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BACKGROUND/PURPOSE To characterize the nature of posterior segment ocular injuries in combat trauma. METHODS Eyes in the Walter Reed Ocular Trauma Database were evaluated for the presence of posterior segment injury. Final visual outcomes in open-globe versus closed-globe injuries and by zone of injury and the types of posterior segment injuries in open-globe versus closed-globe injuries were assessed. RESULTS Four hundred fifty-two of 890 eyes (50.8%) had at least one posterior segment injury. The mechanism of injury was most commonly an improvised explosive device in 280 (62.0%) eyes. Sixty-one patients (13.5%) had a Zone I injury, 50 (11.1%) a Zone II injury, and 341 (75.4%) a Zone III injury. Patients with Zone I injuries were more likely to have a final visual acuity of 20/200 or better compared with patients with either a Zone II (P < 0.001) or Zone III injury (P = 0.007). Eyes with a closed-globe injury were more likely to have a final visual acuity of 20/200 or better compared with those with an open-globe injury (P < 0.001). Furthermore, closed-globe injury compared with open-globe injury had a lower risk of vitreous hemorrhage (odds ratio 0.32, P < 0.001), proliferative vitreoretinopathy (odds ratio 0.14, P < 0.001), and retinal detachment (odds ratio 0.18, P < 0.001) but a higher risk of chorioretinal rupture (odds ratio 2.82, P < 0.001) and macular hole (odds ratio 3.46, P = 0.004). CONCLUSION Patients with combat ophthalmic trauma had similar posterior segment injury patterns to civilian trauma in open-globe versus closed-globe injuries. Zone II and III injuries were associated with a worse visual prognosis.

Objectives: Self-inflicted facial gunshot wounds (GSWs) result in complex but consistent injuries that are often survivable. We suggest a novel method for rapid stratification into groups that may ...

Ophthalmic trauma is a leading cause of preventable monocular blindness worldwide. The prevalence of ophthalmic trauma varies considerably based on geographic location, socio-economic status, age groups, occupation, and cultural practices such as firework celebrations. Clinical registries are known to be valuable in guiding the diagnosis, management, and prognostication of complex diseases. However, there is currently a lack of a centralized international data repository for ophthalmic trauma. We draw lessons from past and existing clinical registries related to ophthalmology and propose a new suitable international multicenter clinical registry for ophthalmic trauma: the International Globe and Adnexal Trauma Epidemiology Study (IGATES). IGATES is hosted on a secure web-based platform which exhibits user-friendly smart features, an integrated Ocular Trauma Score (OTS) prognosis calculator, efficient data collection points, and schematic graphical software. IGATES currently has 37 participating centers globally. The data collected through IGATES will be primarily used to develop a more robust and improved ophthalmic trauma prognostic classification system, the Ocular Trauma Score-2 (OTS-2), which builds on previous systems such as the Birmingham Eye Trauma Terminology System (BETTS) and Ocular Trauma Score (OTS). Furthermore, IGATES will act as a springboard for further research into the epidemiology, diagnosis, and management of ophthalmic trauma. Ultimately, IGATES serves to advance the field of ophthalmic trauma and improve the care that patients with ophthalmic trauma receive.

Trauma scores are used to give clinicians appropriate quantitative context in making decisions. Studies show that anatomical trauma scores predicted intensive care unit admission better, while physiological trauma scores predicted mortality better. We hypothesize that trauma scores have a hierarchy of efficacies at predicting mortality and operative decision making.We performed a retrospective analysis of our trauma patient database at a level 1 trauma center from 2016 to 2020 and calculated the following trauma scores: Glasgow Coma Scale, Revised Trauma Score, Trauma Injury Severity Score, Injury Severity Score, Shock Index, and New Trauma Injury Severity Score (NISS). Receiver operating characteristic curves were used to evaluate the sensitivity and specificity of trauma scores for predicting mortality.A total of 738 patients were included (mean ± SD age, 35.7 ± 15.6 years). Area under the curve (AUC) results from the DeLong test showed that NISS predicted mortality the best compared with other trauma scores. New Trauma Injury Severity Score was superior in predicting mortality for penetrating trauma (AUC, 0.86 ± 0.02; p0.001) compared with blunt trauma (AUC, 0.73 ± 0.04; p0.001). Trauma Injury Severity Score was the best predictor of mortality for patients with gunshot wounds (AUC, 0.83; 95% confidence interval [CI], 0.73-0.92; p0.001), motor vehicle accidents (AUC, 0.80; 95% CI, 0.61-1.00; p = 0.01), and falls (AUC, 0.73; 95% CI, 0.61-0.85; p = 0.007).New Trauma Injury Severity Score was the best scoring index for predicting mortality in trauma patients, especially for penetrating trauma. Clinicians should consider incorporating other trauma scores, especially NISS and Trauma Injury Severity Score, in determining injury severity and the likelihood of mortality. These scores can help physicians determine the best course of action in patient management.Prognostic and Epidemiologic; level IV.

OBJECTIVE: Major negative life events, such as trauma exposure, can play a key role in igniting or exacerbating psychopathology. However, few disorders are diagnosed with respect to precipitating events, and the role of these events in the unfolding of new psychopathology is not well understood. The authors conducted a multisite transdiagnostic longitudinal study of trauma exposure and related mental health outcomes to identify neurobiological predictors of risk, resilience, and different symptom presentations. METHODS: A total of 146 participants (discovery cohort: N = 69; internal replication cohort: N = 77) were recruited from emergency departments within 72 hours of a trauma and followed for the next 6 months with a survey, MRI, and physiological assessments. RESULTS: Task-based functional MRI 2 weeks after a motor vehicle collision identified four clusters of individuals based on profiles of neural activity reflecting threat reactivity, reward reactivity, and inhibitory engagement. Three clusters were replicated in an independent sample with a variety of trauma types. The clusters showed different longitudinal patterns of posttrauma symptoms. CONCLUSIONS: These findings provide a novel characterization of heterogeneous stress responses shortly after trauma exposure, identifying potential neuroimaging-based biotypes of trauma resilience and psychopathology.

Background: Given the rising prevalence of subways in combination with an increasing incidence of subway-related injuries, understanding subway-related trauma is becoming ever more relevant. The aim of this study was to characterize the potential causes, injury characteristics and outcomes of subway-related trauma at a level 1 adult trauma centre in Toronto, Ontario. Methods: We conducted a retrospective cohort study to identify patients who presented to the emergency department a level 1 adult trauma centre with a subway-related injury between Jan. 1, 2010, and Dec. 31, 2018. Patients were identified via International Statistical Classification of Diseases and Related Health Problems, 10th Revision E-codes (X81, Y02, V050, V051 and W17). We then further screened for descriptions of subway-related injuries. Patients whose injuries did not involve a moving subway train were excluded. Results: We identified 51 patients who presented to the emergency department after being hit by a moving subway train. The majority of incidents (39 [76%]) were due to self-harm, 10 (20%) were unintentional injuries, and 2 (4%) were due to assault. The presence of alcohol was detected in 8 patients (80%) with unintentional injuries and 3 (8%) of those with self-inflicted injuries. Thirteen patients (25%) had a systolic blood pressure less than 90 mm Hg. The median Injury Severity Score was 17 (interquartile range 9–29). Seventeen patients (33%) presented with severe injuries (Abbreviated Injury Scale score ≥ 3) in 1 body region, and 19 (37%) had severe injuries in 2 or more body regions. The most common isolated severe injury was in the lower extremity, and the most common combinations of severe injuries were in the head and lower extremity, and head and thorax. Ten patients (20%) were declared dead in the emergency department. Of the 41 patients who survived their initial presentation, 12 (29%) went directly to the operating room, and 17 (41%) were transferred to the intensive care unit. The overall mortality rate was 29%. Conclusion: Patients with subway-related injuries experienced high mortality rates and severe injuries. Most incidents were due to self-harm or alcohol-related. Further research into early identification of those at risk and optimal prevention strategies is necessary to curb further incidents.

Injuries are an extremely important problem in public life and account for up to one-third of deaths in the entire human population. Available trauma scoring systems provide a good estimation of mortality; however, some factors affect their utility in daily practice. Therefore, a new easily applicable in any given country trauma scoring system has been developed and proposed in this study.A retrospective study of the medical records of 485 patients were evaluated, together with diagnostic performance with regard to mortality, was calculated for the Revised Trauma Score (RTS), Injury Severity Score (ISS), The New Injury Severity Score (NISS), Trauma and Injury Severity Score (TRISS), International Classification based Injury Severity Score (ICISS) and the newly-developed Life Threat Index (LTI). Sensitivity, specificity, accuracy, PPV and NPV were calculated for each scoring system, and overall diagnostic performance was estimated with the use of ROC curves.Apart from RTS, all scoring systems showed similar performance regarding mortality prediction. TRISS and LTI showed the highest sensitivity reaching 0.998 and AUC of 0.89 and 0.87, respectively, which proved its usefulness in predicting mortality.LTI proved to be one of the most sensitive in comparison with widely-used and recognized trauma scoring systems. Based on LTI methodology, it can be applied in any given country or region, even without a previously developed trauma database.

