Cumulative costs of severe traffic injuries in Finland: a 2-year retrospective observational study of 252 patients.

Road traffic injuries cause considerable financial strain on health care systems worldwide. We retrospectively analyzed injury-related costs of 252 severely injured (New Injury Severity Score, NISS ≥ 16) patients treated at Tampere University Hospital (TAUH) between 2013 and 2017, with 2-year follow-up. The costs were divided into direct treatment, indirect costs, and other costs. We analyzed various injury- and patient-related factors with costs. The total costs during the 2-year study period were 20 million euros. Median cost was 41,202 euros (Q1 23,409 euros, Q3 97,726 euros), ranging from 2,753 euros to 549,787 euros. The majority of costs (69.1%) were direct treatment costs, followed by indirect costs (28.4%). Other costs were small (5.4%). Treatment costs increased with the severity of the injury or when the injury affected the lower extremities or the face. Indirect costs were higher in working age patients and in patients with a higher level of education. The relative proportions of direct and indirect costs were constant regardless of the amount of the total costs. The largest share of costs was caused by a relatively small proportion of high-cost patients during the 1st year after injury. Combined, this makes planning of resource use challenging and calls for further studies to further identify factors for highest costs.

Health-Related Quality of Life in severely injured patients in Finland: an observational cohort study of 325 patients with 1-year follow-up.

BACKGROUND: Major trauma has a significant effect on Health-Related Quality of Life (HR-QoL). It is unclear, however, which factors most affect HR-QoL. This study aims to evaluate HR-QoL after severe injury in Finland and determine how different injury patterns and patient-related factors, such as level of education and socioeconomic group, are associated with HR-QoL. We also assess how well different injury scoring systems associate with HR-QoL. METHODS: We retrospectively analyzed 325 severely injured trauma patients (aged ≥ 18 years, New Injury Severity Score, (NISS) ≥ 16, and alive at 1 year after injury) treated in the Intensive Care Unit (ICU) or High Dependence Unit (HDU) of Tampere University Hospital (TAUH) from 2013 through 2016. HR-QoL was assessed with the EQ-5D-3L questionnaire completed during ICU stay and 1 year after injury. HR-QOL index values and reported problems were further compared with Finnish population norms. RESULTS: The severity of the injury (measured by ISS and NISS) had no significant association with the decrease in HR-QoL. Length of ICU stay had a weak negative correlation with post-injury HR-QoL and a weak positive correlation with the change in HR-QoL. The largest mean decrease in HR-QoL occurred in patients with spinal cord injury (Spine AIS ≥ 4) (-0.338 (SD 0.136)), spine injury in general (Spine AIS ≥ 2 (-0.201 (SD 0.279)), and a lower level of education (-0.157 (SD 0.231)). Patient's age, sex, or socioeconomic status did not seem to associate with smaller or greater changes in HR-QoL. CONCLUSIONS: After serious injury, many patients have permanent disabilities which reduce HR-QoL. Injury scoring systems intended for assessing the risk for death did not seem to associate with HR-QoL and are not, therefore, a meaningful way to predict the future HR-QoL of a severely injured patient. Recovery from the injury seems to be weaker in poorer educated patients and patients with spinal cord injury, and these patients may benefit from targeted additional measures. Although there were significant differences in baseline HR-QoL levels between different socioeconomic groups, recovery from injury appears to be similar, which is likely due to equal access to high-quality trauma care.

Suprapatellar tibial fracture nailing is associated with lower rate for acute compartment syndrome and the need for fasciotomy compared with the infrapatellar approach.

