Severe isolated injuries have a high impact on resource use and mortality: a Dutch nationwide observational study.

PURPOSE: The Berlin poly-trauma definition (BPD) has proven to be a valuable way of identifying patients with at least a 20% risk of mortality, by combining anatomical injury characteristics with the presence of physiological risk factors (PRFs). Severe isolated injuries (SII) are excluded from the BPD. This study describes the characteristics, resource use and outcomes of patients with SII according to their injured body region, and compares them with those included in the BPD. METHODS: Data were extracted from the Dutch National Trauma Registry between 2015 and 2019. SII patients were defined as those with an injury with an Abbreviated Injury Scale (AIS) score ≥ 4 in one body region, with at most minor additional injuries (AIS ≤ 2). We performed an SII subgroup analysis per AIS region of injury. Multivariable linear and logistic regression models were used to calculate odds ratios (ORs) for SII subgroup patient outcomes, and resource needs. RESULTS: A total of 10.344 SII patients were included; 47.8% were ICU admitted, and the overall mortality was 19.5%. The adjusted risk of death was highest for external (2.5, CI 1.9-3.2) and for head SII (2.0, CI 1.7-2.2). Patients with SII to the abdomen (2.3, CI 1.9-2.8) and thorax (1.8, CI 1.6-2.0) had a significantly higher risk of ICU admission. The highest adjusted risk of disability was recorded for spine injuries (10.3, CI 8.3-12.8). The presence of ≥ 1 PRFs was associated with higher mortality rates compared to their poly-trauma counterparts, displaying rates of at least 15% for thoracic, 17% for spine, 22% for head and 49% for external SII. CONCLUSION: A severe isolated injury is a high-risk entity and should be recognized and treated as such. The addition of PRFs to the isolated anatomical injury criteria contributes to the identification of patients with SII at risk of worse outcomes.

Dutch trauma system performance: Are injured patients treated at the right place?

BACKGROUND: The goal of trauma systems is to match patient care needs to the capabilities of the receiving centre. Severely injured patients have shown better outcomes if treated in a major trauma centre (MTC). We aimed to evaluate patient distribution in the Dutch trauma system. Furthermore, we sought to identify factors associated with the undertriage and transport of severely injured patients (Injury Severity Score (ISS) >15) to the MTC by emergency medical services (EMS). METHODS: Data on all acute trauma admissions in the Netherlands (2015-2016) were extracted from the Dutch national trauma registry. An ambulance driving time model was applied to calculate MTC transport times and transport times of ISS >15 patients to the closest MTC and non-MTC. A multivariable logistic regression analysis was performed to identify factors associated with ISS >15 patients' EMS undertriage to an MTC. RESULTS: Of the annual average of 78,123 acute trauma admissions, 4.9% had an ISS >15. The nonseverely injured patients were predominantly treated at non-MTCs (79.2%), and 65.4% of patients with an ISS >15 received primary MTC care. This rate varied across the eleven Dutch trauma networks (36.8%-88.4%) and was correlated with the transport times to an MTC (Pearson correlation -0.753, p=0.007). The trauma networks also differed in the rates of secondary transfers of ISS >15 patients to MTC hospitals (7.8% - 59.3%) and definitive MTC care (43.6% - 93.2%). Factors associated with EMS undertriage of ISS >15 patients to the MTC were female sex, older age, severe thoracic and abdominal injury, and longer additional EMS transport times. CONCLUSIONS: Approximately one-third of all severely injured patients in the Netherlands are not initially treated at an MTC. Special attention needs to be directed to identifying patient groups with a high risk of undertriage. Furthermore, resources to overcome longer transport times to an MTC, including the availability of ambulance and helicopter services, may improve direct MTC care and result in a decrease in the variation of the undertriage of severely injured patients to MTCs among the Dutch trauma networks. Furthermore, attention needs to be directed to improving primary triage guidelines and instituting uniform interfacility transfer agreements.

Evaluation of the Berlin polytrauma definition: A Dutch nationwide observational study.

