Fracture healing is an issue that has not yet been fully elucidated. It is generally accepted in the literature that head trauma accelerates fracture healing and causes higher volume callus tissue. Recent studies have examined the relationship between head trauma and fracture healing more molecularly. Based on this research; the aim of this study is to show the effect of head trauma on fracture healing radiologically and histologically and to investigate the relationship between serum β-Catenin level and fracture healing with the experiment we performed on rats. A total of 36 Wistar Albino female rats with a mean age of 24 weeks were included in the study with the permission of Mersin University Animal Experiments Local Ethics Committee. Six rats in the first group were not traumatized and their blood samples were collected on the day of the experiment started, end of the third week and end of the sixth week. In the second group, only head trauma was performed and blood samples were collected at the end of the third and sixth weeks. In the third group, only open femoral fracture model was applied, blood samples were collected at the third and sixth weeks and AP and Lateral radiographs of the fractured femurs were taken. After sacrification, femurs were dissected from the surrounding soft tissues and subjected to histological examination. In the fourth group, both head trauma and open femur fracture model were applied, blood samples were collected at the end of third and sixth weeks and AP and Lateral radiographs of the fractured femurs were taken. After sacrification, femurs were dissected from the surrounding soft tissues and subjected to histological examination. The expression level of β-Catenin was measured by PCR from all blood samples. Direct radiographs of the third and fourth groups at 3 and 6 weeks were evaluated by two orthopedists according to Rust and Lane & Sandhu scoring system. The histomorphometric examination was performed by evaluating the Huo scoring and the ratio of fracture callus components (cartilage callus, bone callus, fibrous callus) to areas. According to PCR analysis, the change of expression of β-Catenin by weeks was not statistically significant in the first and second groups. However, a statistically significant decrease was observed in the 0–6 week interval in the third and fourth groups (p = 0.002, p <0.0001, respectively). In the radiological examination, the union scores of the rats with head trauma + femoral fracture were higher than the isolated femoral fractures at 3 weeks and 6 weeks. In histomorphometric examination, no statistically significant difference was found between head trauma + femur fracture group and isolated femur fracture group. In addition, there was no correlation between the groups in the correlation studies between radiological findings, histomorphmetric findings and PCR findings. Considering that each molecule involved in fracture healing processes has a time interval and concentration; We concluded that the expression levels of β-catenin can be repeated in smaller time periods including the early stages of fracture healing

The effect of head injury on systemic physiology, including bone healing is still a topic of vivid discussion. We aimed to investigate whether in patients with long bone fractures the presence of head injury is associated with excessive callus formation. Data on patients with head injury and femoral diaphyseal fracture admitted to our trauma unit between 1997- 2002 were collected and analysed. Patients with factors that could influence bone healing such as smoking, NSAIDs and hormonal disorders were excluded. The severity of head injury was quantified using GCS, AIS and CT scan reports. Patients matched for age, sex and ISS with femoral shaft fractures and no head injury formed the control group of the study. All the fractures were stabilised with reamed femoral nail. The quantification of fracture healing response was estimated by taking the radiological ratio of the largest diameter of callus formed into two planes and the adjacent normal diameter of femoral canal. The minimum follow-up of the patients was 12 months. In total 42 patients were studied, 17 with head injury and femoral fracture and 25 with an isolated femoral fracture, (control group). Both groups were comparable in terms of age, sex, ISS. The difference between the mean callus to diaphyseal ratio was statistically significant for both the AP and Lateral projections (AP – mean difference 0.462, 95% CI 0.312 to 0.602, p<0.0001, LAT – mean difference 0.289, 95% CI 0.142 to 0.436, p<0.001) with the head injured patients having more florid callus compared to the control group. This study supports the view that head injury leads to exuberant callus formation in patients with long bone fractures. The mechanisms of this response could be both central and local. Research is ongoing to elucidate the pathways involved in this biological phenomenon

