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Introduction: Traumatic injuries constitute a major cause of mortality and morbidity. Still, the public health burden of trauma in Norway has not been characterised using nationwide registry data. More knowledge is warranted on trauma risk factors and the long-term outcomes following trauma. The Injury Prevention and long-term Outcomes following Trauma project will establish a comprehensive research database. The Norwegian National Trauma Registry (NTR) will be merged with several data sources to pursue the following three main research topics: (1) the public health burden of trauma to society (eg, excess mortality and disability-adjusted life-years (DALYs)), (2) trauma aetiology (eg, socioeconomic factors, comorbidity and drug use) and (3) trauma survivorship (eg, survival, drug use, use of welfare benefits, work ability, education and income)., Methods and Analysis: The NTR (n≈27 000 trauma patients, 2015-2018) will be coupled with the data from Statistics Norway, the Norwegian Patient Registry, the Cause of Death Registry, the Registry of Primary Health Care and the Norwegian Prescription Database. To quantify the public health burden, DALYs will be calculated from the NTR. To address trauma aetiology, we will conduct nested case-control studies with 10 trauma-free controls (drawn from the National Population Register) matched to each trauma case on birth year, sex and index date. Conditional logistic regression models will be used to estimate trauma risk according to relevant exposures. To address trauma survivorship, we will use cohort and matched cohort designs and time-to-event analyses to examine various post-trauma outcomes., Ethics and Dissemination: The project is approved by the Regional Committee for Medical Research Ethics. The project's data protection impact assessment is approved by the data protection officer. Results will be disseminated to patients, in peer-reviewed journals, at conferences and in the media., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Traumatic injuries, defined as physical injuries with sudden onset, are a major public health problem worldwide. There is a paucity of knowledge regarding rehabilitation needs and service provision for patients with moderate and major trauma, even if rehabilitation research on a spectrum of specific injuries is available., Objective: This study aims to describe the prevalence of rehabilitation needs, the provided services, and functional outcomes across all age groups, levels of injury severity, and geographical regions in the first year after trauma. Direct and indirect costs of rehabilitation provision will also be assessed. The overarching aim is to better understand where to target future efforts., Methods: This is a population-based prospective follow-up study. It encompasses patients of all ages with moderate and severe acute traumatic injury (New Injury Severity Score >9) admitted to the regional trauma centers in southeastern and northern Norway over a 1-year period (2020). Sociodemographic and injury data will be collected. Upon hospital discharge, rehabilitation physicians estimate rehabilitation needs. Rehabilitation needs are assessed by the Rehabilitation Complexity Scale Extended-Trauma (RCS E-Trauma; specialized inpatient rehabilitation), Needs and Provision Complexity Scale (NPCS; community-based rehabilitation and health care service delivery), and Family Needs Questionnaire-Pediatric Version (FNQ-P). Patients, family caregivers, or both will complete questionnaires at 6- and 12-month follow-ups, which are supplemented by telephone interviews. Data on functioning and disability, mental health, health-related quality of life measured by the EuroQol Questionnaire (EQ-5D), and needs and provision of rehabilitation and health care services are collected by validated outcome measures. Unmet needs are represented by the discrepancies between the estimates of the RCS E-Trauma and NPCS at the time of a patient's discharge and the rehabilitation services the patient has actually received. Formal service provision (including admission to inpatient- or outpatient-based rehabilitation), informal care, and associated costs will be collected., Results: The project was funded in December 2018 and approved by the Regional Committee for Medical and Health Research Ethics in October 2019. Inclusion of patients began at Oslo University Hospital on January 1, 2020, and at the University Hospital of North Norway on February 1, 2020. As of February 2021, we have enrolled 612 patients, and for 286 patients the 6-month follow-up has been completed. Papers will be drafted for publication throughout 2021 and 2022., Conclusions: This study will improve our understanding of existing service provision, the gaps between needs and services, and the associated costs for treating patients with moderate and major trauma. This may guide the improvement of rehabilitation and health care resource planning and allocation., International Registered Report Identifier (irrid): DERR1-10.2196/25980., (©Helene Lundgaard Soberg, Håkon Øgreid Moksnes, Audny Anke, Olav Røise, Cecilie Røe, Eline Aas, Unni Sveen, Christine Gaarder, Pål Aksel Næss, Eirik Helseth, Hilde Margrete Dahl, Frank Becker, Marianne Løvstad, Kristian Bartnes, Christoph Schäfer, Mari S Rasmussen, Paul Perrin, Juan Lu, Torgeir Hellstrøm, Nada Andelic. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 14.04.2021.)

Introduction: Geriatric patients have a high risk of poor outcomes after trauma and is a rapid-increasing group within the trauma population. Given the need to ensure that the trauma system is targeted, efficient, accessible, safe and responsive to all age groups the aim of the present study was to explore the epidemiology and characteristics of the Norwegian geriatric trauma population and assess differences between age groups within a national trauma system., Materials and Methods: This retrospective analysis is based on data from the Norwegian Trauma Registry (2015-2018). Injury severity was scaled using the Abbreviated Injury Scale (AIS), and the New Injury Severity Score (NISS). Trauma patients 16 years or older with NISS ≥9 were included, dichotomized into age groups 16-64 years (Group 1, G1) and ≥65 years (Group 2, G2). The groups were compared with respect to differences in demographics, injury characteristics, management and outcome. Descriptive statistics and relevant parametric and non-parametric tests were used., Results: Geriatric patients proved to be at risk of sustaining severe injuries. Low-energy falls predominated in G2, and the AIS body regions 'Head' and 'Pelvis and lower extremities' were most frequently injured. Crude 30-day mortality was higher in G2 compared to G1 (G1: 2.9 vs. G2: 13.6%, P<0.01) and the trauma team activation (TTA) rate was lower (G1: 90 vs. G2: 73%, P<0.01). A lower proportion of geriatric patients were treated by a physician prehospitally (G1: 30 vs. G2: 18%, [NISS 15-24], P<0.01) and transported by air-ambulance (G1: 24 vs. G2: 14%, [NISS 15-24], P<0.01). Median time from alarm to hospital admission was longer for geriatric patients (G1: 71 vs. G2: 78 min [NISS 15-24], P<0.01), except for the most severely injured patients (NISS≥25)., Conclusion: In this nationwide study comparing adult and geriatric trauma patients, geriatric patients were found to have a higher mortality, receive less frequently advanced prehospital treatment and transportation, and a lower TTA rate. This is surprising in the setting of a Nordic country with free access to publicly funded emergency services, a nationally implemented trauma system with requirements to pre- and in-hospital services and a national trauma registry with high individual level coverage from all trauma-receiving hospitals. Further exploration and a deeper understanding of these differences is warranted., Competing Interests: Declaration of Competing Interest The authors declare no competing interests., (Copyright © 2020. Published by Elsevier Ltd.)

