Elderly trauma associated with high-risk recreational activity: A population-based study, United States, 2010 through 2016.

BACKGROUND: Understanding trends in prevalence and etiology is critical to public health strategies for prevention and management of injury related to high-risk recreation in elderly Americans. METHODS: The National Emergency Department Sample from 2010 through 2016 was queried for patients with a principal diagnosis of trauma (ICD-9 codes 800.0-959.9) and who were 55 years and older. High-risk recreation was determined from e-codes a priori. Primary outcome measures were mortality and total hospital charges. RESULTS: Of the 29,491,352 patient cohort, 458,599 (1.56%) engaged in high-risk activity, including those age 85 and older. High-risk cases were younger (median age 61 vs 70) and majority male (71.87% vs 39.24%). The most frequent activities were pedal cycling (45.81%), motorcycling (29.08%), and off-road vehicles (9.13%). Brain injuries (8.82% vs 3.88%), rib/sternal fractures (13.35% vs 3.53%), and cardiopulmonary injury (5.25% vs 0.57%) were more common among high-risk cases. Mortality (0.75% vs 0.40%) and total median hospital charges ($3,360 vs $2,312) were also higher for high-risk admissions, where the odds of mortality increased exponentially per year of age (odds ratio, 1.06; 99.5% CI, 1.05-1.08). High-risk recreation was associated with more than $1 billion in total hospital charges and more than 100 deaths among elderly Americans per year. CONCLUSION: Morbidity, mortality, and resource utilization due to high-risk recreation extend into the ninth decade of life. The patterns of injury described here offer opportunities for targeted injury prevention education to minimize risk among this growing segment of the United States population.

Pelvic fracture pattern predicts the need for hemorrhage control intervention-Results of an AAST multi-institutional study.

BACKGROUND: Early identification of patients with pelvic fractures at risk of severe bleeding requiring intervention is critical. We performed a multi-institutional study to test our hypothesis that pelvic fracture patterns predict the need for a pelvic hemorrhage control intervention. METHODS: This prospective, observational, multicenter study enrolled patients with pelvic fracture due to blunt trauma. Inclusion criteria included shock on admission (systolic blood pressure <90 mm Hg or heart rate >120 beats/min and base deficit >5, and the ability to review pelvic imaging). Demographic data, open pelvic fracture, blood transfusion, pelvic hemorrhage control intervention (angioembolization, external fixator, pelvic packing, and/or REBOA [resuscitative balloon occlusion of the aorta]), and mortality were recorded. Pelvic fracture pattern was classified according to Young-Burgess in a blinded fashion. Predictors of pelvic hemorrhage control intervention and mortality were analyzed by univariate and multivariate regression analyses. RESULTS: A total of 163 patients presenting in shock were enrolled from 11 Level I trauma centers. The most common pelvic fracture pattern was lateral compression I, followed by lateral compression I, and vertical shear. Of the 12 patients with an anterior-posterior compression III fracture, 10 (83%) required a pelvic hemorrhage control intervention. Factors associated with the need for pelvic fracture hemorrhage control intervention on univariate analysis included vertical shear pelvic fracture pattern, increasing age, and transfusion of blood products. Anterior-posterior compression III fracture patterns and open pelvic fracture predicted the need for pelvic hemorrhage control intervention on multivariate analysis. Overall in-hospital mortality for patients admitted in shock with pelvic fracture was 30% and did not differ based on pelvic fracture pattern on multivariate analysis. CONCLUSION: Blunt trauma patients admitted in shock with anterior-posterior compression III fracture patterns or patients with open pelvic fracture are at greatest risk of bleeding requiring pelvic hemorrhage control intervention. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Current management of hemorrhage from severe pelvic fractures: Results of an American Association for the Surgery of Trauma multi-institutional trial.

BACKGROUND: There is no consensus as to the optimal treatment paradigm for patients presenting with hemorrhage from severe pelvic fracture. This study was established to determine the methods of hemorrhage control currently being used in clinical practice. METHODS: This prospective, observational multi-center study enrolled patients with pelvic fracture from blunt trauma. Demographic data, admission vital signs, presence of shock on admission (systolic blood pressure < 90 mm Hg or heart rate > 120 beats per minute or base deficit < -5), method of hemorrhage control, transfusion requirements, and outcome were collected. RESULTS: A total of 1,339 patients with pelvic fracture were enrolled from 11 Level I trauma centers. Fifty-seven percent of the patients were male, with a mean ± SD age of 47.1 ± 21.6 years, and Injury Severity Score (ISS) of 19.2 ± 12.7. In-hospital mortality was 9.0 %. Angioembolization and external fixator placement were the most common method of hemorrhage control used. A total of 128 patients (9.6%) underwent diagnostic angiography with contrast extravasation noted in 63 patients. Therapeutic angioembolization was performed on 79 patients (5.9%). There were 178 patients (13.3%) with pelvic fracture admitted in shock with a mean ± SD ISS of 28.2 ± 14.1. In the shock group, 44 patients (24.7%) underwent angiography to diagnose a pelvic source of bleeding with contrast extravasation found in 27 patients. Thirty patients (16.9%) were treated with therapeutic angioembolization. Resuscitative endovascular balloon occlusion of the aorta was performed on five patients in shock and used by only one of the participating centers. Mortality was 32.0% for patients with pelvic fracture admitted in shock. CONCLUSION: Patients with pelvic fracture admitted in shock have high mortality. Several methods were used for hemorrhage control with significant variation across institutions. The use of resuscitative endovascular balloon occlusion of the aorta may prove to be an important adjunct in the treatment of patients with severe pelvic fracture in shock; however, it is in the early stages of evaluation and not currently used widely across trauma centers. LEVEL OF EVIDENCE: Prognostic study, level II; therapeutic study, level III.

