Research priorities for the management of major trauma: an international priority setting partnership with the James Lind Alliance.

OBJECTIVE: The objective of this study is to determine research priorities for the management of major trauma, representing the shared priorities of patients, their families, carers and healthcare professionals. DESIGN/SETTING: An international research priority-setting partnership. PARTICIPANTS: People who have experienced major trauma, their carers and relatives, and healthcare professionals involved in treating patients after major trauma. The scope included chest, abdominal and pelvic injuries as well as major bleeding, multiple injuries and those that threaten life or limb. METHODS: A multiphase priority-setting exercise was conducted in partnership with the James Lind Alliance over 24 months (November 2021-October 2023). An international survey asked respondents to submit their research uncertainties which were then combined into several indicative questions. The existing evidence was searched to ensure that the questions had not already been sufficiently answered. A second international survey asked respondents to prioritise the research questions. A final shortlist of 19 questions was taken to a stakeholder workshop, where consensus was reached on the top 10 priorities. RESULTS: A total of 1572 uncertainties, submitted by 417 respondents (including 132 patients and carers), were received during the initial survey. These were refined into 53 unique indicative questions, of which all 53 were judged to be true uncertainties after reviewing the existing evidence. 373 people (including 115 patients and carers) responded to the interim prioritisation survey and 19 questions were taken to a final consensus workshop between patients, carers and healthcare professionals. At the final workshop, a consensus was reached for the ranking of the top 10 questions. CONCLUSIONS: The top 10 research priorities for major trauma include patient-centred questions regarding pain relief and prehospital management, multidisciplinary working, novel technologies, rehabilitation and holistic support. These shared priorities will now be used to guide funders and teams wishing to research major trauma around the globe.

Identifying and Validating Alcohol Diagnostics for Injury-Related Trauma in South Africa: Protocol for a Mixed Methods Study.

BACKGROUND: The burden of alcohol use among patients with trauma and the relative injury risks is not routinely measured in South Africa. Given the prominent burden of alcohol on hospital trauma departments, South Africa needs practical, cost-effective, and accurate alcohol diagnostic tools for testing, surveillance, and clinical management of patients with trauma. OBJECTIVE: This study aims to validate alcohol diagnostics for injury-related trauma and assess its use for improving national health practice and policy. METHODS: The Alcohol Diagnostic Validation for Injury-Related Trauma study will use mixed methods across 3 work packages. Five web-based focus group discussions will be conducted with 6 to 8 key stakeholders, each across 4 areas of expertise (clinical, academic, policy, and operational) to determine the type of alcohol information that will be useful for different stakeholders in the injury prevention and health care sectors. We will then conduct a small pilot study followed by a validation study of alcohol diagnostic tools (clinical assessment, breath analysis, and fingerprick blood) against enzyme immunoassay blood concentration analysis in a tertiary hospital trauma setting with 1000 patients. Finally, selected alcohol diagnostic tools will be tested in a district hospital setting with a further 1000 patients alongside community-based participatory research on the use of the selected tools. RESULTS: Pilot data are being collected, and the protocol will be modified based on the results. CONCLUSIONS: Through this project, we hope to identify and validate the most appropriate methods of diagnosing alcohol-related injury and violence in a clinical setting. The findings from this study are likely to be highly relevant and could influence our primary beneficiaries-policy makers and senior health clinicians-to adopt new practices and policies around alcohol testing in injured patients. The findings will be disseminated to relevant national and provincial government departments, policy experts, and clinicians. Additionally, we will engage in media advocacy and with our stakeholders, including community representatives, work through several nonprofit partners to reach civil society organizations and share findings. In addition, we will publish findings in scientific journals. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52949.

Optimising the Orthopaedic Trauma Society Open Fracture Classification system: a proposal for modification in the context of high civilian gunshot fractures.