Introduction: Over the past three decades, extensive research has been undertaken to understand the elements of what constitutes high quality in healthcare. Yet, much of this research has been conducted on individual elements and their specific challenges. Hence, goals other than understanding the complex of factors and elements that comprises quality in healthcare have been privileged. This lack of progress has led to the conclusion that existing approaches to research are not able to address the inherent complexity of healthcare systems as characterised by a significant degree of performance variability within and across system levels, and what makes them resilient. A shift is, therefore, necessary in such approaches. Resilience in Healthcare (RiH) adopts an approach comprising a comprehensive research programme that models the capacity of healthcare systems and stakeholders to adapt to changes, variations and/or disruptions: that is, resilience. As such, RiH offers a fresh approach capable of capturing and illuminating the complexity of healthcare and how high-quality care can be understood and advanced., Methods and Analysis: Methodologically, to illuminate what constitutes quality in healthcare, it is necessary to go beyond single-site, case-based studies. Instead, there is a need to engage in multi-site, cross-national studies and engage in long-term multidisciplinary collaboration between national and international researchers interacting with multiple healthcare stakeholders. By adopting such processes, multiple partners and a multidisciplinary orientation, the 5-year RiH research programme aims to confront these challenges and accelerate current understandings about and approaches to researching healthcare quality.The RiH research programme adopts a longitudinal collaborative interactive design to capture and illuminate resilience as part of healthcare quality in different healthcare settings in Norway and in five other countries. It combines a meta-analysis of detailed empirical research in Norway with cross-country comparison from Australia, Japan, Netherlands, Switzerland and the UK. Through establishing an RiH framework, the programme will identify processes with outcomes that aim to capture how high-quality healthcare provisions are achieved. A collaborative learning framework centred on engagement aims to systematically translate research findings into practice through co-construction processes with partners and stakeholders., Ethics and Dissemination: The RiH research programme is approved by the Norwegian Centre for Research Data (No. 864334). The empirical projects selected for inclusion in this longitudinal research programme have been approved by the Norwegian Centre for Research Data or the Regional Committees for Medical and Health Research Ethics. The RiH research programme has an embedded publication and dissemination strategy focusing on the progressive sharing of scientific knowledge, information and results, and on engaging with the public, including relevant patient and stakeholder representatives. The findings will be disseminated through scientific articles, PhD dissertations, presentations at national and international conferences, and through social media, newsletters and the popular media., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Ageing is associated with worse treatment outcome after traumatic brain injury (TBI). This association may lead to a self-fulfilling prophecy that affects treatment efficacy. The aim of the current study was to evaluate the role of treatment bias in patient outcomes by studying the intensity of diagnostic procedures, treatment, and overall 30-day mortality in different age groups of patients with TBI., Methods: Included in this study was consecutively admitted patients with TBI, aged ≥ 15 years, with a cerebral CT showing intracranial signs of trauma, during the time-period between 2015-2018. Data were extracted from our prospective quality control registry for admitted TBI patients. As a measure of management intensity in different age groups, we made a composite score, where placement of intracranial pressure monitor, ventilator treatment, and evacuation of intracranial mass lesion each gave one point. Uni- and multivariate survival analyses were performed using logistic multinomial regression., Results: A total of 1,571 patients with TBI fulfilled the inclusion criteria. The median age was 58 years (range 15-98), 70% were men, and 39% were ≥ 65 years. Head injury severity was mild in 706 patients (45%), moderate in 437 (28%), and severe in 428 (27%). Increasing age was associated with less management intensity, as measured using the composite score, irrespective of head injury severity. Multivariate analyses showed that the following parameters had a significant association with an increased risk of death within 30 days of trauma: increasing age, severe comorbidities, severe TBI, Rotterdam CT-score ≥ 3, and low management intensity., Conclusion: The present study indicates that the management intensity of hospitalised patients with TBI decreased with advanced age and that low management intensity was associated with an increased risk of 30-day mortality. This suggests that the high mortality among elderly TBI patients may have an element of treatment bias and could in the future be limited with a more aggressive management regime.

Background: Elderly trauma patients constitute a vulnerable group, with a substantial risk of morbidity and mortality even after low-energy falls. As the world's elderly population continues to increase, the number of elderly trauma patients is expected to increase. Limited data are available about the possible patient safety challenges that elderly trauma patients face. The outcomes and characteristics of the Norwegian geriatric trauma population are not described on a national level., Objective: The aim of this project is to investigate whether patient safety challenges exist for geriatric trauma patients in Norway. An important objective of the study is to identify risk areas that will facilitate further work to safeguard and promote quality and safety in the Norwegian trauma system., Methods: This is a population-based mixed methods project divided into 4 parts: 3 quantitative retrospective cohort studies and 1 qualitative interview study. The quantitative studies will compare adult (aged 16-64 years) and elderly (aged ≥65 years) trauma patients captured in the Norwegian Trauma Registry (NTR) with a date of injury from January 1, 2015, to December 31, 2018. Descriptive statistics and relevant statistical methods to compare groups will be applied. The qualitative study will comprise focus group interviews with doctors responsible for trauma care, and data will be analyzed using a thematic analysis to identify important themes., Results: The project received funding in January 2019 and was approved by the Oslo University Hospital data protection officer (No. 19/16593). Registry data have been extracted for 33,344 patients, and the analysis of these data has begun. Focus group interviews will be conducted from spring 2020. Results from this project are expected to be ready for publication from fall 2020., Conclusions: By combining data from the NTR with interviews with doctors responsible for treatment and transfer of elderly trauma patients, we will provide increased knowledge about trauma in Norwegian geriatric patients on a national level that will form the basis for further research aiming at developing interventions that hopefully will make the trauma system better equipped to manage the rising tide of geriatric trauma., International Registered Report Identifier (irrid): PRR1-10.2196/15722., (©Mathias Cuevas-Østrem, Olav Røise, Torben Wisborg, Elisabeth Jeppesen. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 30.04.2020.)

Background: Understanding the resilience of healthcare is critically important. A resilient healthcare system might be expected to consistently deliver high quality care, withstand disruptive events and continually adapt, learn and improve. However, there are many different theories, models and definitions of resilience and most are contested and debated in the literature. Clear and unambiguous conceptual definitions are important for both theoretical and practical considerations of any phenomenon, and resilience is no exception. A large international research programme on Resilience in Healthcare (RiH) is seeking to address these issues in a 5-year study across Norway, England, the Netherlands, Australia, Japan, and Switzerland (2018-2023). The aims of this debate paper are: 1) to identify and select core operational concepts of resilience from the literature in order to consider their contributions, implications, and boundaries for researching resilience in healthcare; and 2) to propose a working definition of healthcare resilience that underpins the international RiH research programme., Main Text: To fulfil these aims, first an overview of three core perspectives or metaphors that underpin theories of resilience are introduced from ecology, engineering and psychology. Second, we present a brief overview of key definitions and approaches to resilience applicable in healthcare. We position our research program with collaborative learning and user involvement as vital prerequisite pillars in our conceptualisation and operationalisation of resilience for maintaining quality of healthcare services. Third, our analysis addresses four core questions that studies of resilience in healthcare need to consider when defining and operationalising resilience. These are: resilience 'for what', 'to what', 'of what', and 'through what'? Finally, we present our operational definition of resilience., Conclusion: The RiH research program is exploring resilience as a multi-level phenomenon and considers adaptive capacity to change as a foundation for high quality care. We, therefore, define healthcare resilience as: the capacity to adapt to challenges and changes at different system levels, to maintain high quality care. This working definition of resilience is intended to be comprehensible and applicable regardless of the level of analysis or type of system component under investigation.