BACKGROUND: Intramedullary tibial nailing (IMN) is the gold standard for stabilizing tibial shaft fractures. IMN can be performed through an infra- or suprapatellar approach. PURPOSE: The aim of this study is to compare the rate of fasciotomies for acute compartment syndrome between infra- and suprapatellar approaches. METHODS: A total of 614 consecutive patients who were treated with IMN for tibial fracture between October 2007 and February 2020 were included in the study. The approach used for IMN was determined by the operating surgeon. Infrapatellar IMN was performed with the knee in deep flexion position, with or without calcaneal traction. Suprapatellar IMN was performed in straight or semiflexed position. The diagnosis of compartment syndrome was based on clinical analysis, but for some patients, a continuous compartment pressure measurement was used. The primary outcome was the rate of peri- and postoperative compartment syndrome treated with fasciotomies. RESULTS: The study sample included 513 patients treated with infrapatellar IMN and 101 patients treated with suprapatellar IMN technique. The mean age of the patients was 44.7 years (infrapatellar technique) and 48.4 years (suprapatellar technique). High energy trauma was seen in 138 (27%) patients treated with infrapatellar technique and in 39 (39%) patients treated with suprapatellar technique. In the suprapatellar group (n = 101), there were no cases of peri- or postoperative compartment syndrome treated with fasciotomies. In the infrapatellar group (n = 513), the need for fasciotomies was stated in 67 patients, 31 patients (6.0%) perioperatively and in 36 patients (7.0%) postoperatively. The rate of fasciotomies (0/101 versus 67/513 cases) differed significantly (p < 0.001). There were no significant differences in the fracture morphology or patient demographics between the study groups. CONCLUSIONS: The suprapatellar technique is recommended over the infrapatellar approach in the treatment of tibial shaft fractures. The rate of peri- and postoperative compartment syndrome and the need for fasciotomies was significantly lower with the suprapatellar technique. The major cause of increased rate of peri- or postoperative acute compartment syndrome with infrapatellar IMN technique is presumably associated with the positioning of the patient during the operation.

Severely injured patients do not disappear in a pandemic: Incidence and characteristics of severe injuries during COVID-19 lockdown in Finland.

Background and purpose - COVID-19 lockdowns have resulted in noteworthy changes in trauma admissions. We report and compare the incidence and characteristics of severe injuries (New Injury Severity Score [NISS] > 15) during the COVID-19 lockdown in Finland with earlier years.Methods - We retrospectively analyzed incidence rate, injury severity scores, injury patterns, and mechanisms of injury of all severely injured patients (NISS >15) in 4 Finnish hospitals (Tampere University Hospital, Kuopio University Hospital, Central Finland Hospital, Mikkeli Central Hospital) during the 11-week lockdown period (March 16-May 31, 2020) with comparison with a matching time period in earlier years (2016-2018). These 4 hospitals have a combined catchment area of 1,150,000 people or roughly one-fifth of the population of Finland.Results - The incidence rate of severe injuries during the lockdown period was 4.9/105 inhabitants (95% CI 3.7-6.4). The incidence rate of severe injuries during years 2016-2018 was 5.1/105 inhabitants (CI 3.9-6.5). We could not detect a significant incidence difference between the lockdown period and the 3 previous years (incidence rate difference -0.2 (CI -2.0 to 1.7). The proportion of traffic-related accidents was 55% during the lockdown period and 51% during previous years. There were no detectable differences in injury patterns. During the lockdown period, the mean age of patients was higher (53 years vs. 47 years, p = 0.03) and the rate of severely injured elderly patients (aged 70 or more) was higher (30% vs. 16%).Interpretation - Despite heavy social restrictions, the incidence of severe injuries during the lockdown period was similar to previous years. Notably, a decline in road use and traffic volumes did not reduce the number of severe traffic accidents. Although our data is compatible with a decrease of 2.0 to an increase of 1.7 severely injured patients per 105 inhabitants, we conclude that severely injured patients do not disappear even during pandemic and stabile hospital resources are needed to treat these patients.

Alcohol use in severely injured trauma patients.

