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Background: The study was performed to examine the hypothesis that functional outcomes following major lower-extremity trauma sustained in the military would be similar between patients treated with amputation and those who underwent limb salvage.Methods: This is a retrospective cohort study of 324 service members deployed to Afghanistan or Iraq who sustained a lower-limb injury requiring either amputation or limb salvage involving revascularization, bone graft/bone transport, local/free flap coverage, repair of a major nerve injury, or a complete compartment injury/compartment syndrome. The Short Musculoskeletal Function Assessment (SMFA) questionnaire was used to measure overall function. Standard instruments were used to measure depression (the Center for Epidemiologic Studies Depression Scale), posttraumatic stress disorder (PTSD Checklist-military version), chronic pain (Chronic Pain Grade Scale), and engagement in sports and leisure activities (Paffenbarger Physical Activity Questionnaire). The outcomes of amputation and salvage were compared by using regression analysis with adjustment for age, time until the interview, military rank, upper-limb and bilateral injuries, social support, and intensity of combat experiences.Results: Overall response rates were modest (59.2%) and significantly different between those who underwent amputation (64.5%) and those treated with limb salvage (55.4%) (p = 0.02). In all SMFA domains except arm/hand function, the patients scored significantly worse than population norms. Also, 38.3% screened positive for depressive symptoms and 17.9%, for posttraumatic stress disorder (PTSD). One-third (34.0%) were not working, on active duty, or in school. After adjustment for covariates, participants with an amputation had better scores in all SMFA domains compared with those whose limbs had been salvaged (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports. There were no significant differences between the groups with regard to the percentage of patients with depressive symptoms, pain interfering with daily activities (pain interference), or work/school status.Conclusions: Major lower-limb trauma sustained in the military results in significant disability. Service members who undergo amputation appear to have better functional outcomes than those who undergo limb salvage. Caution is needed in interpreting these results as there was a potential for selection bias. [ABSTRACT FROM AUTHOR]

Background: Urgent débridement of open fractures has been considered to be of paramount importance for the prevention of infection. The purpose of the present study was to evaluate the relationship between the timing of the initial treatment of open fractures and the development of subsequent infection as well as to assess contributing factors.Methods: Three hundred and fifteen patients with severe high-energy lower extremity injuries were evaluated at eight level-I trauma centers. Treatment included aggressive débridement, antibiotic administration, fracture stabilization, and timely soft-tissue coverage. The times from injury to admission and operative débridement as well as a wide range of other patient, injury, and treatment-related characteristics that have been postulated to affect the risk of infection within the first three months after injury were studied, and differences between groups were calculated. In addition, multivariate logistic regression models were used to control for the effects of potentially confounding patient, injury, and treatment-related variables.Results: Eighty-four patients (27%) had development of an infection within the first three months after the injury. No significant differences were found between patients who had development of an infection and those who did not when the groups were compared with regard to the time from the injury to the first débridement, the time from admission to the first débridement, or the time from the first débridement to soft-tissue coverage. The time between the injury and admission to the definitive trauma treatment center was an independent predictor of the likelihood of infection.Conclusions: The time from the injury to operative débridement is not a significant independent predictor of the risk of infection. Timely admission to a definitive trauma treatment center has a significant beneficial influence on the incidence of infection after open high-energy lower extremity trauma. [ABSTRACT FROM AUTHOR]

Background: Lower-extremity injuries constitute the leading cause of trauma hospitalizations among people under the age of 65 years. Rehabilitation has the potential to favorably influence the outcomes associated with traumatic lower-extremity injuries. Objectives: The objectives of this study were to explore variability in surgeon and physical therapist assessments of the need for physical therapy in patients with traumatic lower-extremity injuries and to determine the factors associated with assessments of need. Design: This study was a retrospective cohort investigation. Methods: Participants were 395 patients treated by reconstruction in the Lower-Extremity Assessment Project. They were evaluated at 8 level I trauma centers at 3, 6, and 12 months after hospitalization by an orthopedic surgeon and a physical therapist to determine the need for physical therapy. Analyses included multilevel logistic regression. Results: Chi-square analyses showed that surgeon and therapist assessments of need differed statistically across trauma centers. Surgeons were more likely to assess a need for therapy at 3 months when participants had low work self-efficacy, impaired knee flexion range of motion (ROM), and weight-bearing limitations and at 6 and 12 months when participants had impaired knee flexion ROM and weight-bearing and balance limitations. Therapists were more likely to assess a need for therapy at 3 months when participants had moderate to severe pain and at 6 and 12 months when participants had low work self-efficacy, pain, impaired knee flexion ROM, and balance limitations. Conclusions: The results revealed variability in assessments of the need for physical therapy at the provider and trauma center levels. Differences in provider assessments highlight the need for communication and further investigation into the outcomes and timing of physical therapy for the treatment of traumatic lower-extremity injuries. [ABSTRACT FROM AUTHOR]

