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Background: Recent reports have suggested that functional outcomes are similar following either amputation or reconstruction of a severely injured lower extremity. The goal of this study was to compare two-year direct health-care costs and projected lifetime health-care costs associated with these two treatment pathways.Methods: Two-year health-care costs were estimated for 545 patients with a unilateral limb-threatening lower-extremity injury treated at one of eight level-I trauma centers. Included in the calculation were costs related to (1) the initial hospitalization, (2) all rehospitalizations for acute care related to the limb injury, (3) inpatient rehabilitation, (4) outpatient doctor visits, (5) outpatient physical and occupational therapy, and (6) purchase and maintenance of prosthetic devices. All dollar figures were inflated to constant 2002 dollars with use of the medical service Consumer Price Index. To estimate projected lifetime costs, the number of expected life years was multiplied by an estimate of future annual health-care costs and added to an estimate of future costs associated with the purchase and maintenance of prosthetic devices.Results: When costs associated with rehospitalizations and post-acute care were added to the cost of the initial hospitalization, the two-year costs for reconstruction and amputation were similar. When prosthesis-related costs were added, there was a substantial difference between the two groups ($81,316 for patients treated with reconstruction and $91,106 for patients treated with amputation). The projected lifetime health-care cost for the patients who had undergone amputation was three times higher than that for those treated with reconstruction ($509,275 and $163,282, respectively).Conclusions: These estimates add support to previous conclusions that efforts to improve the rate of successful reconstructions have merit. Not only is reconstruction a reasonable goal at an experienced level-I trauma center, it results in lower lifetime costs. [ABSTRACT FROM AUTHOR]

Background: A recent study demonstrated that patients treated with amputation and those treated with reconstruction had comparable functional outcomes at two years following limb-threatening trauma. The present study was designed to determine whether those outcomes improved after two years, and whether differences according to the type of treatment emerged.Methods: Three hundred and ninety-seven patients who had undergone amputation or reconstruction of the lower extremity were interviewed by telephone at an average of eighty-four months after the injury. Functional outcomes were assessed with use of the physical and psychosocial subscores of the Sickness Impact Profile (SIP) and were compared with similar scores obtained at twenty-four months.Results: On the average, physical and psychosocial functioning deteriorated between twenty-four and eighty-four months after the injury. At eighty-four months, one-half of the patients had a physical SIP subscore of > or = 10 points, which is indicative of substantial disability, and only 34.5% had a score typical of a general population of similar age and gender. There were few significant differences in the outcomes according to the type of treatment, with two exceptions. Compared with patients treated with reconstruction for a tibial shaft fracture, those with only a severe soft-tissue injury of the leg were 3.1 times more likely to have a physical SIP subscore of 5 points (p < 0.05) and those treated with a through-the-knee amputation were 11.5 times more likely to have a physical subscore of 5 points (p < 0.05). There were no significant differences in the psychosocial outcomes according to treatment group. Patient characteristics that were significantly associated with poorer outcomes included older age, female gender, nonwhite race, lower education level, living in a poor household, current or previous smoking, low self-efficacy, poor self-reported health status before the injury, and involvement with the legal system in an effort to obtain disability payments. Except for age, predictors of poor outcome were similar at twenty-four and eighty-four months after the injury.Conclusions: The results confirm previous conclusions that reconstruction for the treatment of injuries below the distal part of the femur typically results in functional outcomes equivalent to those of amputation. Regardless of the treatment option, however, long-term functional outcomes are poor. Priority should be given to efforts to improve post-acute-care services that address secondary conditions that compromise optimal recovery. [ABSTRACT FROM AUTHOR]

Background: High-energy trauma to the lower extremity presents challenges with regard to reconstruction and rehabilitation. Failed efforts at limb salvage are associated with increased patient mortality and high hospital costs. Lower-extremity injury-severity scoring systems were developed to assist the surgical team with the initial decision to amputate or salvage a limb. The purpose of the present study was to prospectively evaluate the clinical utility of five lower-extremity injury-severity scoring systems.Methods: Five hundred and fifty-six high-energy lower-extremity injuries were prospectively evaluated with use of five injury-severity scoring systems for lower-extremity trauma designed to assist in the decision-making process for the care of patients with such injuries. Four hundred and seven limbs remained in the salvage pathway six months after the injury. The sensitivity, specificity, and area under the receiver operating characteristic curve were calculated for the Mangled Extremity Severity Score (MESS); the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA); and the Hannover Fracture Scale-97 (HFS-97) for ischemic and nonischemic limbs. The scores were analyzed in two ways: including and excluding limbs that required immediate amputation.Results: The analysis did not validate the clinical utility of any of the lower-extremity injury-severity scores. The high specificity of the scores in all of the patient subgroups did confirm that low scores could be used to predict limb-salvage potential. The converse, however, was not true. The low sensitivity of the indices failed to support the validity of the scores as predictors of amputation.Conclusions: Lower-extremity injury-severity scores at or above the amputation threshold should be cautiously used by a surgeon who must decide the fate of a lower extremity with a high-energy injury. [ABSTRACT FROM AUTHOR]