Thoracolumbar spine trauma can result in potentially life-threatening consequences and requires careful management to ensure good outcomes. The purpose of this chapter is to discuss the anatomy, diagnostic tools, non-operative, and operative treatments important when addressing thoracolumbar trauma.

Understanding the effects of age on longitudinal traumatic brain injury (TBI) outcomes requires attention to both chronic and evolving TBI effects and age-related changes in health and function. The present study examines the independent and interactive effects of aging and chronicity on functional outcomes after TBI. We leveraged a well-defined cohort of individuals who sustained a moderate/severe TBI and received acute inpatient rehabilitation at specialized centers with high follow up rate as part of their involvement in the TBI Model Systems longitudinal study. We selected individuals at one of two levels of TBI chronicity (either 2 or 10 years post-injury) and used an exact matching procedure to obtain balanced chronicity groups based on age and other characteristics (N = 1993). We found that both older age and greater injury chronicity were related to greater disability, reduced functional independence, and less community participation. There was a significant age by chronicity interaction, indicating that the adverse effects of greater time post-injury were most pronounced among survivors who were age 75 or older. The inflection point at roughly 75 years of age was corroborated by post hoc analyses, dividing the sample by age at 75 years and examining the interaction between age group and chronicity. These findings point to a need for provision of rehabilitation services in the chronic injury period, particularly for those who are over 75 years old. Future work should investigate the underlying mechanisms of this interaction towards the goal of developing interventions and models of care to promote healthy aging with TBI.

Traumatic brain injury (TBI) is a major clinical and public health problem with few therapeutic interventions successfully translated to the clinic. Identifying imaging-based biomarkers characterizing injury severity and predicting long-term functional and cognitive outcomes in TBI patients is crucial for treatment. TBI results in white matter (WM) injuries, which can be detected using diffusion tensor imaging (DTI). Trauma-induced pathologies lead to accumulation of free water (FW) in brain tissue, and standard DTI is susceptible to the confounding effects of FW. In this study, we applied FW DTI to estimate free water volume fraction (FW-VF) in patients with moderate-to-severe TBI and demonstrated its association with injury severity and long-term outcomes. DTI scans and neuropsychological assessments were obtained longitudinally at 3, 6, and 12 months post-injury for 34 patients and once in 35 matched healthy controls. We observed significantly elevated FW-VF in 85 of 90 WM regions in patients compared to healthy controls (p

AimsThe aim of this study is to provide a detailed description of cases combining bridging patch repair with artificial ligament “internal brace” reinforcement to treat irreparable massive rotator cuff tears, and report the preliminary results.MethodsThis is a retrospective review of patients with irreparable massive rotator cuff tears undergoing fascia lata autograft bridging repair with artificial ligament “internal brace” reinforcement technique between January 2017 and May 2018. Inclusion criteria were: patients treated arthroscopically for an incompletely reparable massive rotator cuff tear (dimension > 5 cm or two tendons fully torn), stage 0 to 4 supraspinatus fatty degeneration on MRI according to the Goutallier grading system, and an intact or reparable infraspinatus and/or subscapularis tendon of radiological classification Hamada 0 to 4. The surgical technique comprised two components: first, superior capsular reconstruction using an artificial ligament as an “internal brace” protective device for a fascia lata patch. The second was fascia lata autograft bridging repair for the torn supraspinatus. In all, 26 patients with a mean age 63.4 years (SD 6.2) were included.ResultsAll patients underwent more than two years of follow-up (mean 33.5 months (24 to 45)). All clinical scores were also improved at two-year follow-up (mean visual analogue scale 0.7 (SD 0.5) vs 6.1 (SD 1.2); p < 0.001; mean American Shoulder and Elbow Surgeons score 93.5 (SD 5.3) vs 42.5 (SD 10.8); p < 0.001; mean University of California, Los Angeles score, 31.7 (SD 3.7) vs 12.0 (SD 3.1); p < 0.001; and mean Constant-Murley score 88.7 (SD 3.5) vs 43.3 (SD 10.9); p < 0.001), and 24 of 26 fascia lata grafts were fully healed on MRI (92%). One patient had haematoma formation at the harvesting side of the fascia lata at two days postoperatively.ConclusionThe fascia lata autograft bridging repair combined with artificial ligament internal brace reinforcement technique achieved good functional outcomes, with a high rate of graft healing at two-year follow-up. Although the short-term results are promising, further studies with a greater number of patients would provide clearer results. Cite this article: Bone Joint J 2021;103-B(10):1619–1626.

The 1990 Small Bowel and Colon Organ Injury Scales (OIS) were revised to incorporate the imaging (CT), operative and pathologic findings to better describe the level of injury. The new revised OIS separates blunt bowel injuries from penetrating bowel injuries due to differences in imaging findings. A new OIS was created for bowel mesenteric injuries.

Opioid misuse and overdose in the United States remain a public health emergency. Overprescribing has been recognized as a significant contributor to the epidemic. Opioids are the mainstay for pain management after burn; however, to date, no large-scale nationally representative study has evaluated outpatient opioid prescribing practices in this population.A retrospective study was conducted of patients up to 65 years old with burn injuries between 2007 and 2017 using national commercial insurance data. The primary outcome was initial opioid prescribing after burn injury. Secondary outcomes were total days' supply, oral daily morphine milligram equivalents, and number of refills.Of the 140,753 patients with burns, 34,685 (24.6%) received an opioid prescription. The odds of prescription opioid use were lower in 2015, 2016, and 2017 compared with 2007. Interactions with age, severity (P.0001), and region (P = .003) showed significant variation in rates of decline from 2007 to 2017, with the steepest decline in those aged20 and in residents of Northeast United States. Prescribing rates remained stable over time among those with more severe burn injuries. The significant decline in daily opioid morphine milligram equivalents after 2013 was paralleled by an increase in days of supply (P values.005). The odds of refill declined in 2016 and 2017.While opioid prescribing after burn has declined in the past decade, significant variation remains among regions and age groups, suggesting a need to develop uniform guidelines to improve the quality of opioid prescribing and pain management protocols in burn patients.

BACKGROUND: This study aimed to assess the prevalence of chest wall injuries due to cardiopulmonary resuscitation for out-of-hospital cardiac arrest (OHCA) and to compare in-hospital outcomes in patients with versus without chest wall injuries. METHODS: A retrospective cohort study of all intensive care unit (ICU)-admitted patients who underwent cardiopulmonary resuscitation for OHCA between January 1, 2007, and December 2019 was performed. The primary outcome was the occurrence of chest wall injuries, as diagnosed on chest computed tomography. Chest wall injury characteristics such as rib fracture location, type, and dislocation were collected. Secondary outcomes were in-hospital outcomes and subgroup analysis of patients with good neurological recovery to identify those who could possibly benefit from the surgical stabilization of rib fractures. RESULTS: Three hundred forty-four patients were included, of which 291 (85%) sustained chest wall injury. Patients with chest wall injury had a median of 8 fractured ribs (P25-P75, 4-10 ribs), which were most often undisplaced (on chest computed tomography) (n = 1,574 [72.1%]), simple (n = 1,948 [89.2%]), and anterior (n = 1,785 [77.6%]) rib fractures of ribs 2 to 7. Eight patients (2.3%) had a flail segment, and 136 patients (39.5%) had an anterior flail segment. Patients with chest wall injury had fewer ventilator-free days (0 days [P25-P75, 0-16 days] vs. 13 days [P25-P75, 2-22 days]; p = 0.006) and a higher mortality rate (n = 102 [54.0%] vs. n = 8 [22.2%]; p < 0.001) than those without chest wall injury. For the subgroup of patients with good neurological recovery, the presence of six or more rib fractures or a single displaced rib fracture was associated with longer hospital and ICU length of stay, respectively. CONCLUSION: Cardiopulmonary resuscitation-related chest wall injuries in survivors of OHCA and especially rib fractures are common. Patients with chest wall injury had fewer ventilator-free days and a higher mortality rate. Patients with good neurological recovery might represent a subgroup of patients who could benefit from surgical stabilization of rib fractures. LEVEL OF EVIDENCE: Therapeutic, level IV; Epidemiological, Level IV.

