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• The use of pelvic binders in the emergent management of potential pelvic trauma.

  Authors: T J S Chesser, A M Cross, A J Ward

  Injury. 43(6):667-9.

• Characteristics of acute treatment costs of traumatic brain injury in Eastern China-a multi-centre prospective observational study.

  Authors: Qiang Yuan, Hua Liu, Xing Wu, Yirui Sun, Haijun Yao, Liangfu Zhou, Jin Hu

  Injury.

  INTRODUCTION: This study investigated acute treatment costs and related factors for traumatic brain injuries (TBI) in eastern China based on a prospective multicentre study. MATERIALS AND METHODS:INTRODUCTION: This study investigated acute treatment costs and related factors for traumatic brain injuries (TBI) in eastern China based on a prospective multicentre study. MATERIALS AND METHODS: Data were prospectively collected from 80 hospitals in eastern China by standardized structured questionnaires during 2004. Included patients were admitted to hospitals via an emergency service with a diagnosis of TBI. The total acute hospitalization treatment costs derived from unsubsidized total hospital billings were used as the main outcome measure. Univariate and multivariable regression models were used to examine factors associated with each outcome. RESULTS: In total, 13,007 TBI cases were identified from 80 hospitals in eastern China. The median cost per hospitalization was $879 US (range, $72-45,894). The median cost per day was $79 (interquartile range, $49-126). The hospitalization costs varied based on the cause of TBI, with a median of $1017 for traffic accidents, $816 for falls, $490 for blows to the head, and $712 for falls. The hospitalization costs also varied by injury type with a mean of $918 for TBI associated with other injuries and $831 for isolated TBI. Using multiple regression analyses, lower admission Glasgow Coma score, longer hospital stay (LOS), male sex, transient patient status, traffic accident, injury occurring on a construction site, treatment at a tertiary hospital, neurosurgical intensive care unit (NICU) or ICU stay, associated polytrauma, and those who needed a neurosurgical operation had significantly higher total acute hospitalization costs than those of other groups. Good recovery and self-paying patients had lower total costs. A double LOS was associated with a 1.61 (95% confidence interval, 1.59-1.62) times higher hospital cost. CONCLUSION: Our results have potential implications for health-care resource planning during TBI treatment. Measures to prevent traffic accidents and reduce the LOS may help to reduce acute hospitalization costs.

• Multi-disciplinary update on pelvic fracture associated bladder and urethral injuries.

  Authors: Brad Figler, C Edward Hoffler, William Reisman, K Jeff Carney, Thomas Moore, David Feliciano, Viraj Master

  Injury.

  Pelvic ring fractures often result in severely injured patients with multiple organ injuries. The most common associated injuries are intraabdominal or urogenital, and urogenital injuries are thePelvic ring fractures often result in severely injured patients with multiple organ injuries. The most common associated injuries are intraabdominal or urogenital, and urogenital injuries are the most common associated injuries in those with severe pelvic fractures. Prompt and effective diagnosis and management of these injuries is essential to successful outcomes, but this is potentially complicated by poor communication and coordination among the many specialists involved. To address this, we present a multi-disciplinary review of pelvic fracture-associated bladder and urethral injuries that is specifically geared towards orthopaedic, urology, and trauma surgeons caring for these patients.

• Size matters: How accurate is clinical estimation of traumatic wound size?

  Authors: N Peterson, H Stevenson, V Sahni

  Injury.

  AIMS: The presentation of traumatic wounds is commonplace in the accident & emergency department. Often, these wounds need referral to specialist care, e.g. trauma & orthopaedic, plastic orAIMS: The presentation of traumatic wounds is commonplace in the accident & emergency department. Often, these wounds need referral to specialist care, e.g. trauma & orthopaedic, plastic or maxillofacial surgeons. Documentation and communication of the size of the wound can influence management, e.g. Gustilo & Anderson classification of open fractures. Several papers acknowledge the variability in measurement of chronic wounds, but there is no data regarding accuracy of traumatic wound assessment. The authors hypothesised that the estimation of wound size and subsequent communication or documentation was often inaccurate, with high inter-observer variability. A study was designed to assess this hypothesis. METHODS: A total of 7 scaled images of wounds related to trauma were obtained from an Internet search engine. The questionnaire asked 3 questions regarding mechanism of injury, relevant anatomy and proposed treatment, to simulate real patient assessment. One further question addressed the estimation of wound size. 50 doctors of varying experience across several specialities were surveyed. The images were analysed after data collection had finished to provide appropriate measurements, and compared to the questionnaire results by a researcher blinded to the demographics of the individual. RESULTS: Our results show that there is a high inter-observer variability and inaccuracy in the estimation of wound size. This inaccuracy was directional and affected by gender. Male doctors were more likely to overestimate the size of wounds, whilst their female colleagues were more likely to underestimate size. CONCLUSIONS: The estimation of wound size is a common requirement of clinical practice, and inaccurate interpretation of size may influence surgical management. Assessment using estimation was inaccurate, with high inter-observer variability. Assessment of traumatic wounds that require surgical management should be accurately measured, possibly using photography and ruler measurement.