OBJECTIVES: Uniformly classifying long bone open fractures is challenging. The purpose of this study was to propose a modified Orthopaedic Trauma Society (OTS) Open Fracture Classification System, developed in a setting with a high incidence of civilian gunshot fractures. METHODS: From our prospectively collected database, we identified all patients with open tibia and femur fractures treated with intramedullary nailing over a 4 year period. All open fractures were retrospectively reclassified from the Gustilo-Anderson Classification system to the OTS Open Fracture Classification System. RESULTS: One hundred and thirty-seven cases were identified. Ninety per cent of subjects were males. Their mean age was 34 years. The most common mechanism of injury was low-velocity civilian gunshot wounds (GSW) in 54.7% of cases. Soft tissue management was primary closure in 23.4% and soft tissue reconstruction in 24.1%. In 52.6% of cases (these all being secondary to civilian GSW), soft tissue management was healing via secondary intention. This is not included as a soft tissue management option in the OTS classification system. Fracture reclassification using the OTS Open Fracture Classification System was only possible in 47.5% of cases (Simple in 23.4%, Complex B in 24.1%). CONCLUSION: We conclude that the OTS Open Fracture Classification System is not inclusive of all open tibia and femur fractures as it does not cater for gunshot fractures. We propose a modification as follows: alter 'wound debridement' to 'appropriate wound care' and to subcategorise 'Simple' into type A and B: healing via secondary intention and primary closure, respectively.

Alcohol diagnostic validation for injury-related trauma: Findings from a pilot study.

Introduction: Alcohol consumption is a key driver of the burden of violence and injury in South Africa (SA). Hence, we aim to validate various alcohol assessment tools against a blood test to assess their utility for improving national health practice and policy. Methods: We conducted a cross-sectional pilot study from 3 to 19 August 2022 at Groote Schuur Hospital in Cape Town, SA. This was to test logistics for the time of venous blood centrifugation and validation of alcohol assessment tools used in injured patients ahead of the main validation study. Adults aged 18 years and older, who were injured <8 h before arrival were included. Consent was obtained for venous blood alcohol testing to validate, as the gold standard, against the following: active- and passive breath alcohol testing, clinical screening and a finger prick test. Descriptive statistics were reported for the pilot study. Results: The active breath alcohol test's digital reading and the passive test's 'yes/no' results corresponded well against the venous blood alcohol results. The average time to centrifugation was within the laboratory's 2-h cut-off requirement to preserve the alcohol in the serum. Discussion and Conclusion: The pilot study was helpful in identifying challenges with one of the alcohol assessment tools and prevented further costs ahead of the main validation study. We also determined that the selected tertiary hospital site caused a delay in recruiting eligible patients due to other hospital referrals. Hence, the main validation study is in progress at a district-level hospital for a larger sample of eligible patients for testing.

Is human immunodeficiency virus a risk factor for the development of nonunion?-a case-control study.

Objective: Human immunodeficiency virus (HIV) infection has been suggested to be associated with an increased risk of the development of nonunion after a fracture. This prospective matched case-control study in South Africa investigated common risk factors, including HIV status, that influence the development of a nonunion after a femur or tibia fracture. Methods: Adult participants (cases) with established nonunions of the femur or tibia shaft were recruited over a 16-month period, between December 2017 and April 2019. They were matched for (1) age; (2) sex; (3) fracture site; and (4) fracture management type, with "control" participants who progressed to fracture union within 6 months of injury. All participants were tested for HIV. Multivariable logistic regression models were constructed to investigate associations between known risk factors for the development of nonunion and impaired fracture healing. Results: A total of 57 cases were matched with 57 "control" participants (44/57 male, 77.2% vs. 13/57 female, 22.8%, median age 36 years). HIV status was not associated with the development of nonunion after the management of tibia and femur fractures, on both univariate (odds ratio, 0.40; confidence interval, 0.10-1.32; P = 0.151) or multivariable (odds ratio, 0.86; confidence interval, 0.18-3.73; P = 0.831) analysis. No other confounding factors were shown to have any statistically significant impact on the odds of developing nonunion in this study cohort. Conclusion: This study demonstrates that HIV does not seem to increase the risk of the development of nonunion and HIV-positive individuals who sustain a fracture can be managed in the same manner as those who are HIV negative.

