Aims. Machine-learning (ML) prediction models in orthopaedic trauma hold great promise in assisting clinicians in various tasks, such as personalized risk stratification. However, an overview of current applications and critical appraisal to peer-reviewed guidelines is lacking. The objectives of this study are to 1) provide an overview of current ML prediction models in orthopaedic trauma; 2) evaluate the completeness of reporting following the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement; and 3) assess the risk of bias following the Prediction model Risk Of Bias Assessment Tool (PROBAST) tool. Methods. A systematic search screening 3,252 studies identified 45 ML-based prediction models in orthopaedic trauma up to January 2023. The TRIPOD statement assessed transparent reporting and the PROBAST tool the risk of bias. Results. A total of 40 studies reported on training and internal validation; four studies performed both development and external validation, and one study performed only external validation. The most commonly reported outcomes were mortality (33%, 15/45) and length of hospital stay (9%, 4/45), and the majority of prediction models were developed in the hip fracture population (60%, 27/45). The overall median completeness for the TRIPOD statement was 62% (interquartile range 30 to 81%). The overall risk of bias in the PROBAST tool was low in 24% (11/45), high in 69% (31/45), and unclear in 7% (3/45) of the studies. High risk of bias was mainly due to analysis domain concerns including small datasets with low number of outcomes, complete-case analysis in case of missing data, and no reporting of performance measures. Conclusion. The results of this study showed that despite a myriad of potential clinically useful applications, a substantial part of ML studies in orthopaedic trauma lack transparent reporting, and are at high risk of bias. These problems must be resolved by following established guidelines to instil confidence in ML models among patients and clinicians. Otherwise, there will remain a sizeable gap between the development of ML prediction models and their clinical application in our day-to-day orthopaedic trauma practice. Cite this article: Bone Jt Open 2024;5(1):9–19

Aims. The use of fluoroscopy in orthopaedic surgery creates risk of radiation exposure to surgeons. Appropriate personal protective equipment (PPE) can help mitigate this. The primary aim of this study was to assess if current radiation protection in orthopaedic trauma is safe. The secondary aims were to describe normative data of radiation exposure during common orthopaedic procedures, evaluate ways to improve any deficits in protection, and validate the use of electronic personal dosimeters (EPDs) in assessing radiation dose in orthopaedic surgery. Methods. Radiation exposure to surgeons during common orthopaedic trauma operations was prospectively assessed using EPDs and thermoluminescent dosimeters (TLDs). Normative data for each operation type were calculated and compared to recommended guidelines. Results. Current PPE appears to mitigate more than 90% of ionizing radiation in orthopaedic fluoroscopic procedures. There is a higher exposure to the inner thigh during seated procedures. EPDs provided results for individual procedures. Conclusion. PPE currently used by surgeons in orthopaedic trauma theatre adequately reduces radiation exposure to below recommended levels. Normative data per trauma case show specific anatomical areas of higher exposure, which may benefit from enhanced radiation protection. EPDs can be used to assess real-time radiation exposure in orthopaedic surgery. There may be a role in future medical wearables for orthopaedic surgeons. Cite this article: Bone Jt Open 2022;3(11):907–912

Aims. This study aims to estimate economic outcomes associated with 30-day deep surgical site infection (SSI) from closed surgical wounds in patients with lower limb fractures following major trauma. Methods. Data from the Wound Healing in Surgery for Trauma (WHiST) trial, which collected outcomes from 1,547 adult participants using self-completed questionnaires over a six-month period following major trauma, was used as the basis of this empirical investigation. Associations between deep SSI and NHS and personal social services (PSS) costs (£, 2017 to 2018 prices), and between deep SSI and quality-adjusted life years (QALYs), were estimated using descriptive and multivariable analyses. Sensitivity analyses assessed the impact of uncertainty surrounding components of the economic analyses. Results. Compared to participants without deep SSI, those with deep SSI had higher mean adjusted total NHS and PSS costs (adjusted mean difference £1,577 (95% confidence interval (CI) -951 to 4,105); p = 0.222), and lower mean adjusted QALYs (adjusted mean difference -0.015 (95% CI -0.032 to 0.002); p = 0.092) over six months post-injury, but this difference was not statistically significant. The results were robust to the sensitivity analyses performed. Conclusion. This study found worse economic outcomes during the first six months post-injury in participants who experience deep SSI following orthopaedic surgery for major trauma to the lower limb. However, the increase in cost associated with deep SSI was less than previously reported in the orthopaedic trauma literature. Cite this article: Bone Jt Open 2022;3(5):398–403

