Natalie Enninghorst

Acute definitive internal fixation of pelvic ring fractures in polytrauma patients: a feasible option.

BACKGROUND Staged surgery is recommended for the management of multiple injuries-associated high-energy pelvic ring fractures (acute temporary skeletal stabilization is followed by definitive internal fixation [ORIF]). Acute definitive internal fixation is a controversial topic. The purpose of this study was to evaluate the safety and efficiency of acute pelvic ORIF by comparing its short-term outcomes with those who had staged surgery. METHODS A 43-month retrospective review of the prospective pelvic fracture database of a level-1 trauma center was performed. Consecutive high-energy trauma patients who sustained a fracture that was suitable for minimally invasive internal fixation (iliosacral screw fixation and symphyseal plating) were included. Patients were categorized as acute ORIF (<24 hours) or staged late ORIF (>24 hours). Demographics, Injury Severity Score, pelvic Abbreviated Injury Score, first 24-hour transfusions, physiologic parameters, time to operating room (OR), angiography requirement, length of stay (LOS), and mortality were recorded. Data are presented as mean +/- SD or percentages. Statistical significance was determined at p < 0.05 based on univariate analysis. RESULTS Forty-five patients met inclusion criteria, 18 patients had acute definitive ORIF (5.5 hours to OR) and 27 had late definitive ORIF (5 days to OR). Acute and late ORIF patients had comparable demographics (age: 48 +/- 22 years vs. 40 +/- 14 years, gender: 82% vs. 79% men) and injury severity (Injury Severity Score: 30 +/- 18 vs. 24.5 +/- 13, pelvic Abbreviated Injury Score: 3.7 +/- 1 vs. 3.4 +/- 1.1). Initial shock parameters were significantly worse in the acute ORIF group (systolic blood pressure, 69.7 +/- 17 mm Hg vs. 108 +/- 21 mm Hg; BD, -7.4 +/- 4 vs. -4.9 +/- 2 mEq/L, lactate 6.67 +/- 7 mmol/L vs. 2.51 +/- 1.3 mmol/L). Angiography was used in 18% (3/18) vs. 21% (6 of 27) of the cases. All early ORIF patients survived and one (3%) of the late ORIF patients died. There was a trend to shorter hospital LOS (25 +/- 24 days vs. 37 +/- 32 days) and a decreased 24-hour red cell transfusion rate (4.7 +/- 5 U vs. 6.6 +/- 4 U) in the early ORIF group. The intensive care unit admission rate (12 of 18 vs. 15 of 27) and LOS was comparable (2.9 +/- 2.5 days vs. 3.7 +/- 3.6 days). CONCLUSION Acute ORIF of unstable pelvic ring fractures within 6 hours could be safely performed even in severely shocked patients with multiple injuries. The procedure did not lead to increased rates of transfusion, mortality, intensive care unit LOS, or overall LOS. Furthermore, all these parameters showed a trend toward benefit compared with a staged approach.

Population-based epidemiology of femur shaft fractures

BACKGROUND The management of patients with femoral shaft fractures (FSFs) is often a decision making dilemma (damage-control orthopedics vs. early total care), with equivocal evidence. The comprehensive, population-based epidemiology of patients with FSF is unknown. The purpose of this prospective study was to describe the epidemiology of patients with FSF, with special focus on patient physiology and timing of surgery. METHODS A 12-month prospective population-based study was performed on consecutive patients with FSF in an area with 850,000 population including all ages and prehospital deaths. Patient demographics, mechanism, Injury Severity Score (ISS), shock parameters (systolic blood pressure, base deficit and lactate), transfusion requirement, fracture type [Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification (OA/OTA)], comorbidities, procedures, and outcomes were recorded. Patients hemodynamic status was described as stable, borderline, unstable, and “in extremis.” RESULTS A total of 126 patients (21 per 100,000 per year) with 136 femur fractures (62% male; age, 38 [28] years; ISS, 20 [19]; 51% multiple injuries) were identified in the region. Sixty patients (48.4%) sustained a high-energy injury with 19 (31.1%) of these being polytrauma patients (ISS, 28 [12]; systolic blood pressure, 98 [39]; base deficit, 6.5 [5.8]; lactate 4 [2]).Fifteen polytrauma patients (94%) required massive transfusion (12 [12] U of packed red blood cells, 8 [5] fresh frozen plasma, 1 [0.4] platelet, 13 [8] cryoprecipitate). Twenty-one patients (16.7%) died at the prehospital setting (3.5 per 100,000 per year). From the 105 hospital admissions, 68.3% was stable (14.3 per 100,000 per year), 8.7% was borderline (1.8 per 100,000 per year), 4.0% was unstable (0.8 per 100,000 per year) and 2.4% (0.5 per 100,000 per year) was in extremis. Six patients (5.7%) died. The length of stay (LOS) was 18 (15) days, and the intensive care unit LOS was 5 (6) days. Fourty-five patients sustained a low-energy injury that had in 85% of cases multiple comorbidities. Eight low-energy patients needed 3 (1) transfusions, and none of the patients died. The LOS was 15 (11) days. CONCLUSION Patients with low-energy FSF have a hospital admission rate similar to the patients with high-energy FSF. Sixty-eight percent of patients with FSF are complicated (open, compromised physiology, multiple injuries, bilateral, elderly with comorbidities, etc.), requiring major resources and highly specialized care. LEVEL OF EVIDENCE Epidemiology study, level III.

