Peculiarities of treatment of maxillofacial polytrauma during wartime.

OBJECTIVE: Aim: Analyzing of the last-time papers in this subject in organizing, diagnostic and surgery tactic is the aim of this work. PATIENTS AND METHODS: Materials and Methods: The study analyzed the experience of treating patients with maxillofacial polytrauma before and after February 24, 2022. Research methods: bibliographic, systematic, comparative, general clinical, radiological and retrospective analysis. CONCLUSION: Conclusions: Tactic of the multidisciplinal team should based on the principles of damage control, which involves the initial performance of manipulations and surgical interventions that ensure the patient's survival. Modern strategies for infusion-transfusion therapy play a significant role in severe trauma cases. Choosing the rational management of this therapy for severe trauma remains an important issue. Reconstructive surgeries are recommended to be performer deferred, after surgical wound management, neurosurgical interventions and stabilization of the patient common status. Patients with maxillofacial polytrauma needs in specialized medical care at all the levels. Active wound management aimed at creating favorable conditions for healing, comprehensive medical treatment, prevention, early detection and timely treatment of complications.

Modifiability of surgical timing in postinjury multiple organ failure patients.

BACKGROUND: Postinjury multiple organ failure (MOF) is the leading cause of late trauma deaths, with primarily non-modifiable risk factors. Timing of surgery as a potentially modifiable risk factor is frequently proposed, but has not been quantified. We aimed to compare mortality, hospital length of stay (LOS), and ICU LOS between MOF patients who had surgery that preceded MOF with modifiable timings versus those with non-modifiable timings. METHODS: Retrospective analysis of an ongoing 17-year prospective cohort study of ICU polytrauma patients at-risk of MOF. Among MOF patients (Denver score>3), we identified patients who had surgery that preceded MOF, determined whether the timing of these operation(s) were modifiable(M) or non-modifiable (non-M), and evaluated the change in physiological parameters as a result of surgery. RESULTS: Of 716 polytrauma patients at-risk of MOF, 205/716 (29%) developed MOF, and 161/205 (79%) had surgery during their ICU admission. Of the surgical MOF patients, 147/161 (91%) had one or more operation(s) that preceded MOF, and 65/161 (40%) of them had operation(s) with modifiable timings. There were no differences in age (mean (SD) 52 (19) vs 53 (21)years), injury severity score (median (IQR) 34 (26-41)vs34 (25-44)), admission physiological and resuscitation parameters, between M and non-M-patients. M patients had longer ICU LOS (median (IQR) 18 (12-28)versus 11 (8-16)days, p < 0.0001) than non-M-patients, without difference in mortality (14%vs16%, p = 0.7347), or hospital LOS (median (IQR) 32 (18-52)vs27 (17-47)days, p = 0.3418). M-patients had less fluids and transfusions intraoperatively. Surgery did not compromise patient physiology. CONCLUSION: Operations preceding MOF are common in polytrauma and seem to be safe in maintaining physiology. The margin for improvement from optimizing surgical timing is modest, contrary to historical assumptions.

Bilateral intertrochanteric fractures in an elderly patient following high-energy trauma: a case report.

BACKGROUND: Cases of bilateral hip fractures are rare, and even more so are cases of bilateral intertrochanteric fractures. Common causes include trauma, internal diseases, and primary or secondary bone diseases. We report a case of bilateral intertrochanteric fractures in an elderly patient following a severe car accident, a scenario not extensively reported in existing literature. CASE PRESENTATION: We report on an 84-year-old male who suffered severe trauma from a car accident, resulting in multiple injuries and shock state, with pain and limited mobility in both hip joints. After examination and imaging studies, the patient was diagnosed with multiple injuries and bilateral intertrochanteric fractures. Following emergency resuscitation, he was admitted to the orthopedic ward. A pre-surgical multidisciplinary team (MDT) consultation was convened to optimize surgical conditions. The patient underwent successful one-stage bilateral intramedullary nailing. The patient was assisted to stand with a walker on the third day after surgery. Six months post-surgery, the patient resumed outdoor activities. CONCLUSION: Managing bilateral intertrochanteric fractures, particularly in the elderly with severe trauma, is notably challenging due to their rarity. However, a coordinated multidisciplinary approach and one-stage bilateral internal fixation can lead to effective treatment outcomes and favorable prognoses.

Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS).

BACKGROUND: The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies. METHODS: A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted. RESULTS: A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak). CONCLUSIONS: This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.

Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures?

BACKGROUND: The timing of definitive surgery in multiple injured patients remains a topic of debate, and multiple concepts have been described. Although these included injury severity as a criterion to decide on the indications for surgery, none of them considered the influence of injury distributions. We analyzed whether injury distribution is associated with certain surgical strategies and related outcomes in a cohort of patients treated according to principles of early and safe fixation strategies. METHODS: In this retrospective cohort study, multiple injured patients were included if they were primarily admitted to a Level I trauma center, had an Injury Severity Score of ≥16 points, and required surgical intervention for major injuries and fractures. The primary outcome measure was treatment strategy. The treatment strategy was classified according to the timing of definitive surgery after injury: early total care (ETC, <24 hours), safe definitive surgery (SDS, <48 hours), and damage control (DC, >48 hours). Statistics included univariate and multivariate analyses of mortality and the association of injury distributions and surgical tactics. RESULTS: Between January 1, 2016, and December 31, 2022, 1,471 patients were included (mean ± SD age, 55.6 ± 20.4 years; mean Injury Severity Score, 23.1 ± 11.4). The group distribution was as follows: ETC, n = 85 (5.8%); SDS, n = 665 (45.2%); and DC, n = 721 (49.0%); mortality was 22.4% in ETC, 16.1% in SDS, and 39.7% in DC. Severe nonlethal abdominal injuries (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.4-3.5) and spinal injuries (OR, 1.6; 95% CI, 1.2-2.2) were associated with ETC, while multiple extremity injuries were associated with SDS (OR, 1.7; 95% CI, 1.4-2.2). Severe traumatic brain injury was associated with DC (OR, 1.3; 95% CI, 1.1-1.4). When a correction for the severity of head, abdominal, spinal, and extremity injuries, as well as differences in the values of admission pathophysiologic parameters were undertaken, the mortality was 30% lower in the SDS group when compared with the DC group (OR, 0.3; 95% CI, 0.2-0.4). CONCLUSION: Major spinal injuries and certain abdominal injuries, if identified as nonlethal, trigger definitive surgeries in the initial setting. In contrast, severe TBI was associated with delayed fracture care. Patients with major fractures and other injuries were treated by SDS (definitive care, <48 hours) when the pathophysiological response was adequate. The choice of a favorable surgical treatment appears to depend on injury patterns and physiological patient responses. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Transcriptomic and Proteomic Characterization of the Immune Response to Elective Spinal Reconstructive Surgery: Impact of Aging and Comparison with Traumatic Injury Response.

BACKGROUND: Major surgery triggers trauma-like stress responses linked to age, surgery duration, and blood loss, resembling polytrauma. This similarity suggests elective surgery as a surrogate model for studying polytrauma immune responses. We investigated stress responses across age groups and compared them with those of polytrauma patients. STUDY DESIGN: Patients undergoing major spinal reconstruction surgery were divided into older (age >65 years, n = 5) and young (age 18 to 39 years, n = 6) groups. A comparison group consisted of matched trauma patients (n = 8). Blood samples were collected before, during, and after surgery. Bone marrow mononuclear cells and peripheral blood mononuclear cells were analyzed using cellular indexing of transcriptomes and epitopes sequencing or single-cell RNA sequencing. Plasma was subjected to dual-platform proteomic analysis (SomaLogic and O-link). RESULTS: Response to polytrauma was highest within 4 hours. By comparison, the response to surgery was highest at 24 hours. Both insults triggered significant changes in cluster of differentiation 14 monocytes, with increased inflammation and lower major histocompatibility complex-class 2 expression. Older patient's cluster of differentiation 14 monocytes displayed higher inflammation and less major histocompatibility complex-class 2 suppression; a trend was also seen in bone marrow mononuclear cells. Although natural killer cells were markedly activated after polytrauma, they were suppressed after surgery, especially in older patients. In plasma, innate immunity proteins dominated at 24 hours, shifting to adaptive immunity proteins by 6 weeks with heightened inflammation in older patients. Senescence-associated secretory phenotype proteins were higher in older patients at baseline and further elevated during and after surgery. CONCLUSIONS: Although both major surgery and polytrauma initiate immune and stress responses, substantial differences exist in timing and cellular profiles, suggesting major elective surgery is not a suitable surrogate for the polytrauma response. Nonetheless, distinct responses in young vs older patients highlight the utility of elective spinal in studying patient-specific factors affecting outcomes after major elective surgery.