Aims. Frailty greatly increases the risk of adverse outcome of trauma in older people. Frailty detection tools appear to be unsuitable for use in traumatically injured older patients. We therefore aimed to develop a method for detecting frailty in older people sustaining trauma using routinely collected clinical data. Methods. We analyzed prospectively collected registry data from 2,108 patients aged ≥ 65 years who were admitted to a single major trauma centre over five years (1 October 2015 to 31 July 2020). We divided the sample equally into two, creating derivation and validation samples. In the derivation sample, we performed univariate analyses followed by multivariate regression, starting with 27 clinical variables in the registry to predict Clinical Frailty Scale (CFS; range 1 to 9) scores. Bland-Altman analyses were performed in the validation cohort to evaluate any biases between the Nottingham Trauma Frailty Index (NTFI) and the CFS. Results. In the derivation cohort, five of the 27 variables were strongly predictive of the CFS (regression coefficient B = 6.383 (95% confidence interval 5.03 to 7.74), p < 0.001): age, Abbreviated Mental Test score, admission haemoglobin concentration (g/l), pre-admission mobility (needs assistance or not), and mechanism of injury (falls from standing height). In the validation cohort, there was strong agreement between the NTFI and the CFS (mean difference 0.02) with no apparent systematic bias. Conclusion. We have developed a clinically applicable tool using easily and routinely measured physiological and functional parameters, which clinicians and researchers can use to guide patient care and to stratify the analysis of quality improvement and research projects. Cite this article: Bone Joint J 2024;106-B(4):412–418

In response to the COVID-19 pandemic public health measures were implemented to limit virus spread. After initial implementation of a province-wide lockdown (Stage 1), there followed a sequential ease of restrictions through Stages 2 and 3 over a 6-month period from March to September 2020 (Table 1). We aimed to determine the impact of COVID-19 public health measures on the epidemiology of operative paediatric orthopaedic trauma and to determine differential effects of each stage of lockdown. A retrospective cohort study was performed comparing all emergency department (ED) visits for musculoskeletal trauma and operatively treated orthopaedic trauma cases at a Level-1 paediatric trauma center during Mar-Sep 2020 (pandemic), compared with Mar-Sep 2019 (pre-pandemic). All operative cases were analyzed based on injury severity, mechanism of injury (MOI) and anatomic location (AL). Comparisons between groups were assessed using chi-square testing for categorical variables, and student t-tests and Fisher's exact tests for continuous variables. During the pandemic period, ED visits for orthopaedic trauma decreased compared to pre-pandemic levels by 23% (1370 vs 1790 patients) and operative treatment decreased by 28% (283 vs 391 patients). There was a significant decrease in the number of operative cases per day in lockdown Stage 1 (1.25 pandemic vs 1.90 pre- pandemic; p < 0 .001) and Stage 2 (1.65 pandemic vs 3.03 pre-pandemic; p< 0.001) but no difference in operative case number during Stage 3 (2.18 pandemic vs 2.45 pre-pandemic; p=0.35). Significant differences were found in MOI and AL during Stage 1 (p < 0 .001) and Stage 2 (p < 0 .001) compared to pre-pandemic. During Stage 1 and 2, playground injuries decreased by 95% and 82%, respectively; sports injuries decreased by 79% and 13%, and trampoline injuries decreased 44% and 43%, compared to pre-pandemic. However, self-propelled transit injuries (bicycles/skateboards) increased during Stage 1 and Stage 2 by 67% and 28%, respectively compared to pre- pandemic. During lockdown Stage 3 there were no differences in MOI nor AL. There were no significant differences in injury severity in any lockdown stage compared to pre-pandemic. COVID-19 lockdown measures significantly reduced the burden of operative paediatric orthopaedic trauma. Differences in volume, mechanism and pattern of injuries varied by lockdown stage offering evidence of the burden of operative trauma related to specific childhood activities. These findings will assist health systems planning for future pandemics and suggest that improvements in safety of playgrounds and self-propelled transit are important in reducing severe childhood injury requiring operative intervention. For any figures or tables, please contact the authors directly