• Calcar comminution as prognostic factor of clinical outcome after locking plate fixation of proximal humeral fractures.

  Authors: Georg Osterhoff, Armando Hoch, Guido A Wanner, Hans-Peter Simmen, Clément M L Werner

  Injury.

  OBJECTIVE: In the treatment of proximal humeral fractures, the decision between open fixation and arthroplasty is often difficult. Applicable radiographic prognostic factors would be useful. TheOBJECTIVE: In the treatment of proximal humeral fractures, the decision between open fixation and arthroplasty is often difficult. Applicable radiographic prognostic factors would be useful. The purpose of the present study was to investigate the influence of calcar comminution on the clinical and radiologic outcome after locking plate fixation of these fractures. METHODS: In patients with proximal humeral fractures that were treated by locking plate fixation, fracture morphology and the presence of comminution of the calcar were documented on preoperative radiographs. Follow-up for at least 2 years with radiologic assessment and functional outcome measurements including Constant score, subjective shoulder value (SSV), disabilities of the arm, shoulder and hand score (DASH), visual analogue scale (VAS) and short form (SF)-36 was performed. RESULTS: Follow-up examination (50.8±20.6 months) was possible in 74 patients (46 female, 28 male, age 63.0±15.9 years). Mean absolute Constant score (CS abs), CS adapted to age and gender (CS adap), DASH, SSV and VAS were 72.4±14.5, 85.2±17.3%, 15.7±17.3, 80.3±19.6% and 2.1±2.2. Nonunion was present in 1.3%, cut-out in 5.4% and implant failure in 1.3%. Avascular necrosis (AVN) was seen in 12.2%, in three cases >24 months after the initial trauma. In the presence of calcar comminution, the clinical outcome (CS abs, CS adap, SSV and several parameters of SF-36) was significantly impaired, the odds ratio for these patients to have an absolute CS<65 was 4.4 (95% confidence interval (CI): 1.4-13.7). CONCLUSIONS: The treatment of proximal humeral fractures with locking plate fixation achieves good clinical mid-term results. Calcar comminution is a relevant and easy-to-detect prognostic factor for the functional and subjective outcome in these fractures.

• Ready, steady, go or just go? - The question of stabilization before transport for trauma victims.

  Authors: Vineet Kumar, Pritam Suryawanshi, Satish B Dharap, Nobhojit Roy

  Injury.

• Occult pneumothoraces in Chinese patients with significant blunt chest trauma: Radiological classification and proposed clinical significance.

  Authors: Ryan K L Lee, Colin A Graham, Janice H H Yeung, Anil T Ahuja, Timothy H Rainer

  Injury.

  BACKGROUND: An occult pneumothorax (OP) is a pneumothorax not seen on a supine chest X-ray (CXR) but detected on abdominal or thoracic computed tomography (CT) scanning. With the increasing use of CTBACKGROUND: An occult pneumothorax (OP) is a pneumothorax not seen on a supine chest X-ray (CXR) but detected on abdominal or thoracic computed tomography (CT) scanning. With the increasing use of CT in the management of significantly injured trauma patients, more OPs are being detected. The aim of this study was to classify OPs diagnosed on thoracic CT (TCT) and correlate them with their clinical significance. METHODS: Retrospective analysis of prospectively collected trauma registry data. Total 36 (N=36) consecutive significantly injured trauma patients admitted through the emergency department (ED) who sustained blunt chest trauma and underwent TCT between 1 January 2007 and 31 December 2008 were included. OP was defined as the identification (by a consultant radiologist) of a pneumothorax on TCT that had not been detected on supine CXR. OPs were classified by laterality (unilateral/bilateral) and location (apical, basal, non apical/basal). The size of pneumothoraces, severity of injury [including number of associated thoracic injuries and injury severity score (ISS)], length of hospital stay and mortality were compared between groups. The need for tube thoracostomy and clinical outcome were also analysed. RESULTS: Patients with bilateral OPs (N=8) had significantly more associated thoracic injuries (median: 2 vs. 1, p=0.01), higher ISS (median: 35 vs. 23, p=0.02) and longer hospital stay (median: 20days vs. 11days, p=0.01) than those with a unilateral OP (N=28). Basal OPs (N=7) were significantly larger than apical (N=10) and non-apical/basal Ops (N=11). Basal OPs were associated with significantly more associated thoracic injuries (median: 2 vs. 1, p=0.01), higher ISS (median: 35 vs. 25, p=0.04) and longer hospital stays (median: 23days vs. 17days, p=0.02) than apical Ops, which had higher ISS (median: 35 vs. 25, p=0.04) and longer hospital stays (median: 23days vs. 15days, p=0.02) than non-apical/basal OPs. Non-apical/basal OPs were associated with more related injuries (median: 2 vs. 1, p=0.02) than apical OPs. All apical and non-apical/basal OPs were successfully managed expectantly without associated mortality. CONCLUSION: This TCT classification of OP is proposed to help clinicians to decide on subsequent management of the OP. Basal OPs are significantly larger in size, and both basal and bilateral OPs are associated with higher severity of injury and longer hospital stay. These groups of patient may benefit from prophylactic tube thoracostomy instead of conservative treatment. On the other hand, apical and non-apical/basal groups is smaller in size, less severely injured and thus can be successfully managed expectantly.

