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Background: Traumatic pelvic fracture (TPF) is a significant injury that results from high energy impact and has a high morbidity and mortality., Purpose: We aimed to describe the epidemiology, incidence, patterns, management, and outcomes of TPF in multinational level 1 trauma centers., Methods: We conducted a retrospective analysis of all patients with TPF between 2010 and 2016 at two trauma centers in Qatar and Germany., Results: A total of 2112 patients presented with traumatic pelvic injuries, of which 1814 (85.9%) sustained TPF, males dominated (76.5%) with a mean age of 41 ± 21 years. In unstable pelvic fracture, the frequent mechanism of injury was motor vehicle crash (41%) followed by falls (35%) and pedestrian hit by vehicle (24%). Apart from both extremities, the chest (37.3%) was the most commonly associated injured region. The mean injury severity score (ISS) of 16.5 ± 13.3. Hemodynamic instability was observed in 44%. Blood transfusion was needed in one third while massive transfusion and intensive care admission were required in a tenth and a quarter of cases, respectively. Tile classification was possible in 1228 patients (type A in 60%, B in 30%, and C in 10%). Patients with type C fractures had higher rates of associated injuries, higher ISS, greater pelvis abbreviated injury score (AIS), massive transfusion protocol activation, prolonged hospital stay, complications, and mortality (p value < 0.001). Two-thirds of patients were managed conservatively while a third needed surgical fixation. The median length of hospital and intensive care stays were 15 and 5 days, respectively. The overall mortality rate was 4.7% (86 patients)., Conclusion: TPF is a common injury among polytrauma patients. It needs a careful, systematic management approach to address the associated complexities and the polytrauma nature.

Talar fractures are uncommon lesions (0.1-0.9%) and have a high rate of complications. One of the situations in which a fracture of the talus can occur is in the context of polytrauma which may further compromise the functional prognosis. The aim of this study was to analyze the functional results in patients with talar fractures whether or not they occurred in the context of polytrauma. Observational study on a retrospective cohort of 24 patients operated in our centre (2008-2016). They were grouped according to whether they were polytraumatized (ISS>16) or not (ISS≤16). Review of sociodemographic, radiographic, functional variables (VAS pain scale and FADI -Foot and Ankle Disability Index-) and the onset of complications such as arthrosis, arthrodesis or avascular necrosis. Review of 25 talar fractures in 24 patients with a mean age of 38 years (19-75) and a mean follow-up of 4.2 years (0.5-9). According to the ISS, 44% of patients (11) were polytraumatized and 56% (14) were not. The average score according to the FADI scale was 62 points for the polytraumatized patients and 76.9 for the non-polytraumatized patients. The pain according to the VAS scale was 5.8 points in the group of polytraumatized patients and 4.3 in the non-polytraumatized patient group. Regarding complications, 64% of the polytraumatized patients and 43% of the non-traumatized patients had a complication. 36% of the polytraumatized patients had clinical and radiological signs of subtalar arthrosis compared to 35% of the non-traumatized patients, of whom 27% underwent arthrodesis compared to 28% of the non-traumatized patients. 27% of the polytraumatized patients were diagnosed with avascular necrosis as opposed to 0% of the non-polytraumatized patients., (Copyright © 2019 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.)

Urethral injury in major trauma is infrequent, with complex problems of diagnosis and treatment. The aims of this study are to determine the incidence and epidemiological factors relating to urethral injury in major trauma, as well as determine if any additional prognostic factors are evident within this cohort of patients. A retrospective review of patients sustaining urethral injury following major trauma was made over a 6-year period, from 2010 to 2015. Quantitative analysis was made using the national trauma registry for England and Wales, the Trauma Audit and Research Network (TARN) database, identifying all patients with injury codes for urethral injury. 165 patients with urethral injuries were identified, over 90% were male, most commonly injured during road traffic accidents and with an associated overall mortality of 12%. Urethral injury in association with pelvic fracture occurred in 136 patients (82%), representing 0.6% of all pelvic fractures, and was associated with double the rate of mortality. Urethral injury was associated with unstable pelvic fractures (LC2, LC3, APC3, VS, CM) but not with a specific pelvic fracture type. This study confirms the rare incidence of this injury in major trauma at 1 per 2 million population per year., (Copyright © 2019. Published by Elsevier Ltd.)

The idea of damage control (DC) is grounded on a sequential therapeutic strategy that supports physiological restoration over anatomic repair in critically injured patients. This concept is firstly described as damage control surgery (DCS) for war-wounded patients with abdominal exsanguinating trauma. The goal was to avoid prolonged operative times and prevent the outset of the lethal cycle of hypothermia, acidosis and coagulopathy. Damage control orthopedics (DCO) is also based on this concept and it is applied in the treatment of some polytrauma patients with pelvic and long bones fractures as to avoid the "second hit" of a lengthy definitive operation and eliminate initial morbidity and mortality. It is in favor of primary fracture stabilization utilizing provisional external fixation. When the patient is in stable condition, conversion to definitive open reduction and intramedullary nailing can be done. This stepwise approach should be considered as a part of the resuscitation process, and it follows the saying "do no further harm".