Abstract. Background. Alcohol has been associated with up to 40% trauma-related deaths globally. In response to the Covid-19 pandemic, the United Kingdom (UK) entered a state of ‘lockdown’ on 23. rd. March 2020. Restrictions were most significantly eased on 1. st. June 2020, when shops and schools re-opened. This study aimed to quantify the effect of lockdown on trauma admissions specifically regarding alcohol-related trauma. Methods. All adult patients admitted as ‘trauma calls’ to a London Major Trauma Centre (MTC) during April 2018 and April 2019 (pre-lockdown; N=316), and 1. st. April – 31. st. May 2020 (lockdown; N=191) had electronic patient records (EPR) analysed. Patients’ blood alcohol level (BAC) combined with records of intoxication were used to identify alcohol-related trauma. Multiple regression analyses were performed to compare pre- and post-lockdown alcohol-related trauma admissions. Results. Alcohol-related trauma was present in a significantly higher proportion of adult trauma calls during lockdown (lockdown 60/191 (31.4%), versus pre-lockdown 62/316 (19.6%); Odds Ratio (OR 0.83, 95% CI 0.38 to 1.28, p<0.001). Lockdown was also associated with increased weekend admissions of trauma (lockdown 125/191 weekend (65.5%) vs pre-lockdown 179/316 (56.7%); OR -0.40, 95% CI -0.79 to -0.02, p=0.041). No significant difference existed between the age, gender, or mechanism between pre-lockdown and lockdown cohorts (p>0.05). Conclusion. UK lockdown was independently associated with an increased proportion of alcohol-related trauma. Furthermore, trauma admissions were increased during the weekend when staffing levels are reduced. With the possibility of multiple global ‘waves’ of Covid-19, the risk of long-term repercussions of dangerous alcohol-related behaviour must be addressed

The Victorian state government introduced a trial electronic scooter sharing scheme on 1. st. February 2022 in inner city Melbourne. Despite epidemiological data from other jurisdictions that show these devices are associated with significant trauma. This is a descriptive study from the largest trauma centre in Victoria demonstrating the “scope of the problem” after introduction of this government-approved, ride sharing scheme. Retrospective case series. Our hospital orthopaedic department database was searched from 1/1/2021 to 30/6/22 to identify all presentations associated with electronic scooter trauma, the mechanism of injury and admission information was confirmed via chart review. Data collected included: mode of arrival, alcohol/drug involvement, hospital LOS, injury severity score, ICU admission, list of injuries, operations undertaken, surgical procedures, discharge destination, death. In the 12 months prior to and 5 months since introduction of the ride share scheme, 43 patients were identified. 18 patients (42% of our cohort) presented in the 5 months since ride sharing was introduced, and 25 patients in the preceding 12 months. 58% were found to be alcohol or drug affected. All patients were admitted to hospital, 14% of which included ICU admission. 44% were polytrauma admissions. Median hospital length of stay was 2 days. The longest individual hospital stay was 69 days. No patients in this series died. There were 49 surgical procedures in 35 patients including neurosurgical, plastics and maxillofacial operations. Mean Injury Severity Score was 10. Despite data demonstrating their danger in other jurisdictions, the Victorian state government approved a trial of an electronic scooter ride share scheme in inner Melbourne in February 2022. These devices are associated with a significant trauma burden and the rate has increased since the introduction of the ride-sharing scheme. This data may be combined with other hospital data and could be used to inform policy makers

