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INTRODUCTION: Health care patient records have been digitalised the past twenty years, and registries have been automated. Missing registrations are common, and can result in selection bias. OBJECTIVE: To assess the prevalence and characteristics of missed registrations in a Dutch regional trauma registry. METHODS: An automatically generated trauma registry export was done for ten out of eleven hospitals in trauma region Southwest Netherlands, between June 1 and August 31, 2020. Second, lists were checked for being falsely flagged as 'non-trauma'. Finally, a list was generated with trauma tick box flagged as 'trauma' but were not automatically in the export due to administrative errors. Automated and missed registration datasets were compared on patient characteristics and logistic regression models were run with random intercepts and missed registration as outcome variable on the complete dataset. RESULTS: A total of 2,230 automated registrations and 175 (7.3 %) missed registrations were included for the Dutch National Trauma Registry, ranging from 1 to 14 % between participating hospitals. Patients of the missed registration dataset had characteristics of a higher level of care, compared with patients of automated registrations. Level of trauma care (level II OR 0.464 95 % CI 0.328-0.666, p < 0.001; level III OR 0.179 95 % CI 0.092-0.325, p < 0.001), major trauma (OR 2.928 95 % CI 1.792-4.65, p < 0.001), ICU admission (OR 2.337 95 % CI 1.792-4.650, p < 0.001), and surgery (OR 1.871 95 % CI 1.371-2.570, p < 0.001) were potential predictors for missed registrations in multivariate logistic regression analysis. CONCLUSION: Missed registrations occur frequently and the rate of missed registrations differs greatly between hospitals. Automated and missed registration datasets display differences related to patients requiring more intensive care, which held for the major trauma subset. Checking for missed registrations is time consuming, automated registration lists need a human touch for validation and to be complete.
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Hospitais , Humanos , Países Baixos/epidemiologia , Prevalência , Sistema de Registros , Modelos LogísticosRESUMO
OBJECTIVE: The aim of this systematic review was to compare extramedullary fixation and intramedullary fixation for AO type 31-A2 trochanteric fractures in the elderly, with regard to functional outcomes, complications, surgical outcomes, and costs. METHODS: Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results are presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI). RESULTS: Fourteen RCTs (2039 patients) and 13 observational studies (22,123 patients) were included. Statistically superior results in favor of intramedullary fixation were found for Harris Hip Score (MD 4.09, 95% CI 0.91-7.26, p = 0.04), Parker mobility score (MD - 0.67 95% CI - 1.2 to - 0.17, p = 0.009), lower extremity measure (MD - 4.07 95% CI - 7.4 to - 0.8, p = 0.02), time to full weight bearing (MD 1.14 weeks CI 0.92-1.35, p < 0.001), superficial infection (RR 2.06, 95% CI 1.18-3.58, p = 0.01), nonunion (RR 3.67, 95% CI 1.03-13.10, p = 0.05), fixation failure (RR 2.26, 95% CI 1.16-4.44, p = 0.02), leg shortening (MD 2.23 mm, 95% CI 0.81-3.65, p = 0.002), time to radiological bone healing (MD 2.19 months, 95% CI 0.56-3.83, p = 0.009), surgery duration (MD 11.63 min, 95% CI 2.63-20.62, p = 0.01), operative blood loss (MD 134.5 mL, 95% CI 51-218, p = 0.002), and tip-apex distance > 25 mm (RR 1.73, 95% CI 1.10-2.74, p = 0.02). No comparable cost/costs-effectiveness data were available. CONCLUSION: Current literature shows that several functional outcomes, complications, and surgical outcomes were statistically in favor of intramedullary fixation when compared with extramedullary fixation of AO/OTA 31-A2 fractures. However, as several of the differences found appear not to be clinically relevant and for many outcomes data remains sparse or heterogeneous, complete superiority of IM fixation for AO type 31-A2 fractures remains to be confirmed in a detailed cost-effectiveness analysis.
