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Objective Simultaneously evaluate postoperative mortality, length of stay (LOS), and readmission. Data Source National Surgical Quality Improvement Program (NSQIP). Design Retrospective cohort. Methods Data from elective general surgical patients were obtained from the 2012 NSQIP Participant Use File. For each postoperative day, each patient's state was classified as index hospitalization, discharged home, discharged to long-term care (LTC), readmitted, or dead. Transition rates were estimated using exponential regression, assuming constant rates for specified time periods. These estimates were combined into a multistate model, simulated results of which were compared to observed outcomes. Findings Age, comorbidities, more complex procedures, and longer index LOS were associated with lower rates of discharge home and higher rates of death, discharge to LTC, and readmission. The longer patients had been discharged, the less likely they were to die or be readmitted. The model predicted 30-day mortality 0.38 percent (95 percent CI: 0.36–0.41), index LOS 2.85 days (95 percent CI: 2.83–2.86), LTC discharge 2.76 percent (95 percent CI: 2.69–2.82), and readmissions 5.53 percent (95 percent CI: 5.43–5.62); observed values were 0.39 percent, 2.82 days, 2.87 percent, and 5.70 percent, respectively. Conclusions Multistate models can simultaneously predict postoperative mortality, LOS, discharge destination, and readmissions, which allows multidimensional comparison of surgical outcomes.

Objective: To estimate the reduction in traffic mortality in the United States that would result from an automatic crash notification (ACN) system. Methods: 1997 Fatality Analysis Reporting System (FARS) data from 30875 cases of incapacitating or fatal injury with complete information on emergency medical services (EMS) notification and arrival times were analyzed considering cases at any time to be in one of four states: (1) alive prior to notification; (2) alive after notification; (3) alive after EMS arrival; and (4) dead. For each minute after the crash, transition probabilities were calculated for each possible change of state. These data were used to construct models with (1) number of incapacitating injuries ranging from FARS cases up to an estimated total for the US in 1997; (2) deaths equal to FARS total; (3) transitions to death from other states proportional to FARS totals and rates and (4) other state transitions equal to FARS rates. The outcomes from these models were compared to outcomes from otherwise identical models in which all notification times were set to 1 min. Results: FARS data estimated 12 823 deaths prior to notification, 1800 after notification, and 14 015 between EMS arrival and 6 h. If notification times were all set to 1 min, a model using FARS data only predicted 10 703 deaths prior to notification, 2306 after notification, and 15 208 after EMS arrival, while a model using an estimated total number of incapacitating injuries for the US predicted 9569 deaths prior to notification, 2261 after notification, and 15 134 after arrival. In the first model, overall mortality was reduced from 28 638 to 28 217 (421 per year, or 1.5%), while in the second model mortality was reduced to 26964 (1674 per year, or 6%). Conclusions: Modest but important reduction in traffic mortality should be expected from a fully functional ACN system. Imperfect systems would be less effective.

Background: Factors influencing the progression of physical impairment to patient-perceived disability are not well known. We sought to better understand this relationship in the setting of injury. Methods: We followed a cohort of 302 patients with lower extremity fractures over a 1-year period. Physical impairment was assessed by range of motion, strength, and pain. Range of motion and strength were assessed together as a proportion of normal function of the extremity (impairment score). Pain was assessed using a Visual Analogue Scale (VAS) pain score. Disability was assessed using the Sickness Impact Profile (SIP), a widely used measure of patient-perceived limitations of everyday activities attributable to illness. The SIP was administered during hospitalization to assess preinjury baseline. Impairment assessment and readministration of the SIP were performed at 12 months after injury. Results: Impairment in leg function (range of motion and strength) was highly correlated (p < 0.001) with overall SIP score at 12 months, but accounted for only 23% of the variance in overall SIP scores. Likewise, VAS pain score was highly correlated (p < 0.001) with overall SIP score at 12 months, but accounted for only 29% of the variance in overall SIP scores. In a multivariate linear regression analysis, variables that were independently associated with overall SIP score included impairment score, VAS pain score, preinjury SIP, poverty status, education status, social support, having hired a lawyer, and involvement with workers' compensation. These variables accounted for 52% of the variance in overall SIP scores at 12 months. Conclusion: The degree of physical impairment accounts for only a small amount of the variance in disability from lower extremity fracture. Identifiable patient characteristics including age, socio-economic status, preinjury health, and social support together with impairment account for over half of the variance in long-term disability. Further research is needed to increase understanding of other factors that influence the progression of impairment to disability, especially those factors that may be amenable to intervention.

