In-hospital mortality from femoral shaft fracture depends on the initial delay to fracture fixation and Injury Severity Score: a retrospective cohort study from the NTDB 2002-2006.

BACKGROUND: Optimal surgical timing for definitive treatment of femur fractures in severely injured patients remains controversial. This study was performed to examine in-hospital mortality for patients with femur fractures with regard to surgical timing, Injury Severity Score (ISS), and age. METHODS: The National Trauma Data Bank version 7.0 was used to evaluate in-hospital mortality for patients presenting with unilateral femur fractures. Patients were stratified into four groups by surgical timing (ST) and four groups by ISS. χ tests were used to evaluate baseline interrelationships. Binary regression was used to examine the association between time to surgery, ISS score, age, and mortality after adjusting for patient medical comorbidities, and personal demographics. RESULTS: A total of 7,540 patients met inclusion criteria, with a 1.4% overall in-hospital mortality rate. For patients with an isolated femur fracture, surgical delay beyond 48 hours was associated with nearly five times greater mortality risk compared with surgery within 12 hours (adjusted relative risk, 4.8; 95% confidence interval, 1.6-14.1). Only severely injured patients (ISS, 26+) had higher associated mortality with no delay in surgical fixation (ST1 < 12 hours) relative to ST2 of 13 hours to 24 hours with an adjusted relative risk of 4.2 (95% confidence interval, 1.0-16.7). The association between higher mortality rates and surgical delay beyond 48 hours was even stronger in the elderly patients. CONCLUSION: This study supports the work of previous authors who reported that early definitive fixation of femur fractures is not only beneficial, particularly in the elderly, but also consistent with more recent studies recommending at least 12-hour to 24-hour delay in fixation in severely injured patients to promote better resuscitation. LEVEL OF EVIDENCE: Therapeutic study, level III.

How do emergency department physicians rate their orthopaedic on-call coverage?

PURPOSE: Throughout the United States, the lack of orthopaedic on-call coverage at many institutions has been described as a "crisis." This study sought to understand how emergency department (ED) physicians perceive their orthopaedic on-call coverage. Specifically, the study looked at availability of orthopaedic coverage, adequacy of coverage, and reasons for patient transfers. METHODS: After Institutional Review Board approval, written questionnaires were mailed to the ED directors at 39 of the 41 emergency departments in New Hampshire and Vermont. The instrument consisted of 25 items. Survey domains included ED physician demographics, availability and adequacy of orthopaedic coverage, and reasons for patient transfer. All responses were anonymous. RESULTS: A total of 31 questionnaires was returned. Approximately one third (36%) of ED physicians reported they had full-time orthopaedic coverage with 8% reporting they "never" had coverage. Almost two thirds (64%) of respondents felt their daytime orthopaedic coverage was adequate, but this number dropped to 52% for night coverage and 48% for weekend coverage. Over half (55%) of respondents felt their orthopaedist was reluctant to come in to evaluate a patient when the ED physician felt the patient warranted orthopaedic consultation. Approximately half (52%) felt it was often the case that a patient's care could have been improved if they had been evaluated by an orthopaedist. Only 29% of respondents said their orthopaedist always came in when asked to evaluate a patient. The top three reasons ED physicians felt their orthopaedist declined to care for a patient were complexity of the injury, the time of day/night, and if it was a weekend. CONCLUSION/IMPLICATIONS: The findings in this study suggest there is substantial room for improvement in orthopaedic on-call coverage for emergency departments.

Traumatic abdominal hernia and lateral compression type 1 pelvic fracture: a case report.

Pelvic fractures often are associated with concomitant injuries. In general, the more severe the pelvic fracture, the more likely other, potentially life-threatening injuries exist. We present a case of a typical type 1 lateral compression pelvic fracture with the less common associated injury of abdominal wall muscle disruption and large-bowel herniation.