Purpose: To provide guidance for managing the problem of missing data in clinical studies of trauma in order to decrease bias and increase the validity of findings for subsequent use. Organizing Construct: A thoughtful approach to missing data is an essential component of analysis to promote the clear interpretation of study findings. Methods: Integrative review of relevant biostatistics, medical and nursing literature, and case exemplars of missing data analyses using multiple linear regression based upon data from the National Study on the Costs and Outcomes of Trauma (NSCOT) was used as an example. Findings and Conclusions: In studies of traumatically injured people, multiple imputed values are often superior to complete case analyses that might have significant bias. Multiple imputation can improve accuracy of the assessment and might also improve precision of estimates. Sensitivity analyses which implements repeated analyses using various scenarios may also be useful in providing information supportive of further inquiry . This stepwise approach of missing data could also be valid in studies with similar types or patterns of missing data. Clinical Relevance: In interpreting and applying findings of studies with missing data, clinicians need to ensure that researchers have used appropriate methods for handling this issue. If suitable methods were not employed, nurse clinicians need to be aware that the findings may be biased. [ABSTRACT FROM AUTHOR]

ABSTRACT BACKGROUND: Injured survivors of individual and mass trauma are at risk for developing post-traumatic stress disorder (PTSD). Few investigations have assessed PTSD after injury in large samples across diverse acute care hospital settings.MethodA total of 2931 injured trauma survivors aged 18-84 who were representative of 9983 in-patients were recruited from 69 hospitals across the USA. In-patient medical records were abstracted, and hospitalized patients were interviewed at 3 and 12 months after injury. Symptoms consistent with a DSM-IV diagnosis of PTSD were assessed with the PTSD Checklist (PCL) 12 months after injury. RESULTS: Approximately 23% of injury survivors had symptoms consistent with a diagnosis of PTSD 12 months after their hospitalization. Greater levels of early post-injury emotional distress and physical pain were associated with an increased risk of symptoms consistent with a PTSD diagnosis. Pre-injury, intensive care unit (ICU) admission [relative risk (RR) 1.17, 95% confidence interval (CI) 1.02-1.34], pre-injury depression (RR 1.33, 95% CI 1.15-1.54), benzodiazepine prescription (RR 1.46, 95% CI 1.17-1.84) and intentional injury (RR 1.32, 95% CI 1.04-1.67) were independently associated with an increased risk of symptoms consistent with a PTSD diagnosis. White injury survivors without insurance demonstrated approximately twice the rate of symptoms consistent with a diagnosis of PTSD when compared to white individuals with private insurance. By contrast, for Hispanic injury survivors PTSD rates were approximately equal between uninsured and privately insured individuals. CONCLUSIONS: Nationwide in the USA, more than 20% of injured trauma survivors have symptoms consistent with a diagnosis of PTSD 12 months after acute care in-patient hospitalization. Coordinated investigative and policy efforts could target mandates for high-quality PTSD screening and intervention in acute care medical settings. [ABSTRACT FROM AUTHOR]