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Fixação Intramedular de Fraturas , Fraturas do Quadril , Humanos , Fixação Intramedular de Fraturas/métodos , Fraturas do Quadril/cirurgia , Idoso , Resultado do Tratamento , Fixação Interna de Fraturas/métodosRESUMO
BACKGROUND: Trauma networks have multiple designated levels of trauma care. This classification parallels concentration of major trauma care, creating innovations and improving outcome measures. OBJECTIVES: The objective of this study is to assess associations of level of trauma care with patient outcomes for populations with specific severe injuries. METHODS: A systematic literature search was conducted using six electronic databases up to April 19, 2022 (PROSPERO CRD42022327576). Studies comparing fatal, nonfatal clinical, or functional outcomes across different levels of trauma care for trauma populations with specific severe injuries or injured body region (Abbreviated Injury Scale score ≥3) were included. Two independent reviewers included studies, extracted data, and assessed quality. Unadjusted and adjusted pooled effect sizes were calculated with random-effects meta-analysis comparing Level I and Level II trauma centers. RESULTS: Thirty-five studies (1,100,888 patients) were included, of which 25 studies (n = 443,095) used for meta-analysis, suggesting a survival benefit for the severely injured admitted to a Level I trauma center compared with a Level II trauma center (adjusted odds ratio [OR], 1.15; 95% confidence interval [CI], 1.06-1.25). Adjusted subgroup analysis on in-hospital mortality was done for patients with traumatic brain injuries (OR, 1.23; 95% CI, 1.01-1.50) and hemodynamically unstable patients (OR, 1.09; 95% CI, 0.98-1.22). Hospital and intensive care unit length of stay resulted in an unadjusted mean difference of -1.63 (95% CI, -2.89 to -0.36) and -0.21 (95% CI, -1.04 to 0.61), respectively, discharged home resulted in an unadjusted OR of 0.92 (95% CI, 0.78-1.09). CONCLUSION: Severely injured patients admitted to a Level I trauma center have a survival benefit. Nonfatal outcomes were indicative for a longer stay, more intensive care, and more frequently posthospital recovery trajectories after being admitted to top levels of trauma care. Trauma networks with designated levels of trauma care are beneficial to the multidisciplinary character of trauma care. LEVEL OF EVIDENCE: Systematic review and meta-analysis; Level III.
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Centros de Traumatologia , Ferimentos e Lesões , Humanos , Serviços Médicos de Emergência , Hospitalização , Unidades de Terapia Intensiva , Tempo de Internação , Avaliação de Resultados em Cuidados de Saúde , Ferimentos e Lesões/terapiaRESUMO
PURPOSE: The indication for surgical treatment of the chronic exertional compartment syndrome is evaluated by measuring intracompartmental pressures. The validity of these invasive intracompartmental pressure measurements are increasingly questioned in the absence of a standardized test protocol and uniform cut-off values. The aim of the current study was to test compartment pressure monitors and needles for uniformity, thereby supporting the physician's choice in the selection of appropriate test materials. METHODS: A compartment syndrome was simulated in embalmed above-knee cadaveric leg specimen. Four different terminal devices (Compass manometer, Stryker device, Meritrans transduce, and arterial line) were tested with 22 different needle types. Legs were pressurized after introduction of the four terminal devices in the anterior compartment, using the same needle type. Pressure was recorded at a 30-second interval for 11 minutes in total. Before and after pressurization, the intravenous bag of saline was weighed. RESULTS: The simulation of a compartment syndrome resulted in intracompartmental pressure values exceeding 100 mmHg in 17 of the 22 legs (77%). In the other five legs, a smaller built-up of pressure was seen, although maximum intracompartmental pressure was in between 70 and 100 mmHg. The intraclass correlation coefficient was above 0.700 for all possible needle types. Excellent to good resemblance was seen in 16 out of 22 instrumental setups (73%). The mean volume of saline infusion required in runs that exceeded 100 mmHg (309 ± 116 ml) was significantly lower compared to the legs in which 100 mmHg was not achieved (451 ± 148 ml; p = 0.04). CONCLUSION: The intracompartmental pressure recordings of the four terminal devices were comparable, when tested with a standardized pressurization model in a human cadaver model. None of the included terminal devices or needle types were found to be superior. The results provide evidence for more diverse material selection when logistic choices for intracompartmental pressure measurement devices are warranted. LEVEL OF EVIDENCE: Level IV.
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BACKGROUND: Assessing frailty in patients with an acute trauma can be challenging. To provide trustworthy results, tools should be feasible and reliable. This systematic review evaluated existing evidence on the feasibility and reliability of frailty assessment tools applied in acute in-hospital trauma patients. METHODS: A systematic search was conducted in relevant databases until February 2020. Studies evaluating the feasibility and/or reliability of a multidimensional frailty assessment tool used to identify frail trauma patients were identified. The feasibility and reliability results and the risk of bias of included studies were assessed. This study was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and registered in Prospective Register of Systematic Reviews (ID: CRD42020175003). RESULTS: Nineteen studies evaluating 12 frailty assessment tools were included. The risk of bias of the included studies was fair to good. The most frequently evaluated tool was the Clinical Frailty Scale (CFS) (n = 5). All studies evaluated feasibility in terms of the percentage of patients for whom frailty could be assessed; feasibility was high (median, 97%; range, 49-100%). Other feasibility aspects, including time needed for completion, tool availability and costs, availability of instructions, and necessity of training for users, were hardly reported. Reliability was only assessed in three studies, all evaluating the CFS. The interrater reliability varied between 42% and >90% agreement, with a Krippendorff α of 0.27 to 0.41. CONCLUSION: Feasibility of most instruments was generally high. Other aspects were hardly reported. Reliability was only evaluated for the CFS with results varying from poor to good. The reliability of frailty assessment tools for acute trauma patients needs further critical evaluation to conclude whether assessment leads to trustworthy results that are useful in clinical practice. LEVEL OF EVIDENCE: Systematic review, Level II.