Objectives The objective of this study was to investigate accelerated bone healing in patients with femoral shaft fractures. Methods Data on patients with diaphyseal femoral fractures admitted to our trauma unit between 1997 and 2002 was collected and analysed. Patients were categorised into three groups by the presence or absence of head injury, and the reamed or undreamed nailing technique used. Severity of head injury was quantified using abbreviated injury score (AIS) and Glasgow Coma Scale (GCS). Time to bony union was assessed from serial of x-rays and clinical examination. Patients were followed to discharge in outpatient clinics until bony union. Results Group 1 ( Patients with head injury). In total 17 patients (14 male, 3 female). mean age 29.4(14–53). open fractures 2. Mean AIS 3.2 (2–5). Fracture treatment was reamed femoral nail. Bony union 10.5(6–22)weeks. Group 2 ( Patients without head injury). Intotal 25 patients(19 male, 6 female). Mean age 32(16–81). Open fractures 2. Fracture treatment was reamed femoral nail. Bony union 20.5(14–32)weeks. Group 3 ( Patients without head injury). In total 24 patients(18 male, 6 female). Mean age 47(17–83). Open fractures 2. Fracture treatment was unreamed femoral nail. Bony union 26.9 (21–32) weeks. Conclusion This study supports rapid bone union in the presence of head injury. Further research is indicated to provide a definate answer, specially mesenchymal cell and their control pathways which could allow further development of their potential therapeutic uses

Aim: To assess the implications of implementation of the NICE Guidelines for indication for CT scan in head injury patients. Methods and Materials: A retrospective audit of the patients attending our district general hospital with head injuries over a period of one year from October 2004 till Sept 2005. A total of 3150 patients attending the A & E during the study period were diagnosed to have head injuries. The study involved review of the case notes and radiology results of the 135 patients requiring inpatient treatment for head injury. During this tenure the CT scan was requested depending of the clinical judgement of the attending physician. Results: Rigid compliance with the NICE Guidelines during the study tenure would have entailed an additional workload of 36 patients requiring a CT scan, of which 28 patients justified the scan during out of hours period. One elderly patient with a fatal intracerebral bleed was found to have justified an early CT scan on the criteria of more than one vomiting episode and a history of unconsiousness. Discussion: The NICE Guidelines were found to be implemented in most cases admitted during working hours. A reluctance to perform CT scan was encountered during out of hours. A strict compliance with the guidelines would entail on average one additional CT scan every fortnight during the ‘out of hours’ period. Implementation of NICE Guidelines was found to tighten the net (justify CT scan) in order not to miss subtle early signs of potentially fatal head injuries

In February 2004, our institute began to perform routine cervical CT scans in addition to head CT examinations on patients with blunt head trauma who had received high energy injuries. We present the findings of 108 patients who underwent a routine cervical CT within the last year and the usefulness of routine cervical CT examinations is discussed. The present report is, to our knowledge, the only prospective study to examine the utility of routine cervical CT examinations. Among the patients admitted to the emergency room of our institute after receiving high energy injuries, 108 patients had blunt head trauma and underwent a routine cervical CT examination in addition to the head CT examination specified by our original protocol for cervical clearance. The mechanism of injury and the presence of cervical bone lesions were noted in each case. 76 males and 32 females ranging in age from 13 to 77 years (average, 41.0 years) were included in the study. Among these 108 cases, cervical fractures or subluxation were visible in 5 cases on plain films. Although no fractures were seen on the plain films taken in the remaining 103 cases, the additional cervical CT examinations demonstrated 14 cervical fractures in 13 (12.6%) of these cases. For patients with blunt head trauma, a cervical CT examination is not usually performed if no evidence of a cervical fracture is found on plain films and no neurological deficits are present. Nevertheless, the present findings suggest that many cervical fractures may have been missed on plain films in the past, and the routine inclusion of a cervical CT examination in addition to a head CT examination might be appropriate in the evaluation of patients with blunt head trauma who have been involved in a high energy injury

Objective: Prior to the appointment of a dedicated paediatric orthopaedic consultant at a tertiary referral centre (Feb 1999) the treatment of long bone fractures in paediatric patients with associated head injuries was predominately conservative. Current practice is now for early surgical stabilisation wherever possible. The aim of the study was to assess whether this change in clinical practice had resulted in any alteration in outcome. Design: A prospective analysis of patients admitted to the paediatric intensive care unit between Feb 1996 and Jan 2002. Setting: Leeds General Infirmary. Main outcome measures: Duration of ICU admission and time to independent walking was assessed. Results: A total of 37 patients were included in the study.17 patients were treated conservatively and 19 surgically .A reduction of approximately 30% was observed in ICU stay and time to independent walking was observed in those patients that underwent early surgical stabilisation. Conclusions: Early surgical stabilisation of long bone fractures in head injured children allows quicker rehabilitation