BACKGROUND: Long-term outcomes after rib fractures and the effect of treatment modality or chest wall injury severity on these outcomes remains uncertain. This retrospective cohort study evaluated the long-term pulmonary function, thoracic pain, and quality of life in patients admitted with rib fractures. METHODS: Patients admitted with rib fractures between January 1, 2012, and December 1, 2019, were included. Data on long-term outcomes were collected during one follow-up visit. Patients were stratified by chest wall injury severity (one or two rib fractures, ≥3 rib fractures, or a flail chest) and treatment modality (surgical stabilization of rib fractures [SSRF] or nonoperative management). Multivariable analysis was performed to compare outcomes after SSRF with nonoperative treatment in patients with three or more rib fractures. RESULTS: In total, 300 patients were included. The median follow-up was 39 months (P25-P75, 18-65 months). At follow-up, the corrected forced vital capacity returned to 84.7% (P25-P75, 74.3-93.7) and the forced expiratory volume in 1 second to 86.3% (P25-P75, 75.3-97.0) of the predicted reference values. Quality of life was determined using the Short Form-12 version 2 and EuroQoL-5D-5L. The Short Form-12 version 2 physical and mental component summary were 45 (P25-P75, 38-54) and 53 (P25-P75, 43-60), respectively. The EuroQoL-5D-5L utility score was 0.82 (P25-P75 0.66-0.92) and visual analog scale score 75 (P25-P75 70-85). This indicated a quality of life within normal population ranges. Moderate to severe thoracic pain was reported by 64 (21.3%) patients. Long-term outcomes returned to values within population ranges and were similar across chest wall injury severity and for patients treated with SSRF or nonoperatively. CONCLUSION: While long-term pulmonary function and quality of life recover to values considered normal, subjective thoracic complaints, such as pain and dyspnea, remain frequently present following rib fractures. No effect of chest wall injury severity or treatment modality on long-term outcomes was demonstrated. LEVEL OF EVIDENCE: Therapeutic, level III.

BACKGROUND Rib fractures are uncommon in children and are markers of extreme traumatic force from high-energy or nonaccidental etiology. Traditional care includes nonoperative management, with analgesia, ventilator support, and pulmonary physiotherapy. Surgical stabilization of rib fractures (SSRFs) has been associated with improved outcomes in adults. In children, SSRF is performed and its role remains unclear, with data only available from case reports. We created a collected case series of published pediatric SSRF cases, with the aim to provide a descriptive summary of the existing data. METHODS Published cases of SSRF following thoracic trauma in patients younger than 18 years were identified. Collected data included demographics, injury mechanism, associated injuries, surgical indication(s), surgical technique, time to extubation, postoperative hospital stay, and postoperative follow-up. RESULTS Six cases were identified. All were boys, with age range 6 to 16 years. Injury mechanism was high-energy blunt force in all cases, and all patients suffered multiple associated injuries. Five of six cases were related to motor vehicles, and one was horse-related. Indication(s) for surgery included ventilator dependence in five, significant chest deformity in two, and poor pain control in one case. Plating systems were used for rib stabilization in five of six cases, while intramedullary splint was used in one. All patients were extubated within 7 days following SSRF, and all were discharged by postoperative Day 20. On postoperative follow-up, no SSRF-related major issues were reported. One patient underwent hardware removal at 2 months. CONCLUSION Surgical stabilization of rib fractures in children is safe and feasible, and should be considered as an alternative to nonoperative therapy in select pediatric thoracic trauma cases. Potential indications for SSRF in pediatric patients include poor pain control, chest wall deformity, or ventilator dependence. Further studies are needed to establish the role and possible benefits of SSRF in pediatric thoracic trauma. LEVEL OF EVIDENCE Collected case series, level V.

We sought to determine the secondary overtriage rate of pediatric trauma patients admitted to pediatric trauma centers. We hypothesized that pediatric secondary overtriage (POT) would constitute a large percentage of admissions to PTC.The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2017 for pediatric (age ≤ 18 y) trauma patients transferred to accredited pediatric trauma centers in Pennsylvania (n = 6). Patients were stratified based on discharge within (early) and beyond (late) 24 h following admission. POT was defined as patients transferred to a PTC with an early discharge. Multilevel mixed-effects logistic regression model controlling for demographic and injury severity covariates were utilized to determine the adjusted impact of injury patterns on early discharge.A total of 37,653 patients met inclusion criteria. For transfers, POT compromised 18,752 (49.8%) patients. Compared to POT, non-POT were more severely injured (ISS: 10 versus 6;P0.001) and spent less time in the ED (Min: 181 versus 207;P0.001). In adjusted analysis, concussion, closed skull vault fractures, supracondylar humerus fractures, and consults to neurosurgery were associated with increased odds of POT. Overall, femur fracture, child abuse evaluation, and consults to plastic surgery, orthopedics, and ophthalmology were all associated with a decreased risk of being POT.POT comprises 49.8% of PTC transfer admissions in Pennsylvania's trauma system. Improving community resources for management of pediatric concussion and mild TBI could result in decreased rates of POT to PTCs. Developing better inter-facility transfer guidelines and increased education of adult TC and nontrauma center hospitals is needed to decrease POT.Epidemiologic study, level III.

Purpose That thyroid hormones exert pleiotropic effects and have a contributory role in triggering seizures in patients with traumatic brain injury (TBI) can be hypothesized. We aimed at investigating thyroid function tests as prognostic factors of the development of seizures and of functional outcome in TBI. Methods This retrospective study enrolled 243 adult patients with a diagnosis of mild-to-severe TBI, consecutively admitted to our rehabilitation unit for a 6-month neurorehabilitation program. Data on occurrence of seizures, brain imaging, injury characteristics, associated neurosurgical procedures, neurologic and functional assessments, and death during hospitalization were collected at baseline, during the workup and on discharge. Thyroid function tests (serum TSH, fT4, and fT3 levels) were performed upon admission to neurorehabilitation. Results Serum fT3 levels were positively associated with an increased risk of late post-traumatic seizures (LPTS) in post-TBI patients independent of age, sex and TBI severity (OR = 1.85, CI 95% 1.22–2.61, p Conclusions Serum fT3 levels assessed in the subacute phase post-TBI are associated with neurological and functional outcome as well as with the risk of seizure occurrence. Further studies are needed to investigate the mechanisms underlying these associations.

Background Studies evaluating the efficacy of ATLS in low- and middle-income countries are limited. We followed up ATLS providers certified by the ATLS India program over a decade (2009 to 2019), aiming to measure the benefits in knowledge, skills, attitude and their attrition over time. Methods The survey instrument was developed taking a cue from published literature on ATLS and improvised using the Delphi method. Randomly selected ATLS providers were sent the survey instrument via email as a Google form, along with a statement of purpose. Results are presented descriptively. Results ATLS India trained 7,847 providers over the study period. 2500 providers were selected for the survery using computer-generated random number table. One thousand and thirty doctors (41.2%) responded. Improvement in knowledge (n = 1,013 [98.3%]), psychomotor skills (n = 986 [95.7%]), organizational skills (n = 998 [96.9%]), overall trauma management (n = 1,013 [98.7%]) and self-confidence (n = 939 [91%]) were reported. Majority (904 [87.8%]) started ATLS promulgation at workplace in personal capacity. These benefits lasted beyond 2 years in majority (>60%) of respondents. More than 40% reported cognitive (n = 492 [47.8%]), psychomotor (n = 433 [42%]), and organizational benefits (n = 499 [48.4%]) lasting beyond 3 years. Improvement in self-confidence, ATLS promulgation at the workplace, and retention of organizational skills were more pronounced in ATLS faculties than providers. All other benefits were found to be comparable in both sub-groups. Lack of trained staff (n = 660 [64.1%]) and attitude issues (n = 495 [48.1%]) were the major impediments in implementing ATLS at the workplace. More than a third of respondents (n = 373 [36.2%]) could enumerate one or more incidents where ATLS principles were life- or limb- saving. Conclusions Cognitive, psychomotor, organizational, and affective impact of ATLS is overwhelmingly positive in the Indian scenario. Until formal trauma systems are established, ATLS remains the best hope for critically injured patients in resource-contrained settings.

BackgroundGlobally, injuries cause >5 million deaths annually and children and young people are particularly vulnerable. Injuries are the leading cause of death in people aged 5–24 years and a leading cause of disability. In most low-income and middle-income countries where the majority of global child injury burden occurs, systems for routinely collecting injury data are limited.MethodsA new model of injury surveillance for use in emergency departments in Nepal was designed and piloted. Data from patients presenting with injuries were collected prospectively over 12 months and used to describe the epidemiology of paediatric injury presentations.ResultsThe total number of children ConclusionInjuries affecting children in Nepal represent a significant burden. The data on injuries observed from falls, road traffic injuries and injuries related to animals suggest potential areas for injury prevention. This is the biggest prospective injury surveillance study in Nepal in recent years and supports the case for using injury surveillance to monitor child morbidity and mortality through improved data.