Background: The purpose of the present study was to compare the rate of short-term wound complications associated with rotational flaps and that associated with free flaps for coverage of traumatic soft-tissue defects about the tibia.Methods: Of 601 patients prospectively enrolled in a multicenter study of high-energy trauma of the lower extremity, 190 patients (195 limbs) required flap coverage and had six months of follow-up. The injury data included the ASIF/OTA classification of the tibial fracture and the soft-tissue injury and the functional status of the neurovascular and muscular structures of the soft-tissue compartments at the time of soft-tissue coverage. The treatment data consisted of the type of flap, the timing of the flap coverage, and the type of fixation. The patient characteristics that were recorded included the age, gender, presence of comorbidities, and smoking status at the time of the injury. Short-term complications included wound infection, wound necrosis, and loss of the flap within the first six months after the injury.Results: Eighty-eight limbs were treated with a rotational flap, and 107 limbs were treated with a free flap. Overall, complications occurred after fifty-three (27 percent) of the 195 flap procedures; forty-six (87 percent) of the fifty-three required operative treatment. The two treatment groups were similar with respect to age, gender, comorbidities, preinjury smoking status, ASIF/OTA classification of the fracture, and prevalence of vascular injury requiring repair (p>0.05). There were two important differences between the two groups. First, three of the four leg compartments--that is, the anterior, lateral, and deep posterior compartments--were more likely to be functionally compromised in the free-flap group than in the rotational flap group (p<0.05), suggesting that patients in the free-flap group had sustained more severe soft-tissue injuries. Second, the Injury Severity Score was significantly higher (p = 0.001) in the rotational flap group (mean, 14 points) than in the free-flap group (mean, 11 points), suggesting that patients in the former group had sustained more substantial total body trauma. Overall, there were no significant differences between the two groups with respect to the complication rates. However, among those with the most severe grade of underlying osseous injury (an ASIF/OTA type-C injury), 44 percent of the limbs that were treated with a rotational flap had a wound complication compared with 23 percent of the limbs that were treated with a free flap (p = 0.10). To control for any differences between the two groups with respect to the severity of the injury, the treatment methods, or the patient characteristics, multivariate regression modeling was performed. An interaction effect between the type of flap and the severity of the underlying osseous injury demonstrated significance (p<0.05) after controlling for other factors. Of the limbs that sustained an ASIF/OTA type-C osseous injury, those that were treated with a rotational flap were 4.3 times more likely to have a wound complication requiring operative intervention than were those treated with a free flap. No significant difference in the rate of complications was detected with respect to the type of flap used for the limbs that had lower-grade osseous injuries.Conclusions: We found that use of a free flap to treat limbs with a severe underlying osseous injury was significantly less likely to lead to a wound complication requiring operative intervention than was use of a rotational flap. [ABSTRACT FROM AUTHOR]

Mitosis is an essential process in which the duplicated genome is segregated equally into two daughter cells. CTCF has been reported to be present in mitosis and has a role in localizing CENP-E, but its importance for mitotic fidelity remains to be determined. To evaluate the importance of CTCF in mitosis, we tracked mitotic behaviors in wild-type and two different CTCF CRISPR-based genetic knockdowns. We find that knockdown of CTCF results in prolonged mitoses and failed anaphase segregation via time-lapse imaging of SiR-DNA. CTCF knockdown did not alter cell cycling or the mitotic checkpoint, which was activated upon nocodazole treatment. Immunofluorescence imaging of the mitotic spindle in CTCF knockdowns revealed disorganization via tri/tetrapolar spindles and chromosomes behind the spindle pole. Imaging of interphase nuclei showed that nuclear size increased drastically, consistent with failure to divide the duplicated genome in anaphase. Long-term inhibition of CNEP-E via GSK923295 recapitulates CTCF knockdown abnormal mitotic spindles with polar chromosomes and increased nuclear sizes. Population measurements of nuclear shape in CTCF knockdowns do not display decreased circularity or increased nuclear blebbing relative to wild-type. However, failed mitoses do display abnormal nuclear morphologies relative to successful mitoses, suggesting that population images do not capture individual behaviors. Thus, CTCF is important for both proper metaphase organization and anaphase segregation which impacts the size and shape of the interphase nucleus likely through its known role in recruiting CENP-E., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The COVID-19 public health emergency (PHE) led to increased mental health (MH) concerns among Medicare beneficiaries while inhibiting their access to MH services (MHS). To help address these problems, the federal government introduced temporary flexibilities permitting broader telehealth use in Medicare. This study compared rural versus urban patterns of change in telemental health (TMH) use among adult MHS users in fee-for-service Medicare from 2019 to 2020, when PHE-related telehealth expansions were enacted., Methods: In this cross-sectional investigation based on 2019-2020 Medicare claims data, we used chi-square tests, t-tests and adjusted logistic regression to explore how year (pre-PHE vs. PHE), rurality, and beneficiary characteristics were related to TMH use., Findings: From 2019 to 2020, the proportion of MHS users who used TMH rose from 4.8% to 51.9% among rural residents (p < 0.0001) and from 1.1% to 61.3% (p < 0.0001) among urban residents. Across study years, adjusted odds of TMH use grew more than 18-fold for rural MHS users (OR = 18.10, p < 0.001) and nearly 120-fold for their urban counterparts (OR = 119.75, p < 0.001). Among rural MHS users in 2020, adjusted odds of TMH use diminished with increasing age., Conclusions: TMH mitigated PHE-related barriers to MHS access for rural and urban beneficiaries, but urban residents benefited disproportionately. Among rural beneficiaries, older age was related to lower TMH use. To avoid reinforcing existing MHS access disparities, policies must address factors limiting TMH use among rural beneficiaries, especially those over 75 and those from historically underserved communities., (© 2023 National Rural Health Association.)

Background: Trends in the prevalence of hepatitis C virus (HCV) infection among women delivering live births may differ in rural vs. urban areas of the United States, but estimation of trends based on observed counts may lead to unstable estimates in rural counties due to small numbers., Objectives: The objective of the study was to use small area estimation methods to provide updated county-level prevalence estimates and, for the first time, trends in maternal HCV infection among live births by county-level rurality., Methods: Cross-sectional natality data from 2016 to 2020 were used to estimate maternal hepatitis C prevalence using hierarchical Bayesian models with spatiotemporal random effects to produce annual county-level estimates of maternal HCV infection and trends over time. Models included a 6-level rural-urban county classification, year, maternal characteristics and county-specific covariates. Data were analysed in 2022., Results: There were 90,764/18,905,314 live births (4.8 per 1000) with HCV infection reported on the birth certificate. Hepatitis C prevalence was higher among rural counties as compared to urban counties. Rural counties had the largest annual increases in maternal hepatitis C prevalence (per 1000 births) from 2016 to 2020 (micropolitan: 0.39; noncore: 0.40), with smaller increases among less densely populated urban counties (medium metro: 0.28; small metro: 0.28) and urban counties (large central metro:0.11; large fringe metro: 0.14)., Conclusions: The prevalence of maternal HCV infection was the highest in rural counties, and rural counties saw the greatest average prevalence increase during 2016-2020. County-level data can help in monitoring rural-urban trends in maternal HCV infection to reduce geographic disparities., (© 2022 John Wiley & Sons Ltd.)