Current concepts review: Management of civilian transpelvic gunshot fractures.

INTRODUCTION: Civilian gunshot fractures of the pelvic ring represent a unique challenge for orthopaedic surgeons due to a high incidence of complicating associated injuries. Internationally accepted guidelines for these injuries are not available. The aim of this review is to summarize the available literature and to provide concise management recommendations. METHODS: Literature search was performed using PubMed. The review focuses on civilian gunshot fractures of the pelvic ring and includes the acetabulum and hip joint only where it was deemed necessary for the understanding of the management of these patients. RESULTS: The management of civilian transpelvic gunshot fractures is complicated by potentially life-threatening associated injuries, the risk of contamination with bowel content and retained bullets in joints. The infection risk is higher compared to extremity gunshot fractures. There is no clear evidence for the use of antibiotics available. The studies focusing on civilian pelvic ring gunshot fractures reported no case of orthopaedic fracture fixation in their series. Routine wash-out and debridement of fractures is not warranted based on the literature but conflicting recommendations for surgical interventions exist. CONCLUSION: There is limited evidence available for civilian transpelvic gunshot fractures. The high frequency of associated injuries requires a thorough clinical examination and multidisciplinary management. We recommend routine antibiotic prophylaxis for all transpelvic gunshots. For fractures with a high risk of infection, a minimum of 24 h broad-spectrum antibiotics is recommended. The indication for orthopaedic fixation of civilian transpelvic gunshot fractures is based on the assessment of the stability of the fracture and is rarely necessary. Although conflicting recommendations exist, routine wash-out and debridement is not recommended based on the literature. Bullets buried in bone without contact to synovial fluid do not warrant removal, unless they have traversed large bowel and are accessible without undue morbidity. Furthermore, bullets should be routinely removed if they are retained in the hip joint, if mechanical irritation of soft tissues by projectiles is expected or if the bullet traversed large bowel before entering the hip joint.

Orthopaedic trauma residency programs: Perspectives from different countries across the world.

The ability to manage the myriad of musculoskeletal conditions successfully requires multiple years of training. Access to and completion of orthopaedic surgical training entails an often grueling, highly regulated path to certification to practice. Although the world is more connected than ever, the question is whether the local certification criteria for medical specialists leads to a generic residency program and a similar training in all countries. This report from eight nations on five continents details the distinctive features of that training, including the number of positions available, the examinations required, the gender distribution of residents, and available possibilities once the residence period is complete. This analysis shows a wide variation in the orthopaedic trauma training program worldwide, with emphasis on different skills per country.

Surgical management of distal humerus gunshot fractures: descriptive case series.

PURPOSE: The purpose of this study was to report our 5 years surgical experience and the rate of neurovascular injury following gunshot fractures of the distal humerus in a in level-1 Trauma Centre in South Africa. METHODS: A retrospective case series of 25 consecutive adult gunshot injuries to the distal humerus. Demographic and injury data were extracted from clinical case notes and electronic operative records. Imaging archives were used to classify fractures according to the AO/OTA classification. RESULTS: Twenty-five male patients, with mean age of 32-years-old, sustained gunshot injuries to the distal humerus. Eleven patients had multiple gunshots. Forty-four percent of patients underwent Computed Tomography Angiography (CTA), 20% had confirmed brachial artery injury. Limbs with vascular injury were salvaged with arterial repair and external fixation. Fractures were extra-articular in 20 cases (80%). Nineteen fractures were classified as highly comminuted. Nerve injuries occurred in 52% and were all managed expectantly. Only 32% of patients attended follow-up beyond 3 months. CONCLUSIONS: These are rare challenging injuries with high rates of neurovascular damage. This demographic of patients is poorly compliant with follow up highlighting the need for high-quality early care. Brachial artery injury should be excluded with CTA and can be managed with arterial repair and external fixation. All fractures in this series were surgically managed with conventional anatomical plate and screw fixation techniques. For nerve injury, we advocate expectant management. LEVEL OF EVIDENCE: IV.

