Injury

Published by Elsevier
Online ISSN: 0020-1383
Publications
Article
This prospective study of 1000 femoral neck fractures (476 intertrochanteric and 524 subcapital) found the pre-injury mobility to be the most significant determinant for post-operative survival. The intrahospital mortality of the 975 surgically treated fractures was 11.3 per cent. Non-operatively treated fractures had a mortality of 60 per cent. The best predictors of morbidity and discharge mobility were age and pre-injury mobility. Delay was significant in the development of morbidity but only after 30 h from admission. Internal fixation produced a lower mortality than uncemented hemiarthroplasty. The use of acrylic cement was associated with an increased morbidity and mortality rate in hemiarthroplasties. Neither the grade nor the experience of the operating surgeon had an effect on mortality or morbidity.
 
Article
Four years experience in the use of a new orthogeriatric unit run jointly by the orthopaedic Trauma service and the Department of Health Care of the Elderly is presented. There were over 1000 admissions during this period. The Unit was opened in 1978 and was established to meet the increasing problems stemming from fractures of the proximal femur in elderly women. During the ten-year period from 1971 to 1981 the number of patients with fractures of the proximal femur admitted to the orthopaedic trauma unit in Nottingham has doubled--from 290 cases in 1971 to 612 cases in 1981. The effect of the orthogeriatric unit has been to reduce the average length of hospital stay for these patients from 66 days in 1977 before the unit opened, to 48 days in 1979 with a rate of discharge to home or to relatives of 69 per cent of patients: inpatient case fatality within the unit has been 5 per cent.
 
Article
Prediction of the likely outcome of head injury from the outset would allow early rehabilitation to be targeted at those with most to gain. Clinical evaluation of a head injured patient may be confounded by intoxicants such as alcohol. Imaging modalities are insensitive (CT) or impractical (MR) for screening populations of such patients. A peripheral marker that reflected the extent of brain injury might offer an objective indication of likely adverse sequelae. This review evaluates the evidence for Protein S-100B as such a marker. A search of published literature revealed 18 studies designed to evaluate the relation between serum S-100B and measures of outcome after head injury. A cut-off point of 2.5microg/L is related to dependent disability in those presenting with low conscious level, and may be a specific test for this. There appears to be a relation between initial serum S-100B concentration and measures of disability as well as post-concussion symptoms for those with seemingly mild injuries. There does not appear to be a relation between S-100B and measures of neuropsychological performance. Patients with high levels of S-100B at initial assessment (>2.5microg/L) may represent a high risk group for disability after head trauma.
 
Article
Reverse obliquity and transverse fractures of the proximal femur represent a distinct fracture pattern in which the mechanical forces displace the femur medially thus increasing the risk of fixation failure. There is a paucity of published literature in this area of trauma. This study constitutes the largest series of such fractures. Using a retrospective analysis of prospectively collected data from a single institution, 101 reverse obliquity and transverse fracture patterns were identified from 3336 consecutive hip fractures. All surviving patients were followed up for 1 year. Of 100 patients treated operatively, 59 were treated with 135 degrees sliding hip screws (SHS), 19 with a Medoff plates modification of the SHS, three with a sliding hip screw and trochanteric stabilising plate and 19 with intramedullary sliding hip screw devices. Nine fracture fixation-healing complications occurred, with cut-out being the commonest complication (seven cases). Cut-out of the implant was associated with femoral medialisation and a larger tip to apex distance. This fracture pattern is a challenge for the orthopaedic surgeon with a high risk of fracture healing complications. The 135 degrees SHS and the intramedullary devices had similar failure rates.
 
Article
We analysed the pattern of injury of 101 adult patients who were treated in our Trauma Center after a fall from an average height of 7.2 m between 1987 and 1990. In 62 patients the fall was accidental, and 39 jumped with suicidal intent. The most common injuries were fractures of the thoracic and lumbar spine (83.0 per cent) especially of the thoracolumbar junction. The pattern of limb injuries is towards a significant preference of the metaphyseal and epiphyseal parts of the bones of the distal joints (wrist, elbow, ankle, subtalar). Fractures of the diaphyseal areas and the proximal joints (shoulder, humerus, hip, femur) were rare. The incidence of thoracic (20.8 per cent) and pelvic injuries (30.0 per cent) was relatively lower. Blunt abdominal injury (5.9 per cent) was rare after a fall from a great height. Head injuries occurred in only 27 per cent of our patients who all survived their transport to hospital. There is no significant difference in injury patterns between deliberate and accidental falls, but there is a higher number of isolated injuries in all patients after unsuccessful suicidal jumps.
 