• The use of emergency department thoracotomy for traumatic cardiopulmonary arrest.

  Authors: Mark J Seamon, John Chovanes, Nicole Fox, Raymond Green, George Manis, George Tsiotsias, Melissa Warta, Steven E Ross

  Injury.

  Despite the establishment of evidence-based guidelines for the resuscitation of critically injured patients who have sustained cardiopulmonary arrest, rapid decisions regarding patient salvageabilityDespite the establishment of evidence-based guidelines for the resuscitation of critically injured patients who have sustained cardiopulmonary arrest, rapid decisions regarding patient salvageability in these situations remain difficult even for experienced physicians. Regardless, survival is limited after traumatic cardiopulmonary arrest. One applicable, well-described resuscitative technique is the emergency department thoracotomy-a procedure that, when applied correctly, is effective in saving small but significant numbers of critically injured patients. By understanding the indications, technical details, and predictors of survival along with the inherent risks and costs of emergency department thoracotomy, the physician is better equipped to make rapid futile versus salvageable decisions for this most severely injured subset of patients.

• Epidemiology of spinal fractures among the elderly in Chongqing, China.

  Authors: Hongwei Wang, Changqing Li, Qiang Xiang, Hongyan Xiong, Yue Zhou

  Injury.

  OBJECTIVE: To illustrate the epidemiology of spinal fractures including traumatic spinal fractures and osteoporotic spinal fracture with no specific cause, spinal fracture caused by tumour andOBJECTIVE: To illustrate the epidemiology of spinal fractures including traumatic spinal fractures and osteoporotic spinal fracture with no specific cause, spinal fracture caused by tumour and tuberculosis among the elderly. DESIGN: We retrospectively reviewed hospital records on all patients who was 60 years of age or older with spinal fracture at two university-affiliated hospitals between January 2001 and May 2011 (n=996). Variables assessed included age, gender, incidence of hospital admission, mechanism of spinal fracture, anatomic distribution, neurologic deficit, therapeutic method, length of hospitalisation and hospitalisation cost. SETTING: Two university-affiliated hospitals from January 2001 to May 2011. RESULTS: A total of 996 patients with spinal fractures were identified, of whom 34.8% were males. The annual incidence of spinal fractures among the elderly was 24 cases per 100,000 hospital admission in 2001 and then gradually increased to 130 cases per 100,000 hospital admission in 2010. The causes of spinal fractures include traumatic spinal fractures (n=714, 71.7%), osteoporotic fracture with no specific cause (n=264, 26.5%) and spinal fracture caused by tumour and tuberculosis (n=18, 1.8%). The lumbar region was the most common region of spinal fracture (n=823, 48.8%), followed by the thoracic (n=724, 43.0%) and the cervical (n=138, 8.2%) regions. Lumbar spinal fractures and thoracic spinal fractures were more commonly seen as a result of accidental falls from low heights and osteoporotic spinal fractures respectively. Thirty-five (3.5%) patients exhibited a complete motor and sensory deficit and 151 (15.2%) an incomplete neurological deficit. The greatest number of complete motor and sensory neurological deficits was associated with cervical spinal fractures and accidental falls. A total of 87 (8.7%) patients had associated non-spinal injuries, of whom 26 (29.9%) sustained a head and neck injury, 28 (32.2%) patients suffered a thoracic injury and 19 (21.8%) patients suffered a fracture of a lower extremity. CONCLUSION: Spinal fractures usually occur outdoors causing by accidental falls from low heights, most frequently happen on the road. The number of fall-induced injuries and sports injury increased steadily with age, may indicate that there is growing concern for the consequences of falls and sports in the elderly.

• Mild traumatic brain injury diagnosis frequently remains unrecorded in subjects with craniofacial fractures.

  Authors: Jussi Puljula, Hanna Cygnel, Elina Mäkinen, Veli Tuomivaara, Vesa Karttunen, Ari Karttunen, Matti Hillbom

  Injury.