Introduction: The prevalence of hepatitis C virus infection among women delivering live births in the U.S. may be higher in rural areas where county-level estimates may be unreliable. The aim of this study is to model county-level maternal hepatitis C virus infection among deliveries in the U.S., Methods: In 2020, U.S. natality files (2010-2018) with county-level maternal residence information were used from states that had adopted the 2003 revised U.S. birth certificate, which included a field for hepatitis C virus infection present during pregnancy. Hierarchical Bayesian spatial models with spatiotemporal random effects were applied to produce stable annual county-level estimates of maternal hepatitis C virus infection for years when all states had adopted the revised birth certificate (2016-2018). Models included a 6-Level Urban-Rural County Classification Scheme along with the birth year and county-specific covariates to improve posterior predictions., Results: Among approximately 32 million live births, the overall prevalence of maternal hepatitis C virus infection was 3.5 per 1,000 births (increased from 2.0 in 2010 to 5.0 in 2018). During 2016-2018, posterior predicted median county-level maternal hepatitis C virus infection rates showed that nonurban counties had 3.5-3.8 times higher rates of hepatitis C virus than large central metropolitan counties. The counties in the top 10th percentile for maternal hepatitis C virus rates in 2018 were generally located in Appalachia, in Northern New England, along the northern border in the Upper Midwest, and in New Mexico., Conclusions: Further implementation of community-level interventions that are effective in reducing maternal hepatitis C virus infection and its subsequent morbidity may help to reduce geographic and rural disparities., (Copyright © 2021 American Journal of Preventive Medicine. All rights reserved.)

Purpose: Few studies have examined telehealth use among rural Medicaid beneficiaries. This study produced a descriptive overview of telehealth use in 2011, including the prevalence of telehealth use among rural and urban Medicaid beneficiaries, characteristics of telehealth users, types of telehealth services provided, and diagnoses associated with telehealth use., Methods: Using data from the 2011 Medicaid Analytic eXtract (MAX), we conducted bivariate analyses to test the associations between rurality and prevalence and patterns of telehealth use among Medicaid beneficiaries., Findings: Rural Medicaid beneficiaries were more likely to use telehealth services than their urban counterparts, but absolute rates of telehealth use were low-0.26% of rural nondual Medicaid beneficiaries used telehealth in 2011. Psychotropic medication management was the most prevalent use of telehealth for both rural and urban Medicaid beneficiaries, but the proportion of users who accessed nonbehavioral health services through telehealth was significantly greater as rurality increased. Regardless of telehealth users' residence, mood disorders were the most common reason for obtaining telehealth services. As rurality increased, significantly higher proportions of telehealth users received services to address attention-deficit/hyperactivity disorder (ADHD) and other behavioral health problems usually diagnosed in childhood., Conclusions: These findings provide a baseline for further policy-relevant investigations including examinations of changes in telehealth use rates in Medicaid since 2011. Reimbursement policies and unique rural service needs may account for the observed differences in rural-urban Medicaid telehealth use rates., (© 2018 National Rural Health Association.)

Over the past 3 decades, the evolution of pelvic and acetabular surgery has been supported by the advances in intraoperative pelvic fluoroscopic imaging technology. The new Ziehm RFD 3D C-arm unit provides routine fluoroscopic pelvic imaging but also offers rapid and high-quality real-time axial, sagittal, and coronal intraoperative imaging. This technology allows the surgeon to accurately assess fracture reduction, loose body removal, and implant locations while the patient is still under anesthesia. In this way, any necessary corrections can be performed before the patient leaves the operating room. Essentially, this technology should eliminate the need for revision surgeries. In this report, we present our initial experience using this new device.

Scapulothoracic dissociation is a rare, potentially limb- and life-threatening injury of the shoulder girdle. The injury is characterized by lateral displacement of the scapula resulting from traumatic disruption of the scapulothoracic articulation. The typical physical examination findings consist of substantial swelling of the shoulder girdle, along with weakness, numbness, and pulselessness in the ipsilateral upper extremity. Radiographic evaluation includes measurement of the scapular index on a nonrotated chest radiograph and assessment for either a distracted clavicle fracture or a disrupted acromioclavicular or sternoclavicular joint. Although vascular injury occurs in most patients, emergent surgery is performed only in patients with either limb-threatening ischemia or active arterial hemorrhage. Management of neurologic injury can be delayed if necessary. The location and severity of neurologic injury determine whether observation, nerve grafting, nerve transfer, or above-elbow amputation is performed. Skeletal stabilization procedures include plate fixation of clavicle fractures and reduction of distracted acromioclavicular or sternoclavicular joints. The extent of neurologic injury determines clinical outcomes. Medical Outcomes Study 36-Item Short Form scores are significantly lower in patients with complete brachial plexus avulsion injury than in patients with postganglionic injury.