Article
To find out the influencing factors of the immediate and late outcome of replantation and revascularization of the digits the study was carried out as a prospective survey research during 1983 to 1995 with at least 2 year follow up. Traumatic total or subtotal amputation with inadequate circulation of the digits distal to the metacarpal head were included in the study. There were 552 patients with 366 males (675 digits) and 186 females (343 digits). Successful operation was found in 508 patients (92%) with 946 digits (92.9%). Type of injury was the most important factor influencing immediate and late outcome. Regular cigarette smoking resulted in poor immediate survival rate. Prolonged ischaemia had a significant influence in final functional outcome. Using composite skin and subcutaneous vein graft gave good survival rate. Injury at the no man's land area resulted in poor range of movement of the digit. Connecting the profundus tendon stump of the proximal part to the superficialis tendon of the amputated part gave a better result than 2 tendon repair and repairing only the profundus tendon. Replantation should be carried out even if only one digit is involved. At the 2 year follow up 195 patients (38%) were classified in grade I of Chen et al., functional outcome, while 153 (31%) were in grade II, 124 (24%) were in grade III and 36 (7%) were in grade IV.
 
Article
We prospectively studied 1023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using contemporary methods. The overall incidence of avascular necrosis (AVN) was 6.6%. AVN was less common for undisplaced (4.0%) than for displaced fractures (9.5%) and in men (4.9%) than women (11.4%) who had a displaced fracture. The incidence of AVN for those aged less than 60 years and who sustained a displaced fracture was 20.6%, compared to 12.5% for those aged 60-80 years and 2.5% for those aged more than 80 years. Our study showed an increased risk of AVN with younger age and in females with a displaced fracture. We found no association between the incidence of AVN and the interval between injury to surgery.
 
Article
The results for a consecutive series of 1024 trochanteric hip fractures surgically treated by internal fixation with a sliding hip screw in a single centre are presented. The mean age of patients was 81.7 years and 78% were female. Seventy-five percent of fractures were classified as unstable. At 1 year from injury, 69% of patients were surviving. Of these, 95% had minimal or no pain, 85% had at least returned to their pre-fracture level of accommodation and 50% to their pre-fracture level of mobility. Complications related to surgical fixation were encountered in 3.6% of cases. Overall, 2.6% of patients required further surgery as a result of these. While significant mortality remains an issue, the overall fixation failure rate and re-operation rate for trochanteric fractures fixed with a sliding hip screw is low. The final outcome of surgery for the survivors is good, with most patients returning to their pre-fracture level of accommodation and mobility, with minimal pain 1-year post-fracture.
 
Article
This paper reviews 105 fatal cases of blunt trauma, in which death occurred after arrival at hospital. Data are presented with reference to age, sex, nature of injuries and length of stay. An assessment was made as to whether any major lesions remained undiagnosed or were undertreated; 16 per cent of these deaths were found to be due, at least in part, to such lesions.
 
Article
Autogenous bone-grafting is frequently used in the treatment of fracture non-union. The donor-site morbidity and potentially limited supply of suitable autogenous bone are commonly recognized drawbacks. Recent studies advocated the benefit and safety of recombinant human bone morphogenetic protein-7 (rhBMP-7) in several anatomical sites. An observational, retrospective, non-randomized study on the use of BMP-7 in treating non-union in various sites has been carried out by the BMP-7 Italian Observational Study (BIOS) Group. The clinical series included 105 patients. Additional grafts were used based on the surgeon's decision. Radiographic and clinical assessments were carried out at progressive time intervals on two groups: BMP-7+autograft (A) or BMP-7 (B). The mean follow-up was 29.2 months. The last assessment showed an 88.8% success rate with an average healing time of 7.9 months. At >/=9 months there was overlapping between the unions recorded in the two groups (PA-PB=1.5%; CI 95%: -0.149; 0.119). This is an observational study that illustrates the efficacy of BMP-7 with and without bone grafting for the treatment of long bone non-unions.
 