Introduction: Multitrauma patients suffering hindfoot fractures, including calcaneal and talar fractures, often result in poor outcomes. However, less is known about the outcomes following midfoot fracture in the mutitrauma population. This study aims to describe the epidemiology of midfoot fractures in multitrauma patients and to compare the outcomes of midfoot and hindfoot fractures in this population., Methods: Data about multitrauma patients (Injury Severity Score >12) sustaining a unilateral midfoot or hindfoot fracture were obtained from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) and from retrospective review of medical records at a major trauma centre. Further outcome data were obtained via a survey using the American Academy of Orthopedic Surgeons Foot and Ankle Score (AAOS FAS) and the 12-item Short Form Health Survey (SF-12)., Results: 122 multitrauma patients were included; 81 with hindfoot fractures and 41 with midfoot fractures. The median ISS (IQR) was 22 (17-29) and 27 (17-24) for the hindfoot and midfoot groups, respectively (p = 0.23). Hindfoot and midfoot fractures were commonly associated with intracranial injuries (80.3%), spine injuries (60.7%), ipsilateral lower extremity injuries (24.6%) and pelvic injuries (16.4%). The mean (SD) time to follow up was 4.5 (±2.7) years. There were no differences in mean SF-12 physical (37.97 vs 35.22, p = 0.33) or mental (46.90 vs 46.67, p = 0.94) component summary scores between the groups. There were no differences in mean AAOS FAS standard scores (69.3 vs 69.1, p = 0.97) or shoe comfort scores (median 40 vs 40 p = 0.18) between the groups., Conclusion: Functional outcomes in multitrauma patients with midfoot or hindfoot fractures were comparable. These findings suggest that midfoot fractures should be treated with the same degree of due diligence as hindfoot fractures in the multitrauma patient., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Background: This study assessed the surgical outcomes of Lisfranc injuries accompanied by multiple metatarsal fractures. Metatarsal fractures here refers to metatarsal head, neck, and shaft (including shaft fractures accompanied by fractures of the base) fractures, as well as mixed (i.e., segmental fracture) fractures, as seen on imaging studies., Methods: Between 2002 and 2015, one hundred and seventy-six patients were followed-up for a mean of 92 months, including eight patients who underwent secondary arthrodesis due to severe arthritis after ORIF. All the patients underwent surgical fusion (primary partial arthrodesis, PPA; n = 78) or non-fusion (percutaneous or open reduction and internal fixation, ORIF; n = 98) procedures and the outcomes were evaluated by clinical examinations, radiography, visual analogue scale (VAS) pain score, the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score, the Foot and Ankle Outcome Score (FAOS), and the Short Form (SF)-36 physical and SF-36 mental questionnaires. The parameters between the fusion and non-fusion groups were analyzed by repeated-measures ANOVA. Statistically significant differences between the two groups were then further analyzed using a two-independent-samples t-test., Results: Anatomical reduction was achieved in 161 patients. At the last follow-up, the mean AOFAS score was 74.67 (range: 39-91) in the non-fusion group and 82.79 (range: 67-97) in the fusion group (P = 0.003). The PPA and ORIF groups differed significantly with respect to the VAS pain score (1.93 vs. 1.21), the SF-36 physical (75.87 vs. 80.90) and mental (75.76 vs. 81.33) components, and the FAOS pain (72.74 vs. 84.06), symptoms (71.87 vs. 82.49), activities of daily life (ADLs: 73.12 vs. 81.54), sport/recreation (sport/rec: 57.99 vs. 73.23), and quality of life (QoL: 79.95 vs. 86.67) components. In the ORIF group, 23 patients had mild/moderate post-traumatic osteoarthritis., Conclusions: With longer and more conservative postoperative management, fusion results in a better outcome than non-fusion in the treatment of Lisfranc injuries accompanied by multiple metatarsal fractures., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Presence of pelvic fractures in trauma patients has previously been related to high mortality. However, there are controversies on whether pelvic fractures are the underlying cause of death or if it is rather an indicator of injury severity. We aimed to assess whether the presence of pelvic fracture increased mortality among a cohort of trauma patients or if it was simply an indicator of severe injury., Material and Methods: Karolinska University Hospital is the largest trauma centre in Sweden. The hospital is linked to the Swedish National Trauma Registry, "SweTrau". Registry data was collected for the period January 2013 until December 2015 with a one year further follow-up regarding mortality. Patients in the pelvic fracture group were compared to the non-pelvic fracture group and regression analysis was performed adjusting for factors that could possibly affect mortality., Results: Univariable analysis showed that pelvic fracture was associated with an increased mortality, OR 2.4 (CI 1.3-3.4). Multivariable analysis showed that the presence of a pelvic fracture was not associated with an increased 30-day mortality (OR 0.5, CI 0.2-0.9), while factors as Shock (OR 7.1, CI 4.6-10.9), GCS < 9 (OR 6.2, CI 3.9-9.8), ISS > 15 (OR 12.4, CI 8.1-18.9), Age >60 (OR 3.2, CI 2.1-4,9) and ASA 3-4 (OR 4.7, CI 3.1-7.3) were associated with an increased 30-day mortality. Factors affecting 1-year mortality was analysed in the same way and the results were similar., Conclusion: Presence of pelvic fractures in trauma patients is not correlated to increased mortality when adjusted for Age, ISS, ASA, GCS and Shock., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Due to prioritizing care and concomitant injuries, foot fractures in polytrauma patients often receive limited attention initially. However, as foot function is important, treatment and diagnosis of these fractures should be accurate. The aims of this study were to assess the incidence and distribution of foot fractures in polytrauma patients and to examine possible risk factors for delayed diagnosis of foot fractures., Methods: This was a retrospective study on all adult (≥18 years) polytrauma (ISS ≥16) patients admitted to a single level 1 trauma center between 2006 and 2016. Patients with foot fractures were identified by diagnosis codes. Data on demographics and trauma characteristics were collected from the Trauma Quality Improvement Program (TQIP ® ) database. Data on foot fractures were gathered from electronic patient documentation., Results: Out of 4409 polytrauma patients, 221 (5.0%) sustained a total of 511 foot fractures. Metatarsal fractures were most common (41%), followed by calcaneal (17%), and talar (16%) fractures. Thirty percent of the fractures in 33% of all patients were diagnosed in a delayed fashion. This had treatment consequences in 8%. Delayed diagnosed fractures were more common in older patients (p 0.025), patients with a higher ISS (p 0.012), ICU admission (p 0.015), and concomitant head injury (p 0.020)., Conclusions: As one in twenty polytrauma patients sustains at least one foot fracture and a substantial amount of these fractures are diagnosed in a delayed fashion, physicians, regardless of their specialty, should have a high index of suspicion for injuries of the feet in polytrauma patients., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Trauma with multiple injuries is associated with a high risk of complications, which may be related to excessive stimulation of inflammatory and anti-inflammatory responses. Although the effects of polytrauma on the immune response have been well established at the cellular and molecular levels, there is little information about the changes in the cytolytic potential of immunocompetent cells, including expression of cytotoxic molecules such as perforin. Therefore, the objective of the present study was to analyse and compare differences in the frequency and perforin expression of leukocyte subpopulations in the peripheral blood of patients with lower limb fracture, thoracic injury, and simultaneous lower limb fracture and thoracic injury., Patients and Methods: Forty-five patients with trauma injury (15 patients with lower limb injury, 15 patients with thoracic injury, and 15 patients with simultaneous lower limb and thoracic injury) were included in the study. Peripheral blood of 15 sex- and age-matched healthy volunteers served as the control group. Peripheral blood samples were taken from all subjects included in the study and peripheral blood mononuclear cells were isolated by gradient centrifugation. The frequency of T lymphocytes, natural killer (NK) and NK T cells, and their subsets, as well as their perforin expression levels were simultaneously detected and analysed by flow cytometry., Results: There was a statistically significant decrease in the frequency of T lymphocytes, NK and NK T cells as well as perforin expression in the patients with simultaneous lower limb and thoracic injury compared with the other two groups, with a predominantly marked decrease in NK and NK T cells., Conclusion: The decrease in the frequency and cytotoxic potential of peripheral blood lymphocytes is related to the severity of trauma injury, which can explain the underlying mechanism contributing to complication occurrence., (© 2017 Elsevier Ltd. All rights reserved.)