Outcome of severely injured patients in a unique trauma system with 24/7 double trauma surgeon on-call service.

BACKGROUND: The presence of in-house attending trauma surgeons has improved efficiency of processes in the treatment of polytrauma patients. However, literature remains equivocal regarding the influence of the presence of in-house attendings on mortality. In our hospital there is a double trauma surgeon on-call system. In this system an in-house trauma surgeon is 24/7 backed up by a second trauma surgeon to assist with urgent surgery or multiple casualties. The aim of this study was to evaluate outcome in severely injured patients in this unique trauma system. METHODS: From 2014 to 2021, a prospective population-based cohort consisting of consecutive polytrauma patients aged ≥ 15 years requiring both urgent surgery (≤ 24h) and admission to Intensive Care Unit (ICU) was investigated. Demographics, treatment, outcome parameters and pre- and in-hospital transfer times were analyzed. RESULTS: Three hundred thirteen patients with a median age of 44 years (71% male), and median Injury Severity Score (ISS) of 33 were included. Mortality rate was 19% (68% due to traumatic brain injury). All patients stayed ≤ 32 min in ED before transport to either CT or OR. Fifty-one percent of patients who needed damage control surgery (DCS) had a more deranged physiology, needed more blood products, were more quickly in OR with shorter time in OR, than patients with early definitive care (EDC). There was no difference in mortality rate between DCS and EDC patients. Fifty-six percent of patients had surgery during off-hours. There was no difference in outcome between patients who had surgery during daytime and during off-hours. Death could possibly have been prevented in 1 exsanguinating patient (1.7%). CONCLUSION: In this cohort of severely injured patients in need of urgent surgery and ICU support it was demonstrated that surgical decision making was swift and accurate with low preventable death rates. 24/7 Physical presence of a dedicated trauma team has likely contributed to these good outcomes.

Salvage of a severely mangled limb following traumatic injury.

Management of a severely damaged extremity poses a dilemma-whether to perform a primary amputation or attempt limb salvage. A multitude of factors-such as the extent of neurovascular injury, limb ischaemia time, severity of bone and soft tissue loss, physiological reserve of the patient and availability of surgical expertise and resources-influence this decision. The Mangled Extremity Severity Score (MESS) was developed as a predictor of the need for limb amputation, and a MESS of 7 or more is considered a predictor of primary amputation. Here we describe a case where a man in his 20s sustained traumatic avulsion of his right ankle with severe neurovascular damage and multiple tendon injuries onboard a ship at high sea. Despite a MESS of 10, limb ischaemia time of more than 10 hours and injuries to all three extremity vessels (anterior tibial, posterior tibial and peroneal arteries), limb salvage was successfully carried out at a level-II trauma centre.

Reconstruction of multiple fingertip crush injuries with full-thickness skin grafting.

Fingertip crush injuries are commonly encountered as a result of workplace accidents causing significant morbidity. The primary goal of reconstruction is to restore function and sensibility, as well as a faster return to work. We reported a patient with multiple fingertip injuries presented 5 days following the initial injury. Copious irrigation and excisional debridement were performed, followed by a full-thickness skin graft harvested from the volar wrist. At the 4-month follow-up, all of the reconstructed fingertips achieved good functionality without any pain or sensory impairment. The length was well preserved and static two-point discrimination was comparable with the contralateral side. Full-thickness skin grafts may provide an excellent alternative reconstruction option in the management of multiple fingertip crush injuries.