Aims. The first death in the UK caused by COVID-19 occurred on 5 March 2020. We aim to describe the clinical characteristics and outcomes of major trauma and orthopaedic patients admitted in the early COVID-19 era. Methods. A prospective trauma registry was reviewed at a Level 1 Major Trauma Centre. We divided patients into Group A, 40 days prior to 5 March 2020, and into Group B, 40 days after. Results. A total of 657 consecutive trauma and orthopaedic patients were identified with a mean age of 55 years (8 to 98; standard deviation (SD) 22.52) and 393 (59.8%) were males. In all, 344 (approximately 50%) of admissions were major trauma. Group A had 421 patients, decreasing to 236 patients in Group B (36%). Mechanism of injury (MOI) was commonly a fall in 351 (52.4%) patients, but road traffic accidents (RTAs) increased from 56 (13.3%) in group A to 51 (21.6%) in group B (p = 0.030). ICU admissions decreased from 26 (6.2%) in group A to 5 (2.1%) in group B. Overall, 39 patients tested positive for COVID-19 with mean age of 73 years (28 to 98; SD 17.99) and 22 (56.4%) males. Common symptoms were dyspnoea, dry cough, and pyrexia. Of these patients, 27 (69.2%) were nosocomial infections and two (5.1%) of these patients required intensive care unit (ICU) admission with 8/39 mortality (20.5%). Of the patients who died, 50% were older and had underlying comorbidities (hypertension and cardiovascular disease, dementia, arthritis). Conclusion. Trauma admissions decreased in the lockdown phase with an increased incidence of RTAs. Nosocomial infection was common in 27 (69.2%) of those with COVID-19. Symptoms and comorbidities were consistent with previous reports with noted inclusion of dementia and arthritis. The mortality rate of trauma and COVID-19 was 20.5%, mainly in octogenarians, and COVID-19 surgical mortality was 15.4%. Cite this article: Bone Joint Open 2020;1-7:330–338

Trauma and elective orthopaedic demands in New Zealand are increasing. In this study, prospective and retrospective data has been collected at Nelson Hospital and across New Zealand to identify the percentage of elective theatre time lost due to cancellation for acute patient care. Data has been collected from theatre management systems, hospital data systems and logged against secretarial case bookings, to calculate a percentage of elective theatre time lost to acute operating or insufficient bed capacity. Data was collected over a five-month period at Nelson Hospital, with a total of 215 elective and 226 acute orthopaedic procedures completed. A total of 95 primary hip or knee arthroplasties were completed during this trial while 53 were cancelled. The total number of elective operative sessions (one session is the equivalent of a half day operating theatre time) lost to acute workload was 47.9. Thirty-three percent of allocated elective theatre time was cancelled - an equivalent of approximately one-full day elective operating per week. Over a five-week period data was collected across all provincial hospitals in New Zealand, with an average of 18% of elective operating time per week lost due to acute workload. Elective cancellations were due to acute operating 40% of the time and bed shortages 60% of the time. The worst effected centre was Palmerston North which had an average of 33% of elective operating cancelled per week to accommodate acute surgery or due to bed shortages. New Zealand's provincial orthopaedic surgeons are under immense pressure from acute operating that impedes provision of elective surgery. The New Zealand government definition of an ‘acute case’ does not reflect the nature of today's orthopaedic burden. Increasing and aging populations along with staff and infrastructure shortages have financial and societal impacts beyond medicine and require better definitions, further research, and funding from governance

