Injury (INJURY )

Publisher: Institute of Accident Surgery, Elsevier


Injury is an established, internationally renowned academic journal focusing on the rapidly evolving fields of trauma and accident surgery. The journal encourages the exchange of information among all members of the accident and emergency trauma team. Topics covered by Injury include trauma systems and management; surgical procedures; epidemiological studies; surgery (of all tissues); resuscitation; biomechanics; rehabilitation; anaesthesia; radiology and wound management. Regular features include original research papers; review papers; case reports; book reviews; ideas and innovations detailing novel and effective solutions to surgical problems; calendar of courses and worldwide meetings. The journal publishes a series of special supplements documenting the work of AO/ASIF Research, Development and Clinical Studies.

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Publications in this journal

  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Pre-hospital triage is an intricate part of any mass casualty response system. However, in settings where no such system exists, it is not known if hospital-based disaster response efforts are beneficial. This study describes in-hospital disaster response management and patient outcomes following a mass casualty event (MCE) involving 200 victims in a lower-middle income country in South Asia. Methods We performed a single-center, retrospective review of bombing victims presenting to a trauma center in the spring of 2013, after a high energy car bomb leveled a residential building. Descriptive analysis was utilized to present demographic variables and physical injuries. Results A disaster plan was devised based on the canons of North-American trauma care; some adaptations to the local environment were incorporated. Relevant medical and surgical specialties were mobilized to the ED awaiting a massive influx of patients. ED waiting room served as the triage area. Operating rooms, ICU and blood bank were alerted. Seventy patients presented to the ED. Most victims (88%) were brought directly without prehospital triage or resuscitation. Four were pronounced dead on arrival. The mean age of victims was 27 (±14) years with a male preponderance (78%). Penetrating shrapnel injury was the most common mechanism of injury (71%). Most had a systolic blood pressure (SBP) >90 with a mean of 120.3 (±14.8). Mean pulse was 90.2 (±21.6) and most patients had full GCS. Extremities were the most common body region involved (64%) with orthopedics service being consulted most frequently. Surgery was performed on 36 patients, including 4 damage control surgeries. All patients survived. Conclusion This overwhelming single mass-casualty incident was met with a swift multidisciplinary response. In countries with no prehospital triage system, implementing a pre-existing disaster plan with pre-defined interdisciplinary responsibilities can streamline in-hospital management of casualties.
    Injury 08/2014;
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    ABSTRACT: Traffic-related injuries are a major cause of premature death in developing countries. Saudi Arabia has struggled with high rates of traffic-related deaths for decades, yet little is known about health outcomes of motor vehicle victims seeking medical care. This study aims to develop and validate a model to predict in-hospital death among patients admitted to a large-urban trauma centre in Saudi Arabia for treatment following traffic-related crashes.
    Injury 06/2014;
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    ABSTRACT: To establish the primary determinants of operative radiation use during fixation of proximal femur fractures.
    Injury 05/2014;
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    ABSTRACT: The purpose of the study was to assess whether using simultaneously two fluoroscopes in closed reduction and internal fixation of a stable intertrochanteric fracture reduces radiation and operation time. Patients who sustained a stable intertrochanteric femoral fracture were operated in our institution with closed reduction and internal fixation. They were randomly allocated to be operated with the assistance of one or two fluoroscopes. With one device, the radiology technician controlled and moved it to the desired anterior-posterior or axial view. With two fluoroscopes, one was positioned in the anterior-posterior view and the other in the axial view, both controlled by the surgeon. Total radiation and operation time were collected for all patients and compared between the two groups. 27 patients participated. One fluoroscope was used for 13 surgeries and two with 14. Total radiation time was shorter with two fluoroscopes compared to one (36.6±8.6sec vs. 51.2±18.9sec, respectively; p<0.02), as was total operation time, (24.3±4.2min and 34.7±11.9min, respectively; p<0.01). Working simultaneously with two fluoroscopic devices is safer for the medical team in the operating theatre, decreases the patient's radiation exposure, wound exposure time, and anaesthesia time. It saves operating room time and fluoroscopy personnel during the operation. When operating on hip fractures that are planned to be reduced and fixated, we recommend working with two fluoroscopes simultaneously.