Outcomes Following Below Knee Arterial Trauma.

INTRODUCTION: Lower extremity vascular injuries have significant implications for trauma patients with regards to morbidity from limb loss. There is limited evidence on outcomes for patients with injuries to tibial arteries. Our study focuses on defining outcomes of traumatic vascular injury to vessels below the knee. METHODS: A retrospective review using ICD-9 and 10 codes of all patients with below knee vascular injuries was performed at a Level 1 trauma center from November 2014 to June 2022. Interventions, outcomes, and complications were assessed. RESULTS: Seventy-six patients were identified fitting inclusion criteria. The mean age was 35.3 +/- 15.2 years and 67 (88%) patients were male. Thirty-nine suffered penetrating trauma, 37 suffered blunt trauma. The most injured artery was posterior tibial artery (40%) followed by anterior tibial artery (36%). Injuries included 51 transections, 22 occlusions and 4 pseudoaneurysms. Forty-five (59%) patients underwent operative intervention. Thirty (67%) operations were performed by trauma surgery. Arterial ligation was performed in 30 cases (67%), arterial bypass in 12 (27%), and 2 (4%) primary amputations. Vascular surgery performed all bypasses. Overall amputation rate was 8% (n = 6) with 3 for mangled extremity and 3 due to failed bypass graft. All amputations were associated with open fracture and amputations for failed bypass had multiple arterial injuries. CONCLUSION: The management of below knee vascular trauma requires a multidisciplinary approach. Patients requiring reconstruction are more likely to have multiple vessel injuries and may have significant risk of graft failure. These patients as well as those with extensive soft tissue injury and/or multi-vessel injuries are at increased risk for amputation.

Characteristics of multi-ligament knee injuries accompanied with patellar tendon disruption.

PURPOSE: Patella tendon rupture with multi-ligament injury is a rare injury. We observed patients with patella tendon rupture (or patella inferior pole fracture) with multi-ligament injury. This study intends to inspect the mechanism of the injury and classify them. METHODS: This is a case series involving patients from two hospitals. Twelve patients who had patella tendon rupture (PTR) with multi-ligament injury were studied. RESULTS: The incidence of multi-ligament injury in patella tendon rupture patients found to be 13% in retrospective search. Two types of injury were observed. First type is relatively low energy injury involving ACL and patella tendon which does not involve rupture of PCL. Second type is high energy injury involving PCL and patella tendon. Treatment differed among the patients, due to severity of trauma. Two-staged operation was the basis of treatment. Patella tendon was repaired in first stage. Reconstruction of ligaments was done in second stage. The patients who had infection or stiffness did not have a second surgery. CONCLUSION: Patella tendon rupture with multi-ligament injury can be classified into low energy rotational injury and high energy dashboard injury. Two-staged surgery is the basis of treatment.

The role of geographic disparities in outcomes after orthopaedic trauma surgery.