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Fragilidade/classificação , Exame Físico/normas , Medição de Risco/métodos , Ferimentos e Lesões , HumanosRESUMO
PURPOSE: The importance and impact of determining which trauma patients need to be transferred between hospitals, especially considering prehospital triage systems, is evident. The objective of this study was to investigate the association between mortality and primary admission and secondary transfer of patients to level I and II trauma centers, and to identify predictors of primary and secondary admission to a designated level I trauma center. METHODS: Data from the Dutch Trauma Registry South West (DTR SW) was obtained. Patients ≥ 18 years who were admitted to a level I or level II trauma center were included. Patients with isolated burn injuries were excluded. In-hospital mortality was compared between patients that were primarily admitted to a level I trauma center, patients that were transferred to a level I trauma center, and patients that were primarily admitted to level II trauma centers. Logistic regression models were used to adjust for potential confounders. A subgroup analysis was done including major trauma (MT) patients (ISS > 15). Predictors determining whether patients were primarily admitted to level I or level II trauma centers or transferred to a level I trauma center were identified using logistic regression models. RESULTS: A total of 17,035 patients were included. Patients admitted primarily to a level I center, did not differ significantly in mortality from patients admitted primarily to level II trauma centers (Odds Ratio (OR): 0.73; 95% confidence interval (CI) 0.51-1.06) and patients transferred to level I centers (OR: 0.99; 95%CI 0.57-1.71). Subgroup analyses confirmed these findings for MT patients. Adjusted logistic regression analyses showed that age (OR: 0.96; 95%CI 0.94-0.97), GCS (OR: 0.81; 95%CI 0.77-0.86), AIS head (OR: 2.30; 95%CI 2.07-2.55), AIS neck (OR: 1.74; 95%CI 1.27-2.45) and AIS spine (OR: 3.22; 95%CI 2.87-3.61) are associated with increased odds of transfers to a level I trauma center. CONCLUSIONS: This retrospective study showed no differences in in-hospital mortality between general trauma patients admitted primarily and secondarily to level I trauma centers. The most prominent predictors regarding transfer of trauma patients were age and neurotrauma. These findings could have practical implications regarding the triage protocols currently used.
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Centros de Traumatologia , Ferimentos e Lesões , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Transferência de Pacientes , Estudos Retrospectivos , Triagem , Ferimentos e Lesões/terapiaRESUMO
INTRODUCTION: Major trauma often results in long-term disabilities. The aim of this study was to assess health-related quality of life, cognition, and return to work 1 year after major trauma from a trauma network perspective. METHODS: All major trauma patients in 2016 (Injury Severity Score > 15, n = 536) were selected from trauma region Southwest Netherlands. Eligible patients (n = 365) were sent questionnaires with the EQ-5D-5L and questions on cognition, level of education, comorbidities, and resumption of paid work 1 year after trauma. RESULTS: A 50% (n = 182) response rate was obtained. EQ-US and EQ-VAS scored a median (IQR) of 0.81 (0.62-0.89) and 70 (60-80), respectively. Limitations were prevalent in all health dimensions of the EQ-5D-5L; 90 (50%) responders reported problems with mobility, 36 (20%) responders reported problems with self-care, 108 (61%) responders reported problems during daily activities, 129 (73%) responders reported pain or discomfort, 70 (39%) responders reported problems with anxiety or depression, and 102 (61%) of the patients reported problems with cognition. Return to work rate was 68% (37% full, 31% partial). A median (IQR) EQ-US of 0.89 (0.82-1.00) and EQ-VAS of 80 (70-90) were scored for fully working responders; 0.77 (0.66-0.85, p < 0.001) and 70 (62-80, p = 0.001) for partial working respondents; and 0.49 (0.23-0.69, p < 0.001) and 55 (40-72, p < 0.001) for unemployed respondents. CONCLUSION: The majority experience problems in all health domains of the EQ-5D-5L and cognition. Return to work status was associated with all health domains of the EQ-5D-5L and cognition.