BackgroundRespiratory complications are associated with significant morbidity and mortality in trauma patients. The care transition from the intensive care unit (ICU) to the acute care ward is a vulnerable time for injured patients. There is a lack of knowledge about the epidemiology of respiratory events and their outcomes during this transition.MethodsRetrospective cohort study in a single Level I trauma center of injured patients 18 years and older initially admitted to the ICU from 2015 to 2019 who survived initial transfer to the acute care ward. The primary outcome was occurrence of a respiratory event, defined as escalation in oxygen therapy beyond nasal cannula or facemask for three or more consecutive hours. Secondary outcomes included unplanned intubation for a primary pulmonary cause, adjudicated via manual chart review, as well as in-hospital mortality and length of stay. Multivariable logistic regression was used to examine patient characteristics associated with posttransfer respiratory events.ResultsThere were 6,561 patients that met the inclusion criteria with a mean age of 52.3 years and median Injury Severity Score of 18 (interquartile range, 13-26). Two hundred and sixty-two patients (4.0%) experienced a respiratory event. Respiratory events occurred early after transfer (median, 2 days, interquartile range, 1-5 days), and were associated with high mortality (16% vs. 1.8%, p < 0.001), and ICU readmission rates (52.6% vs. 4.7%, p < 0.001). Increasing age, male sex, severe chest injury, and comorbidities, including preexisting alcohol use disorder, congestive heart failure, and chronic obstructive pulmonary disease, were associated with increased odds of a respiratory event. Fifty-eight patients experienced an unplanned intubation for a primary pulmonary cause, which was associated with an in-hospital mortality of 39.7%.ConclusionRespiratory events after transfer to the acute care ward occur close to the time of transfer and are associated with high mortality. Interventions targeted at this critical time are warranted to improve patient outcomes.Level of evidencePrognostic and Epidemiological study, level III.

BACKGROUND Trial outcomes should be relevant to all stakeholders and allow assessment of interventions' efficacy and safety at appropriate timeframes. There is no consensus regarding outcome measures in the growing field of prehospital trauma transfusion research. Harmonization of future clinical outcome reporting is key to facilitate interstudy comparisons and generate cohesive, robust evidence to guide practice. The objective of this study was to evaluate outcome measures reported in prehospital trauma transfusion trials. METHODS Data Sources, Eligibility Criteria, Participants, and InterventionsWe conducted a scoping systematic review to identify the type, number, and definitions of outcomes reported in randomized controlled trials, and prospective and retrospective observational cohort studies investigating prehospital blood component transfusion in adult and pediatric patients with traumatic hemorrhage. Electronic database searching of PubMed, Embase, Web of Science, Cochrane, OVID, clinical trials.gov, and the Transfusion Evidence Library was completed in accordance with Preferred Reporting Items for Meta-analyses guidelines.Study Appraisal and Synthesis MethodsTwo review authors independently extracted outcome data. Unique lists of salutogenic (patient-reported health and wellbeing outcomes) and nonsalutogenic focused outcomes were established. RESULTS A total of 3,471 records were identified. Thirty-four studies fulfilled the inclusion criteria: 4 military (n = 1,566 patients) and 30 civilian (n = 14,398 patients), all between 2000 and 2020. Two hundred twelve individual non-patient-reported outcomes were identified, which collapsed into 20 outcome domains with varied definitions and timings. All primary outcomes measured effectiveness, rather than safety or complications. Sixty-nine percent reported mortality, with 11 different definitions. No salutogenic outcomes were reported. CONCLUSION There is heterogeneity in outcome reporting and definitions, an absence of patient-reported outcome, and an emphasis on clinical effectiveness rather than safety or adverse events in prehospital trauma transfusion trials. We recommend stakeholder consultation and a Delphi process to develop a clearly defined minimum core outcome set for prehospital trauma transfusion trials. LEVEL OF EVIDENCE Scoping systematic review, level III.

Background Traumatic brain injuries (TBI) are associated with high risk of morbidity and mortality. Early outcome prediction in patients with TBI require reliable data input and stable prognostic models. The aim of this investigation was to analyze different CT classification systems and prognostic calculators in a representative population of TBI-patients, with known outcomes, in a neurointensive care unit (NICU), to identify the most suitable CT scoring system for continued research. Materials and methods We retrospectively included 158 consecutive patients with TBI admitted to the NICU at a level 1 trauma center in Sweden from 2012 to 2016. Baseline data on admission was recorded, CT scans were reviewed, and patient outcome one year after trauma was assessed according to Glasgow Outcome Scale (GOS). The Marshall classification, Rotterdam scoring system, Helsinki CT score and Stockholm CT score were tested, in addition to the IMPACT and CRASH prognostic calculators. The results were then compared with the actual outcomes. Results Glasgow Coma Scale score on admission was 3–8 in 38%, 9–13 in 27.2%, and 14–15 in 34.8% of the patients. GOS after one year showed good recovery in 15.8%, moderate disability in 27.2%, severe disability in 24.7%, vegetative state in 1.3% and death in 29.7%. When adding the variables from the IMPACT base model to the CT scoring systems, the Stockholm CT score yielded the strongest relationship to actual outcome. The results from the prognostic calculators IMPACT and CRASH were divided into two subgroups of mortality (percentages); ≤50% (favorable outcome) and > 50% (unfavorable outcome). This yielded favorable IMPACT and CRASH scores in 54.4 and 38.0% respectively. Conclusion The Stockholm CT score and the Helsinki score yielded the closest relationship between the models and the actual outcomes in this consecutive patient series, representative of a NICU TBI-population. Furthermore, the Stockholm CT score yielded the strongest overall relationship when adding variables from the IMPACT base model and would be our method of choice for continued research when using any of the current available CT score models.

BACKGROUND Diabetes is associated with increased hospital complications and mortality following trauma. However, there is limited research on the longer-term recovery of trauma patients with diabetes. The aim of this study was to explore the association between type 2 diabetes (T2D) and in-hospital and 24-month outcomes in major trauma patients. METHODS In this cohort study using the Victorian State Trauma Registry, middle-aged and older adults (≥ 45 years) with major trauma were followed up at 24-months post injury. Logistic regression (univariable and multivariable) analyses were used to determine the association between diabetes status and 24-month patient-reported outcomes. In-hospital outcomes were compared between groups using chi-square tests. RESULTS Of the 11,490 participants who survived to hospital discharge, 8,493 survived to 24-months post-injury and were followed-up at that time point: 953 people (11%) with and 7540 (89%) without T2D. People with T2D had a higher in-hospital death rate (19%) compared to people without T2D (16%), p < 0.001. After adjusting for confounders, people with T2D had poorer outcomes 24-months post injury than people without T2D, with respect to functional recovery (Extended Glasgow Outcome Scale) (adjusted odds ratio [AOR] [95% CI]: 0.58 [0.48, 0.69]) and return to work/study (AOR [95% CI]: 0.51 [0.37, 0.71]). People with T2D experienced higher odds of problems with mobility (AOR [95% CI]: 1.92 [1.60, 2.30]), self-care (AOR [95% CI]: 1.94 [1.64, 2.29]), usual activities (AOR [95% CI]: 1.50 [1.26, 1.79]), pain and discomfort (AOR [95% CI]: 1.75 [1.49, 2.07]), anxiety and depression (AOR [95% CI]: 1.45 [1.24, 1.70]), and self-reported disability (AOR [95% CI]: 1.51 [1.28, 1.79]) than people without T2D. CONCLUSIONS Major trauma patients with T2D have a poorer prognosis than patients without T2D, both during their hospital admission and 24-months post-injury. Patients with T2D may need additional health care and support following trauma to reach their recovery potential. LEVEL OF EVIDENCE Level 3, Prognostic.