OBJECTIVE: To show that the previously-observed inverse relationship between population density and per-capita mortality from motor vehicle crashes can be derived from a simple mathematical model that can be used for prediction. METHODS: The authors proposed models in which the number of fatal crashes in an area was directly proportional to the population and also to some power of the mean distance between hospitals. Alternatively, these can be parameterized as Weibull survival models. Using county and state data from the U.S. Census, the authors fitted linear regression equations on a logarithmic scale to test the validity of these models. RESULTS: The southern states conformed to a different model from the other states. If an indicator variable was used to distinguish these groups, the resulting model accounted for 74% of the variation from state to state (Alaska excepted). After controlling for mean inter-hospital distance, the southern states had a per-capita mortality 1.37 times that of the other states. CONCLUSIONS: Simply knowing the mean distance between hospitals in a region allows a fiarly accurate estimate of its per-capita mortality from vehicle crashes. After controlling for this factor, vehicle crash mortality per capita is higher in the southern states, for reasons yet to be explained. Language: en

OBJECTIVES: This study examined factors influencing return to work (RTW) following severe fracture to a lower extremity. METHODS: This prospective cohort study followed 312 individuals treated for a lower extremity fracture at 3 level-1 trauma centers. Kaplan-Meier estimates of the proportion of RTW were computed, and a Cox proportional hazards model was used to examine the contribution of multiple risk factors on RTW. RESULTS: Cumulative proportions of RTW at 3, 6, 9, and 12 months post-injury were 0.26, 0.49, 0.60, and 0.72. After accounting for the extent of impairment, characteristics of the patient that correlated with higher rates of RTW included younger age, higher education, higher income, the presence of strong social support, and employment in a white-collar job that was not physically demanding. Receipt of disability compensation had a strong negative effect on RTW. CONCLUSIONS: Despite relatively high rates of recovery, one quarter of persons with lower extremity fractures did not return to work by the end of 1 year. The analysis points to subgroups of individuals who are at high risk of delayed RTW, with implications for interventions at the patient, employer, and policy levels.

We performed a prospective study of 302 patients who had a fracture of the lower extremity. Our purpose was to determine whether there was any association between impairment ratings of the lower extremity, derived with use of the Guides to the Evaluation of Permanent Impairment by the American Medical Association, and measurements of task performance based on direct observation as well as the patient's own assessment of activity limitation and disability as recorded on the Sickness Impact Profile. The mean residual impairment of the lower extremity according to the Guides was 27 per cent one year after the injury. Only 130 subjects (43 per cent) could perform all five functional tasks without difficulty. Eighty-four subjects (28 per cent) reported functional limitations that resulted in a score on the Sickness Impact Profile that was more than one standard deviation from the preinjury norm for the sample. Impairment ratings according to a modification of the system of the American Medical Association correlated strongly with the performance of functional tasks (r = 0.57) as well as the patients' reported activity limitations as recorded on the Sickness Impact Profile (r = 0.55). Correlations were highest when measures of impairment were based on strength rather than on range of motion. The relationship between the impairment rating and function (as observed by an examiner and as reported by the patient) was not influenced by the location of the fracture or the receipt of disability compensation. Our results suggest that the American Medical Association developed a valid approach for the measurement of physical impairment after a fracture of the lower extremity. In our study, the anatomical approach of evaluation based on muscle strength that was described in the Guides to the Evaluation of Permanent Impairment was the most sensitive measure of impairment compared with the anatomical measure based on range of motion and compared with the functional and diagnostic methods for the rating of impairment. Until the diagnostic and functional approaches for the measurement of musculoskeletal impairment are refined, we recommend use of the anatomical approach when evaluating impairment after a fracture of the lower extremity.

Background: We sought to develop a simple and effective way to monitor trends in trauma mortality, using objective clinical categories and methods of statistical process control. Study Design: Control charts and Pareto analysis were applied to trauma mortality data at the Maine Medical Center. We collected data prospectively on patients who died in our hospital after acute injury during 1985–1996 (and retrospectively for 1975–1984) to identify cases requiring medical quality review. We excluded from this study patients older than 80 years, those whose Glasgow Coma Scale motor component was never >3 at any time after admission, and those with pathologic fractures, carcinomatosis, high quadriplegia, or severe burns. The remaining deaths were classified as resulting from inability to resuscitate (mostly hemorrhage), neurologic deterioration, or organ failure. The annual numbers in each of these categories were evaluated under the hypothesis of stationary Poisson processes with mean values equal to those seen from 1975–1984. Results: After the exclusions, annual mortality from trauma has remained within control limits consistent with the Poisson model. Death from neurologic deterioration has shown a trend consistent with significant improvement in the process mean. Transient peaks in the other categories did not exceed control limits, but Pareto analysis prompted detailed studies of aortic and liver trauma. Conclusions: Process control methodology is easy to apply and potentially useful in monitoring hospital trauma mortality.