Open Tibia Fractures: Timely Debridement Leaves Injury Severity as the Only Determinant of Poor Outcome

BACKGROUND Recent retrospective studies suggest that the time to debridement of open tibia fractures is not a major determinant of outcome. The aim of this prospective study was to determine the modifiable independent predictors of poor outcomes. METHODS A 36-month prospective observational study ending in December 2009 was performed on consecutive open tibia shaft fracture patients (age >18 years) admitted to a Level 1 trauma center. Demographics, mechanism, Injury Severity Score, fracture type/grade, local contamination, time to debridement, time to antibiotics, and interventions were prospectively recorded. Outcome measures were as follows: length of stay, deep infection, secondary procedures, and presence of union at 6 months and 12 months. Univariate, multivariate, and logistic regression analyses were performed. RESULTS Eighty-nine consecutive patients (74% male, age 41 years±17 years, Injury Severity Score 15±3, and 37% multiple injured) met inclusion criteria. The mean time to surgical debridement and operative stabilization was 8 hours±4 hours (48% within 6 hours). The average length of stay was 21 days±13 days. Fifteen patients (17%) had deep infection and 5 (6%) required amputation (1 acute and 4 late because of the infection). The 6-month and 12-month union rates were 39% and 67%, respectively. Fifty-six patients (63%) required further procedures (a total of 312). The multivariate regression model (18 variables) showed no independent significant predictors for deep infection or nonunion at 6 months and 12 months (multiple injuries and smoking were closest to reach significance, p=0.08). CONCLUSION Timely management of open tibia fractures (mean, 8 hours) eliminates time to debridement and contamination as predictors of poor outcome. Patient factors and local and general injury severity determine the outcomes. Aiming for the earliest safe time to debridement minimizes the negative effects of modifiable factors on the outcome.

The definition of polytrauma: variable interrater versus intrarater agreement--a prospective international study among trauma surgeons.

BACKGROUND The international trauma community has recognized the lack of a validated consensus definition of “polytrauma.” We hypothesized that using a subjective definition, trauma surgeons will not have substantial agreement; thus, an objective definition is needed. METHODS A prospective observational study was conducted between December 2010 and June 2011 (John Hunter Hospital, Level I trauma center). Inclusion criteria were all trauma call patients with subsequent intensive care unit admission. The study was composed of four stages as follows: (1) four trauma surgeons assessed patients until 24 hours, then coded as either “yes” or “no” for polytrauma, and results compared for agreement; (2) eight trauma surgeons representing the United States, Germany, and the Netherlands graded the same prospectively assessed patients and coded as either “yes” or “no” for polytrauma; (3) 12 months later, the original four trauma surgeons repeated assessment via data sheets to test intrarater variability; and (4) individual subjective definitions were compared with three anatomic scores, namely, (a) Injury Severity Score (ISS) of greater than 15, (b) ISS of greater 17, and (c) Abbreviated Injury Scale (AIS) score of greater than 2 in at least two ISS body regions. RESULTS A total of 52 trauma patients were included. Results for each stage were as follows: (1) &kgr; score of 0.50, moderate agreement; (2) &kgr; score of 0.41, moderate agreement; (3) Rater 1 had moderate intrarater agreement (&kgr; score, 0.59), while Raters 2, 3, 4 had substantial intrarater agreement (&kgr; scores, 0.75, 0.66, and 0.71, respectively); and (4) none had most agreement with ISS of greater than 15 (&kgr; score, 0.16), while both definitions ISS greater than 17 and Abbreviated Injury Scale (AIS) score of greater than 2 in at least two ISS body regions had on average fair agreement (&kgr; scores, 0.27 and 0.39, respectively). CONCLUSION Based on subjective assessments, trauma surgeons do not agree on the definition of polytrauma, with the subjective definition differing both within and across institutions.

Borderline femur fracture patients: early total care or damage control orthopaedics?

Background:  A recent randomized controlled trial (RCT) favours damage control orthopaedics (DCO) over early total care (ETC) in the management of high‐energy femoral shaft fracture (FSF) patients with borderline physiology. The purpose of this study was to compare the borderline physiology FSF demographics, management and outcomes of a Level‐1 trauma centre, John Hunter Hospital (JHH) with those of the RCT.

Massive transfusion in trauma: blood product ratios should be measured at 6 hours.

Background:  Most potentially preventable haemorrhagic deaths occur within 6 h of injury. Conventionally, blood component therapy delivery is measured by 24‐h cumulative totals and ratios. The study aim was to examine the effect of a massive transfusion protocol (MTP) on early (6 h) balanced component therapy.