Aims. The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI). Methods. This is a retrospective cohort study of operatively managed orthopaedic trauma patients from 1 January 2007 to 31 December 2016, performed in Queensland, Australia. Record linkage was used to develop a person-centric, population-based dataset incorporating routinely collected administrative, clinical, and health economic information. The FRI group consisted of patients with International Classification of Disease 10th Revision diagnosis codes for deep infection associated with an implanted device within two years following surgery, while all others were deemed not infected. Demographic and clinical variables, as well as healthcare utilization costs, were compared. Results. There were 111,402 patients operatively managed for orthopaedic trauma, with 2,775 of these (2.5%) complicated by FRI. The development of FRI had a statistically significant association with older age, male sex, residing in rural/remote areas, Aboriginal or Torres Strait Islander background, lower socioeconomic status, road traffic accident, work-related injuries, open fractures, anatomical region (lower limb, spine, pelvis), high injury severity, requiring soft-tissue coverage, and medical comorbidities (univariate analysis). Patients with FRI had an eight-times longer median inpatient length of stay (24 days vs 3 days), and a 2.8-times higher mean estimated inpatient hospitalization cost (AU$56,565 vs AU$19,773) compared with uninfected patients. The total estimated inpatient cost of the FRI cohort to the healthcare system was AU$156.9 million over the ten-year period. Conclusion. The results of this study advocate for improvements in trauma care and infection management, address social determinants of health, and highlight the upside potential to improve prevention and treatment strategies. Cite this article: Bone Joint J 2024;106-B(1):77–85

Introduction. Blunt trauma of the lower limb can lead to vascular injury causing devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). Secondary aims included establishing the patient complications and outcomes. Materials and Methods. Retrospective analysis found that from 2013–18, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury. Long-term functional outcomes were determined using postal and telephone questionnaires. Results. Twenty-four patients were male and 6 were female, their mean ages were 32 and 49 respectively. Of the 32 limbs, 27 (84%) were salvaged. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Eleven limbs had prophylactic fasciotomies, 3 limbs developed compartment syndrome – all successfully treated, and three contracted deep infections – one of which necessitated amputation. All but 1 patient survived their injuries and were discharged from hospital. Of the 15 questionnaire responses, self-reported limb function was understandably worse post-injury with patients experiencing mild pain on average. In addition, there was a long-standing psychological impact and the injuries altered many patients’ normal lives significantly, 10 experiencing financial difficulties and 6 having changed or lost jobs post-injury. Conclusions. Fortunately, 27 (84%) limbs were salvaged and nearly all patients survived these injuries when treated at an MTC. Whilst the number of complications was low, the future challenges these patients face are wide-ranging and significant

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

Hip fractures in elderly patients are managed at both major trauma centers (MTC) and trauma units (TU). Previous evidence has demonstrated the importance of early surgery to reduce the morbidity and mortality related to the injury. The aim of this study is to compare the ‘time to theatre' and ‘30 day mortality' in TUs versus MTC in UK. A retrospective review of prospectively collected data on NHFD was performed. The average ‘time to theatre' in hours and ‘30 day mortality' of all hospitals were analysed between January and December 2018. Further subgroup analysis was done to check for any regional variations; in each instance a Shapiro-Wilk test was used to check for normal distribution, followed by a one-way ANOVA with a Tukey's post hoc test. Data from 158 hospitals in England (ENG), Wales (WAL) and Northern Ireland (NI) were used; 18 of which were MTC. There were 57,936 operative cases in TUs and 8606 in MTC's. The mean time (hours) to surgery from presentation was 32.51 and 32.64 for TUs and MTC respectively (p=0.513). There was no significant difference in ‘30 day mortality' (p=0.635) between TUs (6%) and 5.7% MTC's (5.7%), MTC's and TUs in ENG, WAL and NI (p=0.555), and MTC and WAL, NI and the different regions of ENG (p=0.209). A significant difference was observed, between the regional practice for TUs versus MTC's in ENG, WAL and NI (p=0.001) and between MTC's and TUs in WAL, NI and the different regions of ENG (p=0.001), with patients waiting significantly longer in NI for their procedure (mean=60.25 hours, p=0.001). There was no significant difference in time to surgery or 30 day mortality between TUs and MTC's, demonstrating comparable hip fracture care, despite MTCs need to prioritise more serious injuries