Scapula fractures: interobserver reliability of classification and treatment.

OBJECTIVES: There is substantial variation in the classification and management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment. DESIGN: Web-based reliability study. SETTING: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey. PARTICIPANTS: One hundred three orthopaedic surgeons evaluated 35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns. MAIN OUTCOME MEASUREMENTS: Fleiss kappa (κ) was used to assess the reliability of agreement between the surgeons. RESULTS: The overall agreement on the OTA/AO classification was moderate for the types (A, B, and C, κ = 0.54) with a 71% proportion of rater agreement (PA) and for the 9 groups (A1 to C3, κ = 0.47) with a 57% PA. For the New International Classification, the agreement about the intraarticular extension of the fracture (Fossa (F), κ = 0.79) was substantial and the agreement about a fractured body (Body (B), κ = 0.57) or process was moderate (Process (P), κ = 0.53); however, PAs were more than 81%. The agreement on the treatment recommendation was moderate (κ = 0.57) with a 73% PA. CONCLUSIONS: The New International Classification was more reliable. Body and process fractures generated more disagreement than intraarticular fractures and need further clear definitions.

A reliable radiographic measurement technique for extra-articular scapular fractures.

BACKGROUND: Currently, neither well-defined nor standardized measurement techniques exist for assessing deformity of extra-articular scapular fractures. To properly evaluate these injuries, compare observations across studies, and make clinical decisions, a validated measurement protocol for evaluating scapular fractures is needed. QUESTIONS/PURPOSES: We describe techniques to quantitatively characterize extra-articular scapular fracture deformity; evaluate the reliability of these characterizations in plain film radiographs and CT scans; and determine potential differences in the characterization of the deformity between the two imaging modalities. PATIENTS AND METHODS: We evaluated injury radiographs and three-dimensional CT images of 45 patients with extra-articular scapular fracture. Techniques for measuring medial/lateral displacement, angulation, translation, glenopolar angle, and glenoid version were established and utilized in two trials, performed 6 weeks apart, by three observers. We determined descriptive statistics for each measurement parameter. RESULTS: Interobserver reliability based upon interclass correlation coefficients ranged from 0.36 to 0.76 for radiographs and from 0.48 to 0.87 for three-dimensional CT. Intraobserver reliability using Pearson r coefficient ranged from 0.60 to 0.75 for radiographs and 0.64 to 0.89 for three-dimensional CT. Both individual and pooled measurements for angulation and glenopolar angle were higher on three-dimensional CT versus radiographs. CONCLUSIONS: Our data suggest three-dimensional CT is more reliable than plain radiography in the assessment of scapula fracture displacement. Therefore, we believe this modality should be utilized if fracture deformity warrants surgical consideration and to adequately compare data across studies. LEVEL OF EVIDENCE: Level IV, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Radiographic quantification and analysis of dysmorphic upper sacral osseous anatomy and associated iliosacral screw insertions.

OBJECTIVE: To quantify upper sacral dysmorphic osseous anatomy and assess its impact on second sacral segment iliosacral screw insertion. DESIGN: Retrospective evaluation of a prospective trauma database. SETTING: Regional Level I trauma center. PATIENTS: Twenty-four patients with unstable posterior pelvic ring disruptions and sacral dysmorphism were evaluated radiographically and second segment (S2) screws were placed using a standard technique. MAIN OUTCOME MEASUREMENTS: The sacral osseous pathway limits were measured using preoperative pelvic computed tomography at the upper and second sacral segments. The S2 screw location relative to the sacral nerve root tunnels and the maximum possible screw lengths for both S1 and S2 screws were evaluated with postoperative pelvic computed tomography. The S2 screw positions were graded as intraosseous, juxtaforaminal, or extruded. Preoperative and postoperative peripheral neurologic examinations were documented. RESULTS: The dysmorphic S1 width available for screw insertion averaged 13.2 mm. The S2 pathway width averaged 15.2 mm. The maximum potential screw length for the dysmorphic S1 averaged 100.8 mm and for S2 measured 151.9 mm. Twenty of 24 patients with S2 screws were intraosseous and in four patients were juxtaforaminal. There were no extruded screws. There were no neurologic injuries. CONCLUSIONS: Dysmorphic S1 segments are anatomically competent for routine screw fixation. The S2 segment provides a larger osseous site for screw insertion than S1 in dysmorphic sacrums. Significantly longer screws are possible in S2 compared with the dysmorphic S1 segment. S2 iliosacral screws can be safely and accurately accomplished using a standard technique in patients with unstable posterior pelvic ring disruptions and sacral dysmorphism. Safe screw insertions avoid iatrogenic nerve root injuries.