Background: Most emergency transport protocols in the United States currently call for the use of a spine board (SB) to help immobilize the trauma patient. However, there are concerns that their use is associated with a risk of pressure ulcer development. An alternative device, the vacuum mattress splint (VMS) has been shown by previous investigations to be a viable alternative to the SB, but no single study has explicated the tissue-interface pressure in depth., Methods: To determine if the VMS will exert less pressure on areas of the body susceptible to pressure ulcers than a SB we enrolled healthy subjects to lie on the devices in random order while pressure measurements were recorded. Sensors were placed underneath the occiput, scapulae, sacrum, and heels of each subject lying on each device. Three parameters were used to analyze differences between the two devices: 1) mean pressure of all active cells, 2) number of cells exceeding 9.3kPa, and 3) maximal pressure (Pmax)., Results: In all regions, there was significant reduction in the mean pressure of all active cells in the VMS. In the number of cells exceeding 9.3kPa, we saw a significant reduction in the sacrum and scapulae in the VMS, no difference in the occiput, and significantly more cells above this value in the heels of subjects on the VMS. Pmax was significantly reduced in all regions, and was less than half when examining the sacrum (104.3 vs. 41.8kPa, p<0.001)., Conclusion: This study does not exclude the possibility of pressure ulcer development in the VMS although there was a significant reduction in pressure in the parameters we measured in most areas. These results indicate that the VMS may reduce the incidence and severity of pressure ulcer development compared to the SB. Further prospective trials are needed to determine if these results will translate into better clinical outcomes., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Many institutions have abandoned the routine for selective pelvic x-ray (PXR) for initial imaging in blunt trauma patients undergoing computed tomography (CT) scanning., Objective: Our aim was to examine the association between selective use of PXR and time to diagnosis of (major) pelvic fractures, as well as prioritization of key immediate interventions (including hip reduction and pelvic arterial embolization)., Methods: We conducted a 1-year review of early management of pelvic fracture patients undergoing pelvic CT scanning. Time interval and sequence of initial imaging and key immediate interventions were recorded., Results: Of 218 pelvic fracture patients, 79 (36%) had no initial PXR, and instead had an initial CT scan. Time to first pelvic imaging in those patients was 48 min (standard deviation [SD] = 47 min vs. 2 min [SD = 6 min] with PXR; p < 0.001). Of 40 hip dislocations, 15 (38%) were detected first on CT scan. Overall, 22 (55%) required a second CT scan after reduction in the emergency department. No initial PXR was performed in 42 of 120 (35%) pelvic ring fracture patients and in 16 of 61 (26%) unstable pelvic ring fractures. Time to pelvic arterial embolization was longer in 4 patients without initial PXR than in 14 patients with PXR (296 min [SD = 206 min] vs. 170 min [SD = 76 min], respectively, p = 0.038)., Conclusions: Selective PXR was associated with a significant delay in recognition of (major) pelvic fractures, including those with associated hip dislocations and (potential) pelvic bleeding. PXR remains a useful screening tool to rapidly determine the need for immediate interventions and to allow early planning before CT scanning., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Complex dismounted blast injuries from (improvised) explosive devices have caused amputations of the lower extremities associated with open injuries to the pelvic ring, resulting in life-threatening hemorrhage from disruption of blood vessels near the pelvic ring. Provisional stabilization of the skeletal pelvis by circumferential pelvic compression provides stability for intrapelvic clots and reduces the volume of the pelvis, thereby limiting the amount of hemorrhage. The Junctional Emergency Treatment Tool (JETTtm; North American Rescue Products, http://www.narescue.com) is a junctional hemorrhage control device developed to treat pelvic and lower extremity injuries sustained in high-energy trauma on the battlefield and in the civilian environment. Our purpose was to evaluate the compressive function of the JETT in the reduction of pelvic ring injuries in a cadaveric model., Methods: Radiographic comparison of pre (intact) and post pelvic ring disruption and injury was compared with radiographic measurements post reduction with the JETT device in two cadavers. The device's ability to reduce pelvic disruption and injury in a human cadaver model was assessed through measurements of the anteroposterior (AP) and transverse diameters obtained at the inlet and outlet of the pelvis., Results: Computed tomography (CT) scans demonstrated that JETT application effectively induced circumferential soft tissue compression that was evoked near anatomic reduction of the sacroiliac joint and symphysis pubis., Conclusions: The JETT is capable of effectively reducing an AP compression type III injury (APC III) pelvic ring disruption and injury by approximating the inlet and outlet dimensions toward predisruption measurements. Such a degree of reduction suggests that the JETT device may be suitable in the acute setting for provisional pelvic stabilization., (2014.)

Eccentric reaming of cortical bone near a fracture site can introduce malalignment when an intramedullary nail is placed. The authors describe a technique of reaming metadiaphyseal and diaphyseal femur fractures in which maintaining reduction at the fracture site is not necessary to obtain an excellent alignment of long bone fractures after intramedullary nailing. They have found that central reaming proximal and distal to, but not at, the fracture site allows for excellent reduction of long bone fractures when the intramedullary nail is passed. The reamer is stopped just before the fracture site and then "pushed" across the fracture prior to resumption of reaming. The authors present "push-past" reaming as a technical trick to facilitate reduction of femoral fractures treated with intramedullary nails and a consecutive series of 18 cases in which excellent postoperative alignment was achieved., (Copyright 2014, SLACK Incorporated.)

Background: On January 12, 2010, a catastrophic 7.0 magnitude earthquake shook the Haitian capital of Port-au-Prince. Because of their sudden and destructive nature, earthquakes can result in unfamiliar mass casualty situations accompanied by devastating orthopedic injuries. Evaluation of the pelvic fractures resulting from this earthquake revealed several factors that we hope will facilitate optimal preparation and planning for future disaster situations., Methods: A cohort of patients with earthquake-related pelvic ring fractures who were treated aboard the USNS Comfort was retrospectively analyzed. Anteroposterior radiographs of the pelvis were evaluated and categorized according to the Young-Burgess classification system., Results: Sixty-eight patients were included in the cohort. The mean (SD) age was 29.6 (14.4) years. Nineteen patients (29.7%) were male, and 49 (70.3%) were female. Pelvic fractures were categorized as anteroposterior compression in 7 patients, lateral compression (LC) in 47 patients, vertical shear (VS) in 8 patients, and combination of pelvic ring/acetabulum in 6 patients. Among the 23 patients treated operatively, the mean (SD) delay from injury to surgery was 19.2 (7.4) days., Conclusion: Patients showed predominance toward LC injuries (69.1%), consistent with crush under rubble. Thirty-one percent of the fractures were considered unstable (anteroposterior compression Type III, LC Type III, VS, and combination of pelvic ring/acetabulum). The VS injuries observed (11.8%) may be the result of a previously unidentified injury mechanism, an upright individual being struck by falling rubble, violently applying a downward force to the body over an extended lower extremity. A substantial delay in the treatment observed in this series may lead to an underestimation of both quantity and severity of pelvic fractures as critically ill patients may have perished before evaluation and treatment. In addition, the application of pelvic sheeting techniques may be a lifesaving intervention for interval pelvic stabilization following earthquakes in which medical resources are scarce., Level of Evidence: Epidemiologic study, level III; therapeutic study, level V.