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Qualidade de Vida , Retorno ao Trabalho , Ansiedade , Nível de Saúde , Humanos , Dor , Inquéritos e QuestionáriosRESUMO
BACKGROUND: A threshold Injury Severity Score (ISS) ≥ 16 is common in classifying major trauma (MT), although the Abbreviated Injury Scale (AIS) has been extensively revised over time. The aim of this study was to determine effects of different AIS revisions (1998, 2008 and 2015) on clinical outcome measures. METHODS: A retrospective observational cohort study including all primary admitted trauma patients was performed (in 2013-2014 AIS98 was used, in 2015-2016 AIS08, AIS08 mapped to AIS15). Different ISS thresholds for MT and their corresponding observed mortality and intensive care (ICU) admission rates were compared between AIS98, AIS08, and AIS15 with Chi-square tests and logistic regression models. RESULTS: Thirty-nine thousand three hundred seventeen patients were included. Thresholds ISS08 ≥ 11 and ISS15 ≥ 12 were similar to a threshold ISS98 ≥ 16 for in-hospital mortality (12.9, 12.9, 13.1% respectively) and ICU admission (46.7, 46.2, 46.8% respectively). AIS98 and AIS08 differed significantly for in-hospital mortality in ISS 4-8 (χ2 = 9.926, p = 0.007), ISS 9-11 (χ2 = 13.541, p = 0.001), ISS 25-40 (χ2 = 13.905, p = 0.001) and ISS 41-75 (χ2 = 7.217, p = 0.027). Mortality risks did not differ significantly between AIS08 and AIS15. CONCLUSION: ISS08 ≥ 11 and ISS15 ≥ 12 perform similarly to a threshold ISS98 ≥ 16 for in-hospital mortality and ICU admission. This confirms studies evaluating mapped datasets, and is the first to present an evaluation of implementation of AIS15 on registry datasets. Defining MT using appropriate ISS thresholds is important for quality indicators, comparing datasets and adjusting for injury severity. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.
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Escala Resumida de Ferimentos , Ferimentos e Lesões/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Sistema de Registros , Estudos Retrospectivos , Centros de Traumatologia , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidadeRESUMO
BACKGROUND: With implementation of trauma systems, a level of trauma care classification was introduced. Use of such a system has been linked to significant improvements in survival and other outcomes. OBJECTIVES: The aim of this study was assessing the association between level of trauma care and fatal and nonfatal outcome measures for general and major trauma (MT) populations. METHODS: A systematic literature search was conducted using six electronic databases up to December 18, 2019. Studies comparing mortality or nonfatal outcomes between different levels of trauma care in general and MT populations (preferably Injury Severity Score of >15) were included. Two independent reviewers performed selection of relevant studies, data extraction, and a quality assessment of included articles. With a random-effects meta-analysis, adjusted and unadjusted pooled effect sizes were calculated for level I versus non-level I trauma centers. RESULTS: Twenty-two studies were included. Quality of the included studies was good; however, adjustment for comorbidity (32%) and interhospital transfer (38%) was performed less frequently. Nine (60%) of the 15 studies analyzing in-hospital mortality in general trauma populations reported a survival benefit for level I trauma centers. Level I trauma centers were not associated with higher mortality than non-level I trauma centers (adjusted odd ratio, 0.97; 95% confidence interval, 0.61-1.52). Of the 11 studies reporting in-hospital mortality in MT populations, 10 (91%) reported a survival benefit for level I trauma centers. Level I trauma centers were associated with lower mortality than non-level I trauma centers (adjusted odd ratio, 0.77; 95% confidence interval, 0.69-0.87). CONCLUSION: The association between level of trauma care and in-hospital mortality is evident for MT populations; however, this does not hold for general trauma populations. Level I trauma centers produce improved survival in MT populations. This association could not be proven for nonfatal outcomes in general and MT populations because of inconsistencies in the body of evidence. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.
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Atenção à Saúde/organização & administração , Centros de Traumatologia/normas , Ferimentos e Lesões/terapia , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Ferimentos e Lesões/mortalidadeRESUMO
OBJECTIVE: To assess and quantify the effect of perioperative music on medication requirement, length of stay and costs in adult surgical patients. SUMMARY BACKGROUND DATA: There is an increasing interest in nonpharmacological interventions to decrease opioid analgesics use, as they have significant adverse effects and opioid prescription rates have reached epidemic proportions. Previous studies have reported beneficial outcomes of perioperative music. METHODS: A systematic literature search of 8 databases was performed from inception date to January 7, 2019. Randomized controlled trials investigating the effect of perioperative music on medication requirement, length of stay or costs in adult surgical patients were eligible. Meta-analysis was performed using random effect models, pooled standardized mean differences (SMD) were calculated with 95% confidence intervals (CI). This study was registered with PROSPERO (CRD42018093140) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. RESULTS: The literature search yielded 2414 articles, 55 studies (N = 4968 patients) were included. Perioperative music significantly reduced postoperative opioid requirement (pooled SMD -0.31 [95% CI -0.45 to -0.16], P < 0.001, I = 44.3, N = 1398). Perioperative music also significantly reduced intraoperative propofol (pooled SMD -0.72 [95% CI -1.01 to -0.43], P < 0.00001, I = 61.1, N = 554) and midazolam requirement (pooled SMD -1.07 [95% CI -1.70 to -0.44], P < 0.001, I = 73.1, N = 184), while achieving the same sedation level. No significant reduction in length of stay (pooled SMD -0.18 [95% CI -0.43 to 0.067], P = 0.15, I = 56.0, N = 600) was observed. CONCLUSIONS: Perioperative music can reduce opioid and sedative medication requirement, potentially improving patient outcome and reducing medical costs as higher opioid dosage is associated with an increased risk of adverse events and chronic opioid abuse.