The firearm pandemic: time to act and flatten the curve.

N/A.

Conservative Management of Stable, Minimally Displaced Pertrochanteric Fractures: A Case Series.

Background: Hip fractures are common, and account for significant morbidity and mortality. While surgical intervention remains the gold standard, nonoperative treatment protocols are seldom analysed and may be of value in select settings. Objectives: We sought to review our conservatively treated pertrochanteric fractures and present a case series that outlined indications, treatment protocol and early outcomes. Materials and Methods: A retrospective review of medical records and radiographic imaging of all patients who presented with stable pertrochanteric fractures and were treated nonoperatively, from September 2017 to February 2021, at a Level 2 District Hospital in South Africa. Results: Of the 242 patients who were admitted with pertrochanteric fractures, 12 (4.9%) fractures were radiographically classified as AO 31A1.2 (stable, minimally displaced) and eligible for active nonoperative management. Within 6 weeks of injury, 10 (84%) of the patients who received active nonoperative treatment achieved union. Two patients (16%) failed the treatment protocol and required surgery, with one failing during the hospital phase of the treatment protocol and the other on follow up. In the group of united fractures, the neck shaft angle was on average within 3 degrees of the contralateral hip with a range of 0 to 5 degrees. At follow-up, two (16%) patients had a measurable shortening of 5 mm at union. There was no medical morbidity associated with this protocol. Conclusions: In our case series, the active nonoperative management protocol, involving early mobilisation and serial radiographs, in select cases of stable pertrochanteric fractures yielded acceptable outcomes. This is of relevance in low-middle income countries with limited surgical capacity.

Return to Work Following Intramedullary Nailing of Lower-Limb Long-Bone Fractures in South Africa.

BACKGROUND: Injuries are one of the leading causes of global death and disability and commonly have substantial economic implications. The economic impact of injuries is particularly pronounced in low- and middle-income countries, where 90% of injuries occur. In this study, we aimed to assess return-to-work rates of individuals who sustained a lower-limb long-bone fracture in South Africa and to identify factors that influence the ability to return to employment. METHODS: This prospective cohort study was conducted across 2 tertiary trauma centers in Cape Town, South Africa. Adults who received intramedullary nail fixation for a lower-limb fracture between September 2017 and December 2018 were recruited and followed for 18 months postoperatively. The participants' return to employment was assessed at 6 and 18 months post-injury. Multivariate logistic regression was used to identify factors that influence post-injury employment. RESULTS: Of the 194 participants enrolled, 192 completed follow-up. The study population had a median age of 33.0 years, and most of the participants (76.6%) were male. Seventy-five percent of the participants were employed before their injury. At 6 and 18 months post-injury, 34.4% and 56.3% of participants, respectively, were employed. Of those employed pre-injury, 70.1% had returned to work at 18 months. Multivariate regression identified increasing age, unemployment prior to injury, and working in the informal employment sector as factors that impede an individual's likelihood of working 18 months post-injury. For those in employment prior to injury, increasing age was the only factor found to impede the likelihood of returning to work following an injury. CONCLUSIONS: This study highlights the profound effect that lower-limb long-bone fractures may have on an individual's ability to return to work in South Africa, with the potential to cause substantial economic impact on an individual's livelihood and that of their dependents. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Establishing a consensus on research priorities in orthopaedic trauma within South Africa.