BACKGROUND: The Berlin polytrauma definition (BPD) was established to identify multiple injury patients with a high risk of mortality. The definition includes injuries with an Abbreviated Injury Scale score of ≥3 in ≥2 body regions (2AIS ≥3) combined with the presence of ≥1 physiological risk factors (PRFs). The PRFs are based on age, Glasgow Coma Scale, hypotension, acidosis, and coagulopathy at specific cutoff values. This study evaluates and compares the BPD with two other multiple injury definitions used to identify patients with high resource utilization and mortality risk, using data from the Dutch National Trauma Register (DNTR). METHODS: The evaluation was performed based on 2015 to 2018 DNTR data. First, patient characteristics for 2AIS ≥3, Injury Severity Score (ISS) of ≥16, and BPD patients were compared. Second, the PRFs prevalence and odds ratios of mortality for 2AIS ≥3 patients were compared with those from the Deutsche Gesellschaft für Unfallchirurgie Trauma Register. Subsequently, the association between PRF and mortality was assessed for 2AIS ≥3-DNTR patients and compared with those with an ISS of ≥16. RESULTS: The DNTR recorded 300,649 acute trauma admissions. A total of 15,711 patients sustained an ISS of ≥16, and 6,263 patients had suffered a 2AIS ≥3 injury. All individual PRFs were associated with a mortality of >30% in 2AIS ≥3-DNTR patients. The increase in PRFs was associated with a significant increase in mortality for both 2AIS ≥3 and ISS ≥16 patients. A total of 4,264 patients met the BPDs criteria. Overall mortality (27.2%), intensive care unit admission (71.2%), and length of stay were the highest for the BPD group. CONCLUSION: This study confirms that the BPD identifies high-risk patients in a population-based registry. The addition of PRFs to the anatomical injury scores improves the identification of severely injured patients with a high risk of mortality. Compared with the ISS ≥16 and 2AIS ≥3 multiple injury definitions, the BPD showed to improve the accuracy of capturing patients with a high medical resource need and mortality rate. LEVEL OF EVIDENCE: Epidemiological study, level III.

The evolution of radiological measurements and the association with clinician and patient reported outcome following distal radius fractures in non-osteoporotic patients: what is clinically relevant?

INTRODUCTION: Following distal radius fractures in young non-osteoporotic patients, clinical relevancy of outcome has been scarcely reported. Outcome can be put in perspective by using measurement errors of radiological measurements and Minimal Important Change when reporting on clinician and patient reported outcome. Aim of this study was to assess the clinical relevance of radiological measurements, clinician and patient reported outcomes following distal radius fractures in young non-osteoporotic patients. METHODS: Retrospective cohort study. Non-osteoporotic patients following a distal radius fracture were selected. Radiographs of both wrists were obtained at baseline, 6 weeks and at follow-up. Active range of motion and grip strength measurements were obtained at the follow-up visit and 4 questionnaires were answered to assess pain, upper extremity functioning, and health status. RESULTS: Seventy-three patients (32 women, 41 men) with a mean age of 33.5 (SD 9.2) years at the time of injury were included. Median follow up was 62 months (IQR 53.0-84.5). Several radiological measurements evolved statistically significantly over time, however none exceeded measurement errors. Flexion/extension difference of injured compared to uninjured wrist (mean difference 11.2°, t = -7.5, df = 72, p < 0.001), exceeded Minimal Important Change, while grip strength differences did not. When comparing patients with DRFs to healthy controls, only the differences on Patient Reported Wrist Evaluation subscales "pain", "function" and total scores exceeded minimal important change (8, 10 and 13 points, respectively). Multivariable regression analysis revealed statistically significant relationships between residual step-off and respectively diminished flexion/extension (B = -36.8, 95% CI -62; -11.1, p = 0.006), diminished radial/ulnar deviation (B = -17.9, 95% CI -32.0; -3.9, p = 0.013) and worse ShortForm-36 "mental component score" (B = -15.4, 95% CI -26.6; -4.2, p < 0.001). CONCLUSION: Radiological measurements following distal radius fractures seem to evolve over time, but differences were small and were probably not clinically relevant. Range of motion, in particular flexion/extension, was impaired to such extend that it was noticeable for a patient, whereas grip strength was not impaired. The Patient Reported Wrist Evaluation was clinically relevantly diminished. Residual articular incongruency seems to influence range of motion.Implications for rehabilitationReporting Minimal Important Change regarding clinician and patient reported outcome following distal radius fractures is of more clinical value than reporting on statistical significance.Following distal radius fractures, the changes in radiological measurements do not seem to reflect a clinical relevant change.Range of motion, in particular flexion/extension, should be measured following distal radius fractures, as this might be impaired in a clinically relevant way.Measuring grip strength is of less importance following distal radius fractures, because grip strength does not seem to be affected.Residual articular incongruency seems to influence range of motion and therefore should be reduced to a minimum when treating non-osteoporotic patients.

