Femur shaft fractures (FSF) are markers of high energy transfer after injury. The comprehensive, population based epidemiology of FSF is unknown. The purpose of this prospective study was to describe the epidemiology of FSF with special focus on patient physiology and timing of surgery.

A 12-month prospective population-based study was performed on consecutive FSF in a 600,000 population area including all ages and pre-hospital deaths. Patient demographics, mechanism, injury severity score (ISS), shock parameters (SBP, BD and Lactate), transfusion requirement, fracture type (AO), co-morbidities, performed procedure and outcomes were recorded. Patients were categorized: Stable, borderline, unstable and in extremis.

A total of 125 patients (20.8/100,000/year) with 134 femur fractures. (62% male, age 37±28 years, ISS 20±19, 51% multiple injuries) were identified in two hospitals. 69 patients (55%) sustained a high energy injury (MVA, MBA, train related, high fall) with 16 (23%) of these being polytrauma patients (ISS 28±12, SBP 98±39, BD 6.5±5.8, Lactate 4±2), 15 (94%) required massive transfusion (12±12 URBC, 8±5 FFP, 1±0.4 PLT, 13±8 Cryo). Of the 125 patients 69% were stable (14.5/100,000/year), 9% borderline (1.8/100,000/year), 4% unstable (0.8/100,000/year) patients and 2% (0.3/100,000/year) were in extremis. 2 borderline, 1 unstable and 2 extremis patients died of severe CHI. One patient in extremis died due to uncontrollable hemorrhage from a pelvic fracture. 20 patients (16%) (3.3/100,000/year) with FSF were prehospital deaths and died due to the severity of their multiorgan injuries or CHI. The overall LOS was 18±15 days and the ICU LOS was 5±6 days. All high energy patients went to theatre within 6±13 hours. 56 patients (45%) sustained a low energy injury. Of these patients 85% had multiple co-morbidities. 8 patients needed 3±1 transfusions and none of the patients died. Time to surgery was 25±37 hrs and LOS was 15±11 days. There were 29 paediatric FSF, 20 of these were low and 9 high energy injuries. Only 3 patients required surgery.

LE-FSF are as frequent as HE-FSF. 73% of the femur fractures are complicated (open, compromised physiology, multiple injured, bilateral, elderly with co-morbidities etc.) requiring major resources and highly specialized care.

Various injury severity scores exist for trauma; it is known that they do not correlate accurately to military injuries. A promising anatomical scoring system for blast pelvic and perineal injury led to the development of an improved scoring system using machine-learning techniques. An unbiased genetic algorithm selected optimal anatomical and physiological parameters from 118 military cases. A Naïve Bayesian (NB) model was built using the proposed parameters to predict the probability of survival. Ten-fold cross validation was employed to evaluate its performance. Our model significantly out-performed Injury Severity Score (ISS), Trauma ISS, New ISS and the Revised Trauma Score in virtually all areas; Positive Predictive Value 0.8941, Specificity 0.9027, Accuracy 0.9056 and Area Under Curve 0.9059. A two-sample t-test showed that the predictive performance of the proposed scoring system was significantly better than the other systems (p<0.001). With limited resources and the simplest of Bayesian methodologies we have demonstrated that the Naïve Bayesian model performed significantly better in virtually all areas assessed by current scoring systems used for trauma. This is encouraging and highlights that more can be done to improve trauma systems not only for the military, but also in civilian trauma

Background. Referral to centres with a pelvic service is standard practice for the management of displaced acetabular fractures. Hypothesis. The time to surgery: (1) is a predictor of radiological and functional outcome and (2) this varies with the fracture pattern. Methods. A retrospective case review of 254 patients over a ten year period with a minimum follow-up of two years. Patients were divided into two groups based on fracture pattern: elementary or associated. ‘Time to surgery’ was analysed as a continuous and a stratified variable. The primary outcome measures were the quality of reduction and functional outcome. Logistic regression analysis was used to test our hypothesis, while controlling for potential confounding variables. Results. For elementary fractures, an increase in the time to surgery on one day reduced the odds of an excellent/good functional result by 15% (p = 0.001) and of an anatomical reduction by 18% (p = 0.0001). For associated fractures, the odds of obtaining an excellent/good result were reduced by 19% (p = 0.0001) and an anatomical reduction by 18% (p = 0.0001) per day. When ‘time’ was measured as a categorical variable, an anatomical reduction was more likely if surgery was performed within 15 days (elementary) and five days (associated). An excellent/good functional outcome was more likely when surgery was performed within 15 days (elementary) and ten days (associated). Conclusion. The time to surgery is a significant predictor of radiological and functional outcome for both elementary and associated displaced acetabular fractures. The organisation of regional trauma systems must be capable of satisfying these time-critical targets to achieve optimal patient outcome