Background: Focused abdominal sonography for trauma (FAST) relies on hemoperitoneum to identify patients with injury. Blunt trauma victims (BTVs) with abdominal injury, but without hemoperitoneum, on admission are at risk for missed injury. Methods: Clinical, radiologic, and FAST data were collected prospectively on BTVs over a 12-month period. All patients with FAST-negative for hemoperitoneum were further analyzed. Examination findings and associated injuries were evaluated for association with abdominal lesions. Results: Of 772 BTVs undergoing FAST, 52 (7%) ) had abdominal injury. Fifteen of 52 (29%) had no hemoperitoneum by admission computed tomographic scan, and all had FAST interpreted as negative. Four patients with splenic injury underwent laparotomy. Six other patients with splenic injury and five patients with hepatic injury were managed nonoperatively. Clinical risk factors significantly associated with abdominal injury in BTVs without hemoperitoneum include: abrasion, contusion, pain, or tenderness in the lower chest or upper abdomen; pulmonary contusion; lower rib fractures; hemo- or pneumothorax ; hematuria; pelvic fracture; and thoracolumbar spine fracture. Conclusions: Up to 29% of abdominal injuries may be missed if BTVs are evaluated with admission FAST as the sole diagnostic tool. Consideration of examination findings and associated injuries should reduce the risk of missed abdominal injury in BTVs with negative FAST results.

Thirty-seven ventilator-dependent blunt trauma patients (ISS 36 +/- 15) were randomized at 24 hours after injury to receive parenteral (TPN) (n = 15), enteral (TEN) (n = 12), or parenteral plus enteral (PN/EN) (n = 10) nutrition. The TEN and PN/EN patients had endoscopically placed transpyloric feeding tubes. Patients who had nutritional complications were two TPN (13%), three TEN (25%), and five PN/EN (50%). Enteral complications were tube occlusion (two), failed duodenal intubation (one), patient extubation of feeding tube (one), gastric reflux (two), and abdominal distention (two). Mortality rates were not different between the groups, but were significantly related to the nutrition-associated complications (p = 0.01): four deaths in ten (40%) with complications and one death in 27 (3.7%) without complications. All four deaths associated with complications occurred in the four with gastric reflux or abdominal distention. No deaths occurred in the other 18 TEN or PN/EN patients (p = 0.0001). Of the four deaths, three were associated with ARDS and respiratory infection (75%).In mechanically ventilated blunt trauma patients, endoscopic transpyloric tube placement and feeding has a substantial failure rate (36%). Intolerance to duodenal feeding has a remarkably high mortality (100%) in patients in whom gut dysfunction may be a manifestation of injury severity or directly affect survival.

Objective: To assess whether variables reflective of early metabolic responses to injury are predictors of outcome in critically ill trauma patients. Design.- Clinical inception cohort study comparing conventional measures of injury severity with early host response markers for the correlation of each with outcome. These data are prospectively collected in a group of patients being evaluated in a nutritional support investigation. Setting: Intensive care unit (ICU) of a major Level I trauma center. Patients: Seventeen blunt trauma patients, aged 18 to 60 yrs with an Injury Severity Score of ≥15, requiring early mechanical ventilation

