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KEYWORDS Non-union; Pseudarthrosis; Fracture; Classification; Scoring system Summary A new scoring system is proposed in order to assist surgeons with the complex analysis associated with non-union surgery. Patients with non-union are rarely easily compared with one another and this has frustrated research in this field. We have therefore attributed values to clinical features based on clinical experience and research evidence, so that patients of similar complexity can be compared with one another. When greater experience with this scoring system has been gained it will be further refined and validated. We propose that surgeons with a sub specialist interest in non-union surgery use this system in reporting results, and that nonspecialist surgeons use it to inform their decision to treat the fracture themselves

Organization of the first war hospital (War Hospital Dakovo) in the 1991/1992 war in Croatia is presented. During the 13-month period 15123 patients were examined, among them 747 wounded. Complete treatment in the hospital was provided for 334 wounded. Only 23 wounded died immediately after admission, or later on in other hospitals. Most wounds were single and caused by shrapnel. Among the wounded, 75.8 per cent were Croatian soldiers, 22 per cent civilians and 2.2 per cent enemy soldiers.

Two methods of estimating the severity of injury and evaluating outcome, the Injury Severity Score (ISS) and the Polytrauma-Schlussel (PTS), were evaluated. The records of 37 victims of multiple injuries were assessed retrospectively by nine trauma surgeons using both methods of scoring. The agreement among the users was calculated by standard deviation. The standard deviation (SD) among users was smaller for the PTS (4.1) than for the ISS (6.2). Each method of scoring comprises six components contributing to the total score. The three highest scoring components of the ISS were first squared and then summated, the sum being the total ISS score. All the PTS categories were summated. Comparison of the SD for each of the components was not possible. However, the category or categories which mostly influenced the standard deviation could be indicated. For the ISS these were the circulation and central nervous system and for PTS, the limbs. We prefer the Polytrauma-Schlussel method because this takes account of age, needs revision of only one category and gives more consistent results among users.

Both the TRISS and ISS/Age methods have been used to assess the mortality results in a series of injured patients. Though observed survival was not significantly different from that expected using TRISS, the method seemed to place too great an emphasis on the initial clinical signs summarized in the RTS. In particular, early cardiovascular signs can be variable and misleading. The TRISS calculation also seems to make inadequate allowance for age effects in the elderly. The simpler ISS/Age method is free from these difficulties and with further development and a more up-to-date base series might become a better basis for overall survival estimates.

Mangling injuries to the upper extremity can be devastating, and the early management of these injuries is critical for the success of the reconstruction. These are universally high energy injuries that will need to be taken to the operating room for effective management. Evaluation begins in the emergency department with assessment of vascularity, categorization of damaged structures and assessment of salvageability. There is no role for conservative treatment of these wounds, and once in the operating room, restoration of blood supply and adequate debridement are critical to the ultimate outcome. Removal of damaged, contaminated and devitalized tissues must occur. The goal of early treatment is to create a clean wound ready for reconstruction as soon as possible. Inadequate debridement will only delay reconstruction to the detriment of the patient.

In the management of Type IIIb injuries, Gustilo's classification has the disadvantages of a poor intra and inter-observer agreement rate, low specificity and sensitivity to salvage and inability to predict functional outcomes. We propose here a validated score which assesses the severity of injury to the covering structures, skeletal structures and functional tissues of the injured limb separately along with providing weightage to the presence of co-morbid factors. A high sensitivity and specificity for amputation was documented when a score of 14 was used as the threshold score. In salvaged limbs, the score was found to offer guidelines in protocols for reconstruction. According to the total score, injuries were treated by 'Fix and close' protocol; 'Fix, Bone Graft and Close' protocol, 'Fix and Flap' protocol or 'Stabilise, Watch, Assess and Reconstruct' protocol. The score was thus found to be useful clinically not only to assess salvage but also to provide guidelines in reconstruction.