BACKGROUND: Musculoskeletal (MSK) injuries are one of the leading causes of disability worldwide. Despite improvements in trauma-related morbidity and mortality in high-income countries over recent years, outcomes following MSK injuries in low- and middle-income countries, such as South Africa (SA), have not. Despite governmental recognition that this is required, funding and research into this significant health burden are limited within SA. This study aims to identify research priorities within MSK trauma care using a consensus-based approach amongst MSK healthcare practitioners within SA. METHOD: Members from the Orthopaedic Research Collaboration in Africa (ORCA), based in SA, collaborated using a two round modified Delphi technique to form a consensus on research priorities within orthopaedic trauma care. Members involved in the process were orthopaedic healthcare practitioners within SA. RESULTS: Participants from the ORCA network, working within SA, scored research priorities across two Delphi rounds from low to high priority. We have published the overall top 10 research priorities for this Delphi process. Questions were focused on two broad groups-clinical effectiveness in trauma care and general trauma public health care. Both groups were represented by the top two priorities, with the highest ranked question regarding the overall impact of trauma in SA and the second regarding the clinical treatment of open fractures. CONCLUSION: This study has defined research priorities within orthopaedic trauma in South Africa. Our vision is that by establishing consensus on these research priorities, policy and research funding will be directed into these areas. This should ultimately improve musculoskeletal trauma care across South Africa and its significant health and socioeconomic impacts.

Radiographic union score for tibia (RUST) scoring system in adult diaphyseal femoral fractures treated with intramedullary nailing: an assessment of interobserver and intraobserver reliability.

OBJECTIVES: The Radiographic Union Score for Tibia (RUST) scoring system has been validated in multiple studies assessing the healing of tibial fractures. Our objective was to assess the interobserver and intraobserver reliability for the RUST in diaphyseal femoral fractures treated with intramedullary (IM) nailing. PATIENTS AND METHODS: A total of 60 sets of anteroposterior (AP) and lateral radiographs of diaphyseal femoral fractures treated by reamed IM nailing were randomly selected from a prospectively collected database. The 60 sets of radiographs were then scored by three reviewers using the RUST system. Interobserver reliability was measured at initial scoring. The 60 sets of radiographs were scored again by the three reviewers to calculate the intraobserver reliability. RESULTS: The RUST scores ranged from 4 to 12 with a mean score of 11.3 ± 1.3. The interobserver intraclass correlation coefficient (ICC) was 0.87 (95% CI, 0.81-0.92) and the intraobserver ICC was 0.91 (95% CI, 0.88-0.94), which indicated excellent agreement. CONCLUSION: This study demonstrated that the RUST system can be used reliably in the assessment of healing in diaphyseal femur fractures treated by reamed intramedullary nailing, with excellent interobserver and intraobserver reliability.

A tale of three pandemics: Shining a light on a hidden problem.

An "epidemic" is an event in which a disease, infectious or non-infectious, is actively spreading within a population and designated area. The term "pandemic" is defined as "an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people". The global response to the COVID-19 pandemic has not been seen since the outbreak of Human Immunodeficiency Virus in the early eighties. But there is another unseen pandemic running alongside the current COVID-19 pandemic, which affects a vast number of people, crossing international boundaries and occurring in every single country worldwide. The pandemic of traumatic injuries. Traumatic injuries account for 11% of the current Global Burden of Disease, resulting in nearly 5 million deaths annually and is the third-leading cause of death worldwide. For every trauma-related death, it is estimated that up to 50 people sustain permanent or temporary disabilities. Furthermore, traumatic injuries occur at disproportionately higher rates in low- and middle-income countries, with approximately 90% of injuries and more than 90% of global deaths from injury occurring these countries. Injuries are increasing worldwide, crossing international boundaries and affecting a large number of people, in the same manner Human Immunodeficiency Virus did in the 1980's and COVID-19 is today. The tremendous global effort to tackle the COVID-19 and Human Immunodeficiency Virus pandemics has occurred whilst ignoring the comparable pandemic of injury. Without change and future engagement with policy makers and international donors this disparity is likely to continue.

Train related injuries: A descriptive analysis highlighting orthopaedic injuries and management.