Aims: To examine the incidence of intraoperative peripheral nerve injury, symptoms, risk factors, functions, and quality of life in patients undergoing robotic-assisted laparoscopic surgery to lithotomy positioning with steep Trendelenburg., Design: A systematic review., Data Sources: The Cochrane Library catalogue, PubMed, EMBASE, CINHAL and SveMed + databases were searched from January 2000 - February 2019., Review Methods: Titles and abstracts were screened for inclusion. Full-text assessments of each paper were conducted by two reviewers. The quality of the included papers was assessed using the Mixed Methods Appraisal Tool. Descriptive statistics and thematic analysis were used to synthesize the data., Results: Eleven quantitative studies were included with three themes: (a) incidence of intraoperative peripheral nerve injury; (b) upper extremity intraoperative peripheral nerve injury related to steep Trendelenburg positioning; and (c) lower extremity intraoperative peripheral nerve injury related to lithotomy positioning. The overall incidence of intraoperative peripheral nerve injury in robotic-assisted laparoscopic urologic, gynaecologic and colorectal surgery was 0.16%-10.0% and the symptoms appeared immediately after surgical procedures. Risk factors for intraoperative peripheral injury were prolonged operative time, high American Society of Anesthesiologists scores, comorbidities and high body mass index., Conclusion: Intraoperative peripheral nerve injuries are rare, but occasionally serious when related to lithotomy positioning with steep Trendelenburg. Operating room nurses have a responsibility both for positioning patients and for being familiar with the technological developments that will influence the preoperative handling of patients., Impact: This systematic review emphasizes the need for operating room nurses together with surgical team to have knowledge about mechanisms for injury, positioning, anatomy/physiology, and evaluation of risk factors to ensure that patients are not exposed for intraoperative peripheral nerve injuries. Increased robotic-assisted laparoscopic surgery necessitates further research examining the incidence of intraoperative peripheral nerve injury related to positioning and how these affect patients' function and the quality of life., (© 2019 John Wiley & Sons Ltd.)

Objectives: To explore hospital physicians' views on readmission and discharge processes in the interface between hospitals and municipalities., Design: Qualitative case study., Setting: The Norwegian healthcare system., Participants: Fifteen hospital physicians (residents and consultants) from one hospital, involved in the treatment and discharge of patients., Results: The results of this study showed that patients were being discharged earlier, with more complex medical conditions, than they had been previously, and that discharges sometimes were perceived as premature. Insufficient capacity at the hospital resulted in pressure to discharge patients, but the primary healthcare service of the area was not always able to assume care of these patients. Communication between levels of the healthcare service was limited. The hospital stay summary was the most important, and sometimes only, form of communication between levels. The discharge process was described as complicated and was affected by healthcare personnel, by patients themselves and by aspects of the primary healthcare service. Early hospital discharges, poor communication between healthcare services and inadequacies in the discharge process were perceived to affect hospital readmissions., Conclusion: The results of this study provide a better understanding of hospital physicians' views on the discharge and hospital readmission processes in the interface between the hospital and the primary healthcare service. The study also identifies discrepancies in governmental requirements, reform regulations and current practices in municipalities and hospitals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Thirty-day hospital readmissions represent an international challenge leading to increased prevalence of adverse events, reduced quality of care and pressure on healthcare service's resources and finances. There is a need for a broader understanding of hospital readmissions, how they manifest, and how resources in the primary healthcare service may affect hospital readmissions. The aim of the study was to examine how nurses and nursing home leaders experienced the resource situation, staffing and competence level in municipal healthcare services, and if and how they experienced these factors to influence hospital readmissions., Method: The study was conducted as a comparative case study of two municipalities affiliated with the same hospital, chosen for historical differences in readmission rates. Nurses and leaders from four nursing homes participated in focus groups and interviews. Data were analyzed within and across cases., Results: The analysis resulted in four common themes, with some variation in each municipality, describing nurses' and leaders' experience of the nursing home resource situation, staffing level and competence and their perception of factors affecting hospital readmissions. The nursing home patients were described as becoming increasingly complex with a subsequent need for increased nurse competence. There was variation in competence and staffing between nursing homes, but capacity building was an overall focus. Economic limitations and attempts at saving through cost-cutting were present, but not perceived as affecting patient care and the availability of medical equipment. Several factors such as nurse competence and staffing, physician coverage, and adequate communication and documentation, were recognized as factors affecting hospital readmissions across the municipalities., Conclusion: Several factors related to nurses' and leaders' experience of the resource situation, staffing and competence level were suggested to affect hospital readmissions and the municipalities were similar in their answers regarding these factors. Patients were perceived as more complex with higher patient mortality forcing long-term nursing homes to shift towards an acute care or palliative function, and short-term nursing homes to function as "small hospitals", requiring higher nurse competence. Staffing, competence and physician coverage did not seem to have adjusted to the new patient group in some nursing homes.

Background: Hospital readmissions is an increasingly serious international problem, associated with higher risks of adverse events, especially in elderly patients. There can be many causes and influential factors leading to hospital readmissions, but they are often closely related, making hospital readmissions an overall complex area. In addition, a comprehensive coordination reform was introduced into the Norwegian healthcare system in 2012. The reform changed the premises for readmissions with economic incentives enhancing early transfer from secondary to primary care, making research on readmissions in the municipalities more urgent than ever. General practitioners (GPs) and nursing home physicians, have traditionally held a gatekeepers function in hospital readmissions from the municipal healthcare service, as they are the main decision-makers in questions of hospital readmissions. Still, the GPs' gatekeeper function is an under-investigated area in hospital readmission research. The aim of the study was to increase knowledge about factors that lead to hospital readmissions among elderly in municipal healthcare, with special attention to GPs' and nursing home physicians' decision making., Method: The study was conducted as a comparative case study. Two municipalities affiliated with the same hospital, but with different readmission rates were recruited. Twenty GPs and nursing home physicians from each municipality were recruited and interviewed. Forty hours of observation were conducted during the huddles in one long-term and one short-term nursing home in each municipality., Results: Seven themes describing how different factors influence physicians' decision-making in the hospital readmission process in two municipalities were identified. Poor communication, continuity and information flow account for hospital readmissions in both municipalities. Several factors, including nurse staffing and competence, patients and their families, time constraints and experience affected physicians' decision-making., Conclusion: Communication, continuity and information flow contributed to hospital readmissions in both municipalities. The cross-case analysis revealed slight differences between municipalities. More research focusing on GPs' and nursing home physicians' decision-making, nursing home nurses and home care nurses' experience of hospital readmissions and discharges is needed.

Background: Post traumatic arthritis and avascular necrosis of the femoral head are common complications after operatively treated acetabular fractures. This may cause severe disabilities for the patient, necessitating a total hip arthroplasty. Even though an arthroplasty may provide good symptomatic relief, the long-term results are more uncertain and no consensus exists according to preferred prosthetic designs. With this cohort study, we aimed to investigate the medium to long term arthroplasty survival and clinical results of total hip arthroplasty after operatively treated acetabular fractures., Methods: We included 52 patients treated with a secondary total hip arthroplasty at a median of 2.4 (0.1-14.1) years after an operatively treated acetabular fracture. The median age was 54 (11-82) years. Cemented arthroplasty was used for 33 patients, 10 patients had an uncemented arthroplasty and 9 patients received a hybrid arthroplasty. Average follow up was 8.0 (SD 5.0) years., Results: Ten-year revision free arthroplasty survival was 79%. Uncemented arthroplasties had a significantly worse 10-year survival of 57%. Arthroplasties performed at a centre without a pelvic fracture service also had a significantly worse 10-years survival of 51%. Cox regression showed similar results with an 8-fold increase in risk of revision for both uncemented arthroplasties and operations performed at a non-pelvic trauma centre., Conclusion: Total hip arthroplasty secondary to an operatively treated acetabular fracture provides good symptomatic relief. These patients are, however, complex cases and are probably best treated at specialist centres with both pelvic trauma surgeons and arthroplasty surgeons proficient in complex revisions present., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: The Active Straight Leg Raise is a functional test used in the assessment of pelvic girdle pain, and has shown to have good validity, reliability and responsiveness. The Active Straight Leg Raise is considered to examine the patients' ability to transfer load through the pelvis. It has been hypothesized that patients with pelvic girdle pain lack the ability to stabilize the pelvic girdle, probably due to instability or increased movement of the sacroiliac joint. This study examines the movement of the sacroiliac joints during the Active Straight Leg Raise in patients with pelvic girdle pain., Methods: Tantalum markers were inserted in the dorsal sacrum and ilium of 12 patients with long-lasting pelvic girdle pain scheduled for sacroiliac joint fusion surgery. Two to three weeks later movement of the sacroiliac joints during the Active Straight Leg Raise was measured with radiostereometric analysis., Findings: Small movements were detected. There was larger movement of the sacroiliac joint of the rested leg's sacroiliac joint compared to the lifted leg's side. A mean backward rotation of 0.8° and inward tilt of 0.3° were seen in the rested leg's sacroiliac joint., Interpretation: The movements of the sacroiliac joints during the Active Straight Leg Raise are small. There was a small backward rotation of the innominate bone relative to sacrum on the rested leg's side. Our findings contradict an earlier understanding that a forward rotation of the lifted leg's innominate occur while performing the Active Straight Leg Raise., (Copyright © 2017. Published by Elsevier Ltd.)