Background: Recent reports have suggested that functional outcomes are similar following either amputation or reconstruction of a severely injured lower extremity. The goal of this study was to compare two-year direct health-care costs and projected lifetime health-care costs associated with these two treatment pathways.Methods: Two-year health-care costs were estimated for 545 patients with a unilateral limb-threatening lower-extremity injury treated at one of eight level-I trauma centers. Included in the calculation were costs related to (1) the initial hospitalization, (2) all rehospitalizations for acute care related to the limb injury, (3) inpatient rehabilitation, (4) outpatient doctor visits, (5) outpatient physical and occupational therapy, and (6) purchase and maintenance of prosthetic devices. All dollar figures were inflated to constant 2002 dollars with use of the medical service Consumer Price Index. To estimate projected lifetime costs, the number of expected life years was multiplied by an estimate of future annual health-care costs and added to an estimate of future costs associated with the purchase and maintenance of prosthetic devices.Results: When costs associated with rehospitalizations and post-acute care were added to the cost of the initial hospitalization, the two-year costs for reconstruction and amputation were similar. When prosthesis-related costs were added, there was a substantial difference between the two groups ($81,316 for patients treated with reconstruction and $91,106 for patients treated with amputation). The projected lifetime health-care cost for the patients who had undergone amputation was three times higher than that for those treated with reconstruction ($509,275 and $163,282, respectively).Conclusions: These estimates add support to previous conclusions that efforts to improve the rate of successful reconstructions have merit. Not only is reconstruction a reasonable goal at an experienced level-I trauma center, it results in lower lifetime costs. [ABSTRACT FROM AUTHOR]

Background: The open tibial diaphyseal fracture remains a treatment challenge. The purpose of the present analysis of the long-term follow-up data on a previously reported cohort of patients was to identify surgeon-controlled variables that affected fracture union, complications, and final outcome in patients who had sustained a severe open tibial shaft fracture.Methods: A cohort of 156 patients with a limb-threatening open tibial diaphyseal fracture was identified from the Lower Extremity Assessment Project (LEAP) study group. The patients were prospectively followed for two to seven years. In addition to the Sickness Impact Profile, other outcome metrics included the time to fracture union as well as the occurrence of infection and other complications that required rehospitalization. Statistical differences between groups were calculated.Results: Within the parameters of the present study, the timing of débridement, the timing of soft-tissue coverage, and the timing of bone-graft placement had no effect on outcome. Patients in whom the fracture was definitively treated with an external fixator had more surgical procedures, took longer to achieve full weight-bearing status, and had more readmissions to the hospital for the treatment of infection and nonunion than did those in whom the fracture was treated with an intramedullary nail. Patients undergoing external fixation who also had a muscle flap for wound coverage had more physical impairment and a worse functional outcome than did patients who had an amputation.Conclusions: Surgeons should carefully consider alternative treatment options for patients who have a severe open tibial fracture when limb salvage is perceived to require the combination of external fixation for fracture fixation and a muscle flap for wound coverage. [ABSTRACT FROM AUTHOR]

Background and Purpose. Gait has been shown to be a major determining factor of function following limb-salvage surgery. However, little is known regarding the measures associated with gait recovery for this patient population. The purpose of this study was to identify clinical measures associated with impaired walking speed and gait asymmetry in patients with lower-extremity reconstruction. Subjects. Study subjects were 381 patients from the Lower Extremity Assessment Project (LEAP) who had undergone reconstruction following severe lower-extremity trauma. Methods. The LEAP study was a longitudinal study of outcomes following lower-extremity reconstruction. The present study used 24-month clinical follow-up data. A combined outcome measure of reduced walking speed and gait deviation was chosen to provide a comprehensive measure of impaired physical mobility. Results. The most significant clinical factors associated with decreased walking speed and gait deviation were impaired ankle plantar-flexion range of motion, knee flexion strength, and a nonreciprocal stair-climbing pattern. Discussion and Conclusion. The findings provide clinicians with specific clinical measures associated with functional recovery in patients with lower-limb reconstruction. These measures, in turn, can be considered to inform treatment decision making and to prioritize interventions. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To describe the prevalence of perceived environmental barriers in a population of amputees; to compare and contrast those barriers reported by amputees with reported barriers of a sample of disabled and nondisabled persons; and to identify the correlates of barriers among amputees. DESIGN: Cross-sectional survey. SETTING: A community sample who were interviewed by telephone. PARTICIPANTS: A stratified sample by etiology of 914 community-dwelling persons with limb loss. INTERVENTION: Telephone interview. MAIN OUTCOME MEASURES: Frequency (never, less than monthly, monthly, weekly, daily) and magnitude (little problem, big problem) of perceived environmental barriers in 5 domains as measured by the Craig Hospital Inventory of Environmental Factors-Short Form (CHIEF-SF), characteristics of the amputation, prosthetic use, and sociodemographic characteristics of the amputee. RESULTS: The majority (87%) of persons surveyed reported barriers in 1 or more areas with 57% reporting barriers in 4 or more of the 5 domains (policies, physical/structural, work/school, attitudes/support, and services/assistance subscales). Mean frequency-magnitude scores were lower for amputees with cancer-related amputation across all subscales, while traumatic amputees reported the greatest perceived barriers, except in the area of services/assistance. Across all domains, poverty level and comorbidity were significant predictors of significant barriers (CHIEF-SF score >/=3; range, 0-8). When compared with a general population sample of disabled and nondisabled Americans, amputees were more likely to perceive barrier in all areas except work/school. CONCLUSIONS: Perceived environmental barriers among persons with limb loss are highly prevalent. Reduction of environmental barriers may lead to reduction of disability and improvement of overall quality of life for amputees. Copyright © 2006 by Elsevier Inc. [ABSTRACT FROM AUTHOR]

