Background: We aimed to study the relationship between the number of fractured scapular regions, and the severity and distribution of associated injuries in blunt trauma patients. Methods: 107 consecutive patients with fractured scapulae (100 males) with a mean age of 35 (8–65) years were prospectively studied between January 2003 and December 2005. Mechanism of injury, associated injuries, injury severity scale (ISS) and the number of anatomical scapular regions involved in each fracture were studied. Patients were divided into single-region, two-region fracture, and more than two-region fracture groups. Computer tomography was used for fracture classification in 99 patients and plain X-rays in the remaining 8. Results: Road traffic collisions were the most common cause of scapular fracture. 95 patients (89%) sustained associated injuries. The most frequent was chest injury (68 (64%)). The median ISS was 9 (4–57) for the single-region fracture group (n 55), 20 (4–59) for the two-region fracture group (n 30), and 22.5 (4–54) for more than two-region fracture group (n 22) (p=0.02, Kruskal Wallis test). The median values of abbreviated injury scale (AIS) for chest injuries for the three groups were 1 (0–4), 3 (0–5) and 3 (0–5), respectively (p=0.001, Kruskal Wallis test). The single-region fracture group had significantly less posterior structure injury (9/55) compared with the multiple-region fracture group (46/52) (p=0, Fisher’s exact test). Conclusion: Associated injuries are common in patients having scapular fractures. ISS and AIS for chest injuries are higher and posterior structure injuries more frequent in patients with fractures involving multiple scapular regions

There has been a substantial increase in the surgical treatment of unstable chest wall injuries recently. While a variety of fixation methods exist, most surgeons have used plate and screw fixation. Rib-specific locking plate systems are available, however evidence supporting their use over less-expensive, conventional plate systems (such as pelvic reconstruction plates) is lacking. We sought to address this by comparing outcomes between locking plates and non-locking plates in a cohort of patients from a prior randomized trial who received surgical stabilization of their unstable chest wall injury. We used data from the surgical group of a previous multi-centred, prospective, randomized controlled trial comparing surgical fixation of acute, unstable chest wall injuries to non-operative management. In this substudy, our primary outcome was hardware-related complications and re-operation. Secondary outcomes included ventilator free days (VFDs) in the first 28 days following injury, length of ICU and hospital stay, and general health outcomes (SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores). Categorical variables are reported as frequency counts and percentages and the two groups were compared using Fisher's Exact test. Continuous data are reported as median and interquartile range and the two groups were compared using the Wilcoxon rank-sum test. From the original cohort of 207 patients, 108 had been treated surgically and had data available on the type of plate construct used. Fifty-nine patients (55%) had received fixation with non-locking plates (primarily 3.5 or 2.7 mm pelvic reconstruction plates) and 49 (45%) had received fixation with locking plates (primarily rib-specific locking plates). The two groups were similar in regard to baseline and injury characteristics. In the non-locking group, 15% of patients (9/59) had evidence of hardware loosening versus 4% (2/49 patients) in the locking group (p = 0.1). The rate of re-operation for hardware complications was 3% in the non-locking group versus 0% in the locking group (p = 0.5). No patients in either group required revision fixation for loss of reduction or nonunion. There were no differences between the groups with regard to VFDs (26.3 [19.6 – 28] vs. 27.3 [18.3 – 28], p = 0.83), length of ICU stay (6.5 [2.0 – 13.1] vs 4.1 [0 – 11], p = 0.12), length of hospital stay (17 [10 – 32] vs. 17 [10 – 24], p = 0.94) or SF-36 PCS (40.9 [33.6 – 51.0] vs 43.4 [34.1 – 49.6], p = 0.93) or MCS scores (47.8 [36.9 – 57.9] vs 46.9 [40.5 – 57.4], p = 0.95). We found no statistically significant differences in outcomes between patients who received surgical stabilization of their unstable chest wall injury when comparing non-locking plates versus locking plates. However, the rate of hardware loosening was nearly 4 times higher in the non-locking plate group and trended towards statistical significance, although re-operation related to this was less frequent. This finding is not surprising, given the inherent challenges of rib fixation including thin bones, comminution, potential osteopenia and a post-operative environment of constant motion. We believe that the increased cost of locking plate fixation in this setting is likely justifiable given these findings

