Trauma care during the COVID-19 pandemic in the Netherlands: a level 1 trauma multicenter cohort study.

PURPOSE: The coronavirus (COVID-19) pandemic has caused major healthcare challenges worldwide resulting in an exponential increase in the need for hospital- and intensive care support for COVID-19 patients. As a result, surgical care was restricted to urgent cases of surgery. However, the care for trauma patients is not suitable for reduction or delayed treatment. The influence of the pandemic on the burden of disease of trauma care remains to be elucidated. METHODS: All patients with traumatic injuries that were presented to the emergency departments (ED) of the Amsterdam University Medical Center, Location Academic Medical Center (AMC) and VU medical center (VUMC) and the Northwest Clinics (NWC) between March 10, 2019 and May 10, 2019 (non-COVID) and March 10, 2020 and May 10, 2020 (COVID-19 period) were included. The primary outcome was the difference in ED admissions for trauma patients between the non-COVID and COVID-19 study period. Additionally, patient- and injury characteristics, health care consumption, and 30-day mortality were evaluated. RESULTS: A 37% reduction of ED admissions for trauma patients was seen during the COVID-19 pandemic (non-COVID n = 2423 and COVID cohort n = 1531). Hospital admission was reduced by 1.6 trauma patients per day. Fewer patients sustained car- and sports-related injuries. Injuries after high energetic trauma were more severe in the COVID-19 period (Injury Severity Score 17.3 vs. 12.0, p = 0.006). Relatively more patients were treated operatively (21.4% vs. 16.6%, p < 0.001) during the COVID-19 period. Upper-(17.6 vs. 12.5%, p = 0.002) and lower extremity injuries (30.7 vs. 23.0%, p = 0.002) mainly accounted for this difference. The 30-day mortality rate was higher during the pandemic (1.0 vs. 2.3%, p = 0.001). CONCLUSION: The burden of disease and healthcare consumption of trauma patients remained high during the COVID-19 pandemic. Results of this study can be used to optimize the use of hospital capacity and anticipate health care planning in future outbreaks.

Health-Related Quality of Life Is Decreased After Necrotizing Soft-Tissue Infections.

BACKGROUND: A necrotizing soft-tissue infection (NSTI) is a rare but severe infection with a high mortality rate of 12%-20%. Diagnosing is challenging and often delayed. Treatment consists of surgical debridement of all necrotic tissue and administration of antibiotics. Despite adequate treatment, survivors are often left with extensive wounds, resulting in mutilating scars and functional deficits. Both the disease and the subsequent scars can negatively influence the health-related quality of life (HRQoL). The present study was performed to contribute to the knowledge about HRQoL in patients after NSTI. METHODS: We retrospectively identified patients treated for NSTI in a tertiary center in the Netherlands. Patient and treatment characteristics were collected and patients were asked to fill in a Short Form 36 questionnaire. RESULTS: Forty-six patients with a diagnosis of NSTI were identified. Twenty-eight (61%) were male and mean age was 57 y. Thirty-nine patients (80%) survived. Thirty-one (84%) of the survivors returned the questionnaire after a median follow-up of 4.1 y (interquartile range [IQR], 2.4-5.9 y). Statistically significantly decreased scores when compared to the Dutch reference values were observed for the Short Form 36 domains, physical functioning, role-physical functioning, general health, and the combined Physical Component Score. No differences were observed for the other five domains or for the Mental Component Score. CONCLUSIONS: This study confirms that NSTI negatively affects HRQoL as reported by the patient, especially on the physical domains. To learn more about HRQoL in patients after NSTI, studies in larger groups with a more disease-specific questionnaire should be performed. LEVEL OF EVIDENCE: Level 3, prognostic and epidemiological.

[A man with a painful right shoulder]. / Een man met een pijnlijke rechter schouder.