  BACKGROUND: Traumatic brain injuries (TBI) in subjects with craniofacial fractures are usually diagnosed by emergency room physicians. We investigated how often TBI remains unrecorded in theseBACKGROUND: Traumatic brain injuries (TBI) in subjects with craniofacial fractures are usually diagnosed by emergency room physicians. We investigated how often TBI remains unrecorded in these subjects, and whether diagnostic accuracy has improved after the implementation of new TBI guidelines. METHODS: All subjects with craniofacial fractures admitted to Oulu University Hospital in 1999 and in 2007 were retrospectively identified. New guidelines for improving the diagnostic accuracy of TBI were implemented between 2000 and 2006. Clinical symptoms of TBI were gathered from notes on hospital charts and compared to the recorded diagnoses at discharge. Logistic regression was used to identify independent predictors for TBI to remain unrecorded. RESULTS: Of 194 subjects with craniofacial fracture, 111(57%) had TBI, 40 in 1999 and 71 in 2007. Fifty-one TBIs (46%) remained unrecorded at discharge, 48 being mild and 3 moderate-to-severe. Subjects with unrecorded TBI were significantly less frequently referred to follow-up visits. Failures to record the TBI diagnosis were less frequent (29/71, 41%) in 2007 than in 1999 (22/40, 55%), but the difference was not statistically significant. The most significant independent predictor for this failure was the clinical specialty (other than neurology/neurosurgery) of the examining physician (p<0.001). The subject's alcohol intoxication did not hamper the diagnosis of TBI. CONCLUSIONS: TBIs remain frequently unrecorded in subjects with craniofacial fractures. Recording of mild TBI slightly but insignificantly improved after the implementation of new guidelines.

• Insulin up-regulates epithelial sodium channel in LPS-induced acute lung injury model in rats by SGK1 activation.

  Authors: Tao Zhu, Wei Zhang, Dao-Xin Wang

  Injury.

  Activity of the epithelial sodium channels (ENaCs) in the lung tissue plays a critical role on sodium/fluid homeostasis and the lung fluid clearance. The serum- and glucocorticoid-inducible kinase-1Activity of the epithelial sodium channels (ENaCs) in the lung tissue plays a critical role on sodium/fluid homeostasis and the lung fluid clearance. The serum- and glucocorticoid-inducible kinase-1 (SGK1), one of the critical regulation proteins of ENaC, is activated by insulin and growth factors possibly through 3-phosphoinositide-dependent kinase PDK1 or/and phosphatidylinositol 3-kinase (PI3K). However, it is uncertain whether insulin shows its stimulatory action on ENaC by activation of SGK1 in lipopolysaccharide (LPS)-induced acute lung injury (ALI) condition. In our study, Wistar rats were injected with LPS to induce ALI. Evans blue dye albumin (EBA) concentration was used to measure pulmonary oedema. For detecting the ratio of phospho-SGK1/SGK1 and α-ENaC protein, Western blot was performed. Real-time polymerase chain reaction (RT-PCR) was used to assess α-ENaC messenger RNA (mRNA). Immunohistochemistry was used to locate and quantitate α-ENaC expression. The EBA concentration was markedly increased by LPS alone but significantly reduced in rats that also received insulin injection. The ratio of phospho-SGK1/SGK1 was raised significantly in the insulin group and insulin+LPS group, compared with the control group and the LPS group, respectively. Furthermore, α-ENaC was up-regulated by insulin treatment. Simultaneously, injection with LPS significantly reduced α-ENaC expression. These findings demonstrated that insulin up-regulates ENaC in vivo possibly resulting from activation of SGK1.

• Deep infection after hip fracture surgery: Predictors of early mortality.

  Authors: Andrew D Duckworth, Sally-Anne Phillips, Oliver Stone, Matthew Moran, Steffen J Breusch, Leela C Biant

  Injury.

  INTRODUCTION: This study analysed the predictors of mortality in patients who are diagnosed with deep infection following hip fracture surgery. METHODS: Data were prospectively collected for 3 yearsINTRODUCTION: This study analysed the predictors of mortality in patients who are diagnosed with deep infection following hip fracture surgery. METHODS: Data were prospectively collected for 3 years from all patients undergoing hip fracture surgery and who had developed a subsequent deep infection. Infection was defined as positive microbiology culture from deep tissue or fluid samples. Demographic data, treatment, complications and subsequent surgeries were analysed. Potential predisposing factors including chronic medical co-morbidities, American Society of Anesthesiologists (ASA) grade, alcohol excess and smoking were assessed. The main outcome measures were 30-day and 1-year mortality. RESULTS: There were 2718 consecutive operations performed for a fracture of the proximal femur over a 3-year period. Forty-three (1.6%) patients had a deep postoperative infection diagnosed on fluid and/or tissue sampling. The mean age was 73 years (25-94) and 65% were female. Of the 43 patients who developed deep infection, the primary procedure in 25 (58%) patients was reduction and internal fixation, with 18 (42%) undergoing hemi-arthroplasty. The most common causative organism was Staphylococcus epidermidis (n=13, 30%), with methicillin-resistant Staphylococcus aureus (MRSA) accounting for 23% (n=10). The 30-day mortality was significantly higher than that of patients with no deep infection (19% vs. 6.5%; p=0.004). On univariate analysis, increasing age, dementia and diabetes were predictive of both 30-day and 1-year mortality (all p<0.05). S. aureus (sensitive or resistant) was approaching significance at 1year (p=0.065). On multivariate analysis, dementia and diabetes were independent predictors of 30-day mortality, with dementia and S. aureus predictive at 1 year. CONCLUSIONS: The 30-day mortality rate in patients diagnosed with deep infection following hip fracture surgery is higher than those without infection. Dementia, diabetes and S. aureus infection are independent predictors of mortality following deep infection.