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

First rib fractures (FRFs) have historically been a marker for severe trauma and poor outcomes. The aim of this study was to assess whether an association still exists between a fractured first rib and global trauma scores suffered by the patient, examine mortality rate and identify other commonly associated injuries. This study examined patients who presented to the Rockhampton Hospital with a traumatic FRF between the dates of July 2015 to June 2020. Patient demographics, mortality rate and additional injuries sustained by the patients were collected. The Injury Severity Score (ISS) was utilised and calculated for each patient. Analysis was conducted to determine associations between trauma scores and FRFs, mortality rate and other injuries sustained at the time of rib fracture. In total, 545 patients had a rib fracture with 48 patients identified as having an FRF. Median age was 50 years. Thirty-seven (77%) were male. The most common mechanism of FRF was motor vehicle/motorbike accidents (71%). Fifty percent of patients with an observed FRF had the highest global ISS of very severe, with 13% severe, 22% moderate and 15% mild. No patients died from their injuries. Of those with an FRF, 79% experienced fractures other than ribs, 75% had other rib fractures and 52% had chest injuries. A larger than expected proportion of FRFs were not associated with severe trauma scores or high mortality. These findings suggest that patients with an FRF may have a greater chance of surviving their traumatic FRF than previously reported. Clinicians should be aware of the potential for severity and other associated injuries, such as chest wall fractures and thoracic injuries, when treating a patient with a fracture of their first rib

Our aim was to investigate the incidence and outcome of chest injuries after blunt trauma in patients admitted in a level I trauma centre over a 6-year period. This is a review of prospectively collected data (1996–2002); part of the (TARN-UK) data. Patients divided in 6 subgroups based on the chest AIS. Univariate analysis identified factors predicting mortality and a backward stepwise logistic regression multivariate analysis determined relationships with outcome. There were 1,164 patients with chest injuries. The mean overall severity of chest injuries was 3.15+/−1.01. The commonest mechanism of injury was RTAs (57.01%). Rib fractures were the most common injuries (395 patients, 34%) associated with lung contusions in 12.9%. Admission GCS was highest in chest-AIS subgroup 2 and was significantly higher in groups 1 and 3. Complications, invasive operations, and investigations were more common with increasing chest-AIS. The ICU-admissions and the mean length-of-stay were similar for chest-AIS1 and 2, but significantly higher for the rest. Half of the AIS1 patients had associated head injuries; the lowest percentage was in subgroup 2 (18.8%). There was a variable correlation of abdominal injury severity with severity of chest injury. There was a significant difference in mortality rates between group 2 and group 1 and -3. The average time to death in those with chest-AIS1 was significantly lower than the average time in those with AIS4 and 5. Patients in the higher AIS groups had both a higher overall ISS and mortality rate. Minimal chest injury severity (AIS1) showed higher ISS and significantly higher mortality compared with chest-AIS2,3. This has been attributed to the fact that the chest is spare as most of the impact during the course of the accident is been absorbed by the head (head injury). This theory also explains the shorter time period of death seen in patients belonging to the chest AIS1 group