Article
A prospective study of 1086 consecutive injuries caused by glass showed that the mean age of the patients was 15 years and there was a 7 : 3 male to female ratio. The home (35 per cent), public places (31.3 per cent) and places of work (21.1 per cent) were the main locations where these accidents occurred. Although most of the injuries were mild, 3 case histories illustrate that some of them were extremely serious. 4.6 per cent of patients requiring immediate admission to hospital. Extrapolation of the figures indicates that approximately 210,000 people attend hospital each year in England and Wales for treatment of an injury caused by glass. The annual cost to the National Health Service is about 7,500,000 pounds but the full financial implications of these injuries in terms of compensation and insurance payments must be much greater. Suggestions are made of ways to reduce the incidence of these injuries from road traffic accidents and accidents with plate glass and glass containers.
 
Article
In an autopsy study of 180 cervical spines, 109 were from victims of fatal blunt injury. A search was made for injuries to the dorsal root ganglia. The whole cervical spines, from the skull base to T1, were formalin fixed, deep frozen and sagittally sectioned on a specially adapted band saw in 2.5 mm thick slices. In 15 of the 109 fatally injured individuals, 44 examples of interstitial haemorrhage into a dorsal root ganglion (DRG) were found. This was sometimes accompanied by neural tissue disruption, visible only on histological study. The intraneural DRG haemorrhage was found in 13.8 per cent of all the injured individuals, but this prevalence rose to 34.5 per cent when only those (29) individuals surviving the injury between 2 h and 7 days were considered. The possible relevance of such injuries, in survivors of injury, to acute and chronic pain syndromes is discussed.
 
Article
The Maidstone Hospital provides trauma services to one of the largest parachute clubs in the United Kingdom. We studied injuries sustained at the club in 1994 and compared results with equivalent data from 1984. The injury rate for first time jumpers in the current study was 1.2%; half of these cases required admission for an average of 10 d. Individual morbidity and loss of productivity lasted far longer. No lessons had been learned from the first study. We question parachuting as a fund-raising venture and suggest re-evaluating the training of novice parachutists, perhaps with mandatory use of the safer rectangular parachute. At a time when healthcare rationing is an issue, individuals engaging in activities such as these might be required to indemnify themselves against the medical costs of injury currently met by the state.
 
Article
Flexible intramedullary nailing is a relatively safe method of treating femoral fractures in the child, with excellent functional results and a low complication rate. However, this case documents development of osteomyelitis subsequent to nail insertion. This report highlights the need to carefully evaluate the benefits of surgical over conservative management in every case of paediatric femoral fracture.
 
Article
We report 11 cases of interprosthetic dislocation of the Charnley/Hastings hemiarthroplasty in a retrospective study of 350 consecutive patients treated for an acute femoral neck fracture. We found a total of 14 dislocations (4.0%), 11 were interprosthetic. The median age of the 350 patients was 79 (36-99) years and the median age of the 11 patients with an interprosthetic dislocation was 85 years (82-94). The median time from surgery to radiologically acknowledged dislocation was 18 (4-64) days. These interprosthetic dislocations may be caused by either an assembly mistake perioperatively, by maximum angulation and impingement between the components, or by trauma.
 
Article
To identify cytokines useful for diagnosis of traumatic death. Post-mortem serum levels of 11 cytokines were assayed for 43 people who died of traumatic injury or from non-traumatic causes. Levels of granulocyte-macrophage colony stimulating factor, gamma interferon, interleukin IL-1beta, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-13, and tumour necrosis factor-alpha were measured using multiplex immunoassay. Levels of granulocyte-macrophage colony stimulating factor (p<0.01), IL-6 (p<0.001), and IL-8 (p<0.01) among the traumatic group were significantly higher than those among the non-traumatic group. Anatomical trauma severity was also estimated using the total abbreviated injury scale and injury severity score, revealing significant positive correlations between the former and IL-6 (rs=0.6523, p<0.01) and IL-8 levels (rs=0.6584, p<0.01). Levels of IL-6 and IL-8 assist differentiation between traumatic and non-traumatic death, are useful objective indices of trauma severity and can support a diagnosis of traumatic death.
 