Comparison of three types of treatment modalities on the outcome of fingertip injuries.

BACKGROUND: In this retrospective study, we analyzed the outcomes of different types of treatment of fingertip injuries and compared them after a mean follow-up of 4.5 years. METHODS: A total of 53 patients (59 injuries) were included in this study. The fingertip injuries were classified according to Allen classification. The patients were categorized into three groups based on the treatment: reconstructive group, bone-shortening group, and conservative group. As objective assessments, strength, sensibility, and goniometry were measured; as subjective assessments, cold intolerance, nail deformation, and aesthetics were measured. RESULTS: The mean reduction in strength, the Semmes-Weinstein monofilament test, and the reduction in mobility for the injured fingers compared with those of the uninjured finger were not significantly different between the groups. Cold intolerance was reported in 50 (84.7%) of the 59 fingers, and in almost 90% of all the cases, there was some kind of nail distortion. For the cold intolerance and nail distortions, there was no difference between the groups. The aesthetic outcomes judged by patients and surgeon were comparable. CONCLUSION: In conclusion, the outcome of treatment of Allen II, III, and IV fingertip injuries was irrespective of the treatment chosen. In an era where the enormous variety of surgical options suggests that treatment with a flap is the best, this outcome is at least surprising. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline.

Ankle injuries are a huge medical and socioeconomic problem. Many people have a traumatic injury of the ankle, most of which are a result of sports. Total costs of treatment and work absenteeism due to ankle injuries are high. The prevention of recurrences can result in large savings on medical costs. A multidisciplinary clinical practice guideline was developed with the aim to prevent further health impairment of patients with acute lateral ankle ligament injuries by giving recommendations with respect to improved diagnostic and therapeutic opportunities. The recommendations are based on evidence from published scientific research, which was extensively discussed by the guideline committee. This clinical guideline is helpful for healthcare providers who are involved in the management of patients with ankle injuries.

Long-term functional outcome following intramedullary nailing of femoral shaft fractures.

BACKGROUND: The management of femoral shaft fractures using intramedullary nailing is a popular method. The purpose of this study was to evaluate the long-term functional outcome after antegrade or retrograde intramedullary nailing of traumatic femoral shaft fractures. We further determined predictors of these functional outcome scores. METHODS: In a retrospective study, patients with a femoral shaft fracture but no other injuries to the lower limbs or pelvis were included. A total of 59 patients met the inclusion criteria. Functional outcome scores (Short Musculoskeletal Functional Assessment (SMFA), Western Ontario and McMaster University Osteoarthritis (WOMAC) index, Harris Hip Score (HHS) and the Lysholm knee function scoring scale) were measured at a mean of 7.8 years (± 3.5 years) postoperatively. The Visual Analogue Scale (VAS) was used to determine pain complaints of the lower limb. RESULTS: The range of motion (ROM) of the hip and knee joints was comparable between the injured and uninjured leg, regardless of the nailing technique. Correlation between ROM and the final outcome scores was found to be fair to moderate. Even years after surgery, 17% of the patients still reported moderate to severe pain. A substantial correlation was observed between VAS and the patient-reported outcome scores. The most significant predictor of functional outcome was pain in the lower limb. CONCLUSIONS: Our findings suggest that the ROM of hip and knee returns to normal over time, regardless of the nailing method used. However, pain in the lower limb is an important predictor and source of disability after femoral shaft fractures, even though most patients achieved good functional outcome scores.

[Pancreatic injury in abdominal trauma in children: difficult to diagnose and treat]. / Pancreasletsel na buiktrauma bij kinderen: lastig te diagnosticeren en te behandelen.