To evaluate the functional outcome of open humerus diaphyseal fractures treated with the Three-stitch technique of antegrade humerus nailing. This is a retrospective study conducted at the Department of Orthopaedics in D. Y. Patil University, School of Medicine, Navi Mumbai, India. The study included 25 patients who were operated on from January 2019 to April 2021 and follow-ups done till May 2022. Inclusion criteria were adult patients with open humerus diaphyseal fractures (Gustilo-Anderson Classification). All patients with closed fractures, skeletally immature patients, and patients with associated head injury were excluded from the study. All patients were operated on with a minimally invasive Three-stitch technique for antegrade humerus nailing. All patients were evaluated based on DASH score. Out of the 25 patients included in the study, all patients showed complete union. The mean age of the patients was 40.4 years (range 23–66 years). The average period for consolidation of fracture was 10.56 weeks (range 8–14 weeks). The DASH score ranged from 0 to 15.8 with an average score of 2.96. Five patients reported complications with three patients of post-operative infection and delayed wound healing and two patients with screw loosening. All complications were resolved with proper wound care and the complete union was noted. None of the patients had an iatrogenic neurovascular injury. Three-stitch antegrade nailing technique is a novel method to treat diaphyseal humerus fractures and provides excellent results. It has various advantages such as minimal invasiveness, minimal injury to the rotator cuff, fewer infection rates, minimal iatrogenic injuries, and good functional outcomes. Therefore, this treatment modality can be effectively used for open humerus diaphyseal fractures

Objective: To investigate the incidence, treatment and outcome of spinal injuries in paediatric patients with head injuries admitted ventilated to the paediatric ICU. Design: Retrospective review of all head injury patients admitted ventilated to Birmingham Children’s Hospital from September 1995 to March 2001. Outcome Measures: Severe head injury is defined as an initial GCS of 8 or less; moderate head injury as GCS between 9 – 12 and minor head injury – GCS above 12. Spine injuries detected on plain trauma radiographs and/or CT. Outcome is described by Glasgow Outcome Scale and Frankel grade. Subjects: Two hundred and two consecutive patients were admitted during period: 141 (70%) patients had severe head injury; 44 (22%) patients had moderate head injury; 17 (8%) had minor head injuries. There were 131 males (65%) and 49 females (35%). Age ranged from nine months to sixteen years (mean eight years). The head injuries were: 35 extradural haematoma, 47 acute subdural haematoma, 41 contusions and 79 diffuse axonal injury (DAI). Results: All 202 patients had cervical radiographs done. Forty-eight patients (24%) had further cervical spine CT mainly for inadequate cervical radiographs. Seven patients (3.5%) had CT of the thoracic or lumbar spine. Nineteen patients (9.5%) had MRI of the spine performed. In total, eight of the 202 (4%) patients had spinal injuries (aged two to ten years): 6/8 (75%) were cervical and 2/8 (25%) thoracic and lumbar spine. They were: C3 lamina fracture, C2/3 subluxation, C1/2 sub-luxation, C2 fracture with C6/7 dislocation and cord transection, C6/7 dislocation with cord transection, distraction of atlanto-axial junction, T12 crush fracture and L3/4 fracture dislocation. The cause was road traffic accidents (n=5) and falls from windows (n=3). All had the spinal injury diagnosed on radiographs with no false negative radiographs. All were treated conservatively: one halo vest, one thoracolumbar corset and five hard collars. There were three deaths due to the head injury (C6/7 dislocation with cord transection, L3/4 fracture dislocation and distraction of atlanto-axial junction) at day one, day five and day ten of injury respectively, one patient (C2 fracture) remained quadraplegic (Frankel A), four patients (C3 lamina fracture, C2/3 subluxation, C1/2 subluxation, T12 crush fracture) had good outcomes (Frankel D). Four patients had a GOS of 5 and one patient had GOS of 3 at six months. Conclusion: The incidence of spinal injuries especially cervical injuries was higher than expected, probably reflecting the severity of the injury in this group of patients. Plain cervical and thoracolumbar radiographs detected all patients with spinal injuries suggesting that this investigation alone is sensitive enough for this purpose. Non-operative treatment resulted in good outcome for most of the patients