Article
Introduction: There are few studies on Modic changes of the cervical spine in patients suffering from whiplash. This study compared Modic changes seen in whiplash patients 10 years after the injury with those observed in asymptomatic volunteers. Methods: This is a follow-up study of 133 patients who suffered whiplash injuries in 1994-1996 and underwent MRI with a superconductive imager (63 men, 70 women, mean age 49.6±15.3 years, mean follow-up 11.4 years). In addition, 223 healthy volunteers who underwent MRI during the same period were included as controls (123 men, 100 women, mean age 50.5±15.0 years, mean follow-up 11.6 years). All participants underwent follow-up MRI. We examined all participants for Modic changes, and investigated relationships between Modic changes and clinical symptoms or potentially related factors. Results: Modic changes were observed in 4 patients (3%) and at 7 intervertebral levels in the initial study, and in 17 patients (12.8%) and at 30 intervertebral levels at the follow-up. Modic Type 2 changes were the most prevalent in the whiplash patients in both the initial and follow-up studies. There was no significant difference in the percentage of whiplash patients versus control subjects with positive Modic changes, either at the initial study or at follow-up. Modic changes were not related to clinical symptoms present at follow-up, but were associated with preexisting disc degeneration. There was no association between Modic changes and the details of the car accident that caused the injury. Conclusions: While Modic changes became more common in whiplash patients in the 10-year period after the accident, they occurred with a similar frequency in control subjects. We did not find any association between Modic changes and the nature of the car accident in which the whiplash occurred. Modic changes found in whiplash patients may be a result of the physiological ageing process rather than pathological findings relating to the whiplash injury.
 
Article
We present our experience in the management of penetrating pancreatic injuries, focusing on factors related to complications and death. Retrospective trauma registry-based analysis of 62 consecutive patients with penetrating pancreatic injuries during an 11-year period. Overall injury severity was assessed by the injury severity score (ISS) and the penetrating abdominal trauma index (PATI). Pancreatic injuries were graded according to the American Association for the Surgery of Trauma (AAST) Organ Injury Scaling (OIS). Complications were characterised using standardised definitions. Mortality was recorded as early (within 48 h after admission) and late (after 48 h). Thirty patients suffered gunshot wounds and 24 had grade I pancreatic injuries. Shotgun and gunshot wounds were more destructive than stab wounds (higher PATI, number of intraabdominal injuries and mortality). Seventeen patients died. Most deaths occurred within 1 h after admission due to massive bleeding and severe associated injuries. Only one death was potentially related to the pancreatic injury. Mortality rate also correlated with pancreatic injury grading. Sixty-one patients had associated intraabdominal injuries. Combined pancreaticoduodenal injuries were present in 13 patients, and five died. Simple drainage was the most common procedure performed. Pancreas-related complications were found in 12 out of 47 patients who survived more than 48 h; intraabdominal abscess (n=7) that was associated with colon injuries, and pancreatic fistula (n=5). An approach based on injury grade and location is advised. Routine drainage is recommended; distal resection is indicated in the presence of main duct injury, and the management of severe injuries will be tailored according to the overall physiologic status, presence of associated injuries, and duodenal viability. Morbidity and mortality is mainly due to associated injuries.
 
Article
Introduction: The optimal method of fixation of symphyseal disruptions in pelvic ring injuries and post-operative rehabilitation is still debated. Options include two-hole, multi-hole and multiplanar plates. Post-operative rehabilitation can range from non-weight bearing bilaterally to full weight-bearing with crutches. Locking symphyseal plates have recently been introduced. There is a paucity of literature evaluating their use in such injuries. We present the first clinical case series of symphyseal diastasis managed with locking plates. Methods: A retrospective analysis of a single centre case series between August 2008 and December 2011 was conducted. A total of 11 patients; 2 females and 9 males with a mean age of 42 years were included. The mean radiological follow up was 27 weeks. Radiological failure and need for revision were evaluated. Results: 4 patients sustained their injury as a result of a motorcycle accident, 3 patients following a car accident, 2 fell from a height and 2 had crush injuries. 9 patients had other concomitant injuries. The mechanism of injury was classified as anterior-posterior compression injury in 6 patients, vertical shear in 4 patients and combined mechanism in 1 patient. 6 patients required posterior pelvic fixation. Patients were mobilised fully or partially weight bearing. One patient had a significant radiological failure. All patients were asymptomatic at last follow-up and none required revision surgery. Conclusion: Our series represents the first published clinical series of patients with symphyseal diastasis managed with locking plates. We have found the use of locking plates across the pubic symphysis to be safe with low complication rates despite early weight bearing.
 