Abstract. Background. University Hospital of Wales (UHW) went live as a Major Trauma Centre (MTC) on the 14th September 2020. New guidelines have been set up by the Wales Trauma Network. Aim. Prospective audit to see how many admissions, correct pathways were followed?. Materials & Methods. Prospective data collection prospective over a period of 3 months: starting from 8.11.2020 to 31.01.2021. Results. Spinal admissions represent around 22% of MTC admissions. The closing loop showed higher amount of admission (45 in comparison with the first audit 28). 42 patients had fractures where three had cord syndromes. 13 patients out of the 45 (29%) were managed operatively. After changing to MTC, more indirect referral from other hospitals representing 64% of total admission with one wrong referral (2.2%) that came to the MTC and could have been managed locally. On the other hand, repatriation rate has improved from 61% to 84%, however, repatriation time was longer than expected with >1 week represents 78%. Conclusions. Changing to MTC had a great impact with increased work load in the trust. Repatriation would be aimed for within 72 hours from treatment either conservative or postoperative. More attention should be paid towards the appropriate referral pathways to avoid wrong referral

Abstract. Background. Different surgical sub specialities rely on fixed number of porters each morning to bring patients to operating theatre. In daily morning trauma meetings usual practice is to present the whole list of one theatre and then move on to next theatre list. Once all the theatres trauma list are presented, porters are sent to get patients to theatre. With different sub-specialities starting simultaneously and competing for fixed numbers of porters, this can cause significant delay in getting the patients to anaesthetic room. Methods. Retrospective pilot project in level 1 major trauma centre were more that two trauma list a day is a common norm. Pilot project:. First (Golden) patient for every trauma list would be presented at the start of the trauma meeting. Meeting would pause and consultant chairing the meeting would request the trauma theatre representative to send for these patients. Once this is done the meeting would recommence as usual. Results. (a). The porters were sent on an average more than 30 minutes earlier in the pilot week. (b). This was further reflected in the patients being brought into holding bay. (c). The patients were in the anaesthetic room on an average 40 minutes before in pilot group compared to usual practice. Conclusion/Findings. Presenting first patient of each trauma list and then asking theatre to send porter to get the patient to theatre can save appreciable time. Implications. To run an hour of theatre costs £1200. This initiative can save lot of money for NHS

Aims. Periprosthetic proximal femoral fractures (PFFs) are a major complication after total hip arthroplasty (THA). Health status after PFF is not specifically investigated. The aim of this study is to evaluate the health status pattern over two years after sustaining a PFF. Methods. A cohort of patients with PFF after THA was derived from the Brabant Injury Outcomes Surveillance (BIOS) study. The BIOS study, a prospective, observational, multicentre follow-up cohort study, was conducted to obtain data by questionnaires pre-injury and at one week, and one, three, six, 12, and 24 months after trauma. Primary outcome measures were the EuroQol five-dimension three-level questionnaire (EQ-5D-3L), the Health Utility Index 2 (HUI2), and the Health Utility Index 3 (HUI3). Secondary outcome measures were general measurements such as duration of hospital stay and mortality. Results. A total of 70 patients with a PFF were included. EQ-5D utility scores were significantly lower on all timepoints except at six months’ follow-up compared to pre-injury. EuroQol visual analogue scale (EQ-VAS) scores at one month's follow-up were significantly lower compared to pre-injury. The percentage of reported problems at two years was higher for all dimensions except anxiety/depression when compared to pre-injury. The mean EQ-5D utility score was 0.26 higher in males compared to females (95% confidence interval (CI) 0.01 to 0.42; p = 0.003). The mean EQ-VAS score for males was 8.9 points higher when compared to females over all timepoints (95% CI 1.2 to 16.7; p = 0.027). Mortality was 10% after two years’ follow-up. Conclusion. PFF patients are a frail population with substantial functional impairment at baseline. Post-injury, they have a significant and clinically relevant lower health status two years after trauma when compared to pre-injury. Health status improves the most between one and three months after injury. Two years after PFF, more patients experience problems in mobility, self-care, usual activities, and pain/discomfort than pre-injury. Cite this article: Bone Joint J 2024;106-B(5):442–449