Purpose: To determine any relation between scapular fracture, severity of chest injury and mortality in patients with multiple injuries. Patients and Methods: We reviewed 621 consecutive patients admitted over a five year period (1995–1999) with multiple injuries. All had an associated chest injury. Such details were recorded and analyzed as – mechanism of injury, ISS, AIS for chest, GCS, ICU stay, total hospital stay, operations performed, presence or absence of scapular fracture, complications and mortality. Patients with chest injury but without scapula fracture formed the control group of the study. Results: Out of 621 patients with multiple injuries (mean ISS 27.5), 79 (17 women) (12.72%) – group 1 were identified with scapular fractures. 542 (122 women) patients with chest injury but no scapular fracture formed the control group – group 2. The mean age of group 1 was 42 years versus 40 years of group 1 and the mean ISS was 27.12 (SD 15.13) and 28. 41 (SD 14.21) in group 1 and group 2 respectively (p value > 0.05). In group 1 the chest AIS was 3.46 (SD 1.10) and 3.18 (SD 1.06) in group 2 (p value < 0.05).The most common associated chest injury in group 1 was pneumothorax (28%) followed by pulmonary contusion (15.2%) whereas in group 2 it was likewise pneumothorax (20%) followed by pulmonary contusion (21%). There were 8 (10.1%) flail segments in the scapula group, versus 50 flail segments (9%) in the non scapula group. In group 1 there was an incidence of 3.8 % associated thoracic vertebral fractures compared to 8.3% in group 2. 2.6 % of patients in group 1 had major vessel injury or cardiac laceration as compared to 3 % in group 2. There were 4 brachial plexus injuries in group 1 (5.1%) versus nil in group 2. In group 1, 32 (40.5%) patients had sustained associated abdominal injuries mean AIS 3.1 versus 190 (34.6%) in group 2 with a mean AIS of 2.9. In the scapula group there were 31 clavicle fractures, 12 humerus fractures and 4 shoulder dislocations. In the non-scapula group there were 137 clavicle fractures, 93 fractures of the humerus and 2 shoulder dislocations. The mean hospital stay in both groups was 22 days (range 5–153). In group 1 the mortality rate was 11.4% (9 patients) mean ISS 48 (range 24–75) versus 25% (136 patients) mean ISS 41.3 (range 17–75) in group 2. Conclusion: Patients with scapular fractures were found to have a higher chest and abdominal AIS. Overall, the scapular fracture was not associated with higher ISS or higher mortality and does not correlate with a poorer outcome

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

Introduction: Fractured scapula is rare because the scapula is mobile and well protected. We report the first prospective study in the literature of scapular fractures caused by blunt trauma. Patients: 67 consecutive patients (64 males and 3 females, with a mean age of 33 (8–60) years) were included between January 2003 and September 2004. Data regarding the mechanism of injury, associated injuries, the Injury Severity Score (ISS), the location of the scapular fracture, whether it was isolated or involved more than one part of the scapula, and the accuracy of radiographic modality used were analyzed. Results: 50 (75%) fractures were caused by road traffic accidents, 11 by afall from height, 4 from a fall from the same level and 2 by heavy object. 56 patients (84%) sustained associated injuries of which chest injury occurred in 48 (72 %) and was the most frequent. Many patients had more than one substantial chest injury. 30 (45%) patients had lung contusion, 27 rib fracture, 23 haemothorax and 22 pneumothorax. The abbreviated injury score for chest injury for the isolated fractures (n=41) was 2.1 (0–5) and for the combined fracture group (n=26) was 2.4 (NS). Other associated injuries were upper limb fractures in 29 patients, head and facial injuries in 25, 17 had pelvic fractures, lower limb fractures occurred in 16 patients, 15 had spinal fractures and 10 abdominal injuries. No brachial plexus or subclavian artery injury occurred. The mean ISS was 20 for both fracture groups. 41 (61%) of fractures were isolated. Of these, 31 (75%) involved the body of the scapula, 4 acromion, 2 glenoid, 2 coracoid, 1 neck and 1 spine. For the 26 combined fractures, the body was involved in 24 (92%), 13 the neck, 12 spine, 4 glenoid, 4 acromion and 3 coracoid. Plain chest X-ray was done in 63 patients and the scapular fracture was shown in 40 (63%). 42 patients had scapular X-rays and the fracture was seen in 35 (83%). The fracture was shown in all 42 patients that had computer tomography (CT) of the chest. The same was true for the 19 patients who had CT of the scapula. In total, CT was done in 61 (91%) of the 67 patients. Discussion; Scapular fracture has a high rate of associated injuries, mainly to the chest. Lung contusion, haemo- and pneumothorax were very frequent in our series compared with other reports. The liberal use of trauma CT protocols and the prospective nature of the study may explain this finding