Background: Bacterial translocation is defined as a phenomenon in which live bacteria cross the intestinal barrier and spread the other systemic organs after various type of traumatic insults such as hemorrhagic shock, burn, malnutrition and abdominal trauma. It has also been shown that multiple fractures of long bones associated with head injury promote bacterial translocation. Aim: To determine whether early internal fixation of long bone fractures helps to prevent bacterial translocation. Materials and methods: Thirty-seven male Sprague-Dawley rats were divided into three groups. 1) anesthesia only (control group, n=12); 2) anesthesia + tibia fracture + femur fracture + moderate head trauma (trauma group, n=14), and 3) anesthesia + fixation of both tibia and femur fractures + moderate head trauma (fixation group, n=11). Head injury was created by using Marmarou’s impaction-acceleration model and fractures were created by using a blunt guillotine. After 24 hours, mesenteric lymph nodes, liver, spleen and systemic blood samples were quantitatively cultured to detect bacterial translocation. Finally, ileum was cultured to determine the indigenous intestinal flora. Results: The most commonly translocating bacteria were enterococci, E.coli, and group D streptococci. The incidence of bacterial translocation was lower in fixation group (2/11) than the trauma group (10/14) (Fishers exact test, p=0.025). No statistical difference was detected between the control and the fixation group. The number of organs containing viable bacteria was significantly lower in the control and fixation groups than the trauma group (Mann Whitney U test, p=0.002). Conclusion: Multiple organ failure which is the most severe complication after trauma has a mortality rate of 50–70%. It is believed that MOF results from sepsis from organisms in the intestinal flora; a process termed bacterial translocation. Our data revealed that in case of multiple long bone fractures combined with moderate head injury, systemic translocation of the gut bacteria may be prevented by early internal fixation of the bones

Unstable chest wall injuries have high rates of mortality and morbidity. These injuries can lead to respiratory dysfunction, and are associated with high rates of pneumonia, sepsis, prolonged ICU stays, and increased health care costs. Numerous studies have demonstrated improved outcomes with surgical fixation compared to non-operative treatment. However, an adequately powered multi-centre randomized controlled study using modern fixation techniques has been lacking. We present a multi-centred, prospective, randomized controlled trial comparing surgical fixation of acute, unstable chest wall injuries with the current standard of non-operative management. Patients aged 16–85 with a flail chest (3 or more consecutive, segmental, displaced rib fractures), or severe deformity of the chest wall, were recruited from multiple trauma centers across North America. Exclusion criteria included: severe pulmonary contusion, severe head trauma, randomization>72 hours from injury, inability to perform surgical fixation within 96 hours from injury (in those randomized to surgery), fractures of the floating ribs, or fractures adjacent to the spine not amendable to surgical fixation. Patients were seen in follow-up for one year. The primary outcome was days free from mechanical ventilation in the first 28 days following injury. Secondary outcomes were days in ICU, rates of pneumonia, sepsis, need for tracheostomy, mortality, general health outcomes, pulmonary function testing, and other complications of treatment. A sample size of 206 was required to detect a difference of 2 ventilator-free days between the two groups, using a 2-tailed alpha error of 0.05 and a power of 0.80. A total of 207 patients were recruited from 15 sites across Canada and USA, from 2011–2018. Ninety-nine patients were randomized to non-operative treatment, and 108 were randomized to surgical fixation. Overall, the mean age was 53 years, and 75% of patients were male, with 25% females. The commonest mechanisms of injury were: motor vehicle collisions (34%), falls (20%), motorcycle collisions (14%), and pedestrian injuries (11%). The mean injury severity score (ISS) at admission was 26, and patients had a mean of 10 rib fractures. Eighty-nine percent of patients had pneumothorax, 76% had haemothorax, and 54% had pulmonary contusion. There were no differences between the two groups in terms of demographics. The final results will be available and presented at the COA meeting in Halifax. This is the largest randomized controlled trial to date, comparing surgical fixation to non-operative treatment of unstable chest wall and flail chest injuries. The results of this study will shed light on the best treatment options for patients with such injuries, help understand outcomes, and guide treatment. The final results will be available and presented at the COA meeting in Halifax