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Analgésicos Opioides/uso terapêutico , Hipnóticos e Sedativos/uso terapêutico , Tempo de Internação/estatística & dados numéricos , Musicoterapia , Dor Pós-Operatória/terapia , Humanos , Período Perioperatório , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
PURPOSE: Infection near metal implants is a problem that presents challenging treatment dilemmas for physicians. The aim of this study was to analyse the efficacy of two treatment protocols for acute fracture-related infections. METHODS: Seventy-one patients in two level-1 trauma centres in the Netherlands were retrospectively included in this study. These trauma centres had different standardised protocols for acute infection after osteosynthesis: 39 patients were selected from protocol A and 32 from protocol B. Both protocols involve immediate surgical debridement and soft tissue coverage, but differ in antibiotic approach: (A) immediate empirical combination antibiotic therapy with rifampicin, or (B) postponed (1-5 days) targeted antibiotic therapy. The primary outcome of these protocols was success, defined as a fracture healing in the absence of infection. The secondary outcome was antibiotic resistance patterns. Logistic regression was conducted on patients and treatment-related factors in association with primary success. RESULTS: Primary success was achieved in 72% of protocol A patients, in 47% of those in protocol B (P = 0.033), and with prolongation of treatment success was achieved in 90% and 78% of patients, respectively. Protocol A exhibited a better primary success rate (adjusted OR 3.45, CI 1.13-10.52) when adjusted for age and soft tissue injury. There was no significant difference in antibiotic resistance between the two protocols. CONCLUSION: Both protocols yielded high overall success rates. Immediate empirical antibiotics can be used safely without additional bacterial resistance and may contribute to increased success rates.
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Antibacterianos/uso terapêutico , Fraturas Ósseas/cirurgia , Infecções Relacionadas à Prótese/tratamento farmacológico , Rifampina/uso terapêutico , Infecção da Ferida Cirúrgica/tratamento farmacológico , Adulto , Antibacterianos/classificação , Antibioticoprofilaxia , Protocolos Clínicos , Desbridamento , Farmacorresistência Bacteriana , Feminino , Consolidação da Fratura/efeitos dos fármacos , Humanos , Masculino , Países Baixos/epidemiologia , Infecções Relacionadas à Prótese/microbiologia , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/microbiologia , Centros de TraumatologiaRESUMO
This anatomical study defines a safe zone for percutaneous or minimally invasive fixation of first metacarpal fractures in order to avoid injury of the superficial branch of the radial nerve and the dorsal branch of the radial artery. The courses of the nerve and artery branches were marked in 20 embalmed cadaver specimens. With computer-assisted surgical anatomy mapping, a large diversity in the anatomical patterns for the nerve and a consistent pattern for the artery were found. Based on these findings, we conclude that transfixation of the first and the second metacarpals with K-wires placed in the distal 75% of both the first and second metacarpals is the safest way to avoid damages to the nerve and artery branches during fracture fixation.
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Fraturas Ósseas , Traumatismos da Mão , Ossos Metacarpais , Fios Ortopédicos , Cadáver , Fixação de Fratura , Fixação Interna de Fraturas , Fraturas Ósseas/cirurgia , Humanos , Ossos Metacarpais/lesões , Ossos Metacarpais/cirurgiaRESUMO
BACKGROUND: High rates of pneumonia and death have been reported among elderly patients with rib fractures. This study aims to identify patterns of injury and risk factors for pneumonia and death in elderly patients with rib fractures. METHODS: A retrospective multicenter observational study was performed using data registered in the national trauma registry between 2008 and 2015 in the South West Netherlands Trauma region. Data regarding demographics, mechanism of injury, pulmonary and cardiovascular history, pattern of extra-thoracic and intrathoracic injuries, ICU admission, length of stay, and morbidity and mortality following admission were collected. RESULTS: Eight hundred eighty-four patients were included. Median age was 76 years (P25-P75 70-83). 235 patients (26.6%) were 81 years or older. Moderate or worse extra-thoracic injuries were present in 456 patients (51.6%), of whom 146 (16.6%) had severe head injuries and 45 (5.1%) severe spinal injuries. Median ISS was 9 (P25-P75 5-18). The rate of pneumonia was 10% (n = 84). Ten percent of patients (n = 88) died. Risk factors for in-hospital mortality included age (OR 3.4; p = 0.003), presence of COPD (OR 1.3; p = 0.01), presence of cardiac disease (OR 2.6; p = 0.003), severe or worse head (OR 3.5; p < 0.001), abdominal (OR 6.8; p = 0.004) and spinal injury (OR 4.6; p = 0.011) by AIS, number of rib fractures (OR 2.6; p = 0.03), and need for chest tube drainage (OR 2.1; p = 0.021). CONCLUSIONS: Pneumonia and death occur in about 10% of elderly patients with rib fractures. Apart from the severity of thoracic injuries, the presence and severity of extra-thoracic injuries and cardiopulmonary comorbidities are associated with poor outcome.