• Judet osteoperiosteal decortication for treatment of non-union: The Cornwall experience.

  Authors: Paul Guyver, Christopher Wakeling, Kumar Naik, Mark Norton

  Injury.

  BACKGROUND: The treatment of non union can be challenging with a variety of surgical options available to achieve bone consolidation. Robert Judet first described a method of osteo-periostealBACKGROUND: The treatment of non union can be challenging with a variety of surgical options available to achieve bone consolidation. Robert Judet first described a method of osteo-periosteal decortication in 1963. He stated that by elevating cortical chips that remain attached to the periosteum and overlying soft tissues surrounding the site of non-union, combined with mechanical support, the bone consolidated. Despite excellent results presented in 2008 of 99% union rates with a mean delay of 8 months, the technique has not yet become popularised. We aim to show that Judet's method of decortication can achieve good results in the management of failure of union in a hospital other than Judet's. METHODS: Retrospective analysis was performed from December 2002 to December 2008 of 40 cases in 39 patients of osteoperiosteal decortication for fracture non-union. Concurrent stabilisation was with internal fixation only. All procedures were performed by one surgeon (MN) using the Judet technique after learning the technique in the originators hospital. A preoperative non union scoring system was also used to assess its use in predicting persistent non-union. RESULTS: Union was successfully achieved in 36 of the 39 surviving cases (92.3%) after a median delay of 8 months (range 3-47, SD 9.2) Twenty-six patients (65%) achieved union following the decortication procedure without subsequent operations. Factors such as open fracture and smoking did not have a statistically significant effect on union. The mean number of procedures following decortication was 0.68 (range 0-4). Metalwork failure occurred in 11 cases (28%), the majority in femoral decortications (n=9, 82%). The femur was the site of all persistent non unions in the series. Three patients had superficial infections and two had deep infections. The pre-operative non union scoring system (0-100) means were noticeably worse for the persistent non union group 42.0 (20-46) compared with the union group 31.0 (range 4-52). CONCLUSIONS: Osteoperiosteal decortication remains a highly effective surgical technique in the management of failed fracture union. The non union scoring system is a reliable predictor of persistent non union after this type of surgery. CLINICAL RELEVANCE: Relevant to general trauma orthopaedic surgeon and specialist orthopaedic surgeons with an interest in fracture non-union.

• Femoral replacement for salvage of periprosthetic fracture around a total hip replacement.

  Authors: Aaron L McLean, James T Patton, Matthew Moran

  Injury.

  A total of 20 patients with a mean age of 72 (range: 36-91) were managed with replacement of the proximal (15) or total (5) femur for salvage of a periprosthetic femoral fracture with bone loss. AA total of 20 patients with a mean age of 72 (range: 36-91) were managed with replacement of the proximal (15) or total (5) femur for salvage of a periprosthetic femoral fracture with bone loss. A mean 12.5years had elapsed between primary total hip replacement and surgery and the mean follow-up was 48months (range: 12-116months). Clinical outcome was assessed using the Toronto Extremity Salvage Score (mean: 68, range: 32-98) and Short Form 36 (SF-36; mean Physical Component Score (PCS): 53, range: 44-62; mean Mental Component Score (MCS): 51, range: 41-64). No prostheses were radiologically loose. There were six major complications; three patients suffered a postoperative dislocation; two patients had persistent deep infection (present preoperatively); and one patient suffered a fracture of their femur distal to the femoral stem of a proximal femoral replacement. Endoprosthetic replacement of the femur is a reasonable salvage option for patients with periprosthetic fracture and bone loss, with good clinical results. It allows immediate weight bearing and does not rely on bony union for success.

• The extended flexor carpi radialis approach for partially healed malaligned fractures of the distal radius.

  Authors: Mathieu M E Wijffels, Jorge L Orbay, Igor Indriago, David Ring

  Injury.