Background: We hypothesized that patients with pelvic fractures and hemorrhage admitted during daytime hours were undergoing interventional radiology (IR) earlier than those admitted at night and on weekends, thereby establishing two standards of time to hemorrhage control., Methods: The trauma registry (January 2008 to December 2011) was reviewed for patients admitted with pelvic fractures, hemorrhagic shock, and transfusion of at least 1 U of blood. The control group (DAY) was admitted from 7:30 AM to 5:30 PM Monday to Friday, while the study group (after hours [AHR]) was admitted from 5:30 PM to 7:30 AM, on weekends or holidays., Results: A total of 191 patients met the criteria (45 DAY, 146 AHR); 103 died less than 24 hours and without undergoing IR (29% DAY group vs. 62% AHR, p < 0.001). Sixteen patients (all in AHR group) died while awaiting IR (p = 0.032). Eighty-eight patients (32 DAY, 56 AHR) survived to receive IR. Among these, the AHR group were younger (median, 30 years vs. 54 years; p = 0.007), more tachycardic (median pulse, 119 beats/min vs. 90 beats/min; p = 0.001), and had more profound shock (median base, -10 vs. -6; p = 0.006) on arrival. Time from admission to IR (median, 301 minutes vs. 193 minutes; p < 0.001) and computed tomographic scan to IR (176 minutes vs. 87 minutes, p = 0.011) were longer in the AHR group. There was no difference in the 30-day mortality by univariate analysis. However, after controlling for age, arrival physiology, injury severity, and degree of shock, the AHR group had a 94% increased risk of mortality., Conclusion: The current study demonstrated that patients admitted at night and on weekends have a significant increase in time to angioembolization compared with those arriving during the daytime and during the week. Multivariate regression noted that AHR management was associated with an almost 100% increase in mortality. While this is a single-center study and retrospective in nature, it suggests that we are currently delivering two standards of care for pelvic trauma, depending on the day and time of admission., Level of Evidence: Therapeutic study, level II.

The United Nations has identified road traffic safety as an important objective for the decade 2011-2020. It has implemented a 5-tiered program: improving health care services, improving management of road safety, improving road network safety, improving vehicular safety, and improving road safety legislation. A small body of practical research has been generated by the medical and surgical (including orthopaedic) communities regarding the road traffic safety, but a substantial amount of work remains to be performed. This article will review published research in each of the 5 tiers of the Decade of Action for Road Traffic Safety and will identify areas where research is insufficient or absent, such that new research programming and funding can be developed.

Pelvic fractures range in severity from low-energy, generally benign lateral compression injuries to life-threatening, unstable fracture patterns. Initial management of severe pelvic fractures should follow Advanced Trauma Life Support protocols. Initial reduction of pelvic blood loss can be provided by binders, sheets, or some form of external fixation, which serve to reduce pelvic volume, stabilize clot formation, and reduce ongoing tissue damage. Persistently unstable patients may benefit from angiography with selective embolization, pelvic packing, or a combination of these interventions. Open pelvic fractures involving the perineum or bowel injury benefit from fecal diversion by colostomy. Trauma team coordination facilitates efficient resuscitative efforts and may affect definitive management by optimizing incision, ostomy, or catheter placement. Established protocols for both open and closed pelvic fractures help to standardize care.

Once the patient with pelvic fracture is resuscitated and stabilized, definitive surgical management and anatomic restoration of the pelvic ring become the goal. Understanding injury pattern by stress examination with the patient under anesthesia helps elucidate the instability. Early fixation of the unstable pelvis is important for mobilization, pain control, and prevention of chronic instability or deformity. Current pelvic fracture management employs a substantial amount of percutaneous reduction and fixation, with less emphasis placed on pelvic reconstruction proceeding from posterior to anterior, and most reduction and fixation of unstable pelvic fractures done with the patient supine. Compared with control subjects with acetabular fracture or pelvic fracture alone, patients with combined injury have a significantly higher Injury Severity Score, lower systolic blood pressure, and higher mortality rates; they are also transfused more packed red blood cells. Even with anatomic restoration of the pelvis, long-term outcomes after severe pelvic trauma are below population norms. The most common chronic problems relate to sexual dysfunction and pain. Regardless of fracture type, neurologic injury is a universal harbinger of poor outcome.

Background: Early fixation (<24 hour) of femur fractures with an intramedullary nail (IMN) has been associated with a decreased incidence of pulmonary complication (PC) in stable trauma patients. Early fixation is in accordance with the "two-hit" hypothesis, that is, an increase in proinflammatory markers during Days 3 to 5 after injury, increases the risk of developing a PC. We hypothesized that early IMN fixation of femur fractures would be associated with a decreased incidence of PC, hospital stay, and overall charges., Methods: A retrospective review of all trauma patients with diaphyseal femur fractures was performed from January 2000 through December 2010 at an academic Level 1 trauma center. The cohort was divided into those who underwent early fixation (<24 hours) and delayed fixation (≥24 hours). Multivariable logistic regression modeling was used to adjust for the anatomic (Injury Severity Score [ISS]) and physiologic (Revised Trauma Score [RTS]) severity of injury. The primary outcome of interest was PC, defined as the presence of pneumonia (PNA), pulmonary embolism, or adult respiratory distress syndrome. Continuous variables are expressed as mean (SD). The analysis was repeated for patients with an ISS of greater than 15 and an ISS of greater than 25., Results: During the study period, 1,755 patients were admitted with a diaphyseal femur fracture, of whom 1,376 patients underwent primary IMN. A total of 1,032 (75%) underwent early fixation (median, 7.4 hours; interquartile range [IQR], 3.7-12.9 hours), and 344 (25%) underwent delayed fixation (median, 40.9 hours; IQR, 31.0-64.9 hours). The early fixation group had lower ISS (median [IQR], 10 [10-19] vs. 17.5 [10-27]; p < 0.001) and a higher RTS (median [IQR], 7.84 [7.84-7.84] vs. 7.84 [7.84-7.84]; p < 0.001). PC were reduced in the early fixation group, (3.9% vs. 13.4%, p < 0.001). Specifically, there was a decreased incidence of PNA (2% vs. 11%, p < 0.001), pulmonary embolism (2% vs. 4%, p < 0.21), and adult respiratory distress syndrome (0.002% vs. 0.02%, p < 0.001). After adjustment for anatomic (ISS) and physiologic (RTS) indices of injury severity, early fixation was independently associated with a reduction in PC (odds ratio, 0.43; 95% confidence interval, 0.25-0.72; p = 0.002). The early fixation group also had a decrease in hospital length of stay (median [IQR], 6 [4-11] vs. 10 [6-17]; p < 0.001), ventilator days (median [IQR], 0 [0-0] vs. 0 [0-4]; p < 0.001), and hospital charges (median [IQR], $59,561 [$38,618-$106,780] vs. $97,018 [48,249-205,570]; p < 0.001). Mortality was low in both groups (0.4% vs. 1.7%, p < 0.01). Similar results were seen in patients with an ISS of greater than 15 and ISS of greater than 25., Conclusion: Controlling for anatomic and physiologic severity of injury, early femoral IMN was associated with an almost 60% reduction in odds of developing PCs. Early fixation was also associated with a reduction ventilator days, hospital length of stay, and overall hospital charges. As the list of "never events" continues to expand and improving quality of care while reducing costs is emphasized, early (<24 hours) definitive operative intervention seems to decrease complications, achieve early hospital discharge, and reduce hospital charges., Level of Evidence: Therapeutic study, level IV.