Article
We studied 80 patients (56 females) with an average age of 84 years (range: 80-94). All patients were suffering from osteoporosis (1 or 2 Singh score) and had an unstable intertrochanteric fracture, defined as a fracture with three fragments or more. Patients were divided into group A (40 patients), treated by a cement augmentation technique, and group B (40 patients) treated by Gamma Nail conventional technique. Augmentation was performed with MetilMetacrilate (Mendec Spine, Tecres) inserted through the cannulated cephalic screw at its apex. Parameters such as the length of operating time, early functional recovery using the Harris hip score, assessment with radiography of the TAD index, and development of implant-related complications were evaluated. The Health and Human Services (HHS) average score was 48.2 and 49.31 after 1 month postoperation, 54.37 and 53.56 after 3 months, 54.71 and 56.42 after 6 months, and 57.91 and 59.86 after 12 months, in groups A and B, respectively. The average drop of haemoglobin was 1.55gdl(-1) and 1.05gdl(-1), in groups A and B, respectively. Except one joint penetration with the guide wire and some small amount of cement leakage, no other complications (infection, screw cut out, and femoral head necrosis) were observed. We believe that in femoral intertrochanteric fractures, cement augmentation could improve the mechanical stability of the implant, ensuring early functional recovery.
 
Article
Penetrating missile injuries of the head comprised 3·4 per cent of the missile injuries admitted to our hospital directly or transferred from nearby hospitals. Those who died accounted for approximately 70 per cent of the total deaths in hospital from missiles. The immediate treatment is presented and the results are evaluated in 110 consecutive cases. The points emphasized are, first, that less than rapid evacuation selects those patients who are probably going to survive anyway; second, that bullet wounds of the head are nearly always fatal, especially if inflicted by high-velocity weapons; and, third, that the operation should include wide exposure of the injured site with thorough excision of the wound track and watertight closure of the dura.
 
Article
A total of 110 patients with hepatic injuries was treated at a major urban trauma centre between June 1988 and December 1991. The mechanism of injury was blunt trauma in 86 patients (78 per cent). Non-operative treatment was given in six patients (5 per cent). Simple hepatorrhaphy, use of topical haemostatic agents or peritoneal drainage alone were performed in 79 (72 per cent) cases. Extensive hepatorrhaphy, hepatotomy with selective vascular ligation, resection and débridement or resection, perihepatic packing and major vascular ligation were undertaken, often in combination, in 25 (23 per cent) cases. Percutaneous arterial embolization was carried out in one case. The mortality rate was 18 per cent. The most frequent postoperative complications related to hepatic injury were intra-abdominal abscess (7 per cent) and coagulopathy (5 per cent); prolonged biliary leak (3 per cent), late haemorrhage (2 per cent) and hepatic necrosis (1 per cent) were also observed.
 
Article
Despite the presence of diagnostic guidelines for the initial evaluation in trauma, the reported incidence of missed injuries is considerable. The aim of this study was to assess the missed injuries in a large cohort of trauma patients originating from two European Level-1 trauma centres. We analysed the 1124 patients included in the randomised REACT trial. Missed injuries were defined as injuries not diagnosed or suspected during initial clinical and radiological evaluation in the trauma room. We assessed the frequency, type, consequences and the phase in which the missed injuries were diagnosed and used univariate analysis to identify potential contributing factors. Eight hundred and three patients were male, median age was 38 years and 1079 patients sustained blunt trauma. Overall, 122 injuries were missed in 92 patients (8.2%). Most injuries concerned the extremities. Sixteen injuries had an AIS grade of ≥ 3. Patients with missed injuries had significantly higher injury severity scores (ISSs) (median of 15 versus 5, p<0.001). Factors associated with missed injuries were severe traumatic brain injury (GCS ≤ 8) and multitrauma (ISS ≥ 16). Seventy-two missed injuries remained undetected during tertiary survey (59%). In total, 31 operations were required for 26 initially missed injuries. Despite guidelines to avoid missed injuries, this problem is hard to prevent, especially in the severely injured. The present study showed that the rate of missed injuries was comparable with the literature and their consequences not severe. A high index of suspicion remains warranted, especially in multitrauma patients.
 
Article
One of the factors that affects outcome following severe traumatic brain injury is development and progression of cerebral oedema with associated increase in intracranial pressure (ICP). Uncontrolled elevations of ICP may compromise energy metabolism of the injured brain and lead to secondary injury, affecting neurological outcome of the patient. Decompressive craniectomy has been used for over a century as a treatment of refractory brain swelling in a variety of neurological conditions. However, conclusive evidence of whether it has a beneficial or adverse affect on outcome is lacking. This article reviews the existing evidence on the role of decompressive craniectomy in management of patients with traumatic brain injury and stresses the need for randomised controlled trials.
 
Top-cited authors
Peter Giannoudis
  • University of Leeds
Eleftherios Tsiridis
  • Aristotle University of Thessaloniki
Christian Krettek
  • Hannover Medical School
Charles court-Brown
Hans Christoph Pape
  • University of Zurich