  PURPOSE: The aim of the study is to evaluate the safety and utility of the extended flexor carpi radialis (FCR) exposure and volar locking plate fixation for partially healed malaligned fractures ofPURPOSE: The aim of the study is to evaluate the safety and utility of the extended flexor carpi radialis (FCR) exposure and volar locking plate fixation for partially healed malaligned fractures of distal radius. MATERIALS AND METHODS: Thirty-five patients with a partially healed malaligned fracture of the distal radius had realignment of the fracture using an extended FCR approach (release of the insertion of the brachioradialis and dorsal periosteum) and volar locked plate and screw fixation. RESULTS: Retrospective review an average of 20 months after the index operation patients identified an average wrist extension of 68°, flexion of 64°, pronation of 84° and supination of 85°. Radial inclination, volar tilt and ulnar variance significantly improved compared to preoperative radiographs. All fractures healed, and there were no infections, implant loosening or breakage or tendon ruptures. CONCLUSIONS: This study demonstrated that the extended FCR approach is safe and effective as a treatment method for nascent malunions of the distal radius.

• Costs of falls in an ageing population: A nationwide study from the Netherlands (2007-2009).

  Authors: Klaas A Hartholt, Suzanne Polinder, Tischa J M Van der Cammen, Martien J M Panneman, Nathalie Van der Velde, Esther M M Van Lieshout, Peter Patka, Ed F Van Beeck

  Injury.

  BACKGROUND: Falls are a common mechanism of injury in the older population, putting an increasing demand on scarce healthcare resources. The objective of this study was to determine healthcare costsBACKGROUND: Falls are a common mechanism of injury in the older population, putting an increasing demand on scarce healthcare resources. The objective of this study was to determine healthcare costs due to falls in the older population. METHODS: An incidence-based cost model was used to estimate the annual healthcare costs and costs per case spent on fall-related injuries in patients ≥65 years, The Netherlands (2007-2009). Costs were subdivided by age, gender, nature of injury, and type of resource use. RESULTS: In the period 2007-2009, each year 3% of all persons aged ≥65 years visited the Emergency Department due to a fall incident. Related medical costs were estimated at €675.4 million annually. Fractures led to 80% (€540 million) of the fall-related healthcare costs. The mean costs per fall were €9370, and were higher for women (€9990) than men (€7510) and increased with age (from €3900 at ages 65-69 years to €14,600 at ages ≥85 year). Persons ≥80 years accounted for 47% of all fall-related Emergency Department visits, and 66% of total costs. The costs of long-term care at home and in nursing homes showed the largest age-related increases and accounted together for 54% of the fall-related costs in older people. DISCUSSION: Fall-related injuries are leading to a high healthcare consumption and related healthcare costs, which increases with age. Programmes to prevent falls and fractures should be further implemented in order to reduce costs due to falls in the older population and to avoid that healthcare systems become overburdened.

• Does cardiology intervention improve mortality for post-operative troponin elevations after emergency orthopaedic-geriatric surgery? A randomised controlled study.

  Authors: Carol P Chong, William J van Gaal, Julie E Ryan, Konstantinos Profitis, Judy Savige, Wen Kwang Lim

  Injury.

  OBJECTIVES: Troponin elevations are common after emergency orthopaedic surgery and confer a higher mortality at one year. The objective was to determine if comprehensive cardiology care afterOBJECTIVES: Troponin elevations are common after emergency orthopaedic surgery and confer a higher mortality at one year. The objective was to determine if comprehensive cardiology care after emergency orthopaedic surgery reduces mortality at one year in patients who sustain a post-operative troponin elevation versus standard care. METHODS: A randomised controlled trial was conducted at a metropolitan teaching hospital in Melbourne, Australia. 187 consecutive patients were eligible with 70 patients randomised. Troponin I was tested peri-operatively and patients with a troponin elevation were randomised to cardiology care versus standard ward management. The main outcome measure was one year mortality. RESULTS: The incidence of a post-operative troponin elevation was 37.4% (70/187) and these 70 patients were randomised. In-hospital cardiac complications were similar between the randomised groups: standard care (7/35 or 20.0%) versus cardiology care (8/35 or 22.9%). There was no difference in 1 year mortality between the randomised groups (6/35 or 17.1% in each group). Multivariate predictors of 1 year mortality were post-operative troponin elevation OR 4.3 (95% CI, 1.1-16.4, p=0.035), age OR 1.1 (95% CI, 1.02-1.2, p=0.016) and number of comorbidities OR 2.1 (95% CI, 1.3-3.5, p=0.004). At 1 year 35/187 (18.7%) sustained a cardiac complication and 23/35 (65.7%) had a troponin elevation. CONCLUSIONS: There was no difference in mortality between patients with a post-operative troponin elevation randomised to cardiology care compared with standard care. Troponin elevation predicted one year mortality. Further research is needed to find an effective intervention to reduce mortality.

• CT scanogram for limb length discrepancy in comminuted femoral shaft fractures following IM nailing.

  Authors: Rahul Vaidya, Brent Anderson, Ashraf Elbanna, Robert Colen, Daniel Hoard, Anil Sethi

  Injury.