Background: A better understanding of the factors influencing return to work (RTW) after major limb trauma is essential in reducing the high costs associated with these injuries., Methods: Patients (n = 423) who underwent amputation or reconstruction after limb threatening lower extremity trauma and who were working before the injury were prospectively evaluated at 3, 6, 12, 24, and 84 months. Time to first RTW was assessed. For individuals working at 84 months, the percentage of time limited in performance at work was estimated using the Work Limitations Questionnaire., Results: Estimates of the cumulative proportion returning to work at 3, 6, 12, 24, and 84 months were 0.12, 0.28, 0.42, 0.51, and 0.58. Patients working at 84 months were, on average, limited in their ability to perform the demands of their job 20 to 25% of the time. In the context of a Cox proportional hazards model, differences in RTW outcomes by treatment (amputation versus reconstruction) were not statistically significant. Factors that were significantly associated (p < 0.05) with higher rates of RTW include younger age, being White, higher education, being a nonsmoker, average to high self efficacy, preinjury job tenure, higher job involvement, and no litigation. Early (3 month) assessments of pain and physical functioning were significant predictors of RTW., Conclusions: Return to work after severe lower extremity trauma remains a challenge. Although the causal pathway from injury to impairment and work disability is complex, this study points to several factors that influence RTW that suggest strategies for intervention.

Background: Lower extremity injuries (LEIs) sustained in vehicular crashes result in physical problems and unexpected psychosocial consequences. Their significance is diminished by low Abbreviated Injury Scale scores., Methods: Drivers who sustained LEIs were identified as part of the Crash Injury Research and Engineering Network (CIREN) and interviewed during hospitalization, at 6 months, and at 1 year. All were occupants of newer vehicles with seatbelts and airbags., Results: Sixty-five patients were followed for 1 year. Injuries included mild brain injury (43%), ankle/foot fractures (55%), and bilateral injuries (37%). One year post-injury, 46% reported limitations in walking and 22% with ankle/foot fractures were unable to return to work. Depression (39%), cognitive problems (32%), and post-traumatic stress disorder (18%) were significant in the mild brain injury group., Conclusions: Long-lasting physical and psychological burdens may impede recovery and alter the lifestyle of patients with LEI. These issues need to be addressed by trauma center personnel.

Background: The principal aims of this study were to examine functional outcomes following trauma-related lower-extremity amputation and to compare outcomes according to the amputation levels. We hypothesized that above-the-knee amputations would result in less favorable outcomes than would through-the-knee or below-the-knee amputations. A secondary aim was to examine the factors, in addition to amputation level, that influence outcome, including the type of soft-tissue coverage, selected patient characteristics, and the technological sophistication of the prosthetic device., Methods: A cohort of 161 patients who had undergone an above-the-ankle amputation at a trauma center within three months following the injury was followed prospectively at three, six, twelve, and twenty-four months after the injury. The Sickness Impact Profile, a self-reported measure of functional status, was used as the principal measure of outcome. Secondary outcomes included pain; degree of independence in transfers, walking, and climbing stairs; self-selected walking speed; and the physician's satisfaction with the clinical, functional, and cosmetic recovery of the limb. Longitudinal multivariate regression techniques were used to determine whether outcomes differed according to the level of amputation after we controlled for covariates., Results: There was no significant difference in the scores on the Sickness Impact Profile between the patients treated with above-the-knee and those treated with below-the-knee amputation. However, patients with a below-the-knee amputation performed better than did patients with an above-the-knee amputation on the timed test for walking speed (p = 0.04). Patients with a through-the-knee amputation had worse regression-adjusted Sickness Impact Profile scores (p = 0.05) and slower self-selected walking speeds (p = 0.004) than did patients with either a below-the-knee or an above-the-knee amputation. Differences according to the level of amputation were most pronounced for physical function. In general, physicians were less satisfied with the clinical, cosmetic, and functional recovery of the patients with a through-the-knee amputation. Except for problems encountered with insufficient gastrocnemius coverage of the stump in many patients with a through-the-knee amputation, neither the soft-tissue coverage nor the technological sophistication of the prosthesis correlated with outcome., Conclusions: Severe disability accompanies above-the-ankle lower-extremity amputation following trauma, regardless of the level of amputation. Clinicians should critically evaluate the need for a through-the-knee amputation in patients with a traumatic injury. The results of this study also underscore the need for controlled studies that examine the relationship between the type and fit of prosthetic devices and functional outcomes.

Lower extremity injuries resulting from motor vehicle crashes are common and have become relatively more important as more drivers with newer occupant restraints survive high-energy crashes. CIREN data provide a greater level of clinical detail based on coding guidelines from the Orthopedic Trauma Association. These detailed data, in conjunction with long-term follow-up data obtained from patient interviews, reveal that the most costly and disabling injuries are those involving articular (joint) surfaces, especially those of the ankle/foot. Patients with such injuries exhibit residual physical and psychosocial problems, even at one year post-trauma.