Alcohol is a major risk factor for several types of injuries, and it is associated with almost all types and mechanisms of injury. The focus of the study was to evaluate alcohol use in severely injured trauma patients with New Injury Severity Score (NISS) of 16 or over, and to compare mortality, injury severity scores and mechanisms and patterns of injury between patients with positive and negative blood alcohol levels (BAL). Medical histories of all severely injured trauma patients (n = 347 patients) enrolled prospectively in Trauma Register of Tampere University Hospital (TAUH) between January 2016 to December 2017 were evaluated for alcohol/substance use, injury mechanism, mortality and length of stay in Intensive Care Unit (ICU). A total of 252 of 347 patients (72.6%) were tested for alcohol with either direct blood test (50.1%, 174/347), breathalyser (11.2%, 39/347), or both (11.2%, 39/347). After untested patients were excluded, 53.5% of adult patients (18-64 years), 20.5% of elderly patients (above 65 years) and 13.3% of paediatric patients (0-17 years) tested BAL positive. The mean measured BAL for the study population was 1.9 g/L. The incidence of injuries was elevated in the early evenings and the relative proportion of BAL positive patients was highest (67.7%) during the night. Injury severity scores (ISS or NISS) and length of stay in ICU were not adversely affected by alcohol use. Mortality was higher in patients with negative BAL (18.2% vs. 7.7%, p = 0.0019). Falls from stairs, and assaults were more common in patients with positive BAL (15.4% vs. 5.4% and 8.7% vs. 2.7%, p < 0.006, respectively). There were no notable differences in injury patterns between the two groups. Alcohol use among severely injured trauma patients is common. Injury mechanisms between patients with positive and negative BAL have differences, but alcohol use will not increase mortality or prolong length of stay in ICU. This study supports the previously reported findings that BAL is not a suitable marker to assess patient mortality in trauma setting.

Inter- and intraobserver reliability of non-weight-bearing foot radiographs compared with CT in Lisfranc injuries.

BACKGROUND: Injury of the tarsometatarsal (TMT) joint complex, known as Lisfranc injury, covers a wide range of injuries from subtle ligamentous injuries to severely displaced crush injuries. Although it is known that these injuries are commonly missed, the literature on the accuracy of the diagnostics is limited. The diagnostic accuracy of non-weight-bearing radiography (inter- or intraobserver reliability), however, has not previously been assessed among patients with Lisfranc injury. METHODS: One hundred sets of foot radiographs acquired due to acute foot injury were collected and anonymised. The diagnosis of these patients was confirmed with a CT scan. In one-third of the radiographs, there was no Lisfranc injury; in one-third, a nondisplaced (< 2 mm) injury; and in one-third, a displaced injury. The radiographs were assessed independently by three senior orthopaedic surgeons and three orthopaedic surgery residents. RESULTS: Fleiss kappa (κ) coefficient for interobserver reliability resulted in moderate correlation κ = 0.50 (95% CI: 0.45- 0.55) (first evaluation) and κ = 0.58 (95% CI: 0.52-0.63) (second evaluation). After three months, the evaluation was repeated and the Cohen's kappa (κ) coefficient for intraobserver reliability showed substantial correlation κ = 0.71 (from 0.64 to 0.85). The mean (range) sensitivity was 76.1% (60.6-92.4) and specificity was 85.3% (52.9-100). The sensitivity of subtle injuries was lower than severe injuries (65.4% vs 87.1% p = 0.003). CONCLUSIONS: Diagnosis of Lisfranc injury based on non-weight-bearing radiographs has moderate agreement between observers and substantial agreement between the same observer in different moments. A substantial number (24%) of injuries are missed if only non-weight-bearing radiographs are used. Nondisplaced injuries were more commonly missed than displaced injuries, and therefore, special caution should be used when the clinical signs are subtle. LEVEL OF EVIDENCE: III.

Conservative treatment of finger fractures.

Most fractures of the hand and fingers can be treated conservatively. When evaluating the fracture, special attention should be paid on sufficient quality of the radiographs and that the fracture will not cause a rotational malposition or functionally significant shortening of the finger. A finger fracture can be immobilized as soon as the fracture is stable in motion. This is often possible immediately. A broken finger should not be immobilized for more than a month. Open fractures and properly immobilized fractures still remaining in malposition shall be operated.