Background: Few studies have evaluated the long-term results for nonoperatively treated acetabular fractures. The purpose of this study was to describe the long-term survival of the native acetabulum as well as the clinical and radiographic outcome for patients with nonoperatively treated acetabular fractures., Methods: All patients with acetabular fractures are prospectively registered in our acetabular fracture database and followed up at regular intervals for up to 20 years. We identified 236 patients (237 fractures) who had been treated nonoperatively between 1994 and 2004; 51 patients with incomplete data were excluded. For the survival analysis, 186 fractures with an average follow-up of 9 years (range, 1 to 20 years) were included. For the long-term clinical outcome, 104 patients with an average follow-up of 12.1 years (range, 9 to 20 years) were included., Results: The 10-year survival of the native hips was 94% (111 hips were at risk). Eighty-nine percent of the patients had a good or excellent Harris hip score, and 88% had a good or excellent Merle d'Aubigné and Postel score. The most important negative predictor for clinical outcome and survival of the hip was a fracture step-off of ≥2 mm measured in the obturator oblique radiograph., Conclusions: Nonoperative treatment of minimally displaced acetabular fractures yields good to excellent long-term results. For patients with a questionable indication for fracture surgery, oblique radiographs (Judet views) are a helpful tool in the decision-making process, as a fracture step-off of ≥2 mm is a strong predictor for a poor clinical and radiographic result at 10 years., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.)

Study Design: Retrospective case series., Introduction: Traumatic lumbosacral dissociation (TLSD) is a rare subgroup of sacral fractures caused by high-energy trauma in healthy adults. There are no accepted treatment algorithms for these injuries. Neurologic deficits and pain are commonly associated with these injuries, however, little is known about the long-term functional outcome in patients with TLSD. The objective of this study was to assess long-term functional outcome in patients with traumatic lumbosacral dissociation (TLSD) injuries., Materials and Methods: Thirteen patients with TLSD were retrospectively identified and followed with clinical and radiological examination mean 7.7 (3-12) years after the injury. Five were treated operatively, and eight non-operatively. Sensorimotor impairments in the lower extremities were classified according to ASIA. Urinary function was assessed with uroflowmetry, and bowel- and sexual functions were assessed using a structured interview. Pain was assessed using a visual analogue scale (VAS), and patient-reported health with SF-36. CT images were scrutinized for non-union and kyphotic angulation across the fracture., Results: Eleven patients had neurologic deficits corresponding to L5 and sacral roots. Urinary dysfunction was observed in nine, and bowel dysfunction in three patients. Eight patients reported problems associated with sexual activities, with pain during intercourse and erectile dysfunction being the most common problems. Twelve patients reported pain in the lumbosacral area, in combination with radiating pain in the majority. The overall patient-reported health (SF-36) was significantly lower than the normal population. All sacral fractures were united as seen on CT. Sacral kyphotic angulation was present in 11, which had increased in three patients comparing with the initial radiographs., Conclusion: In this long-term follow-up, functional impairments, pain, and poor patient-reported health were common findings among patients with TLSD. High rates of neurologic, urinary and sexual dysfunctions were reported. Extended follow-up several years after the injury with a special focus on urogenital dysfunctions and pain management may be beneficial to these patients., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: The present study was designed to examine whether oblique radiographs (Judet views) in addition to 2D and 3D CT scans improved the intra- and interobserver reliability when assessing acetabular fractures., Materials and Methods: Four international orthopedic pelvic trauma centers reviewed the radiological images for 20 acetabular fracture patients. Three different image sets were made; one set containing plain radiographs including oblique (Judet) views and 2D axial CT scans. The second set contained an AP radiograph of the pelvis, without oblique views, 2D and 3D CT scans. The third set contained all the images. The image sets were evaluated in three separate sessions, for each session the raters were asked to classify the fracture according to Letournel, as well as record a number of other important radiological features concerning the fracture., Results: The interobserver agreement for the Letournel classification was found to be moderate for all image sets. The image set without oblique views showed the best agreement with a kappa value of 0.60. The intra- and interobserver agreement for important modifiers were found to be substantial. The addition of oblique radiographs did not seem to increase the intra- or interobserver agreement for any of the factors evaluated except for the roof arc score., Conclusion: The moderate agreement found for the Letournel classification is to be expected given the complexity of the classification. The addition of oblique radiographs to the image sets does not seem to improve the reliability and thus its routine use for classification and decision making may be debated.

Objectives: To assess long-term patient-reported health (PRH) after displaced sacral fractures, its association with clinical outcomes, and changes over time., Design: Prospective, longitudinal single-cohort study., Setting: Level I trauma center., Patients/participants: From 1996 to 2001, 31 consecutive patients with operatively treated displaced sacral fractures participated in a 1-year follow-up. Twenty-eight of them were available for the present long-term follow-up of mean 10.7 years (range, 8.1-13.4) postinjury., Intervention: Surgical treatment with open or closed reduction and internal fixation., Main Outcome Measures: PRH was the main outcome, determined by the Short Form-36 (SF-36). Data were also collected on pain (using a visual analog scale), bladder function, neurologic deficits in the lower extremities, bowel function, sexual function, activities of daily living, and employment status. SF-36 scores from the present study were compared with norm-based scores for the Norwegian general population and 1-year scores., Results: At the present follow-up, mean 10.7 years (range, 8.1-13.4) postinjury, SF-36 scores were significantly lower than norm-based scores for all domains except mental health. No significant changes were observed between 1-year scores and scores from the present study. Pain correlated significantly with poor scores in the domains physical functioning (P = 0.05), role physical (P = 0.01), bodily pain (P = 0.003), general health (P = 0.007), and role emotional (P = 0.006). Sexual dysfunction correlated with poor social functioning (P = 0.013) and poor role emotional (P = 0.04); and bowel dysfunction with bodily pain (P = 0.02) and poor role emotional (P = 0.03). No correlations were found between SF-36 scores and bladder dysfunction or neurologic deficits., Conclusions: Patients with displaced sacral fractures reported poor PRH, mean 10.7 years after the initial injury, with no significant improvement compared with 1-year follow-up. A significant association was found between pain and PRH., Level of Evidence: Therapeutic level IV. description of levels of evidence.