Flail chest and multiple rib fractures are common injuries in trauma patients. Several small randomized studies have suggested significant improvements in patient outcomes with surgical fixation, compared to nonoperative management, yet emerging population-level data report some conflicting results. The objectives of this study were to compare the results of surgical fixation and nonoperative management of multiple rib fractures and flail chest injuries and to assess whether effects varied by study design limitations, including risk of confounding by indication. A comprehensive search of electronic databases (Medline, Embase, Web of Science) was performed to identify randomized controlled trials and observational studies. Random effects models were used to evaluate weighted risk ratios (RR) and mean differences (MD). Risk of confounding by indication was assessed for each study (low, medium, and high risk), and this categorization was used to stratify results for clinical outcomes. Publication bias was assessed. Thirty-nine studies, with a total of 19,357 patients met inclusion criteria. Compared to nonoperative treatment, surgical fixation of flail chest and multiple rib fractures was associated with decreased risk of death (overall RR 0.40, 95% confidence interval (CI) 0.28–0.56), pneumonia (overall RR 0.70, 95% CI 0.52–0.93), tracheostomy (overall RR 0.62, 95% CI 0.41–0.93), and chest wall deformity (overall RR 0.16, 95% CI 0.06–0.42). However, many of the observational studies were at risk of confounding by indication, and results varied according to risk of confounding by indication. Differences in ventilator time, intensive care unit length of stay (LOS), hospital LOS, and return to work will be assessed (results pending). Compared to nonoperative treatment, surgical fixation of flail chest and multiple rib fractures is associated with improved clinical outcomes. Discrepancies between some study results may be due to confounding by indication. Additional prospective randomized trials and high-quality observational studies are required to overcome potential threats to validity and to expand on existing evidence around optimal treatment of these injuries

Introduction:. Trauma is endemic in South Africa. The upper thoracic spine is extremely difficult to image and assess clearly with frontline x-rays resulting in up to 22% of proximal fractures being missed. Aim:. To review a series of patients with proximal thoracic fractures. Methods:. Thirty-three patients with proximal thoracic fractures in the T1–T4 area managed in a spinal unit were identified. A retrospective review of medical records and radiology was undertaken. Demographic data, mechanism of injury, diagnostic modalities, level and type of fracture, neurological status, associated injuries, hospital stay, management, complications and outcome was recorded. Results:. There were 21 males and 12 females, with a median age of 31.8 years. Aetiology was 21 MVA passengers, 8 drivers, 1 pedestrian, 1 assault, 1 bicycle and 1 hanglider accident. Delay in diagnosis was 1 day in 8, 2–5 days in 2 and greater than 2 weeks in 5. The fractures were A1 in 7, A3 in 14, B1 in 7, C1 in 2 and C2 in 2. Twenty three patients had neurological compromise, 13 being complete. Twenty-three had associated chest and head injuries. Hospital stay was a mean of 27 days (maximum 246) and ICU stay median 14 (maximum 115) days. Twenty-six patients underwent surgery, posterior instrumented fusion being the commonest procedure. Although the surgery did not change the median kyphosis (25° preop to 20°at 1 year and 21°at 2 years), the most kyphotic patients were improved (55°to 45°). Conclusion:. A high index of suspicion for proximal thoracic fractures needs to be maintained in high energy injuries, especially MVA passengers, where there is chest injury. Prompt exclusion by appropriate special investigations is mandatory. Once recognized, they can be adequately managed with posterior instrumented fusion, although these patients are resource intensive due to the associated neurological impairment and chest injuries

This study was undertaken to identify certain high-risk patient groups admitted following trauma, in an attempt to improve their management. We retrospective reviewed 207 patients admitted to the ICU with orthopaedic injuries between 1997 and 2003, excluding from the study spinal patients, paediatric orthopaedic patients, and patients having elective surgery. The mean age of the patients was 36.7 years. The mean duration of stay in the ICU was 8.4 days. In 32% of patients, the only injuries were orthopaedic, with 51% of this group having multiple fractures. Of the patients with associated injuries, 34% had chest injuries. Acute respiratory distress syndrome (ARDS) developed in 46 patients (22%), of whom 33 (71%) had more than one long bone fracture. The incidence of ARDS in patients with no associated injuries was 11%. The overall mortality rate was 13.5% (28 patients), and the mortality rate of patients with only orthopaedic injuries was 5% (10 patients). Death occurred on the day of admission in 28.5% and 70% of the deaths occurred after 8 days in the ICU. Overall, there was a 10% mortality rate in patients admitted to the ICU for more than a day. We advise close observation of all orthopaedic patients with associated chest injuries and recommend appropriate fracture management within 8 days of admission