Introduction: This study performed a path analysis to uncover the behavioral pathways (from contributing factors, pre-crash actions to injury severities) in bicycle-motor vehicle crashes. Method: The analysis investigated more than 7,000 bicycle-motor vehicle crashes in North Carolina between 2007 and 2014. Pre-crash actions discussed in this study are actions of cyclists and motorists prior to the event of a crash, including “bicyclist failed to yield,” “motorist failed to yield,” “bicyclist overtaking motorist,” and “motorist overtaking bicyclist.” Results: Model results show significant correlates of pre-crash actions and bicyclist injury severity. For example, young bicyclists (18 years old or younger) are 23.5% more likely to fail to yield to motor traffic prior to the event of a crash than elder bicyclists. The “bicyclist failed to yield” action is associated with increased bicyclist injury severity than other actions, as this behavior is associated with an increase of 5.88 percentage points in probability of a bicyclist being at least evidently injured. The path analysis can highlight contributing factors related to risky pre-crash actions that lead to severe injuries. For example, bicyclists traveling on regular vehicle travel lanes are found to be more likely to involve the “bicyclist failed to yield” action, which resulted in a total 44.38% (7.04% direct effect + 37.34% indirect effect) higher likelihood of evident or severe injuries. The path analysis can also identify factors (e.g., intersection) that are not directly but indirectly correlated with injury severity through pre-crash actions. Practical Applications: This study offers a methodological framework to quantify the behavioral pathways in bicycle-motor vehicle crashes. The findings are useful for cycling safety improvements from the perspective of bicyclist behavior, such as the educational program for cyclists.

The predominant tool used to predict outcomes after traumatic spinal cord injury (SCI) is the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). These measures have evolved based on analyses of large amounts of longitudinal neurological recovery data published in numerous separate studies. This article reviews and synthesizes published data on neurological recovery from multiple sources, only utilizing data in which the sacral sparing definition was applied for determination of completeness. Conversion from a complete to incomplete injury is more common in tetraplegia than paraplegia. The majority of AIS conversion and motor recovery occurs within the first 6–9 months, with the most rapid rate of motor recovery occurring in the first three months after injury. Motor score changes, as well as recovery of motor levels, are described with the initial strength of muscles as well as the levels of the motor zone of partial preservation influencing the prognosis. Total motor recovery is greater for patients with initial AIS B than AIS A, and greater after initial AIS C than with motor complete injuries. Older age has a negative impact on neurological and functional recovery after SCI; however, the specific age (whether >50 or >65 years) and underlying reasons for this impact are unclear. Penetrating injury is more likely to lead to a classification of a neurological complete injury compared with blunt trauma and reduces the likelihood of AIS conversion at one year. There are insufficient data to support gender having a major effect on neurological recovery after SCI.

The epidemiology of fracture-related infection (FRI) is unknown, which makes it difficult to estimate future demands and evaluate progress in infection prevention. Therefore, we aimed to determine the nationwide burden’s development over the last decade as a function of age group and gender. FRI prevalence as a function of age group and gender was quantified based on annual ICD-10 diagnosis codes from German medical institutions between 2008 through 2018, provided by the Federal Statistical Office of Germany (Destatis). The prevalence of FRI increased by 0.28 from 8.4 cases per 100,000 inhabitants to 10.7 cases per 100,000 inhabitants between 2008 and 2018. The proportion of fractures resulting in FRI increased from 1.05 to 1.23%. Gender distribution was equal. Patients aged 60–69 years and 70–79 years comprised the largest internal proportion with 20.2% and 20.7%, respectively, whereby prevalence increased with age group. A trend towards more diagnoses in older patients was observed with a growth rate of 0.63 for patients older than 90 years. Increasing rates of fracture-related infection especially in older patients indicate an upcoming challenge for stakeholders in health care systems. Newly emerging treatment strategies, prevention methods and interdisciplinary approaches are strongly required.

Objectives The objectives of this study were to ascertain factors significantly responsible for mortality from traumatic head injuries and prescribe measures necessary to circumvent such outcome. Methods A retrospective cohort study of all traumatic head injuries seen at our facility from October 2013 to September 2015 was done utilizing data from patient's case notes, ward registers, and casualty department. Extracted data were analyzed using descriptive statistics. Results A total of 221 patient records were analyzed with 161 men and 60 women. It was observed that although the younger age group (19–30 years) was the most frequently affected by traumatic head injuries (36.2%), the elderly (>60 years) were 4.6 times more likely to die from traumatic head injuries than any other age group. Also, those with severe head injuries were 58 times more likely to die than any other category of head injury, even though the commonest category of head injuries seen were mild head injuries (68.7%). Patients with traumatic head injury from road traffic accidents were 5.8 times more likely to die than any other cause. The sex of the patient and the length of hospital stay had no significant influence on mortality from traumatic head injuries. Conclusions The postresuscitation Glasgow Coma Scale score, age of the patient, and mechanism of head injuries are important determining factors of outcome in traumatic head injuries, with the Glasgow Coma Scale score being the single most important determining factor. Efforts should be made at preventing such causes, with prompt and aggressive care instituted for cases at risk of unfavorable outcome.

Summary Mammalian bites are common injuries, but management has been shown to vary widely. The aim of this study was to assess how the COVID-19 pandemic impacted management of mammalian bite injuries and resulting outcomes. We conducted a retrospective review of prospectively collected data on mammalian bite injuries assessed in our Plastic and Reconstructive Surgery department during April and May 2020. 37 patients presented with mammalian bite injuries during this period. Median age was 27 (range 1-75) with equal gender distribution. The majority presented on the day or day after injury. Bites were from dogs (78%), humans (14%) and cats (8%). Body parts involved were finger/hand (21), face (8), arm/forearm (5) and thigh/leg (3). 6 wounds were superficial (i.e. not penetrating the full-thickness of the skin) and 4 were associated with a fracture or significant soft tissue damage. 30 out of 31 non-superficial injuries were washed out under local anaesthesia, patients received a tetanus booster (if required) and were discharged with oral antibiotics and safety net advice. One wound associated with extensor tendon injury and metacarpal fracture was admitted and treated in the operating theatre. No complications were registered and only one patient represented with an infected wound, which was washed out under local anaesthesia and the patient discharged. Our experience during the COVID-19 pandemic suggests that the majority of mammalian bite injuries can safely be managed with washout under local anaesthesia, oral antibiotics and discharge on the same day with safety net advice. Going forward, healthcare resources can be optimised by taking these results into account.

Purpose In Dec 2019, COVID-19 was first recognized and led to a worldwide pandemic. The German government implemented a shutdown in Mar 2020, affecting outpatient and hospital care. The aim of the present article was to evaluate the impact of the COVID-19 shutdown on patient volumes and surgical procedures of a Level I trauma center in Germany. Methods All emergency patients were recorded retrospectively during the shutdown and compared to a calendar-matched control period (CTRL). Total emergency patient contacts including trauma mechanisms, injury patterns and operation numbers were recorded including absolute numbers, incidence proportions and risk ratios. Results During the shutdown period, we observed a decrease of emergency patient cases (417) compared to CTRL (575), a decrease of elective cases (42 vs. 13) and of the total number of operations (397 vs. 325). Incidence proportions of emergency operations increased from 8.2 to 12.2% (shutdown) and elective surgical cases decreased (11.1 vs. 4.3%). As we observed a decrease for most trauma mechanisms and injury patterns, we found an increasing incidence proportion for severe open fractures. Household-related injuries were reported with an increasing incidence proportion from 26.8 to 47.5% (shutdown). We found an increasing tendency of trauma and injuries related to psychological disorders. Conclusion This analysis shows a decrease of total patient numbers in an emergency department of a Level I trauma center and a decrease of the total number of operations during the shutdown period. Concurrently, we observed an increase of severe open fractures and emergency operations. Furthermore, trauma mechanism changed with less traffic, work and sports-related accidents.

Objectives: Fireworks are used commonly for celebrations in the United States, but can lead to severe injury to the head and neck. We aim to assess the incidence, types, and mechanisms of head and neck injuries associated with fireworks use from 2010 to 2019. Methods: A retrospective cross-sectional study, using data from the National Electronic Injury Surveillance System, of individuals presenting to United States Emergency Departments with head and neck injuries caused by fireworks and flares from 2010 to 2019. Incidence, types, and mechanisms of injury related to fireworks use in the US population were assessed. Results: A total of 541 patients (349 [64.5%] male, and 294 [54%] under 18 years of age) presented to emergency departments with fireworks-related head and neck injuries; the estimated national total was 20 584 patients (13 279 male, 9170 white, and 11 186 under 18 years of age). The most common injury diagnoses were burns (44.7% of injuries), laceration/avulsion/penetrating trauma (21.1%), and otologic injury (15.2%), which included hearing loss, otalgia, tinnitus, unspecified acoustic trauma, and tympanic membrane perforation. The remaining 19% of injuries were a mix, including contusion, abrasion, hematoma, fracture, and closed head injury. Associations between fireworks type and injury diagnosis (chi-square P Conclusions: Fireworks-related head and neck injuries are more likely to occur in young, white, and male individuals. Burns are the most common injury, while otologic injury is a significant contributor. Annual rates of fireworks-related head and neck injuries have not changed or improved significantly in the United States in the past decade, suggesting efforts to identify and prevent these injuries are insufficient.