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Pneumonia/etiologia , Fraturas das Costelas/etiologia , Acidentes por Quedas/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Traumatismos Cranianos Fechados/etiologia , Traumatismos Cranianos Fechados/mortalidade , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Países Baixos/epidemiologia , Pneumonia/mortalidade , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Doença Pulmonar Obstrutiva Crônica/mortalidade , Sistema de Registros , Estudos Retrospectivos , Fraturas das Costelas/mortalidade , Fatores de Risco , Traumatismos da Coluna Vertebral/etiologia , Traumatismos da Coluna Vertebral/mortalidade , Traumatismos Torácicos/etiologia , Traumatismos Torácicos/mortalidade , Ferimentos não Penetrantes/etiologia , Ferimentos não Penetrantes/mortalidadeRESUMO
OBJECTIVE: To report the number of patients with firework-related injuries treated in December 2017 and January 2018 in a hospital in the south-west Netherlands trauma region, and to provide details about the types of firework used and the specific injuries. DESIGN: A prospective multicentre cohort study (NTR6793). METHODS: Patients of all ages with firework-related injuries were eligible for inclusion. The injury had to have been sustained between 1 December 2017 and 31 January 2018, and treated at a hospital in the south-west Netherlands trauma region (approximately 2.5 million inhabitants). Data were extracted from patients' medical files and additional information was obtained from patient interviews. RESULTS: Fifty-four patients were included. The majority were male (93%) and the median age was 15 years. Twenty-five (46%) patients were bystanders and 12 (22%) were injured by illegal fireworks. Fifty patients were injured by bangers (n=22) or decorative fireworks (n=28). The patients had a total of 79 injuries, of which 29 (37%) were localised to the upper extremity and 19 (24%) to the eyes. Most upper extremity injuries were burns (69%), primarily partial thickness. Of the eye injuries, 14 were caused by blunt trauma, seven by chemical trauma, and one by penetrating trauma. Three patients sustained indirect firework-related injuries. CONCLUSION: Between 1 December 2017 and 31 January 2018 in the south-west Netherlands trauma region mainly teenage males and bystanders sustained firework-related injuries. Most injuries were upper extremity burns and eye injuries, mainly due to legal fireworks and bangers or decorative fireworks. The extent of the sample indicates that the study findings can be extrapolated to the rest of the Netherlands.
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Traumatismos por Explosões/epidemiologia , Queimaduras/epidemiologia , Traumatismos Oculares/epidemiologia , Traumatismos da Mão/epidemiologia , Ferimentos não Penetrantes/epidemiologia , Adolescente , Traumatismos por Explosões/etiologia , Queimaduras/etiologia , Traumatismos Oculares/etiologia , Feminino , Traumatismos da Mão/etiologia , Humanos , Masculino , Países Baixos/epidemiologia , Estudos Prospectivos , Ferimentos não Penetrantes/etiologiaRESUMO
BACKGROUND: Studies comparing plate with intramedullary nail fixation of displaced midshaft clavicle fractures show faster recovery in the plate group and implant-related complications in both groups after short-term followup (6 or 12 months). Knowledge of disability, complications, and removal rates beyond the first postoperative year will help surgeons in making a decision regarding optimal implant choice. However, comparative studies with followup beyond the first year or two are scarce. QUESTIONS/PURPOSES: We asked: (1) Does plate fixation or intramedullary nail fixation for displaced midshaft clavicle fractures result in less disability? (2) Which type of fixation, plate or intramedullary, is more frequently associated with implant-related irritation and implant removal? (3) Is plate or intramedullary fixation associated with postoperative complications beyond the first postoperative year? METHODS: Between January 2011 and August 2012, patients with displaced midshaft clavicle fractures were enrolled and randomized to plate or intramedullary nail fixation. A total of 58 patients with plate and 62 patients with intramedullary nails initially were enrolled. Minimum followup was 30 months (mean, 39 months; range, 30-51 months). Two patients (3%) with plate fixation and two patients (3%) with intramedullary nails were lost to followup. The QuickDASH was obtained at final followup and compared between patients who had plate fixation and those who had intramedullary nail fixation. Postoperative complications measured include infection, implant-related irritation, implant failure, nonunion, and refracture after implant removal. Indications for implant removal included implant-related irritation, implant failure, nonunion, patient's wish, or surgeon's preference. RESULTS: Between patients with plate versus intramedullary nail fixation, there were no differences in QuickDASH scores (plate, 1.8 ± 3.6; intramedullary nail, 1.8 ± 7.2; mean difference, -0.7; 95% CI, -2.2 to 2.04; p = 0.95). The proportion of patients having implant-related irritation was not different (39 of 56 [70%] versus 41 of 62 [66%]; relative risk, 1.05; 95% CI, 0.82-1.35; p = 0.683). Intramedullary fixation was associated with a higher likelihood of implant removal (51 of 62 [82%] versus 28 of 56 [50%]; relative risk, 1.65; 95% CI, 1.24-2.19; p < 0.001). Among the removed implants more plates than intramedullary nails were removed after the 1-year followup (12 of 28 [43%] versus six of 51 [12%]; p = 0.002). There were no infections, implant breakage, nonunions, or refractures between the 1-year and final followup in either group. CONCLUSIONS: After a mean followup of 39 months, disability scores were excellent. Major complications did not occur after the 1-year followup. A frequent and bothersome problem after both surgical treatments is implant-related irritation, resulting in high rates of implant removal, after 1 year. Future research could focus on analyzing risk factors for implant irritation or removal. LEVEL OF EVIDENCE: Level II, therapeutic study.