Background and Purpose: Neurological deficits and pain are common after displaced sacral fractures. However, little is known about the association between the long-term clinical outcomes and radiological findings. We examined the long-term radiological findings and their correlations with lumbosacral pain and neurological deficits in the lower extremities after surgery for sacral fractures., Methods: 28 consecutive patients with operatively treated displaced sacral fractures were followed for mean 11 (8-13) years. Sensorimotor impairments of the lower extremities were classified according to the American Spinal Injury Association (ASIA). Pain was assessed using a visual analog scale (VAS). All patients underwent conventional radiographic examination and CT, and the images were scrutinized for nonunion, residual displacement, narrowing of the sacral foramina, and post-foraminal encroachment of the L5 and S1 nerves., Results: There was residual displacement of ≥ 10 mm in 16 of the 28 patients. 26 patients had narrowing of 1 or more neural root foramina in L5-S4. 8 patients reported having no pain, 11 had pain only in the lumbosacral area, and 9 had pain in combination with radiating leg pain. Statistically significant correlations were found between narrowing of the sacral foramina and neurological deficits in the corresponding dermatomes. Significant correlations were also found between post-foraminal encroachment of L5 nerves and both sensory and motor deficits. No correlations were found between pain and radiological findings., Interpretation: Pathological radiological findings are common 11 years after operatively treated displaced sacral fractures. Sacral foraminal and L5 post-foraminal bony encroachments were common findings and correlated with neurological deficits. However, lumbosacral pain did not correlate with radiological sequelae after fracture healing.

Background: Chamberlain's projections (anterior-posterior X-ray of the pubic symphysis) have been used to diagnose sacroiliac joint mobility during the single-leg stance test. This study examined the movement in the sacroiliac joint during the single-leg stance test with precise radiostereometric analysis., Methods: Under general anesthesia, tantalum markers were inserted into the dorsal sacrum and the ilium of 11 patients with long-lasting and severe pelvic girdle pain. After two to three weeks, a radiostereometric analysis was conducted while the subjects performed a single-leg stance., Findings: Small movements were detected in the sacroiliac joint during the single-leg stance. In both the standing- and hanging-leg sacroiliac join, a total of 0.5 degree rotation was observed; however, no translations were detected. There were no differences in total movement between the standing- and hanging-leg sacroiliac joint., Interpretation: The movement in the sacroiliac joint during the single-leg stance is small and almost undetectable by the precise radiostereometric analysis. A complex movement pattern was seen during the test, with a combination of movements in the two joints. The interpretation of the results of this study is that, the Chamberlain examination likely is inadequate in the examination of sacroiliac joint movement in patients with pelvic girdle pain., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: The fusion of the pelvic joints in patients with severe pelvic girdle pain (PGP) is a controversial and insufficiently studied procedure. The aims of this study were to evaluate physical function and pain after sacroiliac joint (SIJ) fusion., Methods: A single-subject research design study with repeated measurements was conducted; pre-operatively and at 3, 6 and 12 months post-operatively. The outcome measures considered were the Oswestry disability index (ODI), visual analogue scale (VAS), and SF-36. Eight patients with severe PGP received open-accessed unilateral anterior SIJ fusion and fusion of the pubic symphysis., Results: Seven patients reported positive results from the surgery. At 1 year post-operation, significant (p < 0.001) reductions in ODI (54 to 37) and VAS (82 to 57) were reported. The physical functioning, bodily pain, and social functioning scores in the SF-36 were also improved., Conclusion: Positive and significant changes in disability and pain at 1 year after SIJ fusion were observed. Despite these positive results, open accessed anterior fusion of the SIJ was associated with adverse events and complications such as infection and nerve damage.

Background: Injury severity is most frequently classified using the Abbreviated Injury Scale (AIS) as a basis for the Injury Severity Score (ISS) and the New Injury Severity Score (NISS), which are used for assessment of overall injury severity in the multiply injured patient and in outcome prediction. European trauma registries recommended the AIS 2008 edition, but the levels of inter-rater agreement and reliability of ISS and NISS, associated with its use, have not been reported., Methods: Nineteen Norwegian AIS-certified trauma registry coders were invited to score 50 real, anonymised patient medical records using AIS 2008. Rater agreements for ISS and NISS were analysed using Bland-Altman plots with 95% limits of agreement (LoA). A clinically acceptable LoA range was set at ± 9 units. Reliability was analysed using a two-way mixed model intraclass correlation coefficient (ICC) statistics with corresponding 95% confidence intervals (CI) and hierarchical agglomerative clustering., Results: Ten coders submitted their coding results. Of their AIS codes, 2189 (61.5%) agreed with a reference standard, 1187 (31.1%) real injuries were missed, and 392 non-existing injuries were recorded. All LoAs were wider than the predefined, clinically acceptable limit of ± 9, for both ISS and NISS. The joint ICC (range) between each rater and the reference standard was 0.51 (0.29,0.86) for ISS and 0.51 (0.27,0.78) for NISS. The joint ICC (range) for inter-rater reliability was 0.49 (0.19,0.85) for ISS and 0.49 (0.16,0.82) for NISS. Univariate linear regression analyses indicated a significant relationship between the number of correctly AIS-coded injuries and total number of cases coded during the rater's career, but no significant relationship between the rater-against-reference ISS and NISS ICC values and total number of cases coded during the rater's career., Conclusions: Based on AIS 2008, ISS and NISS were not reliable for summarising anatomic injury severity in this study. This result indicates a limitation in their use as benchmarking tools for trauma system performance., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Purpose: Fusion of the sacroiliac joints (SIJ) has been a treatment option for patients with severe pelvic girdle pain (PGP). The primary aims were to evaluate the long-term outcomes in patients who underwent SIJ fusion and to compare 1-year outcomes with long-term outcomes. The secondary aim was to compare patients who underwent SIJ fusion with a comparable group who did not., Methods: This study includes fifty patients that underwent SIJ fusion between 1977 and 1998. Function (the Oswestry disability index; ODI), pain intensity (visual analogue scale; VAS) and health-related quality of life (SF-36) were determined according to a patient-reported questionnaire. The questionnaire scores were compared with previously recorded 1-year outcomes and with questionnaire scores from a group of 28 patients who did not undergo SIJ fusion., Results: The patients who underwent SIJ fusion reported a mean ODI of 33 (95 % CI 24-42) and a mean VAS score of 54 (95 % CI 46-63) 23 years (range 19-34) after surgery. Regarding quality of life, the patients reported reduced physical function, but mental health was not affected in the same manner. The patients with successful 1-year outcomes (48 %) retained significantly improved function and reduced pain levels compared with the subgroup of patients with unsuccessful 1-year outcomes (28 %). The patients who underwent surgery did not differ from the non-surgery group in any outcome at the long-term follow-up., Conclusions: Patients treated with SIJ fusion had moderate disability and pain 23 years after surgery, and the 1-year outcomes were sustained 23 years after surgery. Although many fused patients reported good outcome, this group did not differ from the comparable non-surgical group.