    Injury 02/2014;
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    ABSTRACT: Methods Nineteen cases of extension contracture were operated upon by modified technique of Judet quadricepsplasty, one female and eighteen males. Results were evaluated by HSSKF score as well as Judet criteria. Purpose The hypothesis is that recurrence of adhesions underneath the quadriceps leads to loss of some of the gained intraoperative flexion range. Results In this series, flexion range deteriorates but this was found to be statistically non significant on the functional score of the patients.
    Injury 01/2014;
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    ABSTRACT: The acute rupture of the Achilles tendon is a protracted injury. Surgery is only the beginning of a long rehabilitation period. Therefore, the rehabilitation protocol is an integral aspect to restore the pre-injury activity level. Despite several trials available comparing different treatment regimes, there is still no consensus regarding the optimal protocol. Consequently, the aim of our study was to systematically search the evidence available and define a precise rehabilitation program after operative repair of acute Achilles tendon rupture based on the trials with the highest level of evidence. We performed a systematic literature search in Medline, Embase and Cochrane library. We identified twelve randomized controlled trials comparing different treatment regimes after operative repair of the Achilles tendon. Five trials compared full to non weight bearing, all applying immobilization in equinus. Immediate full weight bearing led to significant higher patient satisfaction, earlier ambulation and return to pre-injury activity. Four trials compared early ankle mobilization to immobilization. All trials found mobilization to be superior as it shortens time to return to work and sports significantly. Three trials compared the combination of full weight bearing and early ankle mobilization to immobilization. This combination was most beneficial. Patients showed significantly higher satisfaction, less use of rehabilitation resources, earlier return to pre-injury activities and further demonstrated significantly increased calf muscle strength, reduced atrophy and tendon elongation. No study found an increased rerupture rate for the more progressive treatment. In conclusion, the rehabilitation protocol after Achilles tendon repair should allow immediate full weight bearing. After the second postoperative week controlled ankle mobilization by free plantar flexion and limited dorsiflexion at 0° should be applied.
    Injury 01/2014;
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    ABSTRACT: Introduction The purpose of the current study was to investigate the effects of residual articular incongruity after Bennett-fracture on load distribution of the joint surface. Our aim was to investigate, if a residual joint step and the altered load distribution leads to negative clinical outcomes or symptomatic degenerative osteoarthritis of the trapeziometacarpal joint. Patients and Methods 24 patients were available for long-term follow-up examination and were contacted by phone and returned for follow-up examination. CT-scans of both carpometacarpal joints were performed. CT-scans were taken in sagittal plane of the forearms with a slice thickness of 0.625 mm for 3-dimensional reconstruction. The CMC-joints were analysed due to a residual step in the joint. Only patients with a residual step-off of were included into this study. To determine the areas of maximum density in the joint CT-osteoabsorptiometry was performed. Results Ten patients had the maximum loading area radial and two patients central. The second major position of mineralization was detected central in four patients, volar-ulnar in two patients, radial in one patient, dorso-radial in one patient, volar in one patient and volar-radial in two patients. Conclusion Finally no higher loading in the area of the beak fragment could be found. The Wagner-technique, even if resulted in a persistent one to two-millimetre intra-articular step-off of the beak fragment, it is still the favourable method for the treatment of Bennett's-luxation-fractures.
    Injury 01/2014;
  • Injury 01/2014; 45(6):1020–1021.
  • Injury 01/2014;
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    ABSTRACT: Background Both-bone diaphyseal forearm fractures constitute up to 5.4% of all fractures in children in the United Kingdom. Most can be managed with closed reduction and cast immobilisation. Surgical fixation options include flexible intramedullary nailing and plating. However, the optimal method is controversial. The main purpose of this study was to systematically search for and critically appraise articles comparing functional outcomes, radiographic outcomes and complications of nailing and plating for both-bone diaphyseal forearm fractures in children under 18 years. Methods A comprehensive search of Medline, Embase and Cochrane databases using specific search terms and limits was conducted. Articles identified were thoroughly screened using strict eligibility criteria and eight retrospective non-randomised comparative studies were identified and reviewed. Results There were no statistically significant differences in functional outcome or time to fracture union between plating and IM nailing. No consistent difference was found in complication rate, fracture angulation, shortening or rotation. Better cosmesis and shorter duration of surgery was noted in the IM nailing group. Post-operative radial bow was significantly abnormal in the IM nailing groups, but did not affect forearm movement. Conclusion Based on similar functional and radiographic outcomes, nailing seems to be a safe and effective option when compared to plating for paediatric forearm fractures. However, critical appraisal of the studies in this review identified some methodological deficiencies and further prospective, randomised trials are recommended.