INTRODUCTION: Orthopaedic injuries constitute a major aspect of morbidity and mortality following train accidents. The pattern of orthopaedic/musculoskeletal injuries sustained following these accidents has not been fully characterised. The main aim of this study is to describe the range of orthopaedic injuries reported in a major trauma centre and evaluate their management, as well as reporting mortality and amputation rates. Further aims are to identify the social and demographic background of the patients to suggest treatment and prevention strategies. METHODS: This study is a retrospective observation of all clinical files of patients presented to Level 1 Trauma Centre in Cape Town, South Africa, as "train casualty" from January 2013 to July 2019, which were reviewed and evaluated. A total of 174 patients were included, of which 92 were orthopaedic referrals. The average age was 29 years, and 87% were male. RESULTS: Tibial fractures were most common (N = 19), 38% of patients sustained open fractures, and 68% of patients (in total) underwent surgery. Wound debridement was the most common operation, followed by open reduction internal fixation (ORIF). Twelve patients (13%) underwent amputation to 14 body parts. Eight patients (4.6%) (in total) died in the trauma unit. DISCUSSION: This study provides insight into train accident victims and their orthopaedic injuries and management patterns. The victims are largely young males. The majority of orthopaedic injuries require surgical intervention, and those who make it to the hospital have a good chance of survival and limb salvage. It appears that in addition to early hospital access and specialised updated treatments, morbidity and mortality in train accidents could be reduced by improving safety measures and social awareness to reduce railway violence and accidents.

Fracture Healing in Patients With HIV in South Africa: A Prospective Cohort Study.

BACKGROUND: HIV reduces bone mineral density, mineralization, and turnover and may impair fracture healing. SETTING: This prospective cohort study in South Africa investigated whether HIV infection was associated with impaired fracture healing after trauma. METHODS: All adults with acute tibia and femur fractures who underwent intermedullary (IM) nailing for fracture fixation between September 2017 and December 2018, at 2 tertiary hospitals, were followed up for a minimum of 12 months postoperatively. The primary outcome was delayed bone union at 6 months (defined by the radiological union scoring system for the tibia score <9), and the secondary outcome was nonunion (defined as radiological union scoring system for the tibia score <9) at 9 months. Multivariable logistic regression models were constructed to investigate the associations between HIV status and impaired fracture healing. RESULTS: In total, 358 participants, who underwent 395 IM nailings, were enrolled in the study and followed up for 12 months. Seventy-one of the 358 (19.8%) participants were HIV-positive [83/395 (21%) IM nailings]. HIV was not associated with delayed fracture healing after IM nailing of the tibia or femur (multivariable odds ratio: 1.06; 95% confidence interval: 0.50 to 2.22). HIV-positive participants had a statistically significant lower odds ratio of nonunion compared with HIV-negative participants (multivariable odds ratio: 0.17; 95% confidence interval: 0.01 to 0.92). CONCLUSIONS: Fractures sustained in HIV-positive individuals can undergo surgical fixation as effectively as those in HIV-negative individuals, with no increased risk of delayed union or nonunion.

Bibliometric analysis of research on the effects of human immunodeficiency virus in orthopaedic and trauma surgery.

BACKGROUND: There is little research investigating how human immunodeficiency virus (HIV) affects outcomes in orthopaedic surgery. With advances in treatment, HIV has become a chronic health problem and the chance of orthopaedic surgeons encountering it in clinical practice is increasing. AIM: To ascertain the quantity and quality of peer-reviewed publications in orthopaedic journals about HIV. METHODS: A search of the Web of Science database was carried out, identifying any articles relating to HIV published in orthopaedic journals. These were assessed for geographic origin and level of evidence. RESULTS: Of 48.7% of orthopaedic journals listed on the Web of Science database had published articles relating to HIV. There were 168 articles about HIV in orthopaedic journals with only 40.5% (n = 68) published in the time frame we analysed (January 2007 to September 2017). Very few articles came from low-income countries and any articles published from that setting were collaborations. All of the articles were low level of evidence. CONCLUSION: There is a need for more high level orthopaedic and trauma research investigating the effects of HIV, particularly research from low-income countries, where higher level research will help to guide improvements in their treatment of its musculoskeletal manifestations and complications.