Background: Plantar sensation is considered to be a critical factor in the evaluation of limb-threatening lower extremity trauma. The present study was designed to determine the long-term outcomes following the treatment of severe lower extremity injuries in patients who had had absent plantar sensation at the time of the initial presentation.Methods: We examined the outcomes for a subset of fifty-five subjects who had had an insensate extremity at the time of presentation. The patients were divided into two groups on the basis of the treatment in the hospital: an insensate amputation group (twenty-six patients) and an insensate salvage group (twenty-nine patients), the latter of which was the group of primary interest. In addition, a control group was constructed from the parent cohort so that the patients in the study groups could be compared with patients in whom plantar sensation was present and in whom the limb was reconstructed. Patient and injury characteristics as well as functional and health-related quality-of-life outcomes at twelve and twenty-four months after the injury were compared between the subjects in the insensate salvage group and those in the other two groups.Results: The patients in the insensate salvage group did not report or demonstrate significantly worse outcomes at twelve or twenty-four months after the injury compared with subjects in the insensate amputation or sensate control groups. Among the patients in whom the limb was salvaged (that is, those in the insensate salvage and sensate control groups), an equal proportion (approximately 55%) had normal plantar sensation at two years after the injury, regardless of whether plantar sensation had been reported to be intact at the time of admission. No significant differences were noted among the three groups with regard to the overall, physical, or psychosocial scores. At two years after the injury, only one patient in the insensate salvage group had absent plantar sensation.Conclusions: Outcome was not adversely affected by limb salvage, despite the presence of an insensate foot at the time of presentation. More than one-half of the patients who had presented with an insensate foot that was treated with limb reconstruction ultimately regained sensation at two years. Initial plantar sensation is not prognostic of long-term plantar sensory status or functional outcomes and should not be a component of a limb-salvage decision algorithm. [ABSTRACT FROM AUTHOR]

Background: A recent study demonstrated that patients treated with amputation and those treated with reconstruction had comparable functional outcomes at two years following limb-threatening trauma. The present study was designed to determine whether those outcomes improved after two years, and whether differences according to the type of treatment emerged.Methods: Three hundred and ninety-seven patients who had undergone amputation or reconstruction of the lower extremity were interviewed by telephone at an average of eighty-four months after the injury. Functional outcomes were assessed with use of the physical and psychosocial subscores of the Sickness Impact Profile (SIP) and were compared with similar scores obtained at twenty-four months.Results: On the average, physical and psychosocial functioning deteriorated between twenty-four and eighty-four months after the injury. At eighty-four months, one-half of the patients had a physical SIP subscore of > or = 10 points, which is indicative of substantial disability, and only 34.5% had a score typical of a general population of similar age and gender. There were few significant differences in the outcomes according to the type of treatment, with two exceptions. Compared with patients treated with reconstruction for a tibial shaft fracture, those with only a severe soft-tissue injury of the leg were 3.1 times more likely to have a physical SIP subscore of 5 points (p < 0.05) and those treated with a through-the-knee amputation were 11.5 times more likely to have a physical subscore of 5 points (p < 0.05). There were no significant differences in the psychosocial outcomes according to treatment group. Patient characteristics that were significantly associated with poorer outcomes included older age, female gender, nonwhite race, lower education level, living in a poor household, current or previous smoking, low self-efficacy, poor self-reported health status before the injury, and involvement with the legal system in an effort to obtain disability payments. Except for age, predictors of poor outcome were similar at twenty-four and eighty-four months after the injury.Conclusions: The results confirm previous conclusions that reconstruction for the treatment of injuries below the distal part of the femur typically results in functional outcomes equivalent to those of amputation. Regardless of the treatment option, however, long-term functional outcomes are poor. Priority should be given to efforts to improve post-acute-care services that address secondary conditions that compromise optimal recovery. [ABSTRACT FROM AUTHOR]