Aims. Hand trauma, consisting of injuries to both the hand and the wrist, are a common injury seen worldwide. The global age-standardized incidence of hand trauma exceeds 179 per 100,000. Hand trauma may require surgical management and therefore result in significant costs to both healthcare systems and society. Surgical site infections (SSIs) are common following all surgical interventions, and within hand surgery the risk of SSI is at least 5%. SSI following hand trauma surgery results in significant costs to healthcare systems with estimations of over £450 per patient. The World Health Organization (WHO) have produced international guidelines to help prevent SSIs. However, it is unclear what variability exists in the adherence to these guidelines within hand trauma. The aim is to assess compliance to the WHO global guidelines in prevention of SSI in hand trauma. Methods. This will be an international, multicentre audit comparing antimicrobial practices in hand trauma to the standards outlined by WHO. Through the Reconstructive Surgery Trials Network (RSTN), hand surgeons across the globe will be invited to participate in the study. Consultant surgeons/associate specialists managing hand trauma and members of the multidisciplinary team will be identified at participating sites. Teams will be asked to collect data prospectively on a minimum of 20 consecutive patients. The audit will run for eight months. Data collected will include injury details, initial management, hand trauma team management, operation details, postoperative care, and antimicrobial techniques used throughout. Adherence to WHO global guidelines for SSI will be summarized using descriptive statistics across each criteria. Discussion. The Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) will provide an understanding of the current antimicrobial practice in hand trauma surgery. This will then provide a basis to guide further research in the field. The findings of this study will be disseminated via conference presentations and a peer-reviewed publication. Cite this article: Bone Jt Open 2024;5(4):361–366

Queensland is in the phase to develop a comprehensive, integrated state wide Trauma System with support from the Queensland Health and Emergency Services. A strategic step in this circumstance is benchmarking the current trauma system with other established trauma systems, to compare performance and indicators of trauma care. Queensland’s first recognized Adult Major Trauma Service, the Princess Alexandra Hospital (PAH) in Brisbane, was compared with the results of the established Trauma Registry of the German Trauma Society (DGU). This study analysed the whole range of trauma care, from the scene of the accident to discharge from the hospital. Methodology: The study populations were retrospectively identified and extracted from the Queensland Trauma Registry and the DGU Trauma Registry. Both databases contain all primary and secondary admitted trauma patients of all ages, with an Injury Severity Score (ISS) > 15, for the year 2005. The collected patient data included demographics, mechanism of injury, details on pre-hospital phase, injury, treatment, complications and outcome. Results: At the PAH 309 patients with an ISS > 15 were treated, compared to 2537 in the DGU Registry. The demographics (age and gender) and trauma mechanisms (blunt vs penetrating injuries) were comparable, even the average ISS scores were higher in the DGU registry (29) than at PAH (25). The primary referrals from the accident scene to the PA Hospital were significantly lower (52%) than to the German Trauma centres (82%). The secondary referrals arrived at PA Hospital on average 13.5 hrs post accident compared to 3.4 hrs in the DGU registry. PAH patients less often needed surgery (61% versus 78%), ICU-admission (49% versus 88%) and mechanical ventilation (44% versus 72%). The average time of the patients in ED was significantly higher with almost 4 hrs compared to 1 hrs in the German trauma centres. Nevertheless the overall mortality was lower at PA Hospital: 10% versus 18%, with an equal time to death, age and injury severity of deaths. Conclusions: Queensland’s enormous size entails significant implications for trauma care. The results of the benchmarking study may reflect an suboptimal care in the first crucial hours after the accident leading to a higher secondary referral rate and a lower ISS score of the arriving patients to PA Hospital. The relatively low number of in-hospital deaths was presumably due to a higher number of prehospital deaths, although we are unable to quantify this at present. The in hospital clinical course was elongated in the ED at PA Hospital, and several reasons can be discussed for this. This benchmarking study helps to reflect the current trauma care coming to PA Hospital, even many issues remain unanswered in a retrospective study. This presentation will review the integrated approach of Queensland to streamline the trauma care and highlights the first steps taken to improve the efficiency of the system