Background: An increasing number of patients and stricter requirements for quality and efficiency in the management of emergency patients have spurred several Norwegian emergency departments (EDs) to introduce triage as one of several measures. This introduction has taken place without any accompanying research. We therefore wanted to investigate the use and organisation of triage, as well as the use of triage scales in the emergency departments., Material and Method: In the spring of 2010, a cross-sectional survey was undertaken among EDs with the aid of a questionnaire and telephone interviews., Results: Altogether 45 of a total of 56 Norwegian emergency hospitals (80%) participated. All our respondents reported that emergency patients underwent assessment for level of urgency. 34 (76%) reported to use triage scales, and 17 (50%) of these used self-composed scales. 21 (68%) of a total of 31 EDs that had goals for triage reported to evaluate these goals. 14 and 15 EDs respectively reported to have designated triage personnel and triage area. 24 EDs required internal triage training for nurses and assistant nurses., Interpretation: Our study reveals varying practices for use and organisation of triage in Norwegian EDs. This may be an effect of the absence of guidelines from the health authorities and reflect the insufficient priority which is given to ED work.

Background: Different techniques have been used to quantify the movement of sacroiliac (SI) joints. These include radiostereometric analysis (RSA), but the accuracy and precision of this method have not been properly evaluated and it is unclear how many markers are required and where they should be placed to achieve proper accuracy and precision., Purpose: The purpose of this study was to test accuracy and precision of RSA, applied to the SI joint, in a phantom model and in patients., Methods: We used a plastic phantom attached to a micrometer to obtain a true value of the movement of the SI joint and compared this value with the measured value obtained by RSA; the difference represented the accuracy. The precision of the system was measured by double examination in the phantom and in six patients, and was expressed by a limit of significance (LOS). We analyzed different marker distributions to find optimal marker placement and number of markers needed., Results: The accuracy was high and we identified no systematic errors. The precision of the phantom was high with a LOS less than 0.25° and 0.16 mm for all directions, and in patients, the precision was less than 0.71° for rotations and 0.47 mm translations. No markers were needed in the pubic symphysis to obtain good precision., Conclusions: The accuracy and precision are high when RSA is used to measure movement in the SI joint and support the use of RSA in research of SI joint motion.

Introduction: The purpose of this study was to assess the natural history of bone bruise and bone mineral density (BMD) after traumatic hip dislocations and conservatively treated acetabular fractures. Our hypothesis was that poor bone quality can influence degree of bone bruise and, in time, cause degenerative changes., Materials and Methods: Eight consecutive patients with traumatic hip dislocations and five patients with conservatively treated fractures in the femoral head and/or acetabulum were included. Magnetic resonance imaging (MRI) was obtained after 1, 17, 42, 82 and 97 weeks. Dual-emission X-ray absorptiometry (DXA) measurements were made after 10 days and 2 years. Sizes of bone bruise lesions were measured and classified. At the 2-year follow-up, Harris hip score (HHS) was calculated and signs of radiological osteoarthritis (OA) registered., Results: The bone bruise changes were small and all changes resolved within 42 weeks in all, except for three patients; one with a small Pipkin fracture had segmental avascular necrosis (AVN) of the femoral head, one had persisting1-3mm small spots of bone bruises in the femoral head and the third had <1cm lesions in both the femoral head and the acetabulum. The lesions were bigger in the femoral head in the hip dislocations and more pronounced in the acetabulum in the fractured acetabuli. We found no significant changes in BMD in four regions of interest (ROIs) after 2 years. No patients developed OA, and all had excellent HHS except for the one patient with AVN., Conclusion: The post-traumatic bone bruise changes in the dislocated hips and the fractured acetabuli were small and transient compared to findings of other authors examining traumatised knees. The patients had excellent function and no OA after 2 years if they did not develop AVN. In our small sample of relatively young patients with normal age-adjusted BMD, no post-traumatic osteopenia was observed. This might differ in the elderly with poorer bone quality; further studies are needed to assess that., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Introduction: Operations in trauma patients represent a second insult and the extent of the surgical procedures influences the magnitude of the inflammatory response. Our hypothesis was that a reamer-irrigator-aspirator (RIA) system would cause a lesser inflammatory response than traditional reaming (TR)., Materials and Methods: Coagulation, fibrinolysis and cytokine responses were studied in Norwegian landrace pigs during and after intramedullary nailing (IMN) with two different reaming systems using ELISA and chromogenic peptide substrate assays. The TR (n=8) and the RIA (n=7) reaming systems were compared to a control group (n=7). The animals were followed for 72 h. Arterial, mixed venous and femoral vein blood were withdrawn simultaneously peroperatively and until 2 h after the nail was inserted for demonstration of local, pulmonary and systemic activation of the cascade systems. At 6 h, 24 h, 48 h and 72 h postoperatively arterial blood samples were withdrawn., Results: Significantly procedure-related increased levels were found for thrombin-antithrombin (TAT) and tissue plasminogen activator (t-PA) in the TR group and TAT in the RIA group. The local and the pulmonary activation of coagulation and fibrinolysis were more pronounced in the TR than in the RIA group, the difference reached significance for plasminogen activator inhibitor-1 (PAI-1) (arterial blood). The cytokine response, mainly represented by IL-6 increase, was more pronounced in the TR than the RIA group, and was significant for IL-6 in femoral vein blood. The arterial levels of IL-6 exceeded the mixed venous levels indicating an additional pulmonary activation of IL-6. Two animals in the TR group, who died of pulmonary embolism (PE) prior to planned study end point, had a more pronounced response compared to the rest of the TR group., Conclusion: A procedure-related coagulation and fibrinolytic response was demonstrated in both reaming groups, with more pronounced response in the TR than in the RIA group. Elevated levels of cytokines were demonstrated related to reaming and nailing, with significantly higher IL-6 levels in the TR than in the RIA group., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Introduction: Intramedullary orthopaedic procedures may increase the intramedullary pressure (IMP) and thereby cause intravasation of bone marrow contents. In recent studies by the authors the reamer-irrigator-aspirator (RIA) has been demonstrated to reduce IMP and coagulation-, fibrinolysis- and cytokine responses, but did not prove any significant difference in cardiopulmonary function parameters or numbers of emboli when compared to a traditional reaming (TR) system. The correlations between IMP increase, regardless type of reamer, and inflammatory- and coagulation responses, pulmonary embolization, and cardiopulmonary alterations have, however, not previously been analyzed in this material. Our hypothesis was that a lower IMP would result in reduced occurrence of pulmonary embolization, reduced inflammatory-and coagulation responses, as well as reduced cardiopulmonary alterations., Materials and Methods: Twenty-eight young Norwegian landrace pigs were exposed to femoral intramedullary reaming, with either the TR (n = 10) or the RIA (n = 10) system, or used as controls (n = 8). IMP was recorded during reaming and nailing. Serial blood samples for demonstration of coagulation-, fibrinolysis-, and cytokine activation were withdrawn peroperatively and until 72 hours post nail insertion. Circulatory and pulmonary effects were monitored peroperatively and until two hours postoperatively. The animals were sacrificed 72 hours post nail insertion and lung tissue biopsies were harvested and examined for lung emboli., Results and Conclusions: A strong correlation between increased IMP and increased coagulation-and cytokine responses was found. The number of emboli was not significantly correlated to IMP, but was strongly correlated to changes in the coagulation- and cytokine responses. No clinical relevant correlations were observed between increased IMP or numbers of lung emboli and changes in hemodynamic- or pulmonary function parameters. A correlation between coagulation activation and cytokine activation was observed. This study confirms the connection between increased IMP, increased coagulation activation and the magnitude of pulmonary emboli in a model evaluating the effects of intramedullary reaming of intact pig femora. In this model, the lowering of IMP during reaming, as obtained with RIA, reduced the magnitude of and the effects of bone marrow extravasation., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background: Due to improved surgical techniques and more efficient decision making in treating severely injured patients, survival rates have increased over the years. This study was initiated to evaluate the incidence and identify risk factors for developing posttraumatic stress symptoms, using both extensive trauma-related data and data assessing the psychological trauma, in a population of severely injured patients., Patients and Methods: 79 patients admitted to the Department of Multitrauma and Spinal Cord Injury at Sunnaas Rehabilitation Hospital from 2003 to 2005, prospectively completed semistructured psychological interviews and questionnaires, such as Impact of Event Scale-Revised. In addition, extensive injury-related data, such as injury severity score (ISS), new injury severity score (NISS), and probability of survival (PS) were collected., Results: 39% had multiple trauma, 34% had multiple injuries including spinal cord injuries, and 27% had isolated spinal cord injuries. Mean NISS was 31.5 (S.D. 13.7). 6% met diagnostic criteria for posttraumatic stress disorder (PTSD) and 9% met the criteria for subsyndromal PTSD. Injury-related data did not influence the prevalence of posttraumatic stress symptoms, however, some psychosocial variables did have a significant impact., Conclusions: We found a low incidence of PTSD and subsyndromal PTSD. No significant differences were found between the patients suffering from posttraumatic stress symptoms and the non-symptoms group in relation to injury-related data such as ISS/NISS, PS, or multiple trauma versus spinal cord injury. The most evident risk factors for developing posttraumatic stress symptoms were symptoms of anxiety, female gender and negative attitudes toward emotional expression.