Background: Polytrauma patients with bilateral femur shaft fractures are known to have a higher rate of complications when compared with those who have sustained unilateral fractures. The current study tests the hypothesis that the high incidence of posttraumatic complications in patients who have no severe head or chest injury is caused by accompanying injuries rather than by the additional femur fracture. Methods: Prospective cohort study. Inclusion criteria: Injury severity score > 16 points; No AIS score value of the head or chest > 3 points. Two study groups: a unilateral (group USF) (n=146) and a bilateral femur shaft fracture (group BSF) (n=29). A further differentiation was made according to the patient’s status. All patients underwent early (< 24 hours after injury) fixation of their extremity fractures. Endpoints monitored were: Pneumonia, Acute lung injury (ALI), Systemic inflammatory response syndrome (SIRS), Sepsis. Statistics: Pearson chi-square test for binary indicators of injury severity, regression analyses regarding clinical complications. Results: Patients with bilateral femur fractures exhibited a longer ICU stay (p< 0.01), a higher incidence of pneumonia (p< 0.02) and SIRS (p=0.04) than those with unilateral fractures. Following corrective analyses for injury severity, no differences in blood transfusion rates, length of ICU stay, or complications was observed. Patients in borderline condition spend significantly more time in the ICU in comparison to those in stable condition. For analyses predicting presence of systemic inflammatory response syndrome, only the variable indicating receipt of a blood transfusion upon admission to the hospital emerged as a significant predictor. Bilateral fracture patients who were in uncertain condition preoperatively, developed significantly more complications postoperatively(p=0.02). Conclusions: Polytrauma patients with bilateral femur shaft fractures have a similar clinical course as those with unilateral fractures when no significant head or chest injury is present. An increased incidence of systemic inflammatory response syndrome was associated with three variables: presence of borderline condition, hemothorax and requirement of blood transfusion. This may have important treatment implications, including the management of major fractures

In the polytrauma patient, intraoperative patient positioning is one factor thought to influence pulmonary complications associated with intramedullary (IM) nailing of the femur. With regards to lateral femoral nailing, it is currently unknown as to whether the position of the injured lung contributes to changes in pulmonary function. It has been proposed that, similar to prone positioning in the ICU for acute respiratory distress syndrome management, having the injured lung in a dependent position during lateral femoral nailing would prevent barotrauma from hyperinflation and promote gas exchange in the non-dependent healthy lung. This study aims to assess the association between the position of the injured lung during lateral femoral nailing and pulmonary complications as determined by ICU LOS. This retrospective cohort study was conducted at a single level 1 trauma centre. All patients treated with IM nailing for femur fracture between 2006 and 2014 were screened for inclusion. Only patients who 1) underwent lateral femoral nailing and 2) had a significant chest injury, defined by chest Abbreviated Injury Scale (AIS) of three or greater, were included. Patients with bilateral femur fractures or symmetric bilateral thoracic injuries were excluded. Intraoperative position of the lung injury was described depending on whether the injured lung was down, or in the dependent position, during lateral femoral nailing, versus the healthy lung down. The primary outcome was ICU LOS in all study patients. Secondary analysis was performed on the subgroup of patients who were admitted to ICU prior to femoral nailing. Data analysis assessing for differences in ICU LOS between groups was performed through Wilcoxan testing. One hundred and thirteen femur fractures were included in the study. During lateral femoral nailing, 53 patients had the injured lung down and 60 patients had the healthy lung down. No differences between age, ICU admission rate, injury severity score, chest AIS or head AIS were detected between the groups. There were no detectable differences in the rate of ICU admission between patients with the injured lung down (47.2%) and patients with the healthy lung down (46.7%) (P=0.96). We were unable to detect a difference in average ICU LOS between patients who had the injured lung down (4.9 days, 95% CI 2.8 – 7) compared to patients with the healthy lung down (6 days, 95% CI 3.7 – 8.4) during lateral femoral nailing (P=0.73). When looking only at patients who were admitted to ICU prior to femoral nailing, the LOS was 10.3 days (95% CI 7 – 13.7) in injured lung down patients compared to 12.9 days (9.2 – 16.6) in healthy lung down patients (P= 0.25). In patients with chest AIS greater than three, the position of the injured lung during lateral femoral IM nailing does not appear to affect ICU LOS