    Injury 01/2014;
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    ABSTRACT: Introduction Knowledge about the functional consequences of lower limb long bone fractures is helpful to inform patients, clinicians and employers about their recovery process and prognosis. This study aims to describe the epidemiology and health outcomes of femoral and tibial shaft fractures treated at two level I trauma centres, by comparing the differences between patients with delayed union or nonunion and patients with union. Patients And Methods An analysis of registry data over two years, supplemented with medical record review, was conducted. Fracture healing was retrospectively assessed by clinical and radiological evidence of union, and the need for surgical intervention. SF-12 scores, and work and pain status were prospectively recorded at six and twelve months post injury. Results 285 fractures progressed to union and 138 fractures developed delayed union or nonunion. There was a significant difference between the two cohorts with regards to the mechanism of injury, association with multi-trauma, open fractures, grade of Gustilo classification, patient fund source, smoking status and presence of comorbidities. The SF-12 physical component score was less than 50 at both six and twelve months with improvement in the union group, but not in the delayed union or nonunion group. 72% of patients with union had returned to work at one year, but 54% continued to have pain. The difference compared to patients with delayed union or nonunion was significant. Discussion Even patients whose fractures unite in the expectant time-frame will have residual physical disability. Patients with delayed union or nonunion have still poorer outcomes, including ongoing problems with returning to work and pain. It is important to educate patients about their injury so that they have realistic expectations. This is particularly relevant given that the patients most likely to sustain femoral or tibial shaft fractures are working-age healthy adults, and up to a third of fractures may develop delayed union or nonunion. Conclusion Despite modern treatment, the patient-reported outcomes of lower limb long bone shaft fractures do not return to normal at one year. Patients with delayed union or nonunion can expect poorer outcomes.
    Injury 01/2014;
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    ABSTRACT: Background The adrenal response in critically ill patients, including trauma victims, has been debated over the last decade. The aim of this study was to assess the early adrenal response after trauma. Methods Prospective, observational study of 50 trauma patients admitted to a level-1-trauma centre. Serum and saliva cortisol were followed from the accident site up to five days after trauma. Corticosteroid binding globulin (CBG), dehydroepiandrosterone (DHEA) and sulphated dehydroepiandrosterone (DHEAS) were obtained twice during the first five days after trauma. The effect of time and associations between cortisol levels and; severity of trauma, infusion of sedative/analgesic drugs, cardiovascular dysfunction and other adrenocorticotropic hormone (ACTH) dependent hormones (DHEA/DHEAS) were studied. Results There was a significant decrease over time in serum cortisol both during the initial 24 h, and from the 2nd to the 5th morning after trauma. A significant decrease over time was also observed in calculated free cortisol, DHEA, and DHEAS. No significant association was found between an injury severity score ≥ 16 (severe injury) and a low (<200 nmol/L) serum cortisol at any time during the study period. The odds for a serum cortisol <200 nmol/L was eight times higher in patients with continuous infusion of sedative/analgesic drugs compared to patients with no continuous infusion of sedative/analgesic drugs. Conclusion Total serum cortisol, calculated free cortisol, DHEA and DHEAS decreased significantly over time after trauma. Continuous infusion of sedative/analgesic drugs was independently associated with serum cortisol <200 nmol/L.
    Injury 01/2014; 45(8):1149–1155.