Posterior sternoclavicular luxations are uncommon and potentially life threatening. When clinically suspected, a computed tomography angiography is the gold standard to investigate whether important structures located in the mediastinum are at risk. A fast reduction should be performed to reduce pain and prevent acute and late complications.

Failure rate and complications of angiography and embolization for abdominal and pelvic trauma.

BACKGROUND: Angiography and embolization have become the treatment of choice after abdominal trauma or pelvic injury in hemodynamically stable patients with a suspicion of internal hemorrhage (contrast extravasation, pseudo-aneurysm, or a vessel cutoff diagnosed on computed tomographic scanning). Some studies, however, report a high incidence of rebleeding (failure) or complications. The aim of this study was to evaluate the failure rate and the complications in trauma patients undergoing such procedures. METHODS: All consecutive patients (n = 97) admitted to our Level I trauma center between January 2002 and December 2008 in whom angiography with or without embolization was performed were analyzed. Complications were classified as organ specific, puncture site related, and systemic. Additional interventions, required to treat complications, were documented. RESULTS: The overall failure rate was 12%. Overall, 48 complications were documented in 28 patients. Organ-specific complications were observed in 18 patients (19%), especially abscess formation and infarction of the liver. Puncture site-related complications occurred in three patients. The incidence of contrast-induced nephropathy was 24%. Three patients developed renal failure. Nine of the 15 patients with rebleeding could be managed with reembolization or operative packing, resulting in an organ salvage rate of 93%. Most (83%) of the organ-specific complications and all of the puncture site-related complications could be managed conservatively or with percutaneous treatment. CONCLUSION: In the present study, the failure rate and incidence of organ-specific and procedure-related complications were low and often could be managed with nonoperative minimally invasive interventions. Trauma patients undergoing angiography have a high chance (24%) of developing contrast-induced nephropathy and should therefore receive optimal prophylactic measures to avoid this complication. LEVEL OF EVIDENCE: Therapeutic study, level IV; prognostic/epidemiologic study, level III.

Significant forefoot varus deformity resulting in progressive stress fractures of all lesser metatarsal bones.

Stress fractures may occur in any bone, but appear most frequently in the metatarsal bones. Consecutive stress fractures of all lesser metatarsals in a short period are rare, and only a few cases have been described in the literature. We report an unusual case of a young man with consecutive stress fractures of four adjacent lesser metatarsal bones. The etiology was in all probability the fixed forefoot varus deformity. This foot deformity may impose increased mechanical loads across the lateral aspect of the foot that, in turn, may result in stress fractures involving the lesser metatarsals. In our patient conservative treatment finally resulted in a satisfactory outcome.

Trans-Atlantic hospital agreement in reading first day radiographs of clinically suspected scaphoid fractures.

The purpose of this study was to describe the agreement between two hospitals on either side of the Atlantic Ocean in reading first day plain radiographs of suspected scaphoid fractures. Two groups of observers, one North American and one European, consisting of observers at various levels of training were compared. Kappa statistics were used to determine inter- and intra-observer agreement. The receiver-operating characteristics (ROC) curves and area under this curve (AUC) for each observer were calculated to determine test performance. Scaphoid radiographs of 80 consecutive patients seen with clinically suspected scaphoid fracture were included in the study. The results of the bone scan were used as the reference standard. There is an acceptable agreement between the USA and Europe for both radiologists and orthopaedic surgeons at various levels of training (kappa 0.45-0.88). Intra-observer agreement is acceptable as well (kappa 0.46-0.86). Considering all normal or equivocal radiographs, there is slight to moderate agreement at all levels of training in and between both centres and specialities (kappa 0-0.64). Overall test performance was acceptable for all consecutive radiographs (AUC 0.65-0.82) and poor for the normal radiographs (AUC 0.46-0.65). We could not detect differences in performance due to location of the readers' hospital or institution of training. The use of more sensitive techniques should be restricted to patients with negative or equivocal radiographs in clinically suspected scaphoid fractures.