Purpose of study. To review the treatment and outcomes of paediatric pelvic ring injuries in the UK. Methods and results. We performed a retrospective review of all pelvic fracture admissions to an English paediatric major trauma centre (MTC) from 2012 to 2016. A total of 29 patients were admitted with pelvic ring injuries with a mean age of 11 years (4- 16yrs). Road traffic accident was the mechanism in majority (72%), followed by fall from height (24%). Femoral shaft fracture was present in 5 (17%), head injury in 5 (17%), chest injuries in 5 (17%) and bladder injury in one child. 48% patients needed surgical procedures for fractures or associated injuries. We differentiated injuries according to the classification system of Torode and Zeig. 17% were Type A, 3% Type B, 48% Type C and 31% Type D. Almost all (93%) patients were treated conservatively. 51% of patients were allowed to mobilize full weight bearing after a period of bed rest. Non-weight bearing mobilization was recommended for fractures extending into the acetabulum, sacral fractures, unstable fracture patterns or associated fractures (neck of femur, femoral shaft and tibial shaft). Surgical fixation occurred in two patients. Both of these patients had significantly displaced Type D fractures. Only 44% of patients were back to sports at six months. Conclusions. Pelvic ring injuries are rare within the paediatric population and are associated with a high incidence of concomitant injury and significant functional morbidity. Their treatment should involve a multidisciplinary approach, which includes specialist in the care of pelvic trauma

Rib fracture fixation by orthopaedic and cardiothoracic surgeons has become increasingly popular for the treatment of chest injuries in trauma. The literature, though mainly limited to Level II and III evidence, shows favourable results for operative fixation. In this paper we review the literature and discuss the indications for rib fracture fixation, surgical approaches, choice of implants and the future direction for management. With the advent of NICE guidance and new British Orthopaedic Association Standards for Trauma (BOAST) guidelines in production, the management of rib fractures is going to become more and more commonplace

High energy chest trauma resulting in flail chest injury is associated with increased rates of patient morbidity. Operative fixation of acute rib fractures is thought to reduce morbidity by reducing pain and improving chest mechanics enabling earlier ventilator weaning. A variety of operative techniques have been described and we report on our unit's experience of acute rib fracture fixation. Over 18 months, 10 patients have undergone acute rib fracture fixation. Outcome measures included; patient demographics, time ventilated pre-operatively, time ventilated post-operatively and time spent on ITU/HDU post operatively. The mean time from presentation to surgery was 5 days (range 2–12 days). The mean time ventilated post operatively was 2 days (range 1–4 days) and the mean number of days spent on ITU/HDU post-operatively was 6 days (range 2–11 days). Our results appear positive in terms of time spent ventilated post-operatively but no conclusion can be drawn as we have no comparable non-operative group. We have however shown, that rib fracture fixation can be carried out successfully and safely in a trauma centre. Further evidence on rib fracture fixation is required from a large, multi-centre randomised controlled trial

Traumatic disruption of the pelvic ring has a high risk of mortality. These injuries are predominantly due to high-energy, blunt trauma and severe associated injuries are prevalent, increasing management complexity. This population-based study investigated predictors of mortality following severe pelvic ring fractures managed in an organised trauma system. Cases aged greater than 15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based state-wide Victorian State Trauma Registry for analysis. Patient demographic, pre-hospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated. There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged greater than 65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15–34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), while patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres). The findings highlight the importance of the need for effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches

A single centre, prospective study of 196 closed tibial diaphyseal fractures treated by monolateral external fixation. Surgical management of all patients followed a protocol of the senior author (PBMT), with regard to technique and fracture reduction. Operations were performed by several different surgeons including the senior author. A definitive fixator was used as a reduction tool in 34 cases, and a separate fracture reduction device was used in 162 patients. Follow-up was in a dedicated external fixator clinic by the senior author until one year post-fracture healing. Fracture healing was determined by fracture stiffness measurements. 196 tibial fractures in 196 patients, average age 29 (range 12-80). 111 right sided and 85 left sided. 166 male and 30 female. 116 fractures due to low energy and 80 due to high energy. Mechanism of injury. football 75, fall 52, RTA 49, others 20. 33 patients had an additional 74 injuries: 38 fractures/dislocations (3 open), 7 compartment syndromes, 7 head injuries, 16 chest injuries, 9 soft tissue injuries. According to AO classification system: 33 A1, 47 A2, 42 A3, 15 B1, 46 B2, 7 B3. Time to fracture healing was 19 weeks on average (range 9-87). 15 patients had coronal deformity >5 degrees and 1 also had saggital deformity >10 degrees. One osteotomy for correction of malunion. 279 pin site infections requiring antibiotics in 35 patients. 7 fixators removed early due to pin site infection. One established osteomyelitis-lautenbach. 7 refractures, all healed (5 with pop, 2 with further fixator). Non-union: 5 hypertrophic, 2 atrophic-all healed with further external fixation. Our results show that external fixation of closed tibial fracture is a viable alternative to other treatment methods with regard to healing time and angular deformity. Our study also uses a well validated end point to define fracture healing and does not rely on the difficulty of defining union on clinical and radiological grounds

Early fracture stabilization has been shown to reduce morbidity and mortality in the patient who is multiply injured. Controversy exists in terms of managing multiple trauma patients who sustain thoracic injuries along with femoral shaft fractures. The purpose of the present study was to determine whether the presence and treatment of femoral shaft fractures increases morbidity in patients with pulmonary contusions and to determine the effect of patient and surgical factors on outcome. Patients that suffered chest injuries between January 1987 and April 2006 were identified from the prospectively collected trauma databases at two hospitals. Patient records were reviewed to verify all data. The diagnosis of pulmonary contusion was confirmed with radiologic or post-mortem investigations. All relevant patient and surgical data was collected. Exclusion criteria included severely injured patients (head/abdomen AIS> 3), age sixty years, death twenty-four hours after injuries occurred. A total of 1190 patients with confirmed pulmonary contusions met inclusion criteria; there were 113 femoral shaft fractures (five bilateral). Patients in both the isolated pulmonary contusion and pulmonary contusion with femoral fracture had similar injury severity scores (ISS) and demographic information. Fractures were reduced with intramedullary nailing in 88% of cases. Mean age was thirty-five years. There were significantly more incidences of fat embolism syndrome and acute lung injury (ALI) in patients with femoral factures (twenty-four hours following the injury had significantly greater risk of developing ARDS (p< 0.05). The presence of femoral shaft fractures in patients with pulmonary contusions increases the duration of admittance to hospital and can lead to higher rates of fat embolism syndrome and ALI, however it does not appear to impact overall mortality or contribute to the development of other common respiratory complications. Early reduction of shaft fractures is encouraged to further decrease complications

Firearm injury is a potentially increasing public health problem worldwide. It is increasingly the subject of media and public attention. We aim to analyze the epidemiology, pattern and outcome as experienced. Data such as age, sex, race, scene and nature of injury, firearm used, alcohol and drug factors, anatomy involved, surgical requirements, transfusion details, ICU/HDU stay, complications, deaths, and outcome were collected from medical notes, WYMAS and Coroners office of all patients who presented with firearm injuries from January 1995 to December 2001. Seventy-eight cases presented to our institution. There were 19 fatalities at the scene of injury. 69 were male. 51 sustained injuries in public places, 20 at their homes and 7 in outdoor areas. Low velocity firearms were involved in 49 cases. 50 were crime related. Alcohol was identified in 34 patients and illicit drugs in 6 cases. 19 cases had bony injury with associated vascular injury in one case. Primary neurological injury was diagnosed in 5 cases. Lower extremities and upper limb injuries accounted for 59% and 26%. 3 had head and neck wounds. 4 patients had thoracic trauma and 5 had abdominal injury. 86% required surgical intervention. 11 patients had a total of 16 complications, the most common being secondary infection. 6% of patients died at the emergency department and 3 after. Chest injuries caused 5 deaths and head wounds caused 3 deaths illustrating criminal intention to cause fatal body harm. Conclusion: Males in younger age groups are disproportionately affected and the majority were crime- related injuries. Alcohol and other drugs were identified as a significant factor. There has been no significant decrease in the reported cases of firearm injuries or firearm-related deaths after the amendment made in the Firearm Rules in September 1998 (No:1941). The incidence of non-fatal firearm injury is comparable to centres involving similar population