This study evaluated the feasibility of establishing a new trauma transfer checklist and assessed its impact on trauma-related interhospital transfers. A standard envelope with a printed checklist (N.E.W.S.) incorporating four key concepts in the care and transfer of trauma patients was used. A prospective comparison of consecutive interhospital trauma transfers to the major trauma service between July 1999-May 2000 (pre-N.E.W.S.) and August 2000-November 2000 (post-N.E.W.S.) was made. Changes in management satisfaction were assessed by a Likert scale (1=poor to 5=excellent). Pre-N.E.W.S., 88 trauma patients were transferred and 20 trauma transfers were recorded post-N.E.W.S. The time to definitive care pre-N.E.W.S. was 443+/-322 min, and 339+/-108 min (P=0.014) post-N.E.W.S. The time in the referring hospital was also reduced from 343+/-310 min pre-N.E.W.S. to 197+/-90 min post-N.E.W.S (P=0.0002). The checklist system prompted changes in the management of the trauma patient in 20% of the cases and there was a high level of satisfaction expressed by users of the checklist (4.6+/-0.7). The N.E.W.S. checklist is effective in facilitating the interhospital transfer of trauma patients by shortening the time to definitive care.

The controversy regarding the management of colon injuries continues, some favouring primary repair while others lean towards a proximal defunctioning procedure. We have reported our experience in this field over a 4-year period. Forty-three patients with large bowel injuries were treated during this period and two of them died in the immediate postoperative period due to continued haemorrhage. Of the remaining 41 patients, 27 underwent primary repair of the colon and 15 per cent of them developed complications. Fourteen patients had a proximal defunctioning procedure and 50 per cent of them developed complications. When severity of injuries was taken into consideration it showed a linear relationship to complications. We conclude that primary repair of the colon should be the preferred method of treatment in patients with grade I and II injuries.

The patient with severe lower limb trauma presents a management dilemma; whether to amputate primarily or to attempt limb salvage. In recent years, many predictive indices have been published which purport to identify limbs which are non-viable. We retrospectively applied two recently described indices, the Mangled Extremity Severity Score (MESS) and the Limb Salvage Index (LSI), to 54 limbs in 50 patients with either Gustilo IIIB or IIIC complex tibial fractures. There were 22 amputations (40.7 per cent) in the series. The mean MESS score in the limb salvage group was 3.8 (range 2-10), and the mean MESS score in the amputation group was 7.7 (range 4-13) (P0.0001). The mean LSI score in the limb salvage group was 3.6 (range 3-8), and the mean LSI score in the amputation group was 6.9 (P0.01). However, in the group with MESS scores7 (which recommends amputation), there were three limbs which were salvaged with acceptable functional outcome. Similarly, in those with LSI scores6 (which recommends amputation), there were seven limbs successfully salvaged. A MESS7 offered a greater relative risk of amputation (9.2) than a LSI score6 (5.3). We found both indices of use in predicting limb salvage and functional outcome. However, neither is sufficiently accurate to be considered absolutely reliable in clinical practice.

Daily serum c-reactive protein (CRP) concentration was monitored in 98 patients (26 female) admitted to the Major Injuries Unit (MIU) at Birmingham Accident Hospital following serious trauma. The mean (SD) increase in CRP concentration for 79 survivors and 19 non-survivors between days 1 and 2 after trauma were 69.5 (74.6) and 111.8 (59.0) mg/l/24 h, respectively (P = < 0.001). By day 4 after trauma the mean serum CRP concentrations for survivors and non-survivors were 150.9 (76.9) and 233.4 (100.8) mg/l (P < 0.001), respectively. Injury severity data were available for 50 patients. The mean (range) injury severity score was 25.2 (4-50), Glasgow coma scale 10.4 (3-15), revised trauma score 6.5 (3.39-7.8) and predicted survival 0.78 (0.02-0.99). Univariate regression analysis of serum CRP on days 1-5 after injury against revised trauma score and injury severity score, revealed an inverse correlation between day 1 serum CRP and Glasgow Coma Score (r = -0.306, P < 0.05), but no correlation with injury severity score or predicted survival on any of the study days. The lack of correlation between serum CRP and injury severity or predicted survival, and the strong association with actual survival, suggests that the acute inflammatory response to serious trauma and subsequent complications, is an important determinant of outcome.