Background and Aims: Both fracture and fracture treatment affect bone mineral density (BMD). BMD after standard intramedullary reaming of the femoral cavity and after reaming with a reamer-irrigator-aspirator (RIA) system were studied with the hypothesis that the RIA technique would lead to lower BMD levels., Material and Methods: Dual-energy X-ray absorptiometry (DXA) was performed on the third day after operation with standard intramedullary nailing technique (n = 6) or RIA technique (n = 7) in intact femora of young Norwegian landrace pigs., Results and Conclusion: Significantly lower BMD were found in the mid-shaft and total femur after reaming with the RIA technique compared to the non-operated femur. Traditional reaming technique resulted in significantly higher BMD in the distal -femur., Interpretation: The results of this study indicate that standard reaming increased BMD in the distal femur, suggesting compressive effects on trabecular bone. The RIA technique decreased BMD in the femoral diaphysis and total femur, suggesting removal of trabecular bone. A possible clinical impact of the findings remains to be investigated.

Four hundred and fifty acetabular fractures in a prospectively recorded cohort were studied. Forty-one patients had died, 201 had a follow-up of more than 2 years and 25 were excluded which left a study population of 176 patients. Harris Hip Score (HHS) and modified HHS were used as outcome instruments. Acetabular fracture displacement and roof arc angles converted into a Roof Arc Score were assessed and correlated with clinical outcome at 2 years follow-up. For surgically treated fractures with residual steps and diastases after operation the correlation between steps and 2 year outcome was good. The location of fracture lines in the acetabular dome, expressed as a Roof Arc Score, proved to be more important than the residual step for 2 years clinical outcome (p<0.05). The impact of location of fracture lines in the acetabular dome on clinical outcome disappeared when open reduction and internal fixation (ORIF) resulted in a perfect anatomic reduction, i.e. without any residual steps or diastases assessed in the three radiographic views. The general association between fracture diastases and functional outcome was poor, except for non-operatively treated fractures without measurable steps.

Background: Increased intramedullary pressure in the femoral cavity causes intravasation of bone marrow content to the circulation which may lead to occlusion of pulmonary vessels and cardiorespiratory dysfunction. A one-step reamer-irrigator-aspirator (RIA) technique has been developed to reduce the intramedullary pressure (IMP) during the reaming procedure. This study was design to compare IMP with a standard reaming technique with IMP during reaming with the RIA system with a hypothesis that the RIA system would involve lower pressures., Material and Method: In a randomised study in 19 Norwegian landrace pigs reamed intramedullary nailing was performed with two different reamer devices. Nine animals were operated with a traditional reamer and 10 animals with RIA. One animal in the RIA group was excluded due to a perioperative femoral fracture, and three animals in the traditional group were excluded due to a perforation of the distal medial femoral cortex. The intramedullary pressure was registrated with a transducer-tipped pressure monitoring catheter during reaming., Results: There was a significantly higher intramedullary pressure (P<0.05) during reaming in the traditional reamer group (mean 188+/-38 mmHg) than in the RIA group (mean 33+/-8 mmHg). Intramedullary pressures recorded before surgery, at the opening of the femoral cavity with an awl, by insertion of a guide wire, at insertion of the intramedullary nail, and 10 min after nail insertion showed no significant differences between the groups., Conclusion: The use of a one-step reamer-irrigator-aspirator technique in the pig femur induced less intramedullary pressure increase than the use of a traditional reamer.

Fat embolism (FE) and fat embolism syndrome (FES) are controversial topics, particularly regarding their clinical relevance and their independency as a clinical syndrome. FE describes the presence of fat globules within the microcirculation. FES on the other hand, is a clinical syndrome characterized by the presence of FE with the manifestation of an identifiable clinical pattern of signs and symptoms. Both experimental and clinical studies have demonstrated the occurrence and the possible harmful effects of FE. For instance, FE involving the lungs can result in adult respiratory distress syndrome (ARDS). The effects of FE are certainly mechanical, leading to capillary congestion, but are also highly likely to be of a proinflammatory and prothrombotic nature. The demarcation of FES against ARDS is mainly demonstrated by the single organ involvement of ARDS, exclusively influencing the lungs, whereas FES has a multiorgan effect with pulmonary, skin and, neurological manifestations. This article is a review of the pathophysiological mechanisms of FE and the clinical occurrence and influence of FE and FES.

Study Design: A prospective, longitudinal single-cohort study of 32 patients treated with internal fixation for unstable sacral fractures., Objectives: To describe the prevalence of associated injuries in blunt pelvic trauma with unstable sacral fractures, and to characterize late impairments., Summary of Background Data: In high-energy pelvic ring injury, the close association of the spine, the intrapelvic organs and the bony pelvic ring result in high risk for additional injuries. These injuries may result in long-term sequels pertaining to mobility, voiding, bowel function, and sexual function. However, little is known about the components of long-term morbidity after unstable sacral fractures., Methods: The minimum 1-year follow-up included 32 patients surgically treated for unstable sacral fractures. Patients were analyzed for associated injuries, fracture classification, severity of trauma, and long-term measures of neurologic recovery, mobility, and functions pertaining to voiding, defecation, and sexual function., Results: Additional injuries occurred in 84%. Injury Severity Score was 27 (range, 9-57). At follow-up, sensory impairments were observed in 91%; impaired gait in 63%, and bladder, bowel, or sexual impairments in 59%. Sacral radiculopathies explained only 60% to 69% of these impairments. The presence of late impairments correlated to the severity of injury and to the presence of associated injuries, but not to fracture characteristics., Conclusions: Unstable fractures of the sacrum are frequently associated with additional injuries. These injuries have a significant effect on morbidity still 1 year after injury. The multifactor etiology of impairments after sacral fractures should be acknowledged in the assessment of these patients.