Introduction: Injuries of the hand can cause significant functional impairment, diminished quality of life and delayed return to work. However, the incidence and functional outcome of hand injuries in polytrauma patients is currently unknown. The aim of this study was to determine the incidence, distribution and functional outcome of fractures and dislocation of the hand in polytrauma patients., Methods: A single centre retrospective cohort study was performed at a level 1 trauma centre. Polytrauma was defined as patients with an Injury Severity Score of 16 or higher. Fractures and dislocations to the hand were determined. All eligible polytrauma patients with hand injuries were included and a Quick Disability of Arm, Shoulder and Hand questionnaire (QDASH) and Patient-Rated Wrist/Hand Evaluation (PRWHE) were administered. Patients were contacted 1-6 years after trauma., Results: In a cohort of 2046 polytrauma patients 72 patients (3.5%) suffered a hand injury. The functional outcome scores of 52 patients (72%) were obtained. The Metacarpal (48%) and carpal (33%) bones were the most frequently affected. The median QDASH score for all patients with hand injury was 17 (IQR 0-31) and the PRWHE 14 (IQR 0-41). Patients with a concomitant upper extremity injury (p=0.002 for PRWHE, p0.006 for QDASH) and those with higher ISS scores (p=0.034 for PRWHE, QDASH not significant) had worse functional outcome scores. As an example, of the 5 patients with the worst outcome scores 3 suffered an isolated phalangeal injury, all had concomitant upper extremity injury or neurological injuries (3 plexus injuries, 1 severe brain injury)., Conclusion: The incidence of hand injuries in polytrauma patients is 3.5%, which is relatively low compared to a general trauma population. Metacarpal and carpal bones were most frequently affected. The functional extremity specific outcome scores are highly influenced by concomitant injuries (upper extremity injuries, neurological injuries and higher ISS)., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Although clavicle fractures are a common injury in polytrauma patients, the functional outcome of displaced midshaft clavicle fractures (DMCFs) in this population is unknown. Our hypothesis was that there would be no differences in fracture healing disorders or functional outcome in polytrauma patients with a DMCF compared with patients with an isolated DMCF, regardless of the treatment modality., Methods: A retrospective cohort study of patients (treated at our level I trauma center) with a DMCF was performed and a follow-up questionnaire was administered. Polytrauma patients, defined as an Injury Severity Score ≥16, and those with an isolated clavicle fracture were compared. Fracture healing disorders (nonunion and delayed union) and delayed fixation rates were determined. Functional outcome was assessed by the Quick Disability of the Arm, Shoulder, and Hand questionnaire., Results: A total of 152 patients were analyzed, 71 polytrauma patients and 81 patients with an isolated DMCF. Questionnaire response of 121 patients (80%) was available (mean, 53 months; standard deviation, 22 months). No differences were found between polytrauma patients and those with an isolated DMCF with regard to nonunion (7% vs. 5%, respectively), delayed union (4% vs. 4%), and delayed fixation rate (13% vs. 13%). Polytrauma patients had an overall worse functional outcome, regardless of initial nonoperative treatment or delayed operative fixation., Conclusion: Polytrauma patients had a similar nonunion and delayed fixation rate but had an overall worse functional outcome compared with patients with an isolated DMCF. For polytrauma patients, a wait and see approach can be advocated without the risk of decreased upper extremity function after delayed fixation., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Elderly polytrauma patients with pelvic fractures are at higher risk than young adults for severe medical outcomes and/or death in the early post-trauma phase. The aim of our study was to identify predictive factors of medical severity among geriatric polytrauma patients., Methods: We conducted a retrospective cross-sectional study of polytrauma patients treated at our center, who had a pelvic fracture and at least two other injuries with an abbreviated injury score ≥3. Our study group included 15 geriatric (mean age, 65 years) and 13 young (mean age, 39 years) adults. Factors related to medical status on admission were compared between the groups to identify those predictive of a severe medical outcome, defined by massive transfusion (>10 units of red blood cells) within the first 24 h of admission and/or death., Results: Groups were comparable in terms of injury severity score (mean, 29), systolic blood pressure, heart rate, shock index, hemoglobin level, the prothrombin time-to-international normalized ratio (PT-INR) and base deficit. Over two-third of geriatric patients required a massive transfusion, with two patients dying, compared with the death of one young patient. Among geriatric patients, predictors of a severe medical outcome were extravasation of contrast medium on computed tomography, a hemoglobin level <11 g/dl, a PT-INR >1.1 and a base deficit >2 mmol/l., Conclusions: Even with our aggressive treatment algorism of pelvic fractures, particularly for the elderly, most of the geriatric polytrauma patients with severe pelvic fractures were at a high risk of massive transfusion. Extravasation on enhanced computed tomography and abnormal levels of select blood serum markers could assist in the early identification of geriatric polytrauma patients at risk for a severe medical outcome.