Background: Limb salvage for severe trauma has replaced amputation as the primary treatment in many trauma centers. However, long-term outcomes after limb reconstruction or amputation have not been fully evaluated., Methods: We performed a multicenter, prospective, observational study to determine the functional outcomes of 569 patients with severe leg injuries resulting in reconstruction or amputation. The principal outcome measure was the Sickness Impact Profile, a multidimensional measure of self-reported health status (scores range from 0 to 100; scores for the general population average 2 to 3, and scores greater than 10 represent severe disability). Secondary outcomes included limb status and the presence or absence of major complications resulting in rehospitalization., Results: At two years, there was no significant difference in scores for the Sickness Impact Profile between the amputation and reconstruction groups (12.6 vs. 11.8, P=0.53). After adjustment for the characteristics of the patients and their injuries, patients who underwent amputation had functional outcomes that were similar to those of patients who underwent reconstruction. Predictors of a poorer score for the Sickness Impact Profile included rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), smoking, and involvement in disability-compensation litigation. Patients who underwent reconstruction were more likely to be rehospitalized than those who underwent amputation (47.6 percent vs. 33.9 percent, P=0.002). Similar proportions of patients who underwent amputation and patients who underwent reconstruction had returned to work by two years (53.0 percent and 49.4 percent, respectively)., Conclusions: Patients with limbs at high risk for amputation can be advised that reconstruction typically results in two-year outcomes equivalent to those of amputation., (Copyright 2002 Massachusetts Medical Society)

Background: Factors thought to influence the decision for limb salvage include injury severity, physiologic reserve of the patient, and characteristics of the patient and their support system., Methods: Eligible patients were between the ages of 16 and 69 with Gustilo type IIIB and IIIC tibial fractures, dysvascular limbs resulting from trauma, type IIIB ankle fractures, or severe open midfoot or hindfoot injuries. Data collected at enrollment relevant to the decision-making process included injury characteristics and its treatment, and the nature and severity of other injuries. Logistic regression and stepwise modeling were used to determine the effect of each covariate on the variable salvage/ amputation., Results: Of 527 patients included in the analysis, 408 left the hospital with a salvaged limb. Of the 119 amputations performed, 55 were immediate and 64 were delayed. The multivariate analysis confirmed the bivariate analysis: all injury characteristics remained significant predictors of limb status with the exception of bone loss; and soft tissue injury and absence of plantar sensation were the most important factors in accounting for model validity., Conclusion: Soft tissue injury severity has the greatest impact on decision making regarding limb salvage versus amputation.

With the increasing availability of modern occupant restraints, more drivers and passengers are surviving high-energy crashes. However, a large number, especially those involved in frontal and offset frontal crashes, incur disabling lower extremity injuries. In the past, not much attention was paid to these injuries, as they were usually not life threatening. Despite the low AIS scores associated with injuries to the lower extremities, they pose a major physical and psychological burden on patients' and their ability to return to pre-crash functioning. Associated injuries, such as mild brain injuries, and psychosocial factors such as depression, also influence the long-term outcome.

Purpose: (a) to report the demographic, socioeconomic, behavioral, social, and vocational characteristics of patients enrolled in a study to examine outcomes after high-energy lower extremity trauma (HELET) and to compare them with the general population; (b) to determine whether characteristics of patients undergoing limb salvage versus amputation after HELET are significantly different from each other., Design and Study Population: A prospective study of 601 patients admitted with high-energy lower extremity trauma to eight Level I trauma centers., Procedures: Patients were evaluated during the initial hospitalization. They are being followed up for 24 months postinjury. Study patients are compared with the general population by using census information, population survey data, and published norms. Characteristics of patients undergoing limb salvage versus amputation are also compared., Results: Most patients were male (77 percent), white (72 percent), and between the ages of twenty and forty-five years (71 percent). Seventy percent graduated from high school (compared with 86 percent nationally) (p < 0.05). One fourth lived in households with incomes below the federal poverty line, compared with 16 percent nationally (p < 0.05). The percentage with no health insurance (38 percent) was also higher than in the general population (20 percent) (p < .05). The percentage of heavy drinkers was over two times higher than reported nationally (p < 0.01). Study patients were slightly more neurotic and extroverted and less open to new experiences. When patient characteristics were compared for those undergoing amputation versus limb salvage, no significant differences were found among any of the variables (p > 0.05)., Conclusion: In conclusion, LEAP patients differ in important ways from the general population. However, the decision to amputate verus reconstruct does not appear to be significantly influenced by patient characteristics.

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.

This article examines two observational and two experimental data sets that emphasize lower limb injuries in passenger car crashes. Statistics show that 60% of moderate-to-severe below-knee injuries sustained by front seat occupants in head-on crashes occur with > 3 cm of footwell intrusion. Moreover, crash tests and computer simulations of car-to-car frontal offset collisions show no causal relationship between the magnitude of footwell intrusion and the axial load measured in the dummy leg. This article correlates below-knee injuries with several factors that influence their frequency and severity, such as the vehicle change in velocity, the magnitude of footwell intrusion, the rate and timing of the intrusion and the size of the vehicle. The vehicle change in velocity and the intrusion rate and timing had the greatest influence on the risk of lower limb injury, while the other factors had much less of an effect.

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.

Objectives: To determine and compare the mortality rates of patients with bilateral versus unilateral femoral fractures and to determine the contribution of the femoral fracture to, and identify risk factors for, such mortality., Study Design: Retrospective analysis using trauma registry data on consecutive blunt trauma patients with unilateral (800 patients, group I) or bilateral (eighty-five patients, group II) femoral fractures., Methods: Univariate data analysis was performed to compare the groups' ages, Injury Severity Scores, Glasgow Coma Scale values, mortality, and the presence of adult respiratory distress syndrome (ARDS). Logistic regression analysis was performed to determine variables statistically associated with mortality., Results: Group II patients had a significantly higher Injury Severity Score (30.2 versus 24.5, p < 0.001), lower Glasgow Coma Scale value (12.3 versus 13.1, p = 0.05), higher mortality rate (25.9 vs 11.7%, p < 0.001), and higher incidence of ARDS (15.7 versus 7.27%, p = 0.014) than group I patients. Group II patients also had significantly more closed head injuries, open skull fractures, intraabdominal injuries requiring surgical intervention, and pelvic fractures; the rates of thoracic injury were similar. Regression analysis of variables evident on admission revealed a significant correlation between bilateral femoral fractures and death; however, other factors (shock, closed head injury, and thoracic injury) had much stronger correlations with mortality., Conclusions: Patients with bilateral femoral fractures have a significantly higher risk of death, ARDS, and associated injuries than patients with unilateral femoral fractures. This increase in mortality is more closely related to associated injuries and physiologic parameters than to the presence of bilateral femoral fractures. The presence of bilateral femoral fractures should alert the clinician to the likelihood of associated injuries, a higher Injury Severity Score, and the potential for a more serious prognosis.