Background: Little is known about the psychological morbidity associated with limb-threatening injuries. It was hypothesized that a substantial proportion of patients who sustain a severe lower-limb injury will report serious psychological distress.Methods: Adult patients who were admitted to one of eight level-I trauma centers for treatment of an injury threatening the lower limb were enrolled during their initial hospitalization. Patients were recontacted at three, six, twelve, and twenty-four months after the injury and asked to complete the Brief Symptom Inventory (BSI), a fifty-three-item, self-reported measure of psychological distress. Patients who screen positive on the BSI are considered likely to have a psychological disorder and should receive a mental health evaluation. Longitudinal regression techniques were used to model positive case status (i.e., likely to have a psychological disorder) as a function of patient, injury, and treatment characteristics.Results: Of the 569 patients enrolled, 545 (96%) completed at least one BSI and 385 (68%) completed all four. Forty-eight percent of the patients screened positive for a likely psychological disorder at three months after the injury, and this percentage remained high (42%) at twenty-four months. Two years after the injury, almost one-fifth of the patients reported severe phobic anxiety and/or depression. While these two subscales reflected the highest prevalence of severe psychological distress, none of the BSI subscales reflected the prevalence expected from a normal sample (i.e., 2% to 3%). Factors associated with a likely psychological disorder included poorer physical function, younger age, non-white race, poverty, a likely drinking problem, neuroticism, a poor sense of self-efficacy, and limited social support. Relatively few patients reported receiving any mental health services following the injury (12% at three months and 22% at twenty-four months).Conclusions: Severe lower-limb injury is associated with considerable psychological distress. More attention to the psychological as well as the physical health of patients who sustain a limb-threatening injury may be needed to ensure an optimal recovery following these devastating injuries. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The Barell body region by nature of injury diagnosis matrix standardizes data selection and reports, using a two dimensional array (matrix) that includes all International Classification of Diseases (ICD)-9-CM codes describing trauma. AIM: To provide a standard format for reports from trauma registries, hospital discharge data systems, emergency department data systems, or other sources of non-fatal injury data. This tool could also be used to characterize the patterns of injury using a manageable number of clinically meaningful diagnostic categories and to serve as a standard for casemix comparison across time and place. CONCEPT: The matrix displays 12 nature of injury columns and 36 body region rows placing each ICD-9-CM code in the range from 800 to 995 in a unique cell location in the matrix. Each cell includes the codes associated with a given injury. The matrix rows and columns can easily be collapsed to get broader groupings or expanded if more specific sites are required. The current matrix offers three standard levels of detail through predefined collapsing of body regions from 36 rows to nine rows to five rows. MATRIX DEVELOPMENT: This paper presents stages in the development and the major concepts and properties of the matrix, using data from the Israeli national trauma registry, and from the US National Hospital Discharge Survey. The matrix introduces new ideas such as the separation of traumatic brain injury (TBI), into three types. Injuries to the eye have been separated from other facial injuries. Other head injuries such as open wounds and burns were categorized separately. Injuries to the spinal cord and spinal column were also separated as are the abdomen and pelvis. Extremities have been divided into upper and lower with a further subdivision into more specific regions. Hip fractures were separated from other lower extremity fractures. FORTHCOMING DEVELOPMENTS: The matrix will be used for the development of standard methods for the analysis of multiple injuries and the creation of patient injury profiles. To meet the growing use of ICD-10 and to be applicable to a wider range of countries, the matrix will be translated to ICD-10 and eventually to ICD-10-CM. CONCLUSION: The Barell injury diagnosis matrix has the potential to serve as a basic tool in epidemiological and clinical analyses of injury data. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine the performance of the ICD/AIS MAP (EJ MacKenzie et al) as a method of classifying injury severity for children. METHODS: Data on all children less than 16 years of age admitted to all designated trauma centers in Pennsylvania from January 1994 through October 1996 were obtained from the state trauma registry. The ICD/AIS MAP was used to convert all injury related ICD-9-CM diagnosis codes into abbreviated injury scale (AIS) score and injury severity score (ISS). Agreement between trauma registry AIS and ISS scores and MAP generated scores was assessed using the weighted kappa (kappaw) coefficient for ordered data and the intraclass correlation coefficient for continuous data. RESULTS: Agreement in ISS scores was excellent, both overall (intraclass correlation coefficient = 0.86, 95% confidence interval (CI) 0.84 to 0.89)), and when grouped into three levels of severity (kappaw= 0.86, 95% CI 0.85 to 0.87). Agreement in AIS scores across all body regions and ages was also excellent, (kappaw= 0.86 (95% CI 0.83 to 0.87). Agreement increased with age (kappaw= 0.78 for children <2 years; kappaw= 0.86 for older children) and varied by body region, though was excellent across all regions. CONCLUSIONS: The performance of the ICD/AIS MAP in assessing severity of pediatric injuries was equal to or better than previous assessments of its performance on primarily adult patients. Its performance was excellent across the pediatric age range and across nearly all body regions of injury. [ABSTRACT FROM AUTHOR]