Surfing is a popular UK water-sport. Recommendations for protective gear are based on studies abroad from trauma from large waves and reef breaks which may not be relevant in the UK. This study assesses the aetiology of UK surfing injuries in order to assist treatment and provide formative recommendations on protective equipment. Data was collected from UK surf clubs via an online survey. 130 individuals reported 335 injuries. M:F ratio 85:45, median age 28 (range 17–65). Head injuries were the most common (24%) followed by foot and ankle (19%). Surfers collided most often with their own boards (31%) followed by rocks/coral (15%), the sea (11%) and other surf boards (10%). Lacerations were the commonest injury (31%); followed by bruises/ black-eyes (24%) and joint/ligament sprains (15%). Concussions (5%), fractures (3%) and teeth injuries (1%) were rare. Less than 1/3 of all injuries required professional medical attention, 2 required operative intervention. Surfing injuries in the UK are common but usually minor. Serious head injuries (fractures and concussions) are rare. There is insufficient evidence to warrant the routine use of protective helmets whilst surfing in the UK, although protective head and foot gear may be considered when surfing the rarer reef/ rock breaks

Injuries to the spinal cord are rarely isolated problems. Multiple trauma patients with spinal injuries can face significant long-term disability. In this retrospective, descriptive study we investigated the relationship between the level of spinal trauma and the injuries associated with this. We aimed to define the populations at risk and highlight trends identified. METHODS: Analysis of 1500 trauma patients admitted to the Royal London Hospital by the Helicopter Emergency Medical Service (HEMS) over 6 years was undertaken. 265 patients of these patients had spinal cord injuries (SCI). Data was obtained from the HEMS trauma registry, patient records and interviews with patients. RESULTS: 265 patients sustained SCI (mean age: 38 25% female). The most common mechanisms of injury were motor vehicle accidents (46%) and falls (29%) Attempted suicide was a common cause of SCI in our study group (mean age 32. M:F ratio 2:1) The most common associated injuries were limb and head trauma. C-spine injuries were the most common spinal injury and were associated with the highest mortality rates (37%). C-injuries presented with a bimodal age distribution, 84% had head trauma and 30% had significant chest injuries. In patients who sustained thoracic spinal injuries 71% had severe chest injuries and 34% had head injuries. The most common associated injury in lumbar spine trauma was injuries to the limbs or pelvis (68%). Injuries to the lumbar spine occurred more frequently in the 20–40 year old age groups. Discussion: Mortality rate in our study was 26%. Mortality rates were highest in patients with cervical spine injuries (37%). The causes of mortality were from suicide attempts, falls and RTA. The mortality rates in these groups were 20%, 22% and 32% respectfully. Our review highlights significantly higher mortality in the over 60-age group. Our population had high numbers of suicide attempts. We highlight suicide attempts as a significant aetiology for SCI. All the deaths in the suicide group were as a result of jumping from high buildings. In patients over 60, c-spine injuries are by far the common level of SCI. Subdural haematomas occurred in almost 10% of patients with c- spine injuries. Any injury to the cervical spine should therefore prompt investigation for intracranial trauma. The GCS should be closely monitored and a low threshold for performing a CT scan is advisable. Thoracic spine injuries are strongly associated with severe chest injuries. Lumbar spine and sacral injuries are strongly associated with severe pelvic and lower limb injuries. Understanding the demographics and etiology is essential to allow effective planning for spinal services. Appreciating the injuries associated with SCI should ensure better care for patients, by recognizing problems earlier and using a multidisciplinary approach to optimize treatment and reduce morbidity and mortality