INTRODUCTION: Healthcare disparities linked to patient rurality and socioeconomic status are known to exist, but few studies have examined the effect of urban versus rural status on outcomes after orthopedic trauma surgery. The aim of this study was to examine the correlation between patient rurality, socioeconomic status, and outcomes after orthopedic trauma. MATERIALS AND METHODS: This is a retrospective cohort study of patients diagnosed with a hip or long bone fracture between January 2016 and December 2017. Data were collected from the Nationwide Inpatient Sample (NIS), a 20% weighted sample of 95% of the U.S. inpatient population. Patients were stratified into 3 groups: isolated hip fracture, isolated long bone fracture, and polytrauma. Bivariate analysis was completed using chi-squared tests for categorical variables and t-tests for continuous variables. Multivariable analysis was completed using population-weighted logistic regression models, based on a conceptual model derived selection of covariates. RESULTS: We included 235,393 patients diagnosed with a hip or extremity fracture. These were weighted to represent 1,176,965 patients nationally. In the hip fracture group, rural patient status was associated with higher odds of mortality (OR 1.32, P < 0.001) but not complications (OR 0.95, P = 0.082). In the extremity fracture and polytrauma groups, rural patient status was not associated with significantly higher odds of mortality or complications. In the urban polytrauma group, zip code with below-median income was associated with increased odds of mortality (OR 1.23, P = 0.002) but not complications. In the rural polytrauma group, zip code with below-median income was not associated with significantly increased odds of mortality or complications. In the hip fracture and extremity fracture groups, below-median income was not associated with significantly higher odds of mortality. CONCLUSION: We found that rural patients with hip fracture have higher mortality compared to urban patients and that socioeconomic disparities in mortality after a polytrauma exist in urban settings. These results speak to the ongoing need to develop objective measures of disparity-sensitive healthcare and optimize trauma systems to better serve low-income patients and patients in rural areas.

How to Clear Polytrauma Patients for Fracture Fixation: Results of a systematic review of the literature.

INTRODUCTION: Early patient assessment is relevant for surgical decision making in severely injured patients and early definitive surgery is known to be beneficial in stable patients. The aim of this systematic review is to extract parameters indicative of risk factors for adverse outcome. Moreover, we aim to improve decision making and separate patients who would benefit from early versus staged definitive surgical fixation. METHODS: Following the PRISMA guidelines, a systematic review of peer-reviewed articles in English or German language published between (2000 and 2022) was performed. The primary outcome was the pathophysiological response to polytrauma including coagulopathy, shock/haemorrhage, hypothermia and soft tissue injury (trauma, brain injury, thoracic and abdominal trauma, and musculoskeletal injury) to determine the treatment strategy associated with the least amount of complications. Articles that had used quantitative parameters to distinguish between stable and unstable patients were summarized. Two authors screened articles and discrepancies were resolved by consensus. Quantitative values for relevant parameters indicative of an unstable polytrauma patient were obtained. RESULTS: The initial systematic search using MeSH criteria yielded 1550 publications deemed relevant to the following topics (coagulopathy (n = 37), haemorrhage/shock (n = 7), hypothermia (n = 11), soft tissue injury (n = 24)). Thresholds for stable, borderline, unstable and in extremis conditions were defined according to the existing literature as follows: Coagulopathy; International Normalized Ratio (INR) and viscoelastic methods (VEM)/Blood/shock; lactate, systolic blood pressure and haemoglobin, hypothermia; thresholds in degrees Celsius/Soft tissue trauma: traumatic brain injury, thoracic and abdominal trauma and musculoskeletal trauma. CONCLUSION: In this systematic literature review, we summarize publications by focusing on different pathways that stimulate pathophysiological cascades and remote organ damage. We propose that these parameters can be used for clinical decision making within the concept of safe definitive surgery (SDS) in the treatment of severely injured patients.

Fixation of humerus shaft fractures in polytrauma patients does not improve short-term outcomes.

BACKGROUND: Surgical fixation of humeral shaft fractures is widely considered a relative indication for polytraumatized patients to improve mobility and expedite care. This study aimed to determine whether operative treatment of humeral shaft fractures improves short term outcomes in polytrauma (PT] patients. METHODS: Using the National Trauma Data Bank, PT patients with humeral shaft fractures were identified from 2010-2015. Three PT groups were analyzed: Group 1 - PT with nonoperative humeral shaft fracture, Group 2 - PT with humeral fixation on Day 1, and Group 3 - PT with humeral fixation on Day 2+. Cox proportional hazards regression models were used to compare discharge timing and days on ventilator and in ICU between the three groups. RESULTS: There were 395 patients in Group 1, 1,346 in Group 2, and 1,318 in Group 3. There were no differences between the three groups when comparing Glasgow Coma Scale (p=0.3]; however, Injury Severity Score and Abbreviated Injury Scale were statistically different (p<0.001]. No differences were found in ICU or ventilator days between the three groups (p=0.2, p=0.5]. For Length of Stay, no difference was observed in Group 1 vs. Group 2 and Group 2 vs. Group 3. However, non-surgical patients were discharged 20% faster than those with Day 1 surgery (p=0.005]. Open fractures were treated one day earlier than closed fractures but discharged one day later (p<0.001]. CONCLUSIONS: This NTDB study demonstrates no differences in length of stay, days in the ICU or on the ventilator in patients with humeral shaft fractures treated non-operatively versus operative fixation. Overall, 44%-58% in all 3 groups had an ISS ≥ 14. Based on these results, we assert that fixation of the humeral shaft provides no short-term benefits in the multiply injured patient.