Background Military guidelines endorse early fasciotomy after revascularization of lower extremity injuries to prevent compartment syndrome, but the real-world impact is unknown. We assessed the association between fasciotomy and amputation and limb complications among lower extremitys with vascular injury. Methods A retrospectively collected lower extremity injury database was queried for limbs undergoing attempted salvage with vascular procedure (2004-2012). Limbs were categorized as having undergone fasciotomy or not. Injury and treatment characteristics were collected, as were intervention timing data when available. The primary outcome measure was amputation. Multivariate models examined the impact of fasciotomy on limb outcomes. Results Inclusion criteria were met by 515 limbs, 335 (65%) with fasciotomy (median 7.7 h postinjury). Of 212 limbs, 174 (84%) with timing data had fasciotomy within 30 min of initial surgery. Compartment syndrome and suspicion of elevated pressure was documented in 127 limbs (25%; 122 had fasciotomy). Tourniquet and shunt use, fracture, multiple arterial and combined arteriovenous injuries, popliteal involvement, and graft reconstruction were more common in fasciotomy limbs. Isolated venous injury and vascular ligation were more common in nonfasciotomy limbs. Fasciotomy timing was not associated with amputation. Controlling for limb injury severity, fasciotomy was not associated with amputation but was associated with limb infection, motor dysfunction, and contracture. Sixty-three percent of fasciotomies were open for >7 d, and 43% had multiple closure procedures. Fasciotomy revision (17%) was not associated with increased amputation or complications. Conclusions Fasciotomy after military lower extremity vascular injury is predominantly performed early, frequently without documented compartment pressure elevation. Early fasciotomy is generally performed in severely injured limbs with a subsequent high rate of limb complications.

Falls and traffic accidents can cause traumatic brain injury (TBI). Assessment of the injury severity is essential to determine the prognosis or the cause of death. Diabetes mellitus (DM) is a common preexisting disease in elderly adults. We hypothesized that preexisting DM exacerbates TBI secondary to prolonged inflammation. In this study, we investigated TBI-induced changes in nerve function and inflammatory cell migration to the injury site, and the extent of brain contusion in KK-Ay (DM) and C57BL/6J (non-DM) mice. A controlled cortical impact device was used to induce TBI in each mouse. The brain contusion volume was measured using magnetic resonance imaging. Nerve function changes were assessed using the following animal behavior tasks: neurological severity score (NSS), Morris water maze, forced swim test, and beam walking. Immunohistochemical examinations of brain sections were performed to assess the infiltration of neutrophils, astrocytes, microglia, and macrophages, and to detect apoptosis. These experiments were performed on post-injury days 1-90 (over five experiments/time-points in each group). Compared with non-DM mice, DM mice showed significantly greater brain contusion volume, greater deterioration in the NSS, and a higher number of neutrophils, macrophages, and apoptotic cells in the brain tissue specimens. This study indicates that the prognosis of normal mice and DM mice differs, even if they acquire a TBI of the same severity. Therefore, it is important to evaluate patients with TBI for DM and other preexisting diseases in order to provide adequate treatment or to determine the correct cause of death.

Background Delirium is common in patients admitted to the surgical trauma intensive care unit (ICU), and the risk factors for these patients differ from medical patients. Given the morbidity and mortality associated with delirium, efforts to prevent it may improve patient outcomes, but previous efforts pharmacologically have been limited by side effects and insignificant results. We hypothesized that scheduled quetiapine could reduce the incidence of delirium in this population. Methods The study included 71 adult patients who were at high-risk for the development of delirium (PRE-DELIRIC Score ≥50%, history of dementia, alcohol misuse, or drug abuse). Patients were randomized to receive quetiapine 12.5 mg every 12 h for delirium or no pharmacologic prophylaxis within 48 h of admission to the ICU. The primary end point was the incidence of delirium during admission to the ICU. Secondary end points included time to onset of delirium, ICU and hospital length of stay (LOS), ICU and hospital mortality, duration of mechanical ventilation, and adverse events. Results The incidence of delirium during admission to the ICU was 45.5% (10/22) in the quetiapine group and 77.6% (38/49) in the group that did not receive pharmacological prophylaxis. The mean time to onset of delirium was 1.4 days for those who did not receive prophylaxis versus 2.5 days for those who did (p = 0.06). The quetiapine group significantly reduced ventilator duration from 8.2 days to 1.5 days (p = 0.002). Conclusions The findings suggested that scheduled, low-dose quetiapine is effective in preventing delirium in high-risk, surgical trauma ICU patients.

The majority of high grade renal trauma can be managed conservatively. However, nephrectomy is still common for acute management. We hypothesized that when controlling for multiple injury severity measures, nephrectomy would be associated with increased mortality.We identified high grade renal trauma patients from the National Trauma Data Bank® from 2007-2016. Exclusion criteria were age18 years, severe head injury and death within 4 hours of admission. We performed conditional logistic regression analysis to determine if nephrectomy was independently associated with mortality, controlling for age, gender, race/ethnicity, mechanism of injury, shock, blood transfusion, Glasgow Coma Scale, Revised Trauma Score and Injury Severity Score. Interaction was measured for mechanism of injury and shock with mortality.We identified 42,898 patients with high grade renal trauma (grade III-V), of whom 3,204 (7.5%) underwent nephrectomy. Unadjusted mortality was 16.6% in nephrectomy vs 5.7% in nonnephrectomy patients. In multivariable logistic regression, nephrectomy was associated with 82% increased odds of death (OR 1.82, 95% CI 1.63-2.03, p0.001). Other significant associations with death included age, nonWhite race, penetrating mechanism, hypotension, blood transfusion, lower Glasgow Coma Scale, lower Revised Trauma Score and higher Injury Severity Score. The association between nephrectomy and death did not differ by mechanism of injury. However, it was slightly attenuated in patients presenting in shock.In the National Trauma Data Bank, nephrectomy is independently associated with increased risk of mortality after adjusting for patient demographics, injury characteristics and multiple measures of overall injury severity. Nephrectomy may impact overall survival and must be avoided when possible.

Objectives To investigate the effectiveness of a futsal-specific warm-up to reduce injuries in amateur teams. Design Quasi-experimental. Setting Two futsal centres followed over one season using a specific report card. Participants 878 teams (Intervention group, n = 458; Control group, n = 420) of both genders and three age groups (U13, U17, adults). Intervention A futsal-specific warm-up consisting of cardiovascular exercises, dynamic stretches, and game-related skills. Main outcome measures The incidence rate and severity of all injuries, lower extremity (LE) injuries and contact injuries. A multivariate Poisson regression analysis was used to compare between-group rates. Results The rate of all injuries was lower in the intervention group (rate ratio (RR) = 0.72, 95% CI = 0.59 to 1.06), yet not significant. There was a significantly lower rate of contact injuries in the intervention group (RR = 0.68, 95% CI = 0.51 to 0.98). Subgroup analysis, based on the warm-up adherence of intervention teams (low, intermediate, high), showed a lower rate of all injuries (RR = 0.52, 95% CI = 0.29 to 0.97), and LE injuries (RR = 0.32, 95% CI = 0.14 to 0.81) in the high compared to low adherence group. Conclusion A futsal-specific warm-up can reduce the rate of contact injuries in amateur players. With high adherence the rate of all injuries and LE injuries may also reduce.

BACKGROUND The use of electric scooters (e-scooters) has dramatically increased as they become an attractive alternative for public transportation in busy metropolitan areas worldwide. Despite their benefits, e-scooters challenge the health-care system with poorly understood forms of injuries, mainly orthopaedic fractures. To our knowledge, this study is the first to investigate e-scooter-related orthopaedic fracture patterns, mechanisms of injury, and management. METHODS Data on 3,331 e-scooter-related admissions were retrospectively collected between May 2017 and February 2020 in a level-I trauma center. These admissions were analyzed for demographic variables, orthopaedic fracture diagnosis (using the AO/OTA classification), associated injuries, and surgical treatment. RESULTS During the study period, a total of 716 fractures were diagnosed in 563 patients, with 46.4% of the patients requiring hospitalization. Of 492 upper-limb fractures, 89.2% occurred in a rider fall mechanism; and of 210 lower-limb fractures, 15.7% occurred in rider-vehicle collisions. Fifty-nine percent of long bone fractures were complex fragmentary and/or intra-articular fractures. Orthopaedic surgeons recommended that 225 fractures undergo surgical treatment. The most common upper-limb fracture was AO/OTA class 2R1A, with open reduction and internal fixation of the distal part of the radius being the most common upper-limb procedure (n = 58). The most common lower-limb fracture was AO/OTA class 41C, with open reduction and internal fixation of the proximal part of the tibia being the most common procedure (n = 28). A total of 22 patients (3.9%) required reoperation within 1 year. CONCLUSIONS This investigation provides unique information on demographic characteristics, patterns, and treatment of orthopaedic fractures secondary to the high-energy mechanism of e-scooter injuries. These new in-depth data are important, first, for health-care system preparedness with regard to management and resource allocation to treat these challenging injuries and, second, for legislators promoting safety and injury prevention strategies.