Traumatic injury of the pancreas is rare in children. It is often difficult to diagnose due to the lack of signs and symptoms, and shortly after trauma laboratory values may be normal. In addition, ultrasound and CT are often not specific. The treatment of grade 1 and 2 injury is non-operative. Although there seems to be a shift towards non-operative management of grade 3-5 injuries (with injury of the pancreatic duct), this is still a matter of debate. We describe 3 children, a girl of 2.5 years-old and a boy of 7 years-old, with grade 3 pancreatic injuries and an 8-year-old boy with a grade 2 injury. We demonstrate that the diagnosis is hard to establish, while the consequences of this injury can be serious. Thinking of pancreatic injury is most important to its diagnosis. We advocate referral to or consultation of specialized centres in these cases.

Functional outcome after antegrade femoral nailing: a comparison of trochanteric fossa versus tip of greater trochanter entry point.

OBJECTIVES: This study was performed to explore the relationship between entry point-related soft tissue damage in antegrade femoral nailing and the functional outcome in patients with a proximal third femoral shaft fracture. DESIGN: Retrospective clinical trial. SETTING: Level I university trauma center. PATIENTS: Seventeen patients with a high femoral shaft fracture treated with an antegrade femoral nail joined the study. INTERVENTION: Nine patients with an Unreamed Femoral Nail (UFN; Synthes, Bettlach, Switzerland) inserted at the trochanteric fossa and eight patients with a long Proximal Femoral Nail (PFN; Synthes) inserted at the tip of the greater trochanter. MAIN OUTCOME MEASUREMENTS: Pain, gait, nerve, and muscle function along with endurance. RESULTS: Five patients with a UFN had a positive Trendelenburg sign and a reinnervated superior gluteal nerve after initial injury of the nerve at operation. None of these findings occurred in the long PFN group (P = 0.01). Isokinetic measurements showed diminished abduction as well as external rotator function in the UFN group rather than in the long PFN group. Leg endurance was significantly lower in patients with a UFN. CONCLUSIONS: Compared with the trochanteric fossa, femoral nailing through the greater trochanter tip may decrease the risk of damage to the superior gluteal nerve and intraoperative damage to the muscular apparatus of the hip region, resulting in some improved muscle function. Therefore, a lateral entry point may be a rational alternative for conventional nailing through the trochanteric fossa.

Persistent knee complaints after retrograde unreamed nailing of femoral shaft fractures.

Retrograde nailing is an attractive method for stabilisation of femoral shaft fractures in cases of polytrauma, ipsilateral pelvic, acetabular, tibial and femoral neck fractures, bilateral femoral fractures, obese and pregnant patients. However, retrograde nailing may result in complaints about the knee. The purpose of this study was to evaluate the incidence and risk factors of lasting knee pain, and its relation to knee function deficits. We conducted a retrospective study of 75 patients in whom 82 femoral shaft fractures were treated with retrograde intramedullary nailing. Complaints of pain about the knee during follow-up were present in 17 patients (23%). The mean age of patients with knee pain was significantly lower (26 years) than the age of those without knee pain (41 years) (p = 0.0002). Both groups, with and without pain about the knee, were not significantly different according to gender, injury severity score, AO type of fracture, associated ipsilateral injuries, open fractures, or type of nail used. In addition, the range of motion did not differ. Although 49% of all patients had also presented ipsilateral pelvis, acetabulum or lower leg fractures, the majority (89%) had a knee flexion > or = 120 degrees. Complaints of knee pain after retrograde intramedullary nailing of femoral fractures were found to be rather common. Younger age appeared to be a risk factor for knee pain. Nevertheless, the majority of patients had excellent knee function.

Relation of the weather and the lunar cycle with the incidence of trauma in the Groningen region over a 36-year period.

BACKGROUND: The time distribution of injuries is not random. To assess the potential impact of weather and the phase of the moon on accidents, adjustment for known periodic and nonperiodic factors may be important. We compared the incidence of injuries with quantitative and qualitative weather variables as well as the lunar cycle, after correction for calendar and holiday-related factors. METHODS: We extracted the daily number of trauma patients treated at the emergency department over 36 years (1970-2005) from the trauma database of our regional hospital. For each patient, age, sex, cause of injury, and severity of injury were recorded. This was combined with daily meteorological data including temperature, precipitation, sunshine, humidity, air pressure, and wind as well as the lunar phase. We also related the rate of change of these parameters with the incidence of injuries. A qualitative weather variable derived from temperature, sunshine duration, and precipitation was defined as bad, normal, or good. Periodicities were adjusted for with Poisson regression spline fitting analysis. RESULTS: Several weather variables were related with the number of injuries. For most of these, better weather conditions were associated with an increase in trauma incidence. Good weather, which was present on 16.5% of the days, resulted in 10.1% (9.3-11.4 95% CI) more traumas compared with normal weather. Full moon was associated with a 2.1% (1.1-3.0 95% CI) lower trauma incidence than new moon. CONCLUSIONS: Better weather conditions contribute to an increased incidence of trauma. Full moon is associated with a slightly lower trauma incidence.