Prospective and contemporaneous medical and economic cost studies of 144 victims of motor vehicle crashes admitted to a regional level I trauma center with multiple injuries (ISSor = 16) revealed 122 non-ejected patients, of whom 102 required extrication (EXTRIC) from the vehicle for physical or medical reasons and 20 who did not (N group). There were no differences in age (EXTRIC, 34 +/- 17 years; N, 41 +/- 24 years), type of crash (Frontal: 57% EXTRIC, 60% N; Lateral: 32% EXTRIC, 35% N) restraint use (35% EXTRIC, 35% N), or mortality (29% EXTRIC, 30% N). However, the estimated maximum speed before the crash was higher in EXTRIC patients (50 +/- 16 mph vs. 46 +/- 18 mph N, p0.04), as was the change in velocity (delta V) on impact (EXTRIC 30 +/- 15 mph; N, 24 +/- 8 mph, p0.01). Brain injuries (51% EXTRIC vs. 35% N) and lower extremity injuries were more numerous in EXTRIC patients (59% vs. 20% N, p0.003) and the number of splenic, lower extremity, and pelvic injuries associated with shock was greater in EXTRIC patients, p0.02; as were postinjury complications. As a result, operating room costs from orthopedic and plastic surgery increased professional charges in the EXTRIC group versus the N group ($20,000, EXTRIC; $17,000, N) and critical care costs ($13,000, EXTRIC; $4,000, N) with total costs of $72,000 and $77,000, respectively. The lower extremity injuries in EXTRIC patients were primarily a result of body part contacts with intrusions (CIs) of the car occupant compartment structures [73% with vs. 24% without (p0.0001)]. In lateral MVCs, brain injuries were also more commonly associated with CIs of the side window frame or A pillar (72% CI vs. 25% no CI; p0.035); but as a whole in MVCs in which extrication was necessary, lower extremity injuries from instrument panel or toepan CIs appeared more frequent than those resulting from contacts only (p0.0001). In EXTRIC patients, 69% of those in shock had CI injuries, and 80% of the deaths in the EXTRIC group were associated with CI injury. These data suggest that measures designed to prevent CIs by strengthening car passenger compartment structures may reduce the incidence of severe brain and lower extremity injuries and may reduce the need for extrication after MVCs.

Clinical data on the nature and severity of injuries was linked with data from police crash reports for 3675 car or truck drivers admitted to trauma centers. Different patterns of injuries were noted for drivers in frontal compared with left lateral collisions. Injuries to the face and lower extremities were significantly greater in frontal collisions; thorax, abdominal, and pelvic injuries were significantly greater in lateral collisions. In addition, drivers in lateral collisions were found to have significantly more multiple injuries to the abdomen and thorax. Despite no difference in mean injury Severity Score, drivers in left lateral collisions had a significantly higher mortality rate; moreover, this increased mortality was not merely a reflection of the increased incidence of lateral collisions among older drivers. In conclusion, information on direction of impact has potential use for clinical decision making, since drivers in lateral collisions have a higher incidence of occult abdominal and thoracic injuries.

The authors compared the injury diagnoses and Injury Severity Scores (ISSs) generated by three data-collection and -coding methods, and examined the times needed and costs associated with the methods. One method involved direct electronic entry of injury data by a physician in the admitting area. Codes, severity scores, and times and costs varied significantly with the different methods, thus suggesting a need for further study of the derivation of injury severity codes.

Objective: To evaluate whether survival of older patients with severe injuries is positively associated with initial presentation to high-volume trauma hospitals. Design: Historical cohort study. Setting: We analyzed Medicare fee-for-service records. Cases were classified by maximum Abbreviated Injury Score (AISmax); those with isolated hip fractures or AISmax

The purpose of this study was to evaluate the effect of population density on the rates of motor vehicle mortality in rural and urban areas, while controlling for vehicle miles traveled (VMT). Rural and urban data for traffic mortality, VMT, and population were obtained for each state from the Federal Highway Administration for 1998-2000. Linear regression was used to estimate the effect of population density, VMT per capita, southern location, and presence of a trauma system on mortality. Variation in rural mortality rate (per 100,000 population) was proportional to rural VMT per capita, but population density and southern location were also independent predictors, together accounting for 91% of this variation. Variation in urban mortality rates was not affected by population density, but urban rates were also higher in the south. The exposure-based rural mortality rate (deaths per 100 million VMT) was inversely proportional to population density, which along with southern location explained 41% of the variation from state to state. The presence of a state trauma system did not measurably affect mortality. After controlling for VMT and southern location, state population density was a moderately strong predictor of rural but not urban traffic mortality rates.