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

Aims

The aim of this study is to determine the effects of the UK lockdown during the COVID-19 pandemic on the orthopaedic admissions, operations, training opportunities, and theatre efficiency in a large district general hospital.

Introduction. The distal radius is the most frequently fractured bone in the forearm with an annual fracture incidence in the UK of about 9–37 in 10,000. Restoration of normal anatomy is an important factor that dictates the final functional outcome. A number of operative options are available, including Kirschner wiring, bridging or non-bridging external fixation and open reduction and internal fixation by means of dorsal, radial or volar plates. We designed this study to analyse the clinical and radiological outcome of distal radial fracture fixation using volar plating. Materials/Methods. Thirty-seven patients with distal radius fractures undergoing open reduction and internal fixation using volar plates were included. Tilt of the fractured distal radial fragment was recorded from the initial radiograph and classification of fractures was done using the Orthopaedic Trauma Association system. The QuickDASH questionnaire was used for evaluation of symptomatic and functional outcome six months to one year after surgery. The radiological outcome was assessed using measurements of radial inclination, ulnar variance and volar tilt. Of the thirty-seven patients, 13 were male and 24 were female. The mean age was 55.6 years (range 18–87 years). According to the AO classification, there were 8 cases each of C2 and C3 fractures, 6 cases of C1 fractures and 3 cases each of class A2, A3, B1 and B3 fractures. There were 2 patients with class B2 fracture. Results. Post-operatively, the average restoration of volar tilt was 6.47 degrees (range −12.4 to 20.3 degrees). Mean restoration of radial inclination was 23 degrees (range 12.5 to 30.0 degrees). Ulnar variance on average was 0.09 mm (range −5.0–6.7mm). The mean QuickDASH score was 9.8. Conclusion. The results of this study indicate that fixation of displaced intra- and extra-articular distal radial fractures is achieved satisfactorily with restoration of both normal anatomy and function using volar plates

To review the effect of MRSA screening, ward ring-fencing and other significant factors on elective orthopaedic operation cancellations: and to study the effect of introducing a multi-disciplinary trauma management system on trauma operation cancellations, we carried out a study at the Royal Gwent Hospital, a district general hospital accepting general emergency admissions. It took the form of a prospective audit of all elective orthopaedic and trauma cancellations from 1 October to 10 November 2002, and in the same period of 2004. Definitions: an ‘elective cancellation’: deemed medically fit at SHO pre-admission assessment; MRSA swabbed with negative results then subsequently cancelled from an elective theatre list under the headings, ‘ward breech by other unscreened patients’, ‘unfit for surgery’ (anaesthetic decision), ‘lack of beds’ and ‘other’ (lack of surgical assistant, theatre time, theatre staff and operation not required). A ‘trauma cancellation’: acute admission with allocation of theatre space; subsequently cancelled under the headings, ‘unfit for surgery’ (anaesthetic decision), ‘lack of theatre time’, ‘surgery not required’ and ‘other’ (patient refused surgery, absconded, incorrect listing, no surgical assistant or theatre staff). Results. In the six week period 198 and 226 elective patients were listed in 2002 and 2004 respectively. 52% were cancelled in 2002 and 35% in 2004, most frequently by ‘ward breech by other unscreened patient’. 234 and 269 trauma cases were listed in 2002 and 2004 respectively. 26% were cancelled in 2002 and 16% in 2004, most frequently in 2002 by ‘unfit for surgery’, and ‘surgery not required’; and in 2004 ‘lack of theatre time’. The MRSA ring-fencing policy was breached frequently by unscreened emergency patients. An elective unit separate from the main hospital may prevent these cancellations. The multi-disciplinary trauma management scheme reduced trauma cancellations, but other factors have reduced theatre efficiency