[Diagnostic image; an infant with suspicious fractures]. / Een zuigeling met verdachte fracturen.

A 10-months-old boy with a haematoma of the left upper leg was diagnosed with bucket-handle fractures of the left lower extremity. These fractures may easily be overlooked and carry a high predictive value for abuse in infants.

Long-term functional outcome after type A3 spinal fractures: operative versus non-operative treatment.

The authors retrospectively studied, by questionnaires, the long-term (5 years) functional outcome after operative (posterior instrumentation: 38 cases) and non-operative treatment (25 cases) for type A3 spinal fractures (Comprehensive Classification) without neurological deficit. A possible bias of this study was the fact that the operative group included 60% A3.2 and A3.3 fractures, versus only 12% in the nonoperative group. Two disease-specific questionnaires were used: the Visual Analogue Scale Spine Score and the Roland-Morris Disability Questionnaire. At follow-up the mean VAS scores were 82.6 and 80.8 in the operatively and non-operatively treated group, respectively; the difference was not significant. The mean RMDQ scores were 3.3 and 3.1 in the operatively and non-operatively treated groups, respectively; again the difference was not significant. Functional outcome appeared to be equally good five years after operative or non-operative treatment of type A3 "burst" fractures.

Reticulocyte counts and their relation to hemoglobin levels in trauma patients.

BACKGROUND: Increased production of red blood cells (RBCs) should be reflected by increased reticulocyte counts (RC). With the introduction of modern fully automated measurements of RC, the recovery of hemoglobin (Hb) after blood loss might be assessed earlier. We investigated the temporal relation of Hb and RC in trauma patients. METHODS: Over a 10-month period, all patients with trauma admitted to our University Medical Center were analyzed. Both Hb (reference values: males, 14.0-17.1 g/dL; females, 12.1-15.9 g/dL) and RC (8-26 promille) were determined with a Sysmex XE-2100 analyzer. RBC transfusions were administered in otherwise healthy patients below an Hb threshold of 6.9 g/dL. Hb and RC were analyzed for a maximum of 30 days posttrauma and related in multivariate analysis to age, sex, and comorbidity. RESULTS: Two hundred and forty-one patients (age 52 years +/- 21 years) were studied. In 28 patients (12%), one or more RBCs were administered with a mean of 2.2 RBCs (range, 1-4). Hb decreased to 10.9 g/dL +/- 2.1 g/dL on day 3. RC rose from 16 +/- 11 at admission to 38 promille +/- 21 promille on day 13 (p < 0.0001). Nadir Hb values and maximum RC values were inversely related according to univariate analysis (Pearson R = -0.62, p < 0.001). In multivariate analysis, Hb remained the only significant determinant of RC (R = 0.64, p < 0.001). CONCLUSIONS: Hb and RC are clearly related in trauma patients. Measuring RC may be helpful in predicting the rise of Hb after acute blood loss.

Plate osteosynthesis of simple forearm fractures: LCP versus DC plates.

The aim of this study was to compare the time to radiological bony union of simple A-type fractures of the forearm, treated with either a locking compression plate (LCP) or a dynamic compression plate (DCP). For each fracture, the relation between the use of compression and radiological healing time was studied. Nine fractures were treated with LCP and 10 fractures with DC plates. The mean time to definite radiological bony union in the LCP group was 33 weeks and in the DCP group 22 weeks. Compression was used in 7 fractures in the DCP group and in 3 fractures in the LCP group. The compressed fractures, irrespective of the type of plate, healed 10 weeks faster than the non-compressed fractures. Time to definite radiological bony union of simple A-type fractures does not depend on the type of plate used, but on the application of axial or interfragmentary compression.