Background: The potential for ligamentous injury of the cervical spine (C-spine) may mandate prolonged neck immobilization via a hard cervical collar in the blunt trauma victim (BTV) with altered sensorium. We investigated the incidence of ligamentous C-spine injuries, and whether applying (post hoc) the practice management guidelines from the Eastern Association for the Surgery of Trauma (three radiograph views plus computed tomographic scan of Cl-C2) would have detected the injuries. Methods: The study was a 3-year retrospective review of BTVs admitted to the state's Primary Adult Resource Center for trauma from 1996 to 1998. Unreliable patients were defined as those with admission Glasgow Coma Scale score < 15. A rigorous algorithm to clear the C-spine was used. Pure ligamentous C-spine injury was defined as a C-spine having abnormal anatomic alignment, dislocation, subluxation, or listhesis, but without fracture. Demographics, diagnostic studies, presence of neurologic deficit, therapy, survival, and disposition were analyzed. Results: There were 14,577 BTVs with 614 (4.2%) patients having C-spine injury. There were 2,605 (18%) unreliable patients, with 143 (5.5%) of these having C-spine injury, 129 (90%) having fracture and 14 (10% of BTVs; 0.5% of unreliable patients) having no fracture. Of the 14 unreliable patients with pure ligamentous C-spine injury, 13 had initial diagnosis by supine cross-table lateral radiograph. The one exception had a normal three-view radiographic series, but atlanto-occipital dislocation was diagnosed by computed tomographic scan. Eight patients had upper level injury (C0-C4) and six were lower (C4-C7). Four patients died within 30 minutes after admission, 4 underwent cervical fusion, and 6 were treated with collar only. Five (50%) of the survivors had no apparent neurologic deficit attributed to the C-spine at admission. Nine patients remained institutionalized after discharge and one was discharged home. Conclusion: Ligamentous injuries without fracture of the C-spine are rare. Application of the practice management guidelines developed by the Eastern Association for the Surgery of Trauma for identifying C-spine instability is effective and should facilitate early removal of the cervical collar in unreliable patients.

This article describes changes that have occurred in the last several years in the epidemiology as well as the diagnostic and therapeutic approaches to abdominal injury. An increasing amount of abdominal injury results from bullets, and the specific injuries resulting from the interaction of vehicles and occupants are different. Both of these epidemiologic changes require that the trauma surgeon adopt a new diagnostic and operative skill set. The approach to the diagnosis of abdominal injury has changed enormously with the advent of surgeon-performed ultrasonography and the increasing availability and use of the CT scan. The diagnostic peritoneal lavage is being supplanted in many institutions by these newer modalities. Laparoscopy is transforming some areas of general abdominal surgery, but its impact in trauma surgery is perhaps less pronounced. Therapeutic approaches to abdominal injuries have also evolved. Nonoperative management of liver injuries is now the rule rather than the exception, and primary closure of penetrating colon wounds has been demonstrated to be safe and effective in several prospective studies. Studies demonstrate that some gunshot wounds to the abdomen can be managed nonoperatively if they are seen to traverse only the liver. Patients who previously died from massive or exsanguinating abdominal injuries are now surviving through initial "damage control" laparotomies, followed by definitive surgery after a period of resuscitation and rewarming. Surgeons also have a better understanding of the negative physiologic effects of increased intra-abdominal pressure and the role for decompression in the setting of the newly termed "abdominal compartment syndrome."

Previous studies have shown that over one-quarter of patients who were working before a severe lower extremity fracture had not returned to work by 12 months after injury. Disabilities also persisted in household management, recreation, and social interaction. The objective of this study was to determine whether recovery extended beyond 12 months. Three hundred nineteen patients who were previously working and were treated at three level I trauma centers for a severe lower extremity fracture were prospectively followed at 3, 6, and 12 months after injury. Patients were queried at each follow-up about their work status and completed the Sickness Impact Profile (SIP) at 6 and 12 months. The SIP is a widely used and well validated measure of general health status; it was used in this study to measure functional recovery across several domains of daily living. Patients who had not recovered by 12 months (i.e., 204 who were not working, working with limitations, or had limitations in performing other daily activities as measured by elevated scores on the SIP) were contacted again at 30 months and asked to complete an interview and the SIP. At 30 months, an estimated 82% of the study patients had returned to work (compared to 72% at 12 months). SIP scores improved only slightly from 6.4 at 12 months to 5.7 at 30 months. At 30 months, 64% of the patients had no disability (SIP scores less than 4), 17% had mild disability (SIP scores of 4 to 9), 12% had moderate disability (SIP scores of 10 to 19), and 7% had severe disability (SIP scores of 20 or higher). Although the majority of patients with persistent disabilities at 30 months had residual physical impairments at 12 months, the extent of impairment did not fully explain why some people had and had not recovered at 30 months after injury. The results confirm those of other studies that conclude that overall, outcomes after serious trauma are good when appropriate trauma and rehabilitation care are rendered. However, a minority of patients still report limitations at 30 months after injury, with one-fifth not returning to work.