Background Trauma severity scoring systems are routinely used to monitor trauma patient outcomes. Yet, the most accurate scoring system remains an elusive target. Objective We aim to compare trauma severity scales (ISS, NISS, RTS, TRISS, and BIG) in multitrauma patients and investigate BIG as one of the new trauma severity scoring systems. Methods The demographic data of the patients, vital signs, injury mechanisms, body regions exposed to trauma, final diagnosis, the injury severity scales-Injury Severity Score (ISS), New Injury Severity Score (NISS), Revised Trauma Score (RTS), base deficit, international normalized ratio, and Glasgow Coma Scale (BIG), and Trauma and Injury Severity Score (TRISS)-the length of stay in hospital, and the progress of the patients were examined. Results A total of 426 cases were included in the study. The best performing score in determining mortality was TRISS (area under the curve [AUC]: 0.93, sensitivity 97.1% and specificity 76.7%). This was followed by the NISS, BIG, ISS, and RTS, respectively. For the prediction of intensive care unit admission, the NISS was the most successful with an AUC value of 0.81. There was a significant relationship in terms of the length of stay in all trauma scores (p Conclusions The most successful score in predicting mortality in trauma patients was the TRISS, whereas the NISS was the most successful in predicting intensive care unit admission. The newly developed BIG score can be used as a strong scoring method for predicting prognosis in trauma patients.

OBJECTIVES/HYPOTHESIS Over 3 million incidents of facial trauma occur each year in the United States. This study aims to determine trends in operative middle and upper maxillofacial trauma in one of the largest US cities. STUDY DESIGN Retrospective case-control study. METHODS Retrospective chart review of all operative middle and upper maxillofacial trauma from July 1993 to July 2010 presenting to Los Angeles County Hospital, a Level I Trauma Center. Data included demographics, mechanism of injury, and fracture characteristics. RESULTS Analysis was performed for a total of 4,299 patients and 5,549 facial fractures. Mean patient age was 34.6, and most patients were male (88%). Between the two time periods (1993-2001 and 2002-2010), there was a 42% reduction in operative maxillofacial trauma (3,510 to 2,039). Orbital floor and zygomaticomaxillary complex fractures were the most prevalent types of fractures. Panfacial fractures demonstrated the largest reduction in number of fractures (325 to 5, P

Purpose: Trauma is the leading cause of mortality in people below the age of 45 years. Abdominal trauma constitutes one-fourth of the trauma burden. Scoring systems in trauma are necessary for grading the severity of the injury and prior mobilization of resources in anticipation. The aim of this study was to evaluate RTS, ISS, CASS and TRISS scoring systems in blunt trauma abdomen. Materials and methods: A prospective single-center study was conducted on 43 patients of blunt trauma abdomen. Revised trauma score (RTS), Injury Severity Score (ISS), Clinical Abdominal Scoring System (CASS) and Trauma and Injury Severity Score (TRISS) were calculated and compared with the outcomes such as need for surgical intervention, post-operative complications and mortality. Results: The majority of the study subjects were males (83.7%). The most common etiology for blunt trauma abdomen as per this study was road traffic accident (72.1%). Spleen was the most commonly injured organ as per the study. CASS and TRISS were significant in predicting the need for operative intervention. Only ISS significantly predicted post-operative complications. All scores except CASS significantly predicted mortality. Conclusions: Among the scoring systems studied CASS and TRISS predicted the need for operative intervention with good accuracy. For the prediction of post-operative complications, only the ISS score showed statistical significance. ISS, RTS and TRISS predicted mortality with good accuracy but the superiority of one score over the other couldn’t be proved.

Background The global pandemic caused by SARS-CoV-2 has impacted population health and care delivery worldwide. As information emerges regarding the impact of “lockdown measures” and changes to clinical practice worldwide; there is no comparative information emerging from the United Kingdom with regard to major trauma. Methods This observational study from a UK Major Trauma Centre matched a cohort of patients admitted during a 10-week period of the SARS-CoV-2-pandemic (09/03/2020–18/05/2020) to a historical cohort of patients admitted during a similar time period in 2019 (11/03/2019–20/05/2019). Differences in demographics, Clinical Frailty Scale, SARS-CoV-2 status, mechanism of injury and injury severity were compared using Fisher’s exact and Chi-squared tests. Univariable and multivariable logistic regression analyses examined the associated factors that predicted 30-days mortality. Results A total of 642 patients were included, with 405 in the 2019 and 237 in the 2020 cohorts, respectively. 4/237(1.69%) of patients in the 2020 cohort tested positive for SARS-CoV-2. There was a 41.5% decrease in the number of trauma admissions in 2020. This cohort was older (median 46 vs 40 years), had more comorbidities and were frail (p Conclusion Patients admitted during the COVID-19 pandemic were older, frailer, more co-morbid and had an associated increased risk of mortality.

Background Open globe injury (OGI) is one of the most devastating form of ocular trauma. The aim of the study is to identify the epidemiology and predict visual outcomes in traumatic open globe injuries using ocular trauma score (OTS) and correlate with final visual acuity (VA) at 3 months. Methods Patients older than 5 years, presenting to B.P. Koirala Lions Centre for Ophthalmic Studies (BPKLCOS) from March 2016- March 2017 with OGI that met inclusion criteria were evaluated. Patient profile, nature and cause of injury, and time to presentation were recorded. Patients were managed accordingly and followed up to 3 months. An OTS score for each patient was calculated and raw scores were categorized accordingly. The VA after 3 months were compared to the predicted OTS values. Results Seventy-three eyes of 72 patients were examined. 76 % were male, and the mean age was 26.17 years (median, 23.5 years). The mean time from injury to presentation was Conclusions OTS can be an accurate predictive tool for final visual acuity even with a short follow up period of 3 months; with poor presenting visual acuity, delayed presentation, posterior zones of injury, need for intravitreal injections, endophthalmitis, and globe rupture associated with poorer prognosis.

Purpose: The poor prognosis in patients with floating knee injuries is mainly contributed to articular involvement (Fraser’s type Ⅱ). This study aims to evaluate and compare the functional outcomes among different Fraser’s type Ⅱ floating knee injuries after surgical management. Methods: Twenty-seven patients with Fraser’s type Ⅱ floating knee injuries (54 fractures) between September 2014 and December 2015 were enrolled prospectively in this study and were distributed according to Fraser’s floating knee classification into three different groups as type ⅡA (ipsilateral femoral shaft and tibial intra-articular involvement, n = 11), type ⅡB (ipsilateral tibial shaft and femoral intra-articular involvement, n = 9) and type ⅡC (both femoral and tibial intra-articular involvement, n = 7). The differences among the groups were evaluated and compared. The functional outcomes of these injuries at one year were analyzed using Knee Injury and Osteoarthritis Outcome Score (KOOS) which covers 5 subscales of pain, other symptoms, activities of daily living, sports and recreation, and quality of life. The result was also compared with standardized age-sex matched healthy population using paired samples t-test. Results: All the patients were male, and the injury mechanism was solely roadside accident. The mean age was 29.8 years and injury severity score 17.9 (comparable in all the three groups). Most injuries were observed on the right side (20 cases, 74.1%). Based on paired samples t-test, the KOOS score of patients with Fraser’s type ⅡA was found to be better than that of type ⅡB and type ⅡC. Compared with the reference age-sex matched control group, patients with Fraser’s type ⅡB and ⅡC fractures had significantly lower mean score in all KOOS subscales (all p

Clinical forensic assessments of injuries’ life-threatening danger may have an impact on the legal aftermath following a violent assault. The pursuit of evidence-based guidelines should ensure a user-independent and reproducible forensic practice. However, does it? The aim of this study was to evaluate the forensic life-threatening danger assessments after a protocol implementation in 2016. The evaluation concerned usability and reproducibility of the protocol, and its influence on assessment severity. We analyzed the level of inter- and intra-rater agreement using 169 blinded, prior-protocol cases that were reassessed by two forensic specialists. We compared assessment made the year before and after protocol implementation (n = 262), and the forensic specialists’ reassessments with the prior-protocol cases’ original assessments (n = 169). Whether to make an assessment, the levels of agreement varied between weak agreement (inter-rater, Κ = 0.43; assessor 1, Κ = 0.57) and strong agreement (assessor 2, Κ = 0.90). Regarding severity, the levels of agreement varied between strong agreement (inter-rater, Κ = 0.87; assessor 1: Κ = 0.90) and almost perfect agreement (assessor 2: Κ = 0.94). The assessments were statistically significant redistributed after the implementation (chi-square test: p