Treatment of traumatic thoracolumbar spine fractures: a multicenter prospective randomized study of operative versus nonsurgical treatment.

STUDY DESIGN: Multicenter prospective randomized trial. OBJECTIVE: To test the hypotheses that thoracolumbar AO Type A spine fractures without neurologic deficit, managed with short-segment posterior stabilization will show an improved radiographic outcome and at least the same functional outcome as compared with nonsurgically treated thoracolumbar fractures. SUMMARY OF BACKGROUND DATA: There are various opinions regarding the ideal management of thoracolumbar Type A spine fractures without neurologic deficit. Both operative and nonsurgical approaches are advocated. METHODS: Patients were randomized for operative or nonsurgical treatment. Data sampling involved demographics, fracture classifications, radiographic evaluation, and functional outcome. RESULTS: Sixteen patients received nonsurgical therapy, and 18 received surgical treatment. Follow-up was completed for 32 (94%) of the patients after a mean of 4.3 years. At the end of follow-up, both local and regional kyphotic deformity was significantly less in the operatively treated group. All functional outcome scores (VAS Pain, VAS Spine Score, and RMDQ-24) showed significantly better results in the operative group. The percentage of patients returning to their original jobs was found to be significantly higher in the operative treated group. CONCLUSIONS: Patients with a Type A3 thoracolumbar spine fracture without neurologic deficit should be treated by short-segment posterior stabilization.

Hyperglycemia has a stronger relation with outcome in trauma patients than in other critically ill patients.

BACKGROUND: Acute hyperglycemia is associated with adverse outcome in critically ill patients. Glucose control with insulin improves outcome in surgical intensive care unit (SICU) patients, but the effect in trauma patients is unknown. We investigated hyperglycemia and outcome in SICU patients with and without trauma. METHODS: A 12-year retrospective study was performed at a 12-bed SICU. We collected the reason for admission, Injury Severity Scores (ISS), and 30-day mortality rates. Glucose measurements were used to calculate the hyperglycemic index (HGI), a measure indicative of overall hyperglycemia during the entire SICU stay. RESULTS: In all, 5234 nontrauma and 865 trauma patients were studied. Trauma patients were younger, more frequently male, and had both lower median admission glucose (123 versus 133 mg/dL) and HGI levels (8.9 vs. 18.4 mg/dL) than nontrauma patients (p < 0.001). Mortality was 12% in both groups. Area under the receiver-operator characteristic for HGI and mortality was 0.76 for trauma patients and 0.58 for nontrauma patients (p < 0.001). In multivariate analysis, HGI correlated better with mortality in trauma patients than in nontrauma patients (p < 0.001). Head-injury and nonhead-injury trauma patients showed similar glucose levels and relation between glucose and mortality. CONCLUSIONS: The relation of hyperglycemia and mortality is more pronounced in trauma patients than in SICU patients admitted for other reasons. The different behavior of hyperglycemia in these patients underscores the need for evaluation of intensive insulin therapy in these patients.

A prospective study on paediatric traffic injuries: health-related quality of life and post-traumatic stress.

OBJECTIVES: To examine children's reports of their health-related quality of life (HRQoL) following paediatric traffic injury, to explore child and parental post-traumatic stress, and to identify children and parents with adverse outcomes. DESIGN: Prospective cohort study. ASSESSMENTS: shortly after the injury, three months and six months post injury. SETTING: Department of Traumatology, University Hospital. SUBJECTS: Fifty-one young traffic injury victims aged 8-15 years. MAIN MEASURES: TNO-AZL Children's Quality of Life questionnaire and the Impact of Event Scale. RESULTS: Short-term adverse changes in the child's HRQoL were observed for the child's motor functioning and autonomy. At three months, 12% of the children and 16% of the parents reported serious post-traumatic stress symptoms. Increased stress at three months, or across follow-up, was observed among hospitalized children, children with head injuries, and children injured in a motor vehicle accident. Parental stress was related to low socioeconomic status and the seriousness of the child's injury and accident (hospitalization, head injury, serious injury, motor vehicle involved, others injured). CONCLUSIONS: The children reported only temporary effects in their motor functioning and autonomy. Post-traumatic stress symptoms following paediatric traffic injury were not only experienced by the children, but also by their parents.