Characterization of a femoral segmental nonunion model in laboratory rats: report of a novel surgical technique.

The literature is lacking conclusive results regarding the exact mechanism of maximizing the fracture healing stages with minimal traumatic side effects. This observation mandates the development of a novel surgical procedure using small animals as a model to study fracture healing in the presence of osteoinductive agents. Previously, stabilization of osteotomies in small animal models has mainly been accomplished using Kirschner wires, but the rat's tremendous ability to heal an osteotomy stabilized by this method has masked the effects of osteoinductive agents. Thus, this study proposes using a modified 20-hole, 1.5-mm stainless-steel plate to stabilize a 5-mm segmental defect. Thirty of 32 adult male rats were fully weight-bearing within 2 days and were followed over a 15-week period. Two animals showed evidence of fixation failure due to technical error, and the animals were humanely sacrificed. At the end of the study, the fractures were stable with significantly less bone formation evident when compared to controls (p < .001). Therefore, this technique can effectively be used to evaluate compounds that will enhance bone formation and allows for stable fixation of the control with minimal callus formation or bony ingrowth. The goal of this article is to allow other investigators to reproduce this technique as well as outline the advantages and disadvantages of this novel plating technique versus the former Kirschner wire technique for the study of osteoinductive agents using small animals as a model.

Targeted sustained delivery of tobramycin at the site of a femoral osteotomy.

Complex fractures are difficult to manage because of the increased risk of secondary infection. Traditional treatments include debridment and local administration of antibiotics. Local antibiotic therapy is a safe technique resulting in high local concentration of antibiotics with minimal systemic levels. Local antibiotics effectively control infection in animal models. The length of implantation and the need for removal of the delivery vehicle places the patient at risk for additional surgical procedure as well as delays the fixation procedure. Development of a bioresorbable carrier that can deposit therapeutic concentrations of antibiotics locally without side-effects will provide positive outcomes for the patient. Tricalcium phosphate lysine (TCPL) ceramic capsules containing tobramycin were implanted at the site of a femoral osteotomy delivered therapeutic concentrations of the drug locally and reduced the incidence of infection compared to TCPL capsule which were uncharged by 50%. In addition, the ceramic material was osteoconductive and animals in TCPL + TOB and TCPL carrier alone showed evidence of osteoblast alkaline phosphatase activity for a period of 15 weeks. Neither the carrier nor the carrier containing antibiotics displayed untoward effects on body weight, vital organs and reproductive organs over a 15 week period. The results from this study demonstrated that TCPL can be used as an effective osteoconductive material capable of delivering therapeutic concentrations of antibiotics over 15 week period.

Operative outcome of partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle for recalcitrant plantar fasciitis.

A retrospective review was conducted of 23 patients (26 feet) to assess operative outcome of partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle for recalcitrant plantar fasciitis. Nonsurgical treatment was implemented in all patients with no relief of symptoms (average 20.8 months) prior to surgery. Using a visual analog pain scale (0-10), the average preoperative pain was 9.2 (range, 8-10). Prior to surgery, 65.2% of patients had severe limitations of activity, and 34.8% of patients had moderate limitations of activity. An average 25.3-month follow-up (range, 8-51) was performed by telephone interview. Average postoperative pain decreased to 1.7 using the same visual analog scale. Thirteen patients (57%) had no functional limitations postoperatively and nine patients (39%) had minimal functional limitations postoperatively. One patient (4%) had moderate functional limitations postoperatively. Twenty patients (87%) were completely satisfied with the surgery, two patients (9%) were satisfied with reservations, and one patient (4%) was unsatisfied with the surgery. The average period before return to work or daily activities was 1.5 months. Two patients had minor complications of partial wound dehiscence that healed uneventfully and mild dorsal midfoot pain which required temporary use of a boot walker. While the majority of patients with plantar fasciitis can be managed with nonoperative treatment, those patients with recalcitrant plantar fasciitis can be effectively treated with partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle.

Plating of rat femoral shaft osteotomies: report of a technique and preliminary results.

Development of a small animal model to study fracture healing has been challenging in the past. Stabilization of osteotomy in small animals has mainly been accomplished using Krishner wires. Krisheners offer stabilization, but can result in a significant increase in fracture callus. An alternative approach using a modified twenty-five hole 1.5 mm stainless steel plate was used to stabilize a 5 mm femoral osteotomy, and fracture stabilization was followed for a period of 15 weeks in adult male rats. Fifty four of fifty-six animals (96%) were followed 15 weeks post operatively. Within the first few days post operatively, two animals showed evidence of fixation failure due to technical error, and the animals were humanely sacrificed. Otherwise, after two days post-operatively the remaining 54 animals were weight bearing. At 15 weeks post-operatively, the fracture was stable with little bone formation evident. Therefore, this technique can effectively be used to evaluate compounds which will enhance bone formation. The technique allows for stable fixation of the control with little callus formation and bone ingrowth. This model will allow for x-ray analysis to follow bone growth in relation to bone enhancing compounds.