Delayed management of high energy femoral shaft fractures is associated with increased complication rates. It has been suggested that there is less urgency to stabilize lower energy femoral shaft fractures. The purpose of this study was to evaluate the effect of surgical delay on 30-day complications following fixation of lower energy femoral shaft fractures. Patients ≥ 18 years who underwent either plate or nail fixation of low energy (falls from standing or up to three steps' height) femoral shaft fractures from 2005 – 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) via procedural codes. Patients with pathologic fractures, fractures of the distal femur or femoral neck were excluded. Patients were categorized into early (< 2 4 hours) or delayed surgery (2–30 days) groups. Bivariate analyses were used to compare demographics and unadjusted rates of complications between groups. A multivariable logistic regression was used to compare the rate of major and minor complications between groups, while adjusting for relevant covariables. Head injury patients and polytrauma patients are not included in the NSQIP database. Of 2,716 lower energy femoral shaft fracture patients identified, 2,412 (89%) were treated within 1 day of hospital admission, while 304 (11.2%) were treated between 2 and 30 days post hospital admission. Patient age, American Society of Anesthesiologists (ASA) classification score, presence of diabetes, functional status, smoking status, and surgery type (nail vs. plate) were significantly different between groups (p After adjusting for all relevant covariables, delayed surgery significantly increased the odds of 30-day minor complications (p=0.02, OR = 1.48 95%CI 1.01–2.16), and 30-day mortality (p < 0 .001), OR = 1.31 (95%CI 1.03–2.14). The delay of surgical fixation of femoral shaft fractures appears to significantly increase patients' risk of minor adverse events as well as increase mortality. With only 89% of patients being treated in the 24 hour timeframe that constitutes best practice for treatment of femoral shaft fractures, there remains room for improvement. These results suggest that early treatment of all femoral shaft fractures, even those with a lower energy mechanism of injury, leads to improved outcomes

The arrival of major trauma centres (MTC) to Scotland highlights the need for structured management of polytrauma patients. The aim was to report the epidemiological profile of polytrauma patients (Injury Severity Score (ISS) 15) admitted to a large trauma unit in the UK and gather information about the initial management of this severely injured cohort. Prospectively collected data from the Scottish Trauma Audit Group (STAG) database of 366 polytrauma patients (ISS <15 & aged ≥13 years) admitted to a single trauma unit, from 1st January 2013 to 31st October 2017 was analysed. Data included patient demographics, injury characteristics, length of stay (LOS) and survivorship. The median age was 49 years (range 13–93) and females made up 31.1% of the population. There was a mean ISS of 25.7 (range 15–75) and mean LOS of 19 days. The overall mortality rate was 21%. Higher mortality occurred among females (p<0.001), patients ≥60 years age (p<0.001), patients who sustained their injury at home (p<0.0001), and those with head injuries (p<0.01). Orthopaedic injuries were present in 187 patients (51.1%) with a mortality rate of 10.7%. The most common mechanism of injury was road traffic collision (41.5%) and these patients had a significantly higher ISS (p<0.01). A fall from height <2m was associated with higher mortality (p=0.01). This study is the largest of its kind and presents a detailed epidemiological profile of patients attending a large UK trauma unit. This knowledge will help guide initial management and aid in resource and capacity planning for the future

Between January 1996 and December 2006, 130 patients were operated on for acquired varus equinus foot deformity. The most frequent aetiologies were stroke or brain damage due to head trauma. The primary indications for surgery included pain, caused by pressure of the foot or toes on the floor or in shoes, ankle instability due to varus deformity, or difficulty wearing orthopaedic shoes or braces. Split anterior tibial transfer was generally done after lengthening of Achillis tendon and tenotomy of long and short toe flexors during the same session. The author did compare preoperative and postoperative autonomy, and shoe or orthosis requirements. The results of this study include significant improvement in patient autonomy demonstrated by an improved ability to ambulate independently and a decreased need to wear orthopedic shoes and orthoses, as well as an increased ability to wear normal shoes, or the ability to ambulate bare foot. Adequate knee flexion during swing phase of the stride was the best indicator for better result. This procedure is safe and yields good results with minimal complications. The indications are very common, inasmuch as the number of young hemiplegic patients surviving after a stroke or head injury is increasing. This procedure can result in definite improvement for these disabled patients and can increase their autonomy