Intercostal catheter insertion: are we really doing well?

Introduction:  Intercostal catheters (ICC) are the standard management of chest trauma, but are associated with complications in up to 30%. The aim of this study was to evaluate errors in technique during ICC insertion to characterize the potential benefit of improved training programmes.

The prevalence of smoking and interest in quitting among surgical patients with acute extremity fractures

INTRODUCTION AND AIMS We studied the prevalence of smoking, the effect of hospital stay on motivation to quit and the exposure to smoking cessation advice in orthopaedic patients who required surgical intervention for acute extremity fractures. DESIGN AND METHODS This cross-sectional study involved a self-administered pen-and-paper survey assessing smoking status, interest and motivation to quit smoking, and current advice to quit among a consecutive cohort of patients aged 18-65 years old with acute extremity fractures. These patients were admitted to the John Hunter Hospital Level 1 trauma facility in New South Wales, Australia, for surgical intervention over a three month period. RESULTS A total of 183 patients (response rate 98%) completed the survey. Sixty-eight patients (37.2%) reported a current smoking habit. The prevalence of smoking was 42.2% among males and 25.5% among females. A total of 40% of smokers reported that they had not received advice to quit from medical staff during hospital admission. Prior to admission, 12.1% of smokers were interested in smoking cessation; this percentage increased to 26.8% post-admission. DISCUSSION AND CONCLUSIONS The prevalence of smoking among surgical patients with extremity fractures was found to be more than twice the prevalence of the population of New South Wales. Hospital admission had a positive impact on the patients interest in smoking cessation. Our study suggests that the identification of orthopaedic patients who smoke is suboptimal, and the opportunity to encourage smoking cessation during hospital admission is currently being overlooked.

Recalled pain scores are not reliable after acute trauma

INTRODUCTION Pain research in emergency settings can be problematic, as data collection is logistically difficult and pain levels are often poorly documented. Short-term recall of acute pain has been evaluated in postoperative, labour and procedural pain, with variable reported accuracy. The reliability of pain recall in trauma resuscitation patients is unknown. This study aims to determine the accuracy of short-term pain recall 1-2 days after trauma. METHODS Prospective, cohort study of trauma resuscitation patients transported by ambulance to a major trauma centre. Patients with haemodynamic instability (SBP<90, HR>120) or GCS<14 on arrival were excluded. Momentary pain scores were measured on an 11-point verbal numerical rating scale by paramedics during prehospital management. Patients were evaluated within 48 h of injury on the recall of their initial pain, pain during transport, and lowest pain score achieved by prehospital analgesia. Spearmans rank correlation and Bland-Altman tests were used to compare ambulance and hospital data. RESULTS 88 trauma resuscitation patients (mean age 44 years ± 18 SD, male 74%, mean ISS: 7 ± 5 SD) were enrolled over a 5 month study period. Comparison of immediate and recalled pain scores produced Spearmans correlation coefficients of 0.71 for initial pain, 0.56 for pain during transport, and 0.45 for minimum pain scores. DISCUSSION In our study patients did not accurately recall their pain levels 1-2 days after acute trauma. The results suggest that retrospective pain ratings are not reliable in trauma patients.

Epidemiology of Acute Transfusions in Major Orthopaedic Trauma

Objectives: The orthopaedic trauma–related blood product usage is largely unknown. Aim of this study was to describe the epidemiology of early (<24 hours of arrival) blood component use in major orthopaedic trauma. Design: 12-month prospective observational study. Setting: John Hunter Hospital, Level 1 Trauma Center, New South Wales, Australia. Patients: 64 consecutive trauma admissions identified, who had an orthopaedic injury and required at least 1 unit of packed red blood cells (PRBC) <24 hours of arrival. Intervention: Epidemiological study. Main outcome measures: Demographics, orthopaedic injury type, procedure type, injury severity score, timing, place of first unit of transfusion, and blood component volumes were collected. Activation of the massive transfusion protocol was recorded. Primary outcome measures were intensive care unit admission and mortality. Results: From 965 major trauma admissions, 64 had one or more orthopaedic injuries and were transfused <24 hours. Forty-eight percent (31/64) required massive transfusion protocol activation. Average age was 41 ± 21 years, 73% (47/64) men. Eighty-four percent (54/64) required emergent orthopaedic intervention, 41% (22/54) having multiple procedures. Overall mortality was 13% (8/64). Twenty-five percent (16/64) required ≥10 units of PRBC. Average PRBC use was 7.2 ± 6.6 units and fresh frozen plasma use 4.3 ± 5.2 units. Thirty-nine percent (25/64) had a pelvic ring injury or acetabular fracture. Thirty-seven percent (24/64) had at least one femoral shaft fracture. Twenty patients had a total of 23 tibia fractures. Conclusions: Orthopaedic trauma patients consume the majority of the blood products <24 hours among blunt trauma patients. This resource-intensive group requires frequent urgent surgical interventions and intensive care unit admission. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.