Management of pediatric polytrauma patients is one of the most difficult challenges for orthopaedic surgeons. Multisystem injuries frequently include complex orthopaedic surgical problems that require intervention. The physiology and anatomy of children and adolescent trauma patients differ from the physiology and anatomy of an adult trauma patient, which alters the types of injuries sustained and the ideal methods for management. Errors of pediatric polytrauma care are included in two broad categories: missed injuries and inadequate fracture treatment. Diagnoses may be missed most frequently because of a surgeon's inability to reliably assess patients who have traumatic brain injuries and painful distracting injuries. Cervical spine injuries are particularly difficult to identify in a child with polytrauma and may have devastating consequences. In children who have multiple injuries, the stabilization of long bone fractures with pediatric fixation techniques, such as elastic nails and other implants, allows for easier care and more rapid mobilization compared with cast treatments. Adolescent polytrauma patients who are approaching skeletal maturity, however, are ideally treated as adults to avoid complications, such as loss of fixation, and to speed rehabilitation.

Introduction: The main cause of mortality in trauma patients with pelvic fractures is hypovolemic shock. We analyzed the association between the source of bleeding, mechanism of action and type of fracture., Methods: Prospective descriptive study involving trauma patients older than 16 years old, admitted to the intensive care unit or dead before admission, with pelvic fractures and hemodynamic instability. Hemodynamic instability was defined as SBP <90 and/or HR> 100 beats/min. Pelvic fracture was defined by the Tile classification., Results: A total of 157 of 1088 trauma patients had pelvic fracture. We included 63 patients, all hemodynamically unstable. A total of 85% of pelvic fractures after falls from great heights bled from the fracture itself, compared to only 44% of victims of impact (hit). A total of 65% of patients with stable pelvic fracture bled from associated lesions; 70% of patients with unstable fracture bled from the fracture itself. There is an interaction between the mechanism of action and type of fracture. The probability of pelvic bleeding is higher in the precipitated patient (> 80%) regardless of the type of fracture. Bleeding from associated injuries is greater in impact victims, doubling when the fracture is stable (91%)., Conclusions: Mechanism of action is a key to determine the source of bleeding in patients with pelvic fracture. After falls patients bleed from the fracture itself, while patients with an impact (hit) can bleed both from the fracture and associated injuries, depending on the type of fracture., (Copyright © 2014 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Fracture healing is a complex process regulated by a variety of cells and signalling molecules which act both locally and systemically. The aim of this study was to investigate potential changes in patients' mesenchymal stem cells (MSCs) in the iliac crest (IC) bone marrow (BM) and in peripheral blood (PB) in relation to the severity of trauma and to correlate them with systemic changes reflective of inflammatory and platelet responses following fracture., Methods: ICBM samples were aspirated from two trauma groups: isolated trauma and polytrauma (n = 8 and 18, respectively) at two time-points post-fracture and from non-trauma controls (n = 7). Matched PB was collected every other day for a minimum of 14 days. BM MSCs were enumerated using colony forming-fibroblast (CFU-F) assay and flow cytometry for the CD45-CD271+ phenotype., Results: Regardless of the severity of trauma, no significant increase or decrease in BM MSCs was observed following fracture and MSCs were not mobilised into PB. However, direct positive correlations were observed between changes in the numbers of aspirated BM MSCs and time-matched changes in their serum PDGF-AA and -BB. In vitro, patients' serum induced MSC proliferation in a manner reflecting changes in PDGFs. PDGF receptors CD140a and CD140b were expressed on native CD45-CD271+ BM MSCs (average 12% and 64%, respectively) and changed over time in direct relationship with platelets/PDGFs., Conclusions: Platelet lysates and other platelet-derived products are used to expand MSCs ex vivo. This study demonstrates that endogenous PDGFs can influence MSC responses in vivo. This indicates a highly dynamic, rather than static, MSC nature in humans.

Objective: To investigate the functional status of fracture victims 4 years after the 2008 Wenchuan earthquake., Methods: A total of 374 fracture victims who were admitted to the rehabilitation department of 5 municipal hospitals in the hardest hit areas in 2008 were interviewed face to face in 2012. Functional assessments, including muscle strength, range of motion, pain, activities of daily living and working status, were conducted., Results: Approximately one-third (33.2%) of the fracture victims had decreased muscle strength and 29.4% had limited range of motion. Among the 55.3% of subjects who still experienced pain, the proportions of mild, moderate and severe pain were 65.7%, 28.5% and 5.8%, respectively. The majority (83.4%) of fracture victims were independent in caring for themselves. However, 1.6% of subjects were highly dependent or totally dependent. Single-fracture victims had better muscle strength, range of motion, pain and independence than those with multiple fractures. The degrees of pain, muscle strength and dependency were worse in the older age group, and better in those with a higher level of education. In addition 17.1% were jobless and 22.2% received economic support mainly from family members. The mean unemployment rate was significantly higher and the annual household income (USD 3,086 (standard deviation 1,985) was lower than in the general population in rural Sichuan province., Conclusion: The prevalence of functional disorders, including pain, limited range of motion, decreased muscle strength and dependency in activities of daily living, remained high among fracture victims 4 years after the Wenchuan earthquake. Unemployment rate was high and annual household income was low in this population.

Pelvic ring fractures often result in severely injured patients with multiple organ injuries. The most common associated injuries are intraabdominal or urogenital, and urogenital injuries are the most common associated injuries in those with severe pelvic fractures. Prompt and effective diagnosis and management of these injuries is essential to successful outcomes, but this is potentially complicated by poor communication and coordination among the many specialists involved. To address this, we present a multi-disciplinary review of pelvic fracture-associated bladder and urethral injuries that is specifically geared towards orthopaedic, urology, and trauma surgeons caring for these patients., (Copyright © 2012. Published by Elsevier Ltd.)