Introduction and objectives. High-energy pelvic fractures are life-threatening injuries. Approximately 15% to 30% of patients with high-energy pelvic injuries are hemodynamic unstable, hemorrhagic shock remains the main cause of death in patients with pelvic fractures, with an overall mortality rate from 6% to 35%. The correlation between fracture pattern and mortality in polytrauma with pelvic fracture has been previously investigated. However, the purpose of our investigation was to evaluate the relationship of hemodynamic instability with the pelvic fracture pattern according to different classifications. Materials and Methods. A retrospective study of high-energy pelvic fractures was performed for consecutive patients admitted to the emergency Level I trauma center in the polytrauma unit of our institution from June 2007 to June 2010. A total of 759 patients polytrauma were attended, whom 100 had a pelvic fracture and were included in our study. Demographic data, mechanism of injury and associated injuries were recorded. The patients were classified as hemodynamic stable or unstable according to the ATLS protocol. The pelvic fracture patterns were divided into stable and unstable according to Young-Burgess and Tile classifications. Statistical analysis was performed to determine the relationship between fracture pattern and hemodynamic stability. Secondary outcomes were obtained: the relationship with TCE and pulmonary injury, usefulness of the external fixation, relationship between fracture pattern and embolization requests. Chi-square test was used for the analysis and OR test. Results. Male was the gender most frequent (70%), the average age was 45.2 years and the mortality rate was 24%, the main mechanism of injury was motor vehicle injury (41%). Pelvic fracture pattern (neither Tile classification nor Young-Burgess classification) showed no correlation with hemodynamic situation (p>0.05). Neither death could not be predicted on the basis of pelvic fracture pattern (p>0.05). We found statistical association between patients affected by pelvic fracture in polytrauma and head injury, and death (p<0.01). Conclusion. Pelvic fracture pattern is not useful to predict hemodynamic instability in polytrauma, regardless the classification system used. Pelvic fracture is not significantly associated with high risk of mortality; however it contributes to increase mortality risk in cases of head injury associated

One million patients with head injuries present to UK hospitals each year. A significant proportion of these patients have ongoing problems and a large number remain disabled at one year. The management of these patients has recently been criticised by a Royal College of Surgeons Working Party Report (published in June 1999). Several recommendations for the care of head injured patients were made. We have undertaken a study to examine the way these cases are currently dealt with in Welsh hospitals. A large proportion (75%) of these patients in Wales are cared for by non-neurosurgical consultants with the orthopaedic speciality receiving referrals in most hospitals (55%). A questionnaire was sent to these non-neurological consultants looking after head injuries with specific questions on the current care of these patients and for their opinion on the current system. We have received an excellent response rate (99%) with the results showing that the Working Party recommendation have not been translated into a change in clinical practice. Our study indicates several shortcomings in the current care of these patients in Wales. It also demonstrates that the almost unanimous (98%) view amongst the consultants that responded is that there is a genuine need for change if we are to offer these patients the best care and rehabilitation in the 21st Century

The causes of a stiff elbow are numerous including: post-traumatic elbow, burns, head injury, osteoarthritis, inflammatory joint disease and congenital. Types of stiffness include: loss of elbow flexion, loss of elbow extension and loss of forearm rotation. All three have different prognoses in terms of the timing of surgery and the likelihood of restoration of function. Contractures can be classified into extrinsic and intrinsic (all intrinsic develop some extrinsic component). Functional impairment can be assessed medicolegally; however, in clinical practice the patient puts an individual value on the arc of motion. Objectively most functions can be undertaken with an arc of 30 to 130 degrees. The commonest cause of a Post-traumatic Stiff elbow is a radial head fracture or a complex fracture dislocation. Risk factors for stiffness include length of immobilisation, associated fracture with dislocation, intra-articular derangement, delayed surgical treatment, associated head injury, heterotopic ossification. Early restoration of bony columns and joint stability to allow early mobilisation reduces incidence of joint stiffness. Heterotopic ossification (HO) is common in fracture dislocation of the elbow. Neural Axis trauma alone causes HO in elbows in 5%. However, combined neural trauma and elbow trauma the incidence is 89%. Stiffness due to thermal injury is usually related to the degree rather than the site. The majority of patients have greater than 20% total body area involved. Extrinsic contractures are usually managed with a sequential release of soft tissues commencing with a capsular excision (retaining LCL/MCL), posterior bundle of the MCL +/− ulna nerve decompression (if there is loss of flexion to 100 degrees). This reliably achieved via a posterior incision, a lateral column exposure +/− ulna nerve mobilisation. A medial column exposure is a viable alternative. Arthroscopic capsular release although associated with a quicker easier rehabilitation is associated with increased neural injury. Timing of release is specific to the type of contracture, i.e. flexion contractures after approx. six months, extension contractures ASAP but after four months, loss of forearm rotation less 6 to 24 months. The use of Hinged Elbow Fixators is increasing. The indications include reconstructions that require protection whilst allowing early movement, persistent instability or recurrent/late instability or interposition arthroplasty. Post-operative rehabilitation requires good analgesia, joint stability and early movement. The role of CPM is often helpful but still being evaluated