Assuntos
Pinos Ortopédicos , Placas Ósseas , Clavícula/lesões , Fixação Interna de Fraturas/métodos , Fraturas Ósseas/cirurgia , Adulto , Clavícula/cirurgia , Feminino , Fixação Intramedular de Fraturas/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Reoperação , Resultado do TratamentoRESUMO
BACKGROUND: The Surgical Therapeutic Index (STI) has been described as an indicator of the benefits and risks of surgical treatment. The index is calculated by dividing the cure rate of an operative treatment by the complication rate. This study introduces the STI in trauma surgery by comparing the indices for surgical plate fixation (PF) and intramedullary fixation (IMF) of displaced midshaft clavicular fractures. METHODS: In a previously reported, randomized controlled fashion, 120 patients were assigned to PF or IMF. Cure was defined by a Disabilities of the Arm, Shoulder and Hand score of 8 or less. Complications were noted as present or not present for each follow-up assessment, and a panel of experts provided weights to the severity of complications. STIs were reported along with their 95% confidence intervals. The higher a procedure's STI, the higher the benefit/risk balance of that procedure. RESULTS: The nonweighted STI after 6 weeks was significantly higher in the PF group. During further follow- up, the differences leveled out and became nonsignificant. When weighting the STI for severity, the indices decrease but are significantly in favor of the PF group at 6 weeks and 6 months after surgery. At 1 year postoperatively, differences are not significant. CONCLUSION: The STI may be a reliable tool to assess the benefits and risks of operative fracture treatment. Further studies with consistent results of this new scoring system are needed before conclusions can be generalized. When determining the indices of PF and IMF, a significant difference in favor of PF was observed during the early phase of recovery.
Assuntos
Clavícula/cirurgia , Fraturas Ósseas/cirurgia , Medição de Risco , Adulto , Placas Ósseas , Clavícula/lesões , Tomada de Decisão Clínica , Redução Fechada , Feminino , Fixação Interna de Fraturas , Fixação Intramedular de Fraturas , Humanos , Masculino , Complicações Pós-Operatórias , Reprodutibilidade dos TestesRESUMO
Rib fractures resulting from blunt thoracic trauma occur frequently in the elderly. Even though these are usually due to a low impact trauma mechanism (e.g. a fall from standing height), rib fractures are associated with significant morbidity and mortality in the elderly patient. This unfavourable clinical course is most often caused by respiratory insufficiency due to lung oedema or pneumonia. This cases series presents three elderly patients who sustained multiple rib fractures and were subsequently admitted to a level I trauma centre for treatment and discusses diagnostic challenges and different treatment approaches for this population. More specifically, age-specific indications and contra-indications for intravenous or epidural analgesia and operative rib fixation are discussed. In addition, we show that a multidisciplinary approach, involving a trauma surgeon, anaesthetist, intensive care physician and physiotherapist, is paramount for the prevention of potentially lethal complications.