  INTRODUCTION: Leg length discrepancy (LLD) following intramedullary nailing of femoral fractures is not uncommon. We designed a prospective study to evaluate the efficacy of routine postoperativeINTRODUCTION: Leg length discrepancy (LLD) following intramedullary nailing of femoral fractures is not uncommon. We designed a prospective study to evaluate the efficacy of routine postoperative computed tomography (CT) scanograms for evaluation of limb length discrepancy in patients with comminuted Winquist III or IV femoral shaft fractures treated with intramedullary nailing. METHODS: The study consisted of 15 patients with Winquist III and 13 with a Winquist IV femoral shaft fracture pattern with an average age of 37 years. The mechanisms of injury were motor vehicle collision (13), gunshot wound (12) and falls (three). All patients were treated with a statically locked intramedullary femoral nail (18 antegrade and 10 retrograde). A CT scanogram evaluated limb length in all patients. A discrepancy of greater than 20mm was considered for correction during the same admission. An LLD of 15-20mm was discussed with the patient extensively for correction. RESULTS: In the 28 patients included in our study, the average limb length discrepancy was 9.1mm with a range of -43.5mm short to 10.3mm long. The LLD was less than 10mm in 18 patients (64%), 10-15mm in four patients (14%), 15-20mm in three patients (11%) and more than 20mm in three patients (11%). Measurement of discrepancy as small as 0.5mm showed that 18 patients were fixed with shortening and in 10 patients the operated femur was longer. Tibia lengths were also evaluated separately. Though none of the tibiae had a previous fracture, only three patients (10%) had tibiae of equal length. In 13 patients, an unequal tibia partially corrected the LLD whilst in 12 it added to the discrepancy. Five patients with LLD of greater than 15mm underwent correction. CONCLUSIONS: A postoperative scanogram in patients with comminuted femoral shaft fractures treated with intramedullary nailing is useful to evaluate LLD and allows for early intervention. The ideal length where correction is necessary remains unclear.

• Biomechanical femoral neck fracture experiments-A narrative review.

  Authors: Trude Basso, Jomar Klaksvik, Unni Syversen, Olav A Foss

  Injury.

  INTRODUCTION: Orthopaedic implants can be introduced in clinical practice if equivalency to an already approved implant can be demonstrated. A preclinical laboratory test can in theory provide theINTRODUCTION: Orthopaedic implants can be introduced in clinical practice if equivalency to an already approved implant can be demonstrated. A preclinical laboratory test can in theory provide the required evidence. Due to the lack of consensus on the optimum design of biomechanical experiments, setups vary considerably. This review aims to make femoral neck fracture models more accessible for evaluation to orthopaedic surgeons without any particular background in biomechanics. Additionally, the clinical relevance of the different setups is discussed. METHODS: This is a narrative review based on a non-systematic search in PubMed, Scopus and Cochrane. SUMMARY: Biomechanical femoral neck fracture experiments should aim at optimizing the recreation of the in vivo situation. The bone quality of the experimental femurs should resemble the hip fracture population, hence cadaveric bones should be preferred to the available synthetic replica. The fracture geometry must be carefully selected to avoid bias. The load applied to the specimen should result in forces within the range of in vivo measured values and the magnitude should be related to the actual weight of the donor. A well designed biomechanical experiment can prevent harmful devices from being introduced in clinical practice, however, positive results can never exclude the necessity of subsequent clinical studies.

• Re: An alternative approach to needle thoracostomy for tension pneumothorax.

  Authors: Takeshi Yamagiwa, Seiji Morita, Sadaki Inokuchi

  Injury.

• Post-traumatic empyema: Aetiology, surgery and outcome in 125 consecutive patients.

  Authors: James V O'Connor, Albert Chi, Manjari Joshi, Joe Dubose, Thomas M Scalea

  Injury.

  INTRODUCTION: Empyema remains a potentially serious condition with multiple etiologies including post-pneumonic, post-resection, and post-traumatic. There are few studies describing the latter. WeINTRODUCTION: Empyema remains a potentially serious condition with multiple etiologies including post-pneumonic, post-resection, and post-traumatic. There are few studies describing the latter. We reviewed our experience at a high volume trauma centre in injured patients with empyema, examining pre-operative status, surgical procedures, pathogens and outcome. METHODS: Retrospective trauma registry review, from 9/01 to 4/10. Empyema was defined as culture positive pleural fluid or purulence at operation. Data collected included demographics, injury mechanism, thoracic injuries, organ dysfunction, pathogens isolated, surgical procedures, outcomes and follow up. RESULTS: One hundred twenty-five consecutive patients with empyema were identified. Average injury severity score and age were 27.3 and 37.2 years respectively; 89.6% were male, 63.2% sustained blunt chest trauma. Time from injury to diagnosis averaged 12.1 days. All underwent decortication; 80% by thoracotomy, the remainder thoracoscopically. At operation over half were mechanically ventilated and 13.6% required vasoactive infusions. Monomicrobial cultures with Gram positive cocci predominating were obtained in 44%, 48% had polymicrobial cultures and 18.4% had a ruptured lung abscess. There were five deaths (4%); two occurring after a ruptured lung abscess. Recurrent empyema occurred in 6.4%, all successfully treated by re-operation or catheter drainage. Intensive care and hospital stays were 18.1 and 30.6 days respectively. All survivors achieved resolution of empyema. CONCLUSIONS: Trauma patients with empyema represent a subset of severely injured critically ill patients with diverse pathogens and polymicrobial flora. Appropriate surgical management and specific antibiotic therapy yields excellent results with acceptable risk. A ruptured lung abscess may be the aetiology of the post-traumatic empyema in a subset of patients and may represent an increased operative risk.