Background: Displaced scapular body fractures most commonly are treated conservatively. However there is conflicting evidence in the literature regarding the outcomes owing to retrospective design of studies, different classification systems, and diverse outcome tools., Questions/purposes: The functional outcome after nonoperative management of displaced scapular body fractures was assessed by change in the DASH (Disability of Arm, Shoulder and Hand) score; (2) the radiographic outcome was assessed by the change of the glenopolar angle (GPA); and (3) associated scapular and extrascapular injuries that may affect outcome were identified., Patients and Methods: Forty-nine consecutive patients were treated with early passive and active ROM exercises for a displaced scapular body fracture. We followed 32 of these patients (65.3%) for a minimum of 6 months (mean, 15 months; range, 6-33 months). Mean age of the patients was 46.9 years (range, 21-84 years) and the mean Injury Severity Score (ISS) was 21.5 (range, 5-50). Subjective functional results (DASH score) and radiographic assessment (fracture union, glenopolar angle) were measured., Results: All fractures healed uneventfully. The mean change of glenopolar angle was 9° (range, 0°-20°). The mean change of the DASH score was 10.2, which is a change with minimal clinical importance. There was a correlation between the change in this score with the ISS and presence of rib fractures., Conclusions: Satisfactory outcomes are reported with nonoperative treatment of displaced scapular body fractures. We have shown that the severity of ISS and the presence of rib fractures adversely affect the clinical outcome.

Objective: The goal was to use a national database to determine the incidence of abusive traumatic brain injuries (TBIs) and/or fractures and the frequency of abuse versus accidents among children <36 months of age., Methods: We used the 2006 Kids' Inpatient Database and classified cases into 3 types of injuries, that is, (1) TBI only, (2) TBI and fracture, or (3) fracture only. Groups 2 and 3 were divided into 3 patterns, that is, (1) skull fractures, (2) skull and nonskull fractures, or (3) nonskull fractures. For each type and pattern, we compared abuse, accidental falls, other accidents, and motor vehicle accidents., Results: The incidence of TBIs and/or fractures attributable to abuse was 21.9 cases per 100,000 children <36 months of age and 50.0 cases per 100,000 children <12 months of age. In the abuse group, 29.9% of children had TBIs only, 28.3% TBIs and fractures, and 41.8% fractures only. Abused children were younger and were more likely to be enrolled in Medicaid. For TBI only, falls were more common than abuse in the first 2 months of life but abuse was more common from 2 to 7 months. For TBI and skull fracture, falls were more common during the first year of life. For skull fracture only, almost all injuries were attributable to falls., Conclusions: There was overlap in TBIs and fractures attributable to abuse. Among <12-month-old children, TBIs and/or fractures attributable to abuse occurred in 1 of 2000. Falls occurred more commonly than abuse, even among very young children.

The diagnostic and therapeutic modalities utilized in the management of pelvic ring fractures depend on patient characteristics, mechanism of injury, and hemodynamic status at the time of presentation. Knowledge of the complex anatomy and biomechanics of pelvic stability may guide appropriate initial management strategies. Even with the development of specific treatment algorithms and advances in both diagnostic and operative techniques, fractures of the pelvis continue to cause significant morbidity and mortality. The current paper reviews the diagnosis and management of pelvic ring fractures, focusing on current concepts with respect to initial assessment and treatment protocols, including the identification of associated injuries and emergency methods of provisional pelvic stabilization.

Anti-vehicular (AV) landmines and improvised explosive devices (IED) have accounted for more than half of the United States military hostile casualties and wounded in Operation Iraqi Freedom (OIF) (Department of Defense Personnel & Procurement Statistics, 2009). The lower extremity is the predominantly injured body region following an AV mine or IED blast accounting for 26 percent of all combat injuries in OIF (Owens et al., 2007). Detonations occurring under the vehicle transmit high amplitude and short duration axial loads onto the foot-ankle-tibia region of the occupant causing injuries to the lower leg. The current effort was initiated to develop lower extremity injury criteria for occupants involved in underbelly blast impacts. Eighteen lower extremity post mortem human specimens (PMHS) were instrumented with an implantable load cell and strain gages and impacted at one of three incrementally severe AV axial loading conditions. Twelve of the 18 PMHS specimens sustained fractures of the calcaneus, talus, fibula and/or tibia. The initiation of skeletal injury was precisely detected by strain gages and corresponded with local peak axial tibia force. Survival analysis identified peak axial tibia force and impactor velocity as the two best predictors of incapacitating injury. A tibia axial force of 5,931 N and impactor velocity of 10.8 m/s corresponds with a 50 percent risk of an incapacitating injury. The criteria may be utilized to predict the probability of lower extremity incapacitating injury in underbelly blast impacts.

Background: The aim of the study was to carry out a comprehensive analysis of determinants of multiple bone fractures in children with regard to densitometric indices and markers of bone metabolism., Material and Methods: The study involved 112 children aged 5-18 years, including 81 patients with a history of at least 3 bone fractures and 31 healthy patients in a control group. Total body and spinal DXA densitometry of the skeleton (DPX-L apparatus, Lunar) was carried out in all children. Laboratory assays comprised the determination of calcium, phosphorus, magnesium (in the serum and 24-hour urine collection), parathormone, liver metabolite of vitamin D, osteocalcin, bone alkaline phosphatase, and N-terminal cross-linked telopeptide of collagen type I (NTx)., Results: Mean values of DXA Z-score, both in total body and in spinal scans, were significantly lower in children with multiple fractures as compared to controls. In children with multiple fractures, there was a higher prevalence of hypercalciuria, hypermagnesuria and hyperphosphaturia. Decreased levels of the liver metabolite of vitamin D were observed in 20/81 (24.7%) patients in this group and in 6/31 controls. Other findings included a higher level of NTx in 38/75 (50.7%) patients with fractures, an increased activity of bone alkaline phosphatase in 29, and of osteocalcin in 12 patients. In this group, there was a significant negative correlation between biochemical bone turnover markers and low bone mass. Also, lower DXA Z-scores were found in children with higher urinary calcium excretion., Conclusions: 1. Decreased bone mineral density was the most frequent risk factor for bone fractures in children; it was found in about 2/3 of the patients with multiple bone fractures. 2. Accelerated bone turnover, and, particularly, increased bone resorption, indicates a derangement of bone metabolism in children with multiple fractures. 3. Repeated fractures during the body growth period are an indication for a quantitative evaluation of bone mass, calcium-phosphate metabolism and bone turnover markers.