Objectives To examine prescription opioid claims among individuals with traumatic spinal cord injury (SCI) and to identify factors associated with both chronic opioid and chronic high-dose opioid use. Design Retrospective cohort study using population-level administrative data. Setting Ontario, Canada. Participants Individuals (N=1842) with traumatic SCI between April 1, 2004 and March 31, 2015. Interventions Not applicable. Main Outcome Measures Proportion of cohort with chronic opioid use (≥90d supply) and proportion with chronic high-dose opioid use (≥90d supply exceeding 90 mg morphine equivalent) between April 1, 2016 and March 31, 2017 (observation period). Results A total of 1842 individuals with traumatic SCI were identified (74% men), with a median age of 51 years (interquartile range [IQR], 34-64y) and median duration of injury of 6 years (IQR, 4-9y). During the observation period, 35% were dispensed at least 1 opioid and 19.8% received chronic opioids, 39% of whom received more than 90 mg daily (chronic high dose). The median daily morphine equivalent dose was 212 mg morphine equivalent (IQR, 135.5-345.3 mg) for chronic high-dose users. Significant risk factors for chronic opioid use were male sex; age between 40 and 60 years; lower income; multimorbidity; thoracic, lumbar, or sacral level of injury; and having a previous diagnosis of osteoarthritis. Risk factors for chronic high-dose opioid use were an extended time since injury, age between 40 and 50 years, and increasing comorbidity. Conclusions A large proportion of individuals with traumatic SCI were dispensed an opioid in a recent 1-year period. A substantial proportion were dispensed more than 90 mg of morphine equivalents, which is the maximum recommended by the Canadian opioid guideline. Further research is needed to understand the risk factors associated with chronic, high-dose opioid use in this population.

Objectives To examine regional differences in rehabilitation outcomes among adult patients with moderate-to-severe traumatic brain injury (TBI) who received care at an inpatient rehabilitation facility (IRF). Design We conducted a secondary analysis of a large, multi-center dataset from the Uniform Data System for Medical Rehabilitation. Setting More than 70% of all IRFs in the United States. Participants Adult TBI patients (N=175,358) aged 18 years or older who were admitted and discharged from an IRF in the United States between 2004 and 2014. Qualifying etiology included traumatic brain dysfunction Impairment Group codes 02.21 (traumatic, open injury) and 02.22 (traumatic, closed injury). Interventions Not applicable. Main Outcome Measures Discharge functional status (total, cognitive, motor), length of stay, and discharge to home. Results Patient and clinical characteristics varied significantly by geographic location, as did median functional status, length of stay, and percentage of patients discharged home. The region where IRF care was received, race and ethnicity, age, occurrence of 1 or more falls during the IRF stay, case mix group, and insurance status were associated with discharge functional status, length of stay, and discharge to home. Conclusions Our findings provide evidence of geographic differences in outcomes and potential disparities in care of TBI patients who received IRF care. More research is needed to identify TBI patients at risk for poor discharge outcomes to inform development and testing of interventions to reduce disparities in outcomes for these patients.

To compare effects of walking training on a walking track with different surfaces (WTDS), including artificial grass, soft, and pebbles, as compared to overground walking training on the functional ability necessary for independence and incidence of falls of ambulatory individuals with spinal cord injury (SCI).A randomized controlled trial (single-blinded design) with 6-month prospective fall data follow-up.Tertiary rehabilitation centers and several communities.Independent ambulatory individuals (N=54) with SCI who walked with or without a walking device.Participants were randomly arranged into a control group (overground walking training, n=26) or experimental group (walking training over a WTDS, n=28) for 30 min/d, 5 d/wk over 4 weeks.The 10-m walk test, timed Up and Go test, five times sit-to-stand test, and 6-minute walk test were repeatedly measured 4 times, including before training, and after 2 and 4 weeks, and 6 months. In addition, participants were prospectively monitored for the fall data over 6 months.Participants who walked with an average speed of 0.52 m/s and postinjury time7 years could safely walk over a WTDS. They demonstrated significant improvement at 2 and 4 weeks after experimental training (P.001), but not after control training. During the 6-month follow-up, participants in the experimental group also had the number of those who fell (n=5, 18%) fewer than those in the control group (n=12, 46%).Being at a chronic SCI with ability of independent walking, participants needed a challenging task to promote their functional outcomes and minimize fall risk. The findings suggest the use of various surfaces as an alternative rehabilitation strategy for these individuals.

Objectives To evaluate the incidence and epidemiologic characteristics of acquired nontraumatic spinal cord injury (NTSCI) in Finland. Design Prospective 4-year epidemiologic multicenter study. Setting Two of the 3 spinal cord injury (SCI) centers in Finland responsible for acute care, immediate rehabilitation, and lifelong follow-up for all SCI patients in a population of 3,073,052 (as of 2013). Participants All newly diagnosed NTSCI patients (N=430) admitted to Tampere University Hospital between 2012 and 2015 and Oulu University Hospital between 2013 and 2016 based on the evaluation of the designated rehabilitation teams. Patients with NTSCI resulting from congenital etiologies or progressive neurologic diseases were excluded. Interventions Not applicable. Main Outcome Measures Incidence and variables, according to the International SCI Core Data Set and the International Standards for Neurological Classification of SCI, including etiology and the severity of injury. Results The incidence of NTSCI was 54.1 per million per year. NTSCI was more common in men (n=260, 60.5%) than women (n=170, 39.5%). The mean age was 62.0±14.6 years old. Degenerative causes were the most common etiology (n=219, 50.9%), followed by malignant (n=88, 20.5%) and benign (n=41, 9.5%) neoplasms. The injury resulted in tetraplegia in 177 patients (41.1%) and paraplegia in 249 patients (57.9%). American Spinal Injury Association Impairment Scale grade D injuries were common, with an incidence of 71% (n=304). Specialized inpatient rehabilitation was needed in 44% (n=189) of the cases. Conclusions There are no previous studies on the epidemiology of NTSCI in Finland, and international reporting has been limited. The incidence of NTSCI in our study was substantially higher than in most previous studies, which was likely owing to our study including individuals with less severe lesions who did not require inpatient rehabilitation.

To describe the association between unmet rehabilitation needs and life satisfaction 5 years after traumatic brain injury (TBI).Prospective observational cohort.Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers.VA TBI Model Systems participants (N=301); 95% male; 77% white; average age, 39±14y).Not applicable.Satisfaction With Life Scale (SWLS).Average SWLS score was 22±8. Univariable analyses demonstrated several statistically significant predictors of life satisfaction, including employment status, participation, psychiatric symptom severity, past year mental health treatment, and total number of unmet rehabilitation needs (all P.05). Multivariable analyses revealed that depression and participation were each associated with life satisfaction. An ad hoc mediation model suggested that unmet rehabilitation needs total was indirectly related to life satisfaction. Total unmet rehabilitation needs ranged from 0-21 (mean, 2.0±3.4). Correlational analyses showed that 14 of the 21 unmet rehabilitation needs were associated with life satisfaction.Findings support the need for rehabilitation engagement in later stages of TBI recovery. Ongoing assessment of and intervention for unmet rehabilitation needs in the chronic phase of recovery have the potential to mitigate decline in life satisfaction.

Background/Objective Straddle fracture, a superior and inferior ramus fracture of both sides, is generally treated conservatively. However, posterior pelvic ring injury is often associated with straddle fracture, leading to unstable pelvic bone fracture that requires surgical treatment. The present study reports the clinical and radiological outcomes of straddle fracture with posterior pelvic ring injury. Methods This study included 73 patients (41 men, 32 women) with a straddle fracture injury. The injury mechanism, injury severity score (ISS), accompanying injuries, presence of posterior pelvic ring injury, and fixation methods for the pelvic fracture were analyzed, and outcomes were evaluated functionally and radiologically. Results Of the 73 patients, 56 (77%) had a posterior pelvic ring injury and 7 died. In 43 patients, the posterior pelvic ring injuries constituted unstable pelvic injury and were treated surgically. The fixation method was determined based on the severity of the posterior pelvic injury. The patients’ mean ISS was 24.7 points. Radiological evaluation of surgical outcomes in 43 patients revealed the outcomes as anatomic in 20, nearly anatomic in 14, moderate in 5, and poor in 4, whereas functional evaluation revealed the outcomes as excellent in 21, good in 9, fair in 7, and poor in 6. Conclusion Posterior pelvic ring fracture can accompany straddle fractures, which may lead to pelvic injury instability. Thus, special attention is required for patients with a straddle fracture.