Context: The premise underlying regionalization of trauma care is that larger volumes of trauma patients cared for in fewer institutions will lead to improved outcomes. However, whether a relationship exists between institutional volume and trauma outcomes remains unknown.Objective: To evaluate the association between trauma center volume and outcomes of trauma patients.Design: Retrospective cohort study.Setting: Thirty-one academic level I or level II trauma centers across the United States participating in the University Healthsystem Consortium Trauma Benchmarking Study.Patients: Consecutive patients with penetrating abdominal injury (PAI; n = 478) discharged between November 1, 1997, and July 31, 1998, or with multisystem blunt trauma (minimum of head injury and lower-extremity long-bone fractures; n = 541) discharged between June 1 and December 31, 1998.Main Outcome Measures: Inpatient mortality and hospital length of stay (LOS), comparing high-volume (>650 trauma admissions/y) and low-volume (Results: After multivariate adjustment for patient characteristics and injury severity, the relative odds of death was 0.02 (95% confidence interval [CI], 0.002-0.25) for patients with PAI admitted with shock to high-volume centers compared with low-volume centers. No benefit was evident in patients without shock (P =.50). The adjusted odds of death in patients with multisystem blunt trauma who presented with coma to a high-volume center was 0.49 (95% CI, 0.26-0.93) vs low-volume centers. No benefit was observed in patients without coma (P =.05). Additionally, a shorter LOS was observed in patients with PAI and New Injury Severity Scores of 16 or higher (difference in adjusted mean LOS, 1.6 days [95% CI, -1.5 to 4.7 days]) and in all patients with multisystem blunt trauma admitted to higher-volume centers (difference in adjusted mean LOS, 3.3 days [95% CI, 0.91-5.70 days]).Conclusions: Our results indicate that a strong association exists between trauma center volume and outcomes, with significant improvements in mortality and LOS when volume exceeds 650 cases per year. These benefits are only evident in patients at high risk for adverse outcomes. [ABSTRACT FROM AUTHOR]