Assuntos
Acidentes por Quedas , Insuficiência Respiratória/etiologia , Fraturas das Costelas/complicações , Traumatismos Torácicos/complicações , Acidentes por Quedas/mortalidade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Analgesia Epidural , Cuidados Críticos , Feminino , Hospitalização , Humanos , Masculino , Traumatismo Múltiplo , Pneumonia/complicações , Fraturas das Costelas/mortalidade , Traumatismos Torácicos/mortalidade , Centros de TraumatologiaRESUMO
BACKGROUND: Over the past decades, the operative treatment of displaced midshaft clavicular fractures has increased. The aim of this study was to compare short and midterm results of open reduction and plate fixation with those of intramedullary nailing for displaced midshaft clavicular fractures. METHODS: A multicenter, randomized controlled trial was performed in four different hospitals. The study included 120 patients, eighteen to sixty-five years of age, treated with either open reduction and plate fixation (n = 58) or intramedullary nailing (n = 62). Preoperative and postoperative shoulder function scores and complications were documented until one year postoperatively. Significance was set at p < 0.05. RESULTS: No significant differences in the Disabilities of the Arm, Shoulder and Hand (DASH) or Constant-Murley score (3.0 and 96.0 points for the plate group and 5.6 and 95.5 points for the nailing group) were noted between the two surgical interventions at six months postoperatively. Until six months after the surgery, the plate-fixation group experienced less disability than the nailing group as indicated by the area under the curve of the DASH scores for this time period (p = 0.02). The mean numbers of complications per patient, irrespective of their severity, were similar between the plate-fixation (0.67) and nailing (0.74) groups (p = 0.65). CONCLUSIONS: The patients in the plate-fixation group recovered faster than the patients in the intramedullary nailing group, but the groups had similar results at six months postoperatively and the time of final follow-up. The rate of complications requiring revision surgery was low. Implant-related complications occurred frequently and could often be treated by implant removal.
Assuntos
Pinos Ortopédicos , Placas Ósseas , Clavícula/lesões , Fixação Interna de Fraturas/métodos , Fraturas Ósseas/cirurgia , Luxação do Ombro/cirurgia , Adolescente , Adulto , Idoso , Clavícula/cirurgia , Feminino , Seguimentos , Fixação Interna de Fraturas/instrumentação , Fixação Intramedular de Fraturas/instrumentação , Fixação Intramedular de Fraturas/métodos , Fraturas Ósseas/complicações , Humanos , Análise de Intenção de Tratamento , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Estudos Prospectivos , Luxação do Ombro/complicações , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: To determine patient and hip fracture characteristics, early postoperative complication rate, and need for institutionalization at the time of discharge from the hospital in patients treated for a second contralateral hip fracture. METHODS: During a 6-year period (2003-2009), 71 patients (60 women and 11 men; age range, 54-94 years) underwent first hip fracture surgery and subsequent contralateral hip fracture surgery at our hospital. Variables, including age, gender, American Society of Anesthesiologists classification (ASA), AO fracture classification, time between both hip fractures, rate and severity of early postoperative complications, and destination of discharge were obtained from the electronic medical records. Data from both hospitalization periods were compared. RESULTS: Forty-six percent of second hip fractures occurred within 2 years after the first hip fracture. After the first hip fracture surgery, 13 patients had 1 or multiple complications compared with 23 patients after a second hip fracture surgery (P = 0.02). The mean time (±SD) between the first and second hip fractures in patients without complications after the second injury was 4.3 (±4.2) years, compared with 2.6 (±2.1) years in patients with complications after the second injury (P = 0.03). The mean ASA classification of patients without complications after the second hip fracture surgery was 2.6 (±0.6) versus 3.0 (±0.6) in patients with complications (P = 0.04). After the first hip fracture surgery, 27 patients (38%) were discharged to an institutional care facility, whereas 72% of patients resided at an institutional care facility after a second hip fracture. CONCLUSIONS: Early complication rate in patients sustaining a second contralateral hip fracture was almost twice that documented after the first hip fracture. After the second hip fracture surgery, most patients resided in an institutional care facility. LEVEL OF EVIDENCE: Prognostic level II. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fraturas do Quadril/epidemiologia , Institucionalização/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Fraturas do Quadril/complicações , Fraturas do Quadril/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Complicações Pós-Operatórias/epidemiologia , RecidivaRESUMO
PURPOSE: In the Netherlands, over 20,000 patients sustain a hip fracture yearly. A first hip fracture is a risk factor for a second, contralateral fracture. Data on the similarity of the treatment of bilateral femoral neck fractures is only scarcely available. The objectives of this study were to determine the cumulative incidence of non-simultaneous bilateral femoral neck fractures and to describe the patient characteristics and treatment characteristics of these patients. METHODS: A database of 1,250 consecutive patients with a femoral neck fracture was available. Patients with a previous contralateral femoral neck fractures were identified by reviewing radiographs and patient files. Patient characteristics, previous fractures, hip fracture type and details on treatment were collected from the patient files. RESULTS: One hundred nine patients (9%, 95% confidence interval 7-10%) had sustained a non-simultaneous bilateral femoral neck fracture. The median age at the first fracture was 81 years; the median interval between the fractures was 25 months. Overall, 73% was treated similarly for both fractures in terms of non-operative treatment, internal fixation or arthroplasty. In patients with identical Garden classification (30%), treatment similarity was 88%. CONCLUSIONS: The cumulative incidence of non-simultaneous bilateral femoral neck fractures was 9%. Most patients with identical fracture types were treated similarly. The relatively high risk of sustaining a second femoral neck fracture supports the importance of secondary prevention, especially in patients with a prior wrist or vertebral fracture.