Trauma, across the United Kingdom, is managed using several software, paper based lists on Microsoft Word/Excel or Teams. There is usually poor handover or no handover in a standard format- during the on call, in the trauma meetings or in the wards. The software in the market for trauma management are not cost friendly or adaptable to local demands. The alternatives like Microsoft WORD based lists are fraught with their own problems. We endeavoured to make our trauma management effective. A Quality Improvement Project was done. The goals to achieve at end of a year were:. Daily Trauma Handover in standardised format >90%. Ward Handover in standardised format >90%. Availability of outcomes of patients in clinic >80%. Reduction of paper usage >90% at the end of six months. Availability of updated “outliers” information >90% at the weekend ward round. Documentation from the Trauma Meeting > 90%. On-Call documentation in standardised format >90%. Doctor Satisfaction >75% in terms of: ease of us;, searchability of patient; ward round experience; morning trauma meeting experience; handover experience; inter-specialty communication; reliability; daily time saving; on-call time saving; patient care/safety; overall satisfaction. We used Microsoft Sharepoint List to manage our trauma workload and have named the tool as “The List”. The List has achieved all objectives as above in one year's time, except Outlier information which was at 67% in a recent PDSA (Plan-Do-Study-Act) cycle. The survey showed excellent doctor satisfaction and 90% respondents felt that The List saved an hour or more during the on-call and also during the ward rounds. We conclude that The List is a very powerful tool making trauma meetings efficient and handover effective. It is indigenous, adaptable, safe, sustainable, cost neutral and easy to use

Determine the prevalence, etiologies, and risk factors of unplanned return to the OR (UROR) in adult orthopaedic trauma patients. Retrospective review of a trauma prospective registry from 2014 – 2019 at a Level 1 academic hospital. An UROR was defined as a patient returning to OR unexpectedly following a planned definitive surgery to either readdress the presenting diagnosis or address a complication arising from the index procedure. Univariate and multivariate logistic regression was performed comparing those patients with an UROR versus those without. A total of 1568 patients were reviewed. The rate of UROR was 9.8% (153 patients). Symptomatic implant was the leading cause of UROR (60%). Other significant UROR causes were infection (15%) and implant failure (9%). The median time between index procedure and UROR was 301 days. For the univariate and multivariate analysis, open fracture (p< 0.05), fracture complexity (p<0.01), and weekend procedure (p< 0.01) were all associated with increased risk of UROR. All other variables were not statistically significant for any associations. Those patients with an UROR for reasons other than symptomatic implants were more likely to have polyorthopaedic injuries (p < 0.05), ISS > 15 (p < 0.05), osteoporosis (p < 0.01), ICU status (p < 0.05), psychiatric history (p < 0.05), compartment syndrome (p < 0.05), neurovascular injury (p < 0.01), open fracture (p < 0.05), and fracture complexity (p < 0.05). The rate of UROR in the orthopaedic trauma patient population is 10%. Most of these cases are due to implant-related issues. UROR for reasons other than symptomatic implants tend to be polytraumatized patients with higher-energy injuries, multiple complex fractures, and associated soft tissue injuries. Future focus on improved implant development and treatments for polytraumatized patients with complex fractures is warranted to decrease a relatively high UROR rate in orthopaedic trauma