Background: High-energy trauma to the lower extremity presents challenges with regard to reconstruction and rehabilitation. Failed efforts at limb salvage are associated with increased patient mortality and high hospital costs. Lower-extremity injury-severity scoring systems were developed to assist the surgical team with the initial decision to amputate or salvage a limb. The purpose of the present study was to prospectively evaluate the clinical utility of five lower-extremity injury-severity scoring systems.Methods: Five hundred and fifty-six high-energy lower-extremity injuries were prospectively evaluated with use of five injury-severity scoring systems for lower-extremity trauma designed to assist in the decision-making process for the care of patients with such injuries. Four hundred and seven limbs remained in the salvage pathway six months after the injury. The sensitivity, specificity, and area under the receiver operating characteristic curve were calculated for the Mangled Extremity Severity Score (MESS); the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA); and the Hannover Fracture Scale-97 (HFS-97) for ischemic and nonischemic limbs. The scores were analyzed in two ways: including and excluding limbs that required immediate amputation.Results: The analysis did not validate the clinical utility of any of the lower-extremity injury-severity scores. The high specificity of the scores in all of the patient subgroups did confirm that low scores could be used to predict limb-salvage potential. The converse, however, was not true. The low sensitivity of the indices failed to support the validity of the scores as predictors of amputation.Conclusions: Lower-extremity injury-severity scores at or above the amputation threshold should be cautiously used by a surgeon who must decide the fate of a lower extremity with a high-energy injury. [ABSTRACT FROM AUTHOR]

OBJECTIVES. To examine the consequences of head injury and the medical, economic, and sociodemographic factors affecting functional status 1 year after injury. METHODS. A follow-up was conducted on 95 children (aged 5 to 15) 1 year after they were hospitalized for head injury. Parents were interviewed by phone concerning their child's preinjury and current health status, and the family's economic and social resources during the 1 year postinjury. Inpatient medical records were reviewed to obtain information regarding the characteristics of the injury. RESULTS. We found that study children were more likely than children from the general population to have limitations in physical health, behavioral problems, and to be enrolled in a special education program. These findings were true for all levels of head injury severity, although children with severe head injuries (Abbreviated Injury Scale 5) were more likely to demonstrate these functional limitations than were children with less severe injuries (Abbreviated Injury Scale 2, 3, 4). After controlling for head injury severity, we found that the poorer outcomes were associated with poverty, preinjury chronic health problems, and lower extremity injuries. CONCLUSIONS. The large proportion of children who demonstrated functional limitations underscores the importance of evaluating all children hospitalized with head injuries for functional limitations and providing rehabilitation and social services when needed. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study analyzed short-term trends in pediatric injury hospitalizations. METHODS: We used a population-based retrospective cohort design to study all children 15 years or younger who were admitted to all acute care hospitals in Pennsylvania with traumatic injuries between 1991 and 1995. RESULTS: Injuries accounted for 9% of all acute hospitalizations for children. Between 1991 and 1995, admissions of children with minor injuries decreased by 29% (P < .001). However, admissions for children with moderate (P = .69) or serious (P = .41) injuries did not change. CONCLUSIONS: Significant declines in pediatric admissions for minor injuries were noted and may reflect both real reductions in injury incidence and changes in admission practices over the period of the study. [ABSTRACT FROM AUTHOR]

Study Design: Prospective longitudinal study.Objective: To determine the association between baseline patient activation and participation in postoperative physical therapy in a cohort of individuals after lumbar spine surgery.Summary Of Background Data: The Patient Activation Measure is a recently developed tool to assess patient activation. Patient activation is defined as an individual's propensity to engage in adaptive health behavior that may, in turn, lead to improved patient outcomes. It has not previously been used in spine research.Methods: We assessed baseline patient activation levels in individuals presenting for surgery of the lumbar spine via the Patient Activation Measure. Differences in patient characteristics across patient-activation quartiles were assessed using analysis of variance. After surgery, we assessed attendance (self-reported weekly) and engagement in physical therapy (at the last visit, using the Hopkins Rehabilitation Engagement Rating Scale) and determined the ratio of sessions attended to sessions prescribed. The influence of baseline patient activation, in the setting of other patient characteristics, to predict attendance and engagement with physical therapy was examined using linear regression methods.Results: Scores on the Patient Activation Measure were positively correlated with participation (r = 0.53) and engagement (r = 0.75) in physical therapy. Individuals with low activation were more likely to report low self-efficacy for physical therapy, low hope, and external locus of control compared with those with high activation.Conclusion: Increased patient activation is associated with improved adherence with physical therapy as reflected in attendance and engagement. [ABSTRACT FROM AUTHOR]