Introduction: The principles of fracture management in patients with multiple injuries continue to be of crucial importance. Early treatment of unstable patients with head, chest, abdomen or pelvic injuries with blood loss) followed by an immediate fracture fixation (“Early Total Care”) may be associated with a secondary life threatening posttraumatic systemic inflammatory response syndrome (SIRS). We present our experience experience in the treatment strategy of polytraumatized patients with femoral shaft fracture. Patients and Methods: From 1995 to 2008 there were 137 polytraumatized patients with femoral shaft fracture treated in our hospital. The outcomes of their treatment were retrospectively analyzed in this study. Patients were grouped according the treatment strategies for stabilization of the femoral shaft fracture: Group A – 99 patients treated with early total care (ETC) - intramedullary nailing (IMN) within 24 h of injury Group B- 38 patients treated with temporary external fixation as a bridge to IMN (DCO surgery starting at 2005). Results: The groups were comparable regarding age, gender distribution and mechanism of injury. ISS was higher in group B (DCO) – 32,2 compared to group A (ETC) – 22,6. The patients in DCO group required significantly more fluids (14,2 L) then those in ETC (8,2 L) and blood (2,2 vs 1,3 L) in the initial 24 hours. Thoracic, abdominal or head injuries were accounted significantly higher number of patients submitted to DCO group from 2005 (24,2%) compared to ETC group (12,4%). Mean operative time for External Fixators was 40 minutes, 110 minutes for IMN. There was a significantly higher incidence of ARDS in ETC group −18,2% compared to DCO group – 8,6%. The incidence of multiple organ failure (MOF) was significantly lower in DCO group – 7,4% than in ETC group – 12,1 %. There were 3 unexpected deaths and 2 cases with conscious worsening in patients with head injury in ETC group. No significant differences in the incidence of local complications were found. Conclusions: Based on this study it seems that a significant reduction in incidence of general systemic complications (ARDS, MOF) was found in DCO group in comparison with ETC group, Changing of the treatment protocol from ETC to DCO is not associated with increased rate of local complications (pin-tract infections, delayed unions or nonunions). There is a lower complication rate in DCO Group despite higher ISS compared with the ETC Group, DCO surgery appears to be an viable alternative for polytraumatized patients with femoral shaft fracture

Purpose: To determine the epidemiology of femoral fractures in children and their associated injuries. Patients and methods: We reviewed 475 consecutive children admitted over a seven-year period (1992–1999) to a university hospital. Such details were recorded and analysed as – mechanism of injury, ISS, GCS, ICU stay, total hospital stay, operations performed, presence or absence of femoral fracture, complications and mortality. Results: Out of 475 children admitted, 57 had a femoral fracture (12%). 14 were girls and 43 were boys. The mean age was 5.1 (range 1–14) and the mean ISS was 6.9 (4–36). The mean GCS was 14 (range 5–15). The commonest cause of injury was a fall from a height 21/57 (37%) followed by road traffic accidents 20/57 (35%), 11 cases were pedestrians. 6 cases were recorded as non-accidental injuries. 8 children underwent operative treatment whereas the rest were treated conservatively. In 36 children the femoral fracture was an isolated injury. The remaining 21 (37%) had 2 or more injuries. The most common associated injury was a head injury of varying severity 10 (50%) followed by fracture tibia 7 (33%) followed by fracture pelvis 4 (19%). Other associated injuries included a splenic laceration, one pancreatic injury, 3 humerus fractures and 3 forearm fractures. None of the children sustained a chest or spinal injury. The mean hospital stay was 22 days (1–67). 4 children were admitted to the intensive care unit (2 had head injuries) and the mean ICU stay was 3 days (2–5). There was no mortality in these series. Two children underwent fasciotomies for tibial compartment syndrome. Conclusion: The incidence of associated injuries in children with femoral fractures appears to be 35% with head injury being the commonest. The overall prognosis is favourable as seen in these series of patients with nil mortality