Full-thickness peroneus longus tendon autograft for anterior cruciate reconstruction in multi-ligament injury and revision cases: outcomes and donor site morbidity.

PURPOSE: Peroneus longus tendon (PLT) autograft has been successfully used for isolated anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) reconstruction cases. Being a powerful evertor and flexor of great toe, there might be associated ankle morbidity with this autograft option. However, there are only a few studies exploring whether the ankle morbidity is significant or not. This study aims to assess the functional outcomes, donor site morbidity, and ankle strength after harvesting ipsilateral peroneus longus autograft for ACL reconstruction in revision ACL and multi-ligament injury cases. METHODS: This was a prospective case series. All of the patients were evaluated by clinical examination for knee for laxity, ankle joint stability, and using visual analog scale (VAS) for pain, International Knee Documentation Committee (IKDC) score, and Lysholm score, preoperatively and postoperatively at two-year follow-up. Morbidity of donor ankle was assessed using American Orthopedic Foot and Ankle Society (AOFAS) score, bilateral evertors, and first ray plantarflexion strength measurement using an isometer (Innovative Design Orthopedics) at two-year follow-up. RESULTS: Ipsilateral PLT graft was used in ten patients of revision ACL reconstruction and 27 patients of the multi-ligament knee injury. The mean length of PLT harvested (cm) was 26.2 (standard deviation 2.6, range 22-31), and mean diameter of the doubled graft (mm) was 7.9 (standard deviation 0.68, range 7.5-8.5). There was a significant improvement in VAS score for pain, Lysholm, and IKDC scores (p = < 0.001) at two -year follow-up. There were no cases of graft failure, superficial, or deep infection. Ankle dorsiflexion(p = 0.32), ankle plantarflexion (p = 0.19), eversion strength(p = 0.6), first ray plantarflexion strength(p = 0.52), and AOFAS score(p = 0.29) were found to be comparable to the normal side in all patients. CONCLUSIONS: Peroneus longus autograft can be considered as a potential autograft option for ACL reconstruction in multi-ligament knee injuries and revision ACL reconstruction. No significant donor site morbidity was noted at follow-up. LEVEL OF EVIDENCE: Level IV.

Bilateral femur fractures are associated with concomitant femoral neck fracture.

OBJECTIVE: The purpose of this study is to determine the rate of femoral neck fractures in patients who have sustained bilateral femur fractures compared to unilateral femur fractures. DESIGN AND SETTING: A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical center. PATIENTS: All patients treated for a femur fracture between May 1, 2018 and December 31, 2020 were included. RESULTS: Twenty-one patients sustained bilateral femur fractures (11%) and 166 sustained unilateral femur fractures. Fifteen associated ipsilateral femoral neck fractures were identified. Eight of the 15 (53%) associated femoral neck fractures were observed in patients who sustained bilateral femur fractures. Eight of the 21 patients with bilateral femur fractures, 42 fractures in total, had an associated ipsilateral femoral neck fracture (38% of patients; 19% of fractures, respectively), while only seven of the 166 patients (4%) with a unilateral femur fracture had an associated femoral neck fracture (p < 0.001). Of the 208 femur fractures, 19 (9%) were open fractures. Ten of the 21 patients with bilateral femur fractures, 42 fractures in total, were identified to have an open femur fracture (48% of patients, 24% of fractures), while only nine of the 166 (5%) unilateral femur fractures were open (p < 0.001). CONCLUSIONS: Our results demonstrate an association between bilateral femur fractures, open femur fractures, and associated femoral neck fractures. Surgeons treating these injuries should maintain a high index of suspicion for associated ipsilateral proximal.