Hypophosphatasia is a rare inherited disorder characterized by defective skeletal mineralization and low alkaline phosphatase activities in the serum. The genetic cause of hypophosphatasia is believed related to inactivating mutations in the TNSALP gene, encoding tissue-nonspecific alkaline phosphatase. Another rare inheritable disease, Saethre-Chotzen syndrome, leads to premature fusion of the cranial sutures caused by heterozygous mutations of the human TWIST1 gene. Because the two disorders apparently are not genetically related (only reported individually) yet both involve defective skeletal formation, we believe it is important to report our findings on a patient harboring mutations of TNSALP and TWIST1.

Introduction: When subjects are selected on the basis of fall risk alone, therapies for osteoporosis have not been effective. In a prospective study of elderly subjects at high risk of falls, we investigated the influence of bone strength and fall risk on fracture., Methods: At baseline we assessed calcaneal bone ultrasound attenuation (BUA) as well as quantitative measures of fall risk in 2005 subjects in residential care. Incident falls and fractures were recorded (median follow-up 705 days)., Results: A total of 6646 fall events and 375 low trauma fracture events occurred. The fall rate was 214 per 100 person years and the fracture rate 12.1 per 100 person years. 82% of the fractures could be attributed to falls. Although fracture rates increased with decreasing BUA (incidence rate ratio 1.94 for lowest vs. highest BUA tertile, p<0.002), incident falls also affected fracture incidence. Subjects who fell frequently (>3.15 falls/per person year) were 3.35 times more likely to suffer a fracture than those who did not fall. Some fall risk factors such as balance were associated with the lowest fracture risk lowest in the worst performing group. Multivariate analysis revealed higher fall rate, history of previous fracture, lower BUA, lower body weight, cognitive impairment and better balance as significant independent risk factors for fracture., Conclusions: In the frail elderly, both skeletal fragility and fall risk including the frequency of exposure to falls are important determinants of fracture risk.

In some groups of polytrauma patients, particularly those with chest injuries, head injuries, and those with mangled extremities, early total care of major bone fractures may be potentially harmful. Delaying all orthopaedic surgery, however, is also not always the best approach. In these situations, damage control orthopaedics, which emphasizes the stabilization and control of the injury rather than repair will add little additional physiologic insult to the patient and is a treatment option that should be considered.

Previous studies have suggested that the lower-extremities are among the most frequently injured body regions in polytrauma patients and have a major impact on the functional recovery following polytrauma. In particular, injuries to the distal part of the lower-extremity appear to be associated with a poor functional outcome. Therefore, the goal of this study was to evaluate the impact of injuries below the knee joint on the long-term functional outcome following polytrauma. Three hundred eighty-nine polytrauma patients with associated lower-extremity fractures and a minimum follow-up of 10 years were included in this study. All patients were examined by a doctor, using a patient questionnaire and a standardised physical examination. Significantly, inferior outcomes were seen in patients with fractures below the knee joint as measured by the modified Karlström-Olerud score, Lysholm score, range of motion, weight bearing status, Hannover score for polytrauma outcome (HASPOC), SF-12, Tegner activity score, and inability to work (P < 0.05). Fractures below the knee joint have a significant impact on the functional recovery following polytrauma. We suggest that delayed treatment, thin soft tissue envelope below the knee joint, high-energy trauma, unfavorable blood supply, and complex fracture patterns contribute to these unfavorable outcomes.

Unlabelled: It was the objective of this investigation to describe the results after stabilisation of pelvic fractures with the pelvic clamp in polytraumatized patients with unstable pelvic ring fractures., Patients: Between 1999 and 2001 11 polytraumatized patients with an average age of 38 years with unstable fractures of the pelvic ring were treated with the "pelvic clamp" (PC)., Method: The patient's data were analysed retrospectively from the moment they were admitted to our department until 48 hours after the treatment with the pelvic clamp. The following data were observed: -- The time period until the pelvic clamp was placed. -- The mean blood pressure. -- The oxygenation level (PaO (2)/FiO (2) coefficient). -- The number of requested blood units. -- The time period until hemodynamic stabilisation took place., Results: 8 patients survived their injuries. 5 of them were admitted primarily to our department (ISS 39.8, PTS 35), the other 3 were secondarily admitted to our department (ISS 48.3, PTS 39). 3 of 11 patients (27 %) died averaged within the first 45 minutes after admittance. They also were treated in other units before admittance to our department. 8 surviving patients showed -- a hemodynamic stabilisation 6 hours after the treatment with the PC. -- an increase of the mean blood pressure about 25 % 20 minutes after the treatment with the PC. -- a stabilisation of the oxygenation level 6 hours after the treatment with the PC. -- a decrease of the number of requested blood units 6 hours after treatment with the PC., Conclusion: Even if the number of patients who were treated is small, the study shows a positive trend in terms of stabilisation of the vital parameters after stabilisation of the pelvic fracture with the pelvic clamp.

Background: Pelvic fractures occur uncommonly in children. Despite serious sequelae, they have been infrequently reviewed., Methods: We conducted a retrospective review of admissions to our institution from January 1983 to December 2000., Results: One hundred twenty children with pelvic fractures were identified. Median age was 9 years (range, 1-16 years) and 66% (n = 80) were boys. Pedestrian-motor vehicle injury accounted for 68% (n = 82) of cases. Associated injuries were present in 78% (n = 94). Management of the pelvic fracture was nonoperative in 113 (94%). Thirty-two children (27%) required surgery for associated injuries. Complications during admission occurred in 28% (n = 34). Five children died as a result of their injuries. With a mean follow-up of 36 months (range, 7-156 months), 27% (n = 32) of children suffered an adverse outcome, including neurologic dysfunction and leg-length discrepancies., Conclusion: The majority of pelvic fractures in children may be satisfactorily treated nonoperatively. Operative interventions were more frequently required for associated injuries. Long-term review is indicated because of delayed complications in children that are continuing to grow and develop.

The authors report a case of an irreducible dorsal dislocation of the first metatarsophalangeal joint, with concomitant Lisfranc dislocation and fractures of the second, third, and fourth metatarsals. This combination has been reported only once in the literature. This extremely rare combined injury results in a floating metatarsal. Open reduction of the metatarsophalangeal joint dislocation and fixation of Lisfranc joint and metatarsal fractures with Kirschner wires was performed. One year after surgery, the patient is active and the first metatarsophalangeal joint is asymptomatic, but there is mild pain in the Lisfranc joint.