Civilian gunshot injuries in orthopaedics: a narrative review of ballistics, current concepts, and the South African experience.

The incidence of civilian gunshot injuries is on the rise worldwide.Unfortunately, there is a lack of high-level evidence guiding management. The treatment of orthopaedic injuries from gunshots is complex and requires consideration of multiple aspects, including energy transfer to the tissue, severity of the wound, possible contamination, presence of fractures and associated injuries. With this narrative review we aim to discuss some of the relevant ballistics, current concepts, and controversies in the general management of civilian gunshot-related orthopaedic injuries based on the available evidence and personal experience. Important points which will be highlighted are the initial management in the emergency room, the assessment and management of soft tissue injuries, associated injuries, use of antibiotics, indication and techniques for fracture fixation, and gunshot injuries to joints.

Anterior-posterior view by full-body digital X-ray to rule out severe spinal injuries in Polytraumatized patients.

BACKGROUND: Spinal injuries are present in 16-31% of polytraumatized patients. Rapid identification of spinal injuries requiring immobilization or operative treatment is essential. The Lodox-Statscan (LS) has evolved into a promising time-saving diagnostic tool to diagnose life-threatening injuries with an anterior-posterior (AP)-full-body digital X-ray. METHODS: We aimed to analyze the diagnostic accuracy and the interrater reliability of AP-LS to detect spinal injuries in polytraumatized patients. Therefore, within 3 years, AP-LS of polytraumatized patients (ISS ≥ 16) were retrospectively analyzed by three independent observers. The sensitivity and specificity of correct diagnosis with AP-LS compared to CT scan were calculated. The diagnostic accuracy was evaluated by using the area under the ROC (receiver operating characteristic curve) for sensitivity and specificity. Interrater reliability between the three observers was calculated using Fleiss' Kappa. The sensitivity of AP-LS was further analyzed by the severity of spinal injuries. RESULTS: The study group included 320 patients (48.5 years ±19.5, 89 women). On CT scan, 207 patients presented with a spinal injury (65%, total of 332 injuries). AP-LS had a low sensitivity of 9% (31 of 332, range 0-24%) and high specificity of 99% (range 98-100%). The sensitivity was highest for thoracic spinal injuries (14%). The interrater reliability was slight (κ = 0.02; 95% CI: 0.00, 0.03). Potentially unstable spinal injuries were more likely to be detected than stable injuries (sensitivity 18 and 6%, respectively). CONCLUSION: This study demonstrated high specificity with low sensitivity of AP-LS in detecting spinal injuries compared to CT scan. In polytraumatized patients, AP-LS, implemented in the Advanced Trauma Life Support-algorithm, is a helpful tool to diagnose life-threatening injuries. However, if spinal injuries are suspected, performing a full-body CT scan is necessary for correct diagnosis.

Effects of Covid-19 on orthopaedic trauma services: early experiences in South Africa and Israel.

South Africa and Israel have significantly different health systems. As South Africa is geographically 500 times as large and has a population nearly 7 times as large as the state of Israel, major differences in the challenges and subsequent handling of the pandemic between these countries were to be expected. South Africa's challenges included being under-resourced, particularly related to trauma, and severe and radical measures had to be undertaken that included extended strict lockdowns, bans on alcohol sales, and cancellation of the majority of the elective surgery during this initial period of the pandemic. Although Israel is much smaller and thereby theoretically easier to control, a complex political situation created difficulties and delays in controlling the pandemic after the initial response, leading to a second wave and additional lockdown. Although massively engaged initially, the Israeli trauma systems had continued functioning almost normally throughout the COVID-19 crisis.