Emergency Radical Nephrectomy in a Polytrauma Patient.

INTRODUCTION: The renal trauma is present in a 5% of all trauma cases. In the most common causes, conservative treatment can be performed. It is reported a case of renal trauma due to metal sick that required surgical management. It is considered that this is a rare clinical case with urgent surgical management that is not usual in this type of trauma. In addition, it is an example of quick decision-making since the patient's life depends on them. CASE REPORT: A 69-year-old man was referred to our institution for polytrauma. In contrast-enhanced computed tomography, renal, intestinal and great vessel were suspected, so an urgent surgical treatment was decided. During surgery, radical nephrectomy was performed due to perforation of the right kidney by a metal stick. CONCLUSIONS: Although conservative treatment of renal trauma can be performed in most cases, it must be taken into account that radical nephrectomy is a possible option when the kidney cannot be preserved.

Differences in characteristics between patients ≥ 65 and < 65 years of age with orthopaedic injuries after severe trauma.

AIM: Many trauma patients have associated orthopaedic injuries at admission. The existing literature regarding orthopaedic trauma often focuses on single injuries, but there is a paucity of information that gives an overview of this group of patients. Our aim was to describe the differences in characteristics between polytrauma patients ≥ 65 and < 65 years of age suffering orthopaedic injuries. METHODS: Patients registered in the Norwegian Trauma Registry (NTR) with an injury severity score (ISS) > 15 and orthopaedic injuries, who were admitted to Haukeland University Hospital in 2016-2018, were included. Data retrieved from the patients' hospital records and NTR were analysed. The patients were divided into two groups based on age. RESULTS: The study comprised 175 patients, of which 128 (73%) and 47 (27%) were aged < 65 (Group 1) and ≥ 65 years (Group 2), respectively. The ISS and the new injury severity score (NISS) were similar in both groups. The dominating injury mechanism was traffic-related and thoracic injury was the most common location of main injury in both groups. The groups suffered a similar number of orthopaedic injuries. A significantly higher proportion of Group 1 underwent operative treatment for their orthopaedic injuries than in Group 2 (74% vs. 53%). The mortality in Group 2 was significantly higher than that in Group 1 (15% vs. 3%). In Group 2 most deaths were related to traffic injuries (71%). High energy falls and traffic-related incidents caused the same number of deaths in Group 1. In Group 1 abdominal injuries resulted in most deaths, while head injuries was the primary reason for deaths in Group 2. CONCLUSIONS: Although the ISS and NISS were similar, mortality was significantly higher among patients aged ≥ 65 years compared to patients < 65 years of age. The younger age group underwent more frequently surgery for orthopaedic injuries than the elderly. There may be multiple reasons for this difference, but our study does not have sufficient data to draw any conclusions. Future studies may provide a deeper understanding of what causes treatment variation between age groups, which would hopefully help to further develop strategies to improve outcome for the elderly polytrauma patient.

Upper Thoracic Erector Spinae Plane Block-A Win-Win Deal For Polytrauma Victims Undergoing Surgeries in the Shoulder Region: A Case Report.

Polytrauma victims are usually in severe pain with difficulty in breathing. There are limited regional analgesia options that cover the shoulder region as well as the rib and other associated fractures. The erector spinae plane block (ESPB) is a versatile block which has established a role in the management of rib fracture pain and has emerging indications for managing pain in the shoulder and upper humerus regions. We examined the efficacy of ultrasound guided ESPB at the T2 level in two polytrauma patients with unilateral scapular, humerus, and rib fractures undergoing surgery in the shoulder region. It provided excellent postoperative analgesia and helped to alleviate pain of associated rib and other fractures, thereby facilitating early postoperative recovery and rehabilitation.