• An alternative approach to needle thoracostomy for tension pneumothorax.

  Authors: Jonathan N Rajan, Winston Fidelis de Mello

  Injury.

• Retrograde nailing and compression bolts in the treatment of type C distal femoral fractures.

  Authors: Christos Garnavos, Panagiotis Lygdas, Nikolaos G Lasanianos

  Injury.

  INTRODUCTION: This is a prospective study that verifies the usefulness of retrograde intramedullary nailing (IMN) combined with 'independent' compression bolts in the management of type C (AO/OTAINTRODUCTION: This is a prospective study that verifies the usefulness of retrograde intramedullary nailing (IMN) combined with 'independent' compression bolts in the management of type C (AO/OTA classification) fractures of the distal femur. PATIENTS AND METHODS: Within a period of 4 years, 17 patients (mean age of 54 years) with intra-articular fractures of the distal femur (type C according to AO/OTA classification) were treated with retrograde IMN and compression condylar bolts. The patients followed an early mobilisation and weight-bearing protocol. RESULTS: All fractures healed in a mean time of 14.78 weeks with no incidences of malunion, nonunion or infections. No secondary failure of fixation occurred. Partial weight bearing was initiated in average 6.35 weeks postoperatively whilst full weight bearing in 14.6 weeks. The patients regained full extension and 117.22° of mean flexion of the knee joint while the mean New Oxford knee score was 42.05. CONCLUSIONS: In the treatment of type C fractures of the distal femur, the combination of retrograde nailing and 'independent' compression condylar bolt (inserted prior to the nailing) provided a strong fixation that facilitated uncomplicated outcomes and uneventful early mobilisation.

• A simple method to protect the great saphenous vein and saphenous nerve in percutaneous plate fixation of distal tibial fractures.

  Authors: Xin Wang, Shi-Min Chang, Guang-Rong Yu, Zhuo Ma

  Injury.

• Penetrating assaults in children: Often non-fatal near-miss events with opportunities for prevention in the UK.

  Authors: L Melling, N Lansdale, D Mullassery, D Taylor-Robinson, E C Jesudason

  Injury.

  INTRODUCTION: Media reports portray a growing problem of gun and stab assaults amongst UK children. Recent legislative changes aim to increase integration between services and protect childrenINTRODUCTION: Media reports portray a growing problem of gun and stab assaults amongst UK children. Recent legislative changes aim to increase integration between services and protect children better. Child victims of gun or stab assaults are at increased risk of reinjury and are therefore vital targets for interventions shown to be effective at preventing violent injury. There is currently a paucity of data with which to inform public debate, guide policy and develop prevention strategies. We therefore aimed to provide contemporary data on the epidemiology and clinical outcomes for intentional gun and stab injuries in children, using a large UK city as a model environment and also to ascertain whether interventions to prevent violent injury are currently in routine use in a sample of UK urban paediatric EDs. METHODS: A retrospective case series analysis was performed of children (<16years) attending Emergency Departments (EDs) in a typical major UK city with high levels of deprivation. In addition, we undertook a qualitative survey of a sample of UK urban paediatric EDs regarding their use of violent injury prevention strategies in children. RESULTS: Contrary to media reports and data from London, rates of gun and stab assault remained unchanged through the study (2003-2008). Although tragic fatal injury can occur, the majority of injuries were minor, with most children not requiring admission. Of those admitted, a minority needed surgery (mainly wound debridement and closure). Socioeconomically deprived, adolescent boys appear to be particularly at risk, with attacks at weekends and in public spaces beyond home and school being more common. Interventions to prevent violent reinjury are not currently employed in paediatric EDs in the 15 most populated urban areas of the UK. CONCLUSIONS: Patient safety literature emphasises the need to identify near miss events. Media reports of tragic child deaths due to gunshot and stabbing are actually accompanied by large numbers of minor wounds that we should see as near miss events. Measures shown to reduce reinjury in these high-risk groups could now be pursued in the UK for patient safety and child protection purposes.

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