There is substantial interest in the early identification of women at risk for osteoporotic fractures, so that preventive measures may be instituted early. We examined whether women with a history of fractures before menopause were at an increased risk of fractures after menopause. We obtained information about any lifetime fractures of the hip, arm, spine, wrist, leg, ankle, foot and finger from 9086 ambulatory white women ages 65 years and older participating in the Study of Osteoporotic Fractures. We also measured bone mineral density and recorded history of falls, maternal fracture history, drug use, diet, functional status, and other characteristics commonly associated with osteoporotic fractures. We used proportional hazards models to estimate the effects of fractures that occurred before menopause on the risk of fractures after menopause, in particular those that occurred during the 12 years of study follow-up. The risk of fractures of all types during the study period was greater among women with a premenopausal fracture of any type compared with women without a premenopausal fracture (hazard ratio (HR), 1.33; 95% confidence interval (CI), 1.14-1.56; p<0.001). Adjustment for possible confounders, including bone mineral density, had only a modest effect (HR, 1.25; 95% CI, 1.03-1.50; p<0.02). An increased risk of fracture among women with a premenopausal fracture was also seen after stratification by estrogen use, propensity to fall and maternal fracture history. Premenopausal fractures are therefore a risk factor for subsequent fractures independent of other risk factors for osteoporotic fractures, such as bone mineral density. A fracture history, including fractures before menopause, should be obtained when making decisions about preventive treatments.

Objective: To study lumbosacral junction injuries (LSJIs) associated with displaced sacral fractures., Design: Prospective., Setting: University hospital., Patients: Eighty-nine patients with pelvic fractures., Interventions: All patients underwent standard x-ray examination consisting of anteroposterior and inlet and outlet views of the injury. In 50 percent of the cases, oblique views were also obtained. Computed tomography (CT) scans were obtained for all vertically unstable lesions and for fifteen of the lateral compression lesions., Main Outcome Measures: Pelvic fractures were classified according to Tile's classification. LSJIs associated with pelvic ring fractures were classified according to Isler., Results: Lumbosacral junction injuries, including one bilateral lesion, were found in thirteen patients. One lesion was associated with a compression fracture, and the other twelve were associated with vertically unstable fractures. In one patient, a facet fracture was associated with a contralateral sacroiliac joint dislocation. A new type of LSJI was identified in three patients: it was characterized by disruption of the annulus fibrosus associated with rising of the hemipelvis and inclination of the L5 body., Conclusion: Lumbosacral junction injuries should be suspected in cases of transforaminal sacral fracture, especially when these fractures are displaced. In such cases, we recommend that the lumbosacral junction be evaluated with appropriate CT scans.

The blood loss during the acute period after complex pelvic trauma is finally responsible for the high mortality associated with this specific type of injury. Several protocols have been published for optimized management, but up to now comparable data are not available as no exact definitions exist judging the severity of trauma and blood loss. As part of a prospective study 19 patients after unstable pelvic injuries with unstable circulation underwent emergency stabilization by the pelvic C-clamp. Beside standard clinical parameter the initial hemoglobin value was converted into a "blood volume equivalent". 18 of the 19 patients had an injury severity according to group III and IV of the Hannover Polytrauma Score (PTS). Concommitant abdominal injuries were seen in 12 cases (23 injuries), concommitant urological injuries in 12 cases (14 injuries). In 13 cases the pelvis was the major source of bleeding in 9 cases an additional intraabdominal hemorrhage was observed. 11 patients died due to sequelae of their injury, 8 patients survived. Although the initial blood loss was comparable both in the group of the deceased patients and the survivors, a 44% higher subsequent blood substitution (= 10089 ml) was observed in the nonsurvivor group. In conclusion the data proofed that early control of hemorrhage is fundamental for the prognoses after complex pelvic trauma. The estimation of the blood loss may help in indicating aggressive emergency procedures like emergency stabilisation, pelvic clamps, surgical exploration and tamponade. This calculation may be a basis for a more detailed analyses of this devastating injury and judging the benefit of different management protocols.

Of 231 patients with fractures of the triquetrum, 65 were followed up after a mean period of 46.8 months. The fractures were classified and radiological and clinical follow-up was carried out. Pathomechanical aspects of the origin of the fracture were also considered. It appears that the chisel action of the dorso-proximal edge of the hamate striking against the fully extended and ulnar-deviated wrist is the major cause of the dorsal chip fracture of the triquetrum. Conservative therapy involving immobilization of the injured wrist for 3 weeks proved to be successful. If the bone fragment healed, it took 6 to 8 weeks. There was no indication for surgical intervention. We found no signs of post-traumatic instability of the joint. There was good vascularization of the bone, which excluded the possibility of avascular necrosis. All fractures involving the main body of the triquetrum united.

Study Objective: To investigate the frequency of emergency department analgesic use in children with presumably painful fractures who are also at risk for associated multiple injuries and to determine whether there are specific factors that distinguish those who are prescribed analgesics from those who are not., Design: Descriptive, retrospective review of a computerized trauma registry., Setting: Regional pediatric ED and trauma center., Participants: Four hundred thirty-three injured children met trauma team activation criteria from January 1, 1991 through June 30, 1992. Of these 433, we selected the 121 children who had fractures of the pelvis, long bones, ankle, wrist, or clavicle. Of these 121, we excluded the 22 children who underwent endotracheal intubation. Trauma registry data from the prehospital and ED phases of care from the remaining 99 children were reviewed for this study., Interventions: None., Main Results: Of the study group, 53% (52 of 99) received analgesics, all narcotics. Excluding the 46 children with multi-system injuries, only 62% (33 of 53) received analgesics. Patients in both the analgesic (52) and no-analgesic groups (47) were mildly to moderately injured based on initial ED trauma scores and vital signs. No statistical or clinical significant differences were found between the analgesic group and the no-analgesic group when comparing age, sex, race, mechanism of injury, vehicle speed, height of fall, time elapsed from injury until arrival at the ED, transport method, prehospital analgesic use, mortality, Injury Severity Score, and initial ED vital signs, Glasgow Coma Scale, Trauma Score, and Pediatric Trauma Score. Fifty-nine percent (ten of 17) of the children with associated internal injuries limited to the chest or abdomen received analgesics compared with 62% (33 of 53) in those with isolated fracture (P = .8). Those with an associated head injury (31%, nine of 29) received analgesics less frequently than those with isolated fracture (62%, 33 of 53) (P = .01)., Conclusion: Our results suggest that ED analgesic use was low in these mildly to moderately injured children with presumably painful fractures who are also at risk for associated multiple injuries. Head injury was associated with especially low analgesic use. We did not identify other specific factors that distinguished those who received analgesics from those who did not. Further investigation is required to determine if after the initial evaluation, a larger proportion of mildly to moderately injured trauma victims with fractures are appropriate candidates for ED analgesic use.