To assess police officers' accuracy in perceiving alcohol or drug intoxication of injured pedestrians, blood test results from pedestrians struck by vehicles and admitted to a Level I trauma center for a 3-year period were linked to police reports of the crashes. Police officers were 64.5% sensitive and 99.3% specific in identifying alcohol use in injured pedestrians when blood tests were positive for alcohol, and 2.2% sensitive and 100% specific in identifying other drug use when blood tests were positive for drugs other than alcohol. Those with higher blood ethanol levels were more often correctly assessed to be under the influence. Injury Severity Score and the presence of head injuries had no apparent effect on police assessments. In conclusion, police assessment of substance abuse is extremely specific, but not particularly sensitive. Efforts are needed to improve police evaluations. The effect of increased legal actions on recurrent alcohol and drug-related injuries remains to be seen. Language: en

To examine various clinical factors for their ability to predict mortality in geriatric patients following blunt trauma.In this retrospective study, trauma registries and medical records from three trauma centers were reviewed for patients 65 years and older who had sustained blunt trauma. The following variables were extracted and examined independently and in combination for their ability to predict death: age, gender, mechanism of injury, admission blood pressure, and Glasgow Coma Scale score, respiratory status, Trauma Score, Revised Trauma Score, and Injury Severity Score.Three urban trauma centers.Geriatric trauma patients entering three trauma centers (Stanford [Calif] University Hospital, Vanderbilt University Medical Center, Nashville, Tenn, and Maryland Institute for Emergency Medical Services Systems, Baltimore) following blunt trauma during a 7-year period (1982 to 1989).The Injury Severity Score was the single variable that correlated most significantly with mortality. Mortality rates were higher for men than for women and were significantly higher in patients 75 years and older. Admission variables associated with the highest relative risks of death included a Trauma Score less than 7; hypotension (systolic blood pressure,90 mm Hg); hypoventilation (respiratory rate,10 breaths per minute); or a Glasgow Coma Scale score equal to 3.Admission variables in geriatric trauma patients can be used to predict outcome and may also be useful in making decisions about triage, quality assurance, and use of intensive care unit beds.

This study involves development of a data collection instrument with which to capture detailed information on crash reconstruction, biomechanics, engineering, and orthopedic aspects of leg/foot fractures. Data are being collected on patients admitted to a Level 1 trauma center so that postulates can be developed regarding mechanisms of injury. To be included in this study, the patient must have been a front seat occupant (restrained or unrestrained) of a late-model passenger vehicle or light truck/van involved in a collision, must not have been the victim of a rollover or ejection type crash, and must have sustained a lower extremity fracture distal to the femur. To date, data have been obtained for 42 trauma patients (22 men and 20 women). The mean Injury Severity Score for this group was 16, with an average of 2.2 lower extremity fractures distal to the femur per patient. The mean change in velocity (delta V) was 28.4 mph (45.7 km/h) (n = 39). Preliminary findings, including postulated patterns for mechanism of injury, are described in this paper.

To determine functional outcomes after lower extremity fracture (LEF), a prospective follow-up study of patients admitted to three level I trauma centers for treatment of unilateral LEFs was conducted. In this paper we describe outcomes at 6 months after discharge from the initial hospitalization and examine the relationship between impairment and disability. A total of 444 patients met the entry criteria for the study. Of these 376 (85%) were successfully located and interviewed at 6 months; 302 (68%) returned to the trauma center at 6 months for a clinical assessment by a physical therapist. Study patients were predominantly young (mean age = 32.4), white (72%) men (70%) who were working before the injury (77%). The fractures resulted primarily from motor vehicle crashes (71%); mean hospital LOS was 12 days. Disability was measured using the Sickness Impact Profile (SIP), a well validated patient assessment of health status. The overall SIP score averaged for all patients was 10.2, denoting a moderate level of dysfunction or disability. Analysis of the 12 subscores that constitute the SIP indicate particularly high scores for ambulation (16.7 postdischarge vs. 1.2 preinjury), sleep and rest (14.0 vs. 5.1), emotional behavior (10.5 vs. 2.2), home management (15.1 vs. 2.6), recreation and pastimes (19.0 vs. 4.4), and most notably, work (33.2 vs. 8.3). Further analysis of the subgroup of patients working before the injury shows that 48% had returned to work at 6 months. Correlations between lower extremity impairment (range of motion, muscle strength, and pain) and the ambulation subscore of the SIP were high. However, correlations between impairment and more global areas of activity such as home management, work, and recreation were considerably lower. These results suggest that other factors, over and above the extent of physical impairment, significantly influence broader disability outcomes such as return to work. Further research is needed to define these factors so that effective interventions after acute care can be identified and appropriately targeted.

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.