Multiply injured patients (an Injury Severity Score of 17 points or more) who were admitted to one of two level-I regional trauma centers between 1983 and 1994 because of a fracture of the femoral shaft with a thoracic injury (an Abbreviated Injury Scale score of 2 points or more) or without a thoracic injury were studied retrospectively. The patient populations and the protocols for the treatment of trauma were similar at the two centers; however, the centers differed with regard to the technique that was used for acute stabilization of the fracture of the femoral shaft. At Center I intramedullary nailing with reaming was used in 217 (95 per cent) of the 229 patients, whereas at Center II a plate was used in 206 (92 per cent) of the 224 patients. This difference was used to investigate the effect of acute femoral reaming on the occurrence of adult respiratory distress syndrome in multiply injured patients who had a chest injury. Three groups of patients were evaluated: those who had both a fracture of the femur and a thoracic injury, those who had a fracture of the femur but no thoracic injury, and those who had a thoracic injury without a fracture of the femur or the tibia. The third group was studied at each center to determine if there was a difference between the institutions with regard to the rate of adult respiratory distress syndrome. Patients who had diabetes, chronic obstructive pulmonary disease, asthma, hepatic or renal failure, or an immunosuppressive condition were excluded from the study. The records were abstracted to determine the Injury Severity Score, Abbreviated Injury Scale score, and Glasgow Coma Score for each patient. Requirements for fluid resuscitation were calculated for the first twenty-four hours; these included the number of units of packed red blood cells, fresh-frozen plasma, and platelets that were transfused and the volume of crystalloid that was used. The duration of intubation, the duration of hospitalization, and the occurence of adverse outcomes (death, multiple organ failure, adult respiratory distress syndrome, pneumonia, and pulmonary embolism) were determined for each patient. The groups of patients were analyzed as a whole and then were stratified into subgroups (according to whether or not they had a thoracic injury and whether the Injury Severity Score was less than 30 points or 30 points or more) to determine if the type of fixation of the femoral fracture affected the rate of adult respiratory distress syndrome or mortality. Logistic regression models were used to analyze the data. The over-all occurrence of adult respiratory distress syndrome in the 453 patients who had a femoral fracture was only 2 per cent (ten patients). The rates of adult respiratory distress syndrome for the patients who had a thoracic injury but no femoral fracture (eight [6 per cent] of 129 patients at Center I, compared with ten [8 per cent] of 125 patients at Center II) did not differ between centers, suggesting that the institutions were comparable in their treatment of multiply injured patients. The occurrence of adult respiratory distress syndrome in the patients who had a femoral fracture without a thoracic injury did not differ substantially according to whether the fracture had been treated with a nail (118 patients) or a plate (114 patients). Likewise, the frequency of adult respiratory distress syndrome, pneumonia, pulmonary embolism, failure of multiple organs, or death for the patients who had a femoral fracture and a thoracic injury was similar regardless of whether nailing with reaming (117 patients) or a plate (104 patients) had been used. The use of intramedullary nailing with reaming for acute stabilization of fractures of the femur in multiply injured patients who have a thoracic injury without a major comorbid disease does not appear to increase the occurrence of adult respiratory distress syndrome, pulmonary embolism, failure of multiple organs, pneumonia, or death.

Objectives: To assess mechanism of injury as a clinical course predictor in patients with complete anterior and posterior pelvic ring disruptions [innominosacral dissociation (ISD)]., Design: Retrospective review of radiographs and medical data., Setting: R Adams Cowley Shock Trauma Center, Baltimore, Maryland, statewide trauma center., Patients: Forty-three patients with ISD were admitted to our institution between August 1986 and October 1991. Five patients were excluded because of incomplete medical records (4) or refusal of blood transfusion (1)., Intervention: Injuries were grouped according to the Young classification: 18 anteroposterior compression (APC), 14 vertical shear (VS), and 6 other injuries., Main Outcome Measurements: The mean blood replacement requirements, incidence of multiple organ system failure, mortality rate, and length of hospital stay for each injury classification were compared., Results: The mean ISS was 34, and the mean 24-hour packed red blood cell transfusion requirement was 12.6 units. Thirteen patients (34.4%) developed multisystem organ failure. Eight patients (21%) died. Patients in the APC group were more likely to require > or = 10 units of blood (15/18, p = 0.001, and those in the VS group were more likely to receive < 10 units (11/14, p = 0.0014). Multisystem organ failure occurred more frequently (11/18 versus 2/14; p < 0.005), mortality was significantly higher (39 versus 0%, respectively; p = 0.01), and mean hospital stay for survivors was longer (48 versus 27 days; p < 0.025) in the APC than in the VS group, respectively., Conclusions: These findings suggest that mechanism of injury is an important determinant of clinical behavior in patients with IDS, and that ISD secondary to the APC mechanism is associated with substantially greater resuscitation requirements, morbidity, and mortality than ISD secondary to the VS mechanism.

Objective: A prospective study of the interaction between airbag (AB) and seat-belt (Bt) protection versus vehicular compartment (VC) intrusion effects on injury patterns in motor vehicle crash (MVC) trauma patients., Methods: Two hundred MVC patients, nonejected drivers or front seat passengers with multiple trauma or severe lower extremity (LE) trauma admitted to two Level I trauma centers., Results: In frontal crashes, airbags (AB) more than Bt reduced Glasgow Coma Scale severity in brain injury, face fracture, shock, and the need for MVC extrication (all p < 0.05). Frontal AB also had a protective effect on LE fractures (41% vs. 66%, p < 0.01), but had no significant protective effect on pelvic fractures. When AB protection was present, it prevented brain and face fracture injuries caused by impact contacts and reduced the incidence of these injuries resulting from VC intrusions (p < 0.05). Thoracoabdominal injuries resulting from steering wheel intrusion showed AB protection against intrusions of twice the magnitude of those seen in non-AB vehicles (p < 0.05). In frontal MVCs, AB reduced LE fracture contact injuries but did not prevent LE fractures resulting from intrusions of instrument panel, toepan, or floor pedal structures. In lateral MVCs, Bt did not protect against brain, face, thorax, or pelvic injuries., Conclusions: Safety measures beyond frontal airbags must address frontal crash LE injuries induced by steering wheel, instrument panel, and toepan passenger compartment structure intrusions. Lateral crash injuries may profit from side AB supplemental restraint protection.