The polytrauma patient who sustains a significant head injury (head and neck Abbreviated Injury Scale of 3 or greater) will require prolonged and technically demanding operative intervention for musculoskeletal and associated soft tissue trauma. The presence of a head injury may delay the immediate surgical intervention for long bone injuries, which has proven to have major advantages for patient care and well-being. This retrospective review of the Sunnybrook Health Science Centre experience between January 1, 1986, and June 1, 1988, identified 153 polytrauma patients with a significant head injury. Forty-five died from complications unrelated to their long bone injuries or treatment thereof, not surviving long enough to reach the operating room for stabilization of their long bone fractures. The 108 survivors sustained 188 long bone injuries, 63 of which were open fractures. Twenty patients were treated nonoperatively. The 88 patients treated operatively had 12 complications: one peroneal nerve palsy; five cases of sepsis (three in open fractures and all resolving with removal of fixation devices); three malunions; and three cases of delayed union. Sixty-nine patients (78%) were available for long-term follow-up, 64 (93%) making a full recovery. Seven required additional surgery to achieve this goal and another patient awaits an ankle arthrodesis. Examining the head and neck AIS and Injury Severity Score of this group showed that 50 (46%) of these patients were expected to die and 22 (44%) made a full recovery.(ABSTRACT TRUNCATED AT 250 WORDS)

To determine patient-perceived functional outcome after lower extremity fracture (LEF), a prospective, follow-up study of patients managed at three level I trauma centers was conducted. Patients with unilateral LEF involving the acetabulum and distally were eligible for the study. A total of 444 patients were enrolled. Of these, 363 (82%) were interviewed at 6 months postdischarge. Study patients were predominantly young (mean age 34 years), white (72%) men (71%) who had been working preinjury (78%). Their injuries resulted primarily from motor vehicle crashes (73%); 30% had more than one fracture to the same extremity. Functional status was measured using the Sickness Impact Profile (SIP), a well-validated, general health status instrument. Mean 6-month SIP scores were significantly worse (higher) than those based on preinjury activities (9.8 vs. 2.5) (p < 0.01). Overall disability levels were moderate compared with other health conditions. Analysis of the 12 subscores comprising the SIP indicated particularly high scores in ambulation (16.2 postdischarge vs. 1.1 preinjury), sleep/rest (13.1 vs. 5.1), household management (14.5 vs. 2.6), recreation (17.6 vs. 4.2), emotional well-being (9.9 vs. 2.1), and most significantly work (33.2 vs. 8.8). Of those working preinjury, only 49% had returned by 6 months. SIP scores were highest for persons with three or more fractures to the same extremity and for fracture patterns typical of high-energy forces.

The clinical entity of "scapulothoracic dissociation" has been reported as an uncommon but devastating shoulder girdle disruption. All previously identified closed injuries have been associated with arterial and brachial plexus compromise; therefore, neurovascular disruption has been presented as an essential diagnostic clinical finding of scapulothoracic dissociation. We have identified and managed four patients who satisfy all the radiographic criteria for scapulothoracic dissociation but who have presented with a spectrum of neurovascular conditions ranging from entirely normal to complete disruption. These patients illustrate a previously unrecognized, or at least unreported, continuum of potential neurovascular compromise associated with disruption of the scapulothoracic articulation. An expanded and more descriptive classification scheme for "traumatic lateral scapular displacement" is proposed to emphasize the spectrum of possible presentations of this injury.

The direction of force impact, lateral or frontal crash force, was estimated from the mechanism of pelvic fracture (PF) and related to the pattern of organ injuries, physiologic consequences, and outcomes in 197 motor vehicle accident (MVA) patients who had all sustained a PF. These data showed that injuries due to anterior-posterior compression (APC) (frontal crashes) were associated with injuries of major severity to the bony pelvis with major retroperitoneal bleeding and massive volume loss shock. Death in the APC patient was frequently due to a late complication of the shock: sepsis, adult respiratory distress syndrome (ARDS), or lung infection. However, in lateral compression (LC) injuries (lateral crashes) with fatal outcomes, there was a significant increase in severe brain injuries and a rise in lung and upper abdominal visceral injuries with relatively minor PF. These data suggest the great vulnerability of the MVA patient, driver or passenger, to lateral crash forces and suggest important areas for occupant protection.

This study examined the efficacy of behavioral strategies in alleviating pain and anxiety associated with severe orthopedic trauma. Sixty-four patients with multiple fractures were divided into four groups: (1) control, (2) attention only, (3) EMG biofeedback-assisted relaxation, and (4) audiotaped relaxation training. All were measured over at least six sessions, or as long as hospital stay permitted. Significant between group differences were found on the following: systolic blood pressure, peripheral temperature, subjective units of discomfort, state anxiety, with a trend for use of sleep medications. No differences were found on other vital signs, EMG recordings, or other medications. EMG-biofeedback relaxation and relaxation training were relatively equivalent for all measures, and little or no change was observed for those patients who received attention only or served as controls.

Forty fractured scapulae in 39 patients treated by nonoperative means were retrospectively reviewed. The nature of injury, associated injuries, site of fracture, and results were evaluated. The data obtained in this series were compared to data from previous studies. Various associated injuries were found in these patients with scapula fractures. Many of these injuries were life threatening although some could have been easily overlooked on initial presentation. Adequate followup was achieved in 67% of the patients. Seventy-three per cent of the patients had good to excellent results using the criteria of subjective complaints, strength, and range of motion. Three of the 39 patients had poor results. These were multiply injured patients or elderly patients in whom early range of motion was not done.