Background: The indication for acquiring angiographic embolization in the initial treatment of severe pelvic fractures is controversial. We describe the characteristics and outcome of 31 patients with traumatic pelvic bleeding who underwent percutaneous angiography with embolization according to a standardized protocol., Patients and Methods: During an 8.5-year period, 1,260 patients were treated for pelvic trauma. We performed a prospective registration of the 46 patients who underwent angiography, and report the 31 patients who had signs of significant arterial injury on angiography, necessitating embolization., Results: The rate of significant arterial injury after pelvic trauma was 2.5%. All patients had been subjected to high-energy injuries and all were severely injured as measured by the Injury Severity Score: 41 (17-66). Pelvic arterial injury was observed with all types of pelvic trauma, including isolated acetabular (4/31) and sacral fractures (3/31). The internal iliac artery or its branches was injured in 28 of 31 patients. Survival rate after embolization was 84%, and correlated inversely with increasing patient age. None of the patients died of bleeding., Interpretation: Our findings show that significant pelvic arterial injuries occur in a minority of patients after pelvic trauma, and predominantly affect patients with multiple high-energy injuries regardless of fracture type. The effect of angiographic embolization was good.

Introduction: Most pelvic haemorrhages are thought to be caused by injury to small arteries or veins in the fractured cancellous pelvic bone or in the surrounding soft-tissues, and only 6-18% of patients with unstable pelvic fractures have haemorrhage from larger arteries. When arterial injuries are present, the majority involve branches of the internal iliac artery with only few published reports of injuries to the external iliac artery or its branches., Materials and Methods: We report of a patient who sustained a combined pelvic and acetabular fracture with multifocal bleeding involving branches of both the internal iliac as well as the external iliac arteries after a crush injury. The primary attention was focused on the most probable arterial injury, the internal iliac artery and only at repeat angiography was the injury to the internal epigastric artery, caused by degloving injury to the trunk, recognized., Results: Arterial control was achieved only following aggressive fluid resuscitation, pelvic packing, repeated embolization and ligation of the peripelvic inferior epigastric artery. After initial haemodynamic control was achieved, the patient sustained multiple complications, partly as a consequence of the injury, but also as a consequence of the life-saving treatments., Conclusion: The case describes a rare combination of arterial injuries in a complex pelvic fracture constituting a partially stable pelvic fracture and a dislocated acetabular fracture in a patient with pelvic crush injury and a degloving injury to the trunk. The case also describes the complex nature of these injuries and rarely reported problems related to the treatment of them.

A 17-year-old man was severely injured including a fractured pelvis and a degloving injury to the lumbar, sacral, and gluteal regions. After multiple revisions, a 6 x 7 cm wide x 10 cm deep defect in the sacral area was successfully treated by transfer of a reversed turnover latissimus dorsi muscle flap. He is now fully mobilised three years later.

The long-term prognosis after open reduction of neglected posterior hip dislocations is poor; as such, primary arthroplasty is recommended by a number of authors. We present a patient with a 5-month-old posterior hip dislocation with concomitant paralysis of the sciatic nerve who had an open reduction. At a follow-up of 3.5 years, the patient has normal function with no signs of arthrosis. Magnetic resonance imaging scans, however, revealed partial avascular necrosis of the femoral head. A discussion based on the literature shows the uniqueness of this case.

18 patients treated with primary or secondary amputations after severe lower limb open fractures were studied. All limbs had clinical signs of a compromised circulation at the primary evaluation. The various injuries are described and discussed with respect to the general guidelines for primary amputation. The Mangled Extremity Severity Score (MESS) and Nerve, Ischemia, Soft tissues, Skeletal, Shock, Age (NISSSA) scores were calculated. In view of the described injuries, primary amputation was indicated in ten patients according to the general recommendations, 11 patients according to NISSSA and 15 patients according to MESS. Delayed amputation leads t a significantly (p = 0.005) higher number of operative procedures than early amputation (9.2 vs. 2.9 treatments). The decision of whether to amputate or not should be based on sound clinical judgement, but injury scores such as MESS and NISSSA may be helpful.

This article presents our experiences from fixation of the sacrum by transiliacal screw in 13 patients with unstable fractures of the pelvic ring. Early mobilization, with no secondary dislocation or postoperative complications, was achieved in all patients. Sagittal instability in unstable pelvic ring fractures must be acknowledged. The transiliac screw offers the possibility of early mobilization of patients with this fracture. The procedure is demanding and patients selected for this treatment should be referred to hospitals with experience in the treatment of pelvic fractures.

Components of the plasma kallikrein-kinin and fibrinolytic systems together with antithrombin III were measured the first days postpartum in 13 premature babies with severe respiratory distress syndrome (RDS). Seven of the patients received a single dose of porcine surfactant (Curosurf) as rescue treatment. Nine premature babies without lung disease or any other complicating disease served as controls. There were no differences in prekallikrein values between surfactant treated and non-treated RDS babies during the first 4 d postpartum. The controls had, however, significantly higher prekallikrein values than the RDS babies already at the first day of age (mean +/- SD 32 +/- 8% in controls versus 22 +/- 6 and 21.5 +/- 5% in the treated and nontreated RDS groups, respectively). Plasma kallikrein activities did not differ between RDS and control patients. Plasma kallikrein inhibition values, which increased steadily in all groups, were lower in the RDS babies treated with surfactant than in controls at d 2 and 4. The degree of degradation of plasma high molecular weight kininogen was measured in RDS patients treated with surfactant and was significantly higher when compared with controls at d 1, demonstrating an increased proteolysis of kininogen to kinin early in RDS. There were no differences in plasminogen and plasmin values between RDS and control babies. This study shows that the plasma kallikrein-kinin system is activated in RDS. This system as well as the fibrinolytic system does not seem to be influenced by rescue instillation of a single dose of porcine surfactant into the lungs of premature babies with RDS.

The article addresses the pathophysiological aspects connected to multiple trauma leading to organ damage. Several studies have shown that early operative stabilization of fractures is a lifesaving treatment involving less pulmonary complications, a shorter stay in hospital and lower hospital costs than operation at a late stage. The author also discusses guidelines for diagnosis and primary treatment of the fractures, and the timing and tactics of the final operative treatment. When the patient has been stabilized and injuries with higher priority (thoracic, abdominal and head injuries) have been successfully treated, it is recommended to operate major fractures as soon as possible (within 24 hours). It is necessary to have a liberal attitude to early operative treatment of minor fractures and injuries to ligaments, since these injuries might otherwise immobilize the patient and reduce the potential for physical restitution. The treatment of multi-traumatized patients imposes demands for extensive skills and experience, not only on the part of surgeons and anaesthetists, but also among the whole trauma team, including nurses in the operating theatre, anaesthetist nurses and nurses in the intensive care unit. This means that care of multi-traumatized patients should be centralized to experienced trauma units.

The most usual causes of blunt renal injuries are motor vehicle accidents, falls and participation in contact sports. Severe injuries are rare and a conservative approach in the treatment of such injuries is advocated by most authors. In this article we present a patient who suffered a major injury to the right kidney which was treated successfully by reconstructive surgery. We discuss the diagnosis of renal injuries, indications for surgery and surgical technique.

The activity of the extrinsic pathway inhibitor (EPI), which is the factor-Xa-dependent inhibitor of the factor VIIa-tissue thromboplastin complex, was serially determined in 13 patients with postoperative/posttraumatic septicemia, and compared to the activity of antithrombin (AT), heparin cofactor II and protein C (PC). In the survivors (n = 8), initial low values for all the inhibitors normalized during recovery. In the demises (n = 5), a progressive increase in EPI activity was observed until death, whereas progressive decreases were observed for the other inhibitors. No correlation was found between the inhibitor values and the endotoxin concentration. We conclude that EPI activities are increased in the late course of fatal septicemia. Apparently, a large EPI-AT gap is a severe prognostic indicator in such patients.