Who Recovers, When, and How Well?

OBJECTIVE: To describe the long-term outcomes of major trauma patients and factors associated with the rate of recovery. BACKGROUND: As injury-related mortality decreases, there is increased focus on improving the quality of survival and reducing nonfatal injury burden. METHODS: Adult major trauma survivors to discharge, injured between July 2007 and June 2012 in Victoria, Australia, were followed up at 6, 12, and 24 months after injury to measure function (Glasgow Outcome Scale-Extended) and return to work/study. Random-effects regression models were fitted to identify predictors of outcome and differences in the rate of change in each outcome between patient subgroups. RESULTS: Among the 8844 survivors, 8128 (92%) were followed up. Also, 23% had achieved a good functional recovery, and 70% had returned to work/study at 24 months. The adjusted odds of reporting better function at 12 months was 27% (adjusted odds ratio 1.27, 95% confidence interval [CI] 1.19-1.36) higher compared with 6 months, and 9% (adjusted odds ratio 1.09, 95% CI, 1.02-1.17) higher at 24 months compared with 12 months. The adjusted relative risk (RR) of returning to work was 14% higher at 12 months compared with 6 months (adjusted RR 1.14, 95% CI, 1.12-1.16) and 8% (adjusted RR 1.08, 95% CI, 1.06-1.10) higher at 24 months compared with 12 months. CONCLUSIONS: Improvement in outcomes over the study period was observed, although ongoing disability was common at 24 months. Recovery trajectories differed by patient characteristics, providing valuable information for informing prognostication and service planning, and improving our understanding of the burden of nonfatal injury.