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    ABSTRACT: Introduction Rib fractures are a common injury presenting to major trauma centres and community hospitals. Aside from the acute impact of rib fracture injury, longer term morbidity of pain, disability and deformity have been described. Despite this, the mainstay of management for the vast majority of rib fracture injuries remains supportive only with analgesia and where required respiratory support. This study aimed to document the long term quality of life in a cohort of major trauma patients with rib fracture injury over 24 months. Methods Retrospective review (July 2006 - July 2011) of 397 major trauma patients admitted to The Alfred Hospital with rib fractures and not treated with operative rib fixation. The main outcome measures were Quality of Life over 24 months post injury assessed using the Glasgow Outcome Scale Extended and SF12 health assessment forms and a pain questionnaire. Results Assessment over 24 months of major trauma patients with multiple rib fractures demonstrated significantly lower quality of life compared with published Australian norms at all time points measured. Return to work rates were poor with only 71% of those who were working prior to their accident, returning to any work. Conclusions This study demonstrates a significant reduction in quality of life for rib fracture patients requiring admission to hospital, which does not return to the level of Australian norms for at least two years.
    Injury 01/2014;
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    ABSTRACT: The gap among fracture fragments is an important factor which influences the healing of bone fracture, and it may be changeable during the early phase of bone healing. In this letter, we pointed out our view that the gap between the butterfly fragment and the shaft in femoral shaft fractures is easily to be changed, so it is hard to study the potential correlation between the size of the gap and fracture healing.
    Injury 01/2014;
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    ABSTRACT: Background Trauma systems have data registries in order to describe and evaluate (the quality of) trauma care. If results between centers or countries (benchmarking) are to be compared, data has to be accurate, reliable and complete. All trauma registries deal with incompleteness. A contributor to incompleteness of the data is failure to include patients that fulfill the criteria; the so-called missing patients. The aim of this study is to assess the number of missing patients in our regional trauma registry and to identify predictors for being missing from the trauma registry. Methods A random sample was taken. Four calendar weeks from 2012 were selected and medical files of all consecutive presentations to the emergency department or trauma room during those weeks were studied. Patients who were already correctly included in the trauma registry were assigned to the ‘included’ group and patients who should have been but were not to the missing group. Multivariable logistic regression analysis was performed to identify predictors for being missed from the trauma registry. Results Of a total of 338 patients, 50 (15%) were identified as missing. Characteristics of the missing patients did not differ substantially from the included patients. Transfer to another hospital after primary assessment and presentation in a Level 3 hospital compared to a Level 1 hospital were independent predictors for being missed from the trauma registry, with an adjusted Odds Ratio of 5.86 (95% CI; 2.08–16.52) and 6.64 (95% CI; 1.86–23.78), respectively. Conclusions Overall, 15% of the patients who met the inclusion criteria of the trauma registry were not included in the registry. Special attention should be paid to patients who are transferred to other hospitals in the network after initial assessment and to registration in Level 3 hospitals.
    Injury 01/2014;
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    ABSTRACT: There are many negative health consequences associated with alcohol dependency. Fractures of the proximal femur carry significant morbidity and mortality. This study examines the outcomes in patients with alcohol dependency, who sustain a fracture of the proximal femur. 28 consecutive alcohol dependent patients who suffered a fracture of the proximal femur were identified over a three year period. Data were collected on demographics, co-morbidity, surgical factors, mobility and mortality. The median age of patients was 61 years. The median weekly alcohol intake was 158 units. 13 patients sustained an extra-capsular fracture and 15 an intra-capsular proximal femoral fracture. 22 fractures were treated with internal fixation and six with arthroplasty. The overall mortality rate was 29% at a median of 15 months post fracture. The failure rate of intra-capsular fractures fixed with cannulated screws was 56% at a median time of 43 days. All patients had a reduction in mobility compared to their pre-operative function. The reduction in mobility was greatest in patients with intra-capsular fractures treated with cannulated screw fixation. Alcohol dependent patients sustaining a fracture of the proximal femur are significantly younger than non-alcohol dependent patients sustaining the same injury. Despite the younger age at presentation the one year mortality rate of this group was high (29%). The high rate of complications with fracture fixation and high one year mortality suggest that hemiarthroplasty may be the best treatment option for intra-capsular fractures in this patient group.
    Injury 01/2014;

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