The effect of COVID-19 on a Major Trauma Network. An analysis of mechanism of injury pattern, referral load and operative case-mix.

PURPOSE: The aim of this study was to evaluate changes in both mechanism and diagnoses of injuries presenting to the orthopaedic department during this lockdown period, as well as to observe any changes in operative case-mix during this time. METHODS: A study period of twelve weeks following the introduction of the nationwide "lockdown period", March 23rd - June 14th, 2020 was identified and compared to the same time period in 2019 as a "baseline period". A retrospective analysis of all emergency orthopaedic referrals and surgical procedures performed during these time frames was undertaken. All data was collected and screened using the 'eTrauma' management platform (Open Medical, UK). The study included data from a five NHS Foundation Trusts within North West London. A total of 6695 referrals were included for analysis. RESULTS: The total number of referrals received during the lockdown period fell by 35.3% (n=2631) compared to the same period in 2019 (n=4064). Falls remained proportionally the most common mechanism of injury across all age groups in both time periods. The proportion sports related injuries compared to the overall number of injuries fell significantly during the lockdown period (p<0.001), however, the proportion of pushbike related accidents increased significantly (p<0.001). The total number of operations performed during the lockdown period fell by 38.8% (n=1046) during lockdown (n=1732). The proportion of patients undergoing operative intervention for Neck of Femur (NOF) and ankle fractures remained similar during both study periods. A more non-operative approach was seen in the management of wrist fractures, with 41.4% of injuries undergoing an operation during the lockdown period compared to 58.6% at baseline (p<0.001). CONCLUSION: In conclusion, the nationwide lockdown has led to a decrease in emergency orthopaedic referrals and procedure numbers. There has been a change in mechanism of injuries, with fewer sporting injuries, conversely, there has been an increase in the number of pushbike or scooter related injuries during the lockdown period. NOF fractures remained at similar levels to the previous year. There was a change in strategy for managing distal radius fractures with more fractures being treated non-operatively.

Complications and its impact in patients with closed and open tibial shaft fractures requiring open reduction and internal fixation.

Aim: To evaluate the rates of infection and nonunion and determine the impact of infections on healthcare resource use and costs following open and closed fractures of the tibial shaft requiring open reduction internal fixation. Methods: Healthcare use and costs were compared between patients with and without infections following pen reduction internal fixation using MarketScan® databases. Results: For commercial patients, the rates of infection and nonunion ranged from 1.82 to 7.44% and 0.48 to 8.75%, respectively, over the 2-year period. Patients with infection had significantly higher rates of hospital readmissions, emergency room visits and healthcare costs compared with patients without infection. Conclusion: This real-world study showed an increasing rate of infection up to 2 years and infection significantly increased healthcare resource use and costs.

Open fractures: epidemiological pattern, initial management and challenges in a sub-urban teaching hospital in Nigeria.

INTRODUCTION: Management of open fractures poses a constant challenge to Orthopaedic surgeons in Nigeria. Our aim is to determine the epidemiological pattern of open fractures in our centre and share our experiences on the initial management and problems encountered. METHODS: This was an 18 month prospective study of patients that presented with open fractures at our emergency room. Already prepared data collection sheets were used to collect relevant data directly from patients and patients' files. RESULTS: There were 58 open fractures in 52 patients (31 males and 21 females). Mean age of patients was 36.4 ± 12.2 years. Most patients (82.7%) fell within the age group of 20-49 years. Traders (28.9%) and students (19.6%) were mostly affected. Most open fractures (88.5%) were due to road traffic accidents. The tibia and fibula were the most frequently affected (44.4%). Most injuries were Gustilo et al. types IIIA & IIIB (79.3%) open fractures. Patients had initial resuscitation followed by debridement in 42 cases (72%). Fractures were initially stabilized with external fixators in 23 cases (39.7%) and cast slabs in 19 cases (32.8%). The average time between presentation and debridement was 30 hours and average hospital stay was 36 days. Forty two point five per cent of wounds were infected. CONCLUSION: Open fractures were mostly due to road traffic accidents and affected the tibia and fibula most frequently with Gustilo et al. types IIIA and IIIB forming the bulk of the injuries. Management was challenging with late presentations, scarcity of resources and consequent high rate of infections, prolonged morbidity and hospital stay. These problems were worsened by delay in antibiotic commencement and initial debridement, sub-optimal treatment at peripherial hospitals and mis-management by traditional bone setters.

Economic outcomes associated with deep surgical site infection in patients with an open fracture of the lower limb.

AIMS: The aim of this study was to estimate economic outcomes associated with deep surgical site infection (SSI) in patients with an open fracture of the lower limb. PATIENTS AND METHODS: A total of 460 patients were recruited from 24 specialist trauma hospitals in the United Kingdom Major Trauma Network. Preference-based health-related quality-of-life outcomes, assessed using the EuroQol EQ-5D-3L and the 6-Item Short-Form Health Survey questionnaire (SF-6D), and economic costs (£, 2014/2015 prices) were measured using participant-completed questionnaires over the 12 months following injury. Descriptive statistics and multivariate regression analysis were used to explore the relationship between deep SSI and health utility scores, quality-adjusted life-years (QALYs), and health and personal social service (PSS) costs. RESULTS: Deep SSI was associated with lower EQ-5D-3L derived QALYs (adjusted mean difference -0.102, 95% confidence interval (CI) -0.202 to 0.001, p = 0.047) and increased health and social care costs (adjusted mean difference £1950; 95% CI £1383 to £5285, p = 0.250) versus patients without deep SSI over the 12 months following injury. CONCLUSION: Deep SSI may lead to significantly impaired health-related quality of life and increased economic costs. Our economic estimates can be used to inform clinical and budgetary service planning and can act as reference data for future economic evaluations of preventive or treatment interventions. Cite this article: Bone Joint J 2018;100-B:1506-10.

A representative assessment of the management of open fractures of the lower limb within UK orthoplastic centres: A two-centre audit of compliance with national standards.

BACKGROUND: Open fractures of the lower limb represent a complex and varied array of injuries. The BOAST 4 document produced by BAPRAS and the BOA provides standards on how to manage these patients, and NICE have recently produced additional guidance. We aimed to assess concordance with these standards in a large cohort representative of UK orthoplastic centres. METHODS: Patients admitted to the orthoplastic units at Norfolk and Norwich University Hospital and Royal Stoke University Hospital with open lower limb fractures between 2009 and 2014 were included. Data was gathered from notes and endpoints based on the BOAST 4 document. RESULTS: In total, 84 patients were included across the two sites, with 83 having their initial debridement within 24h (98.8%). Forty-two patients had a documented out-of-hours initial surgery. Of these, 10 (23.8%) had an indication for urgent surgery. This pattern was consistent across both hospitals. A plastic surgeon was present at 33.3% of initial operations. Of 78 patients receiving definitive soft tissue cover, 56.4% had cover within 72h and 78.2% within 7days. Main reasons for missing these targets were transfer from other hospitals, plastic surgeons not present at initial operation and intervening critical illness. CONCLUSIONS: This study has identified key areas for improving compliance with the national BOAST 4 and NICE standards. Out-of-hours operating is occurring unnecessarily and time targets are being missed. The development of dedicated referral pathways and a true orthoplastic approach are required to improve the management of this complex set of injuries.

A Prospective Randomized Trial to Assess Fixation Strategies for Severe Open Tibia Fractures: Modern Ring External Fixators Versus Internal Fixation (FIXIT Study).

The treatment of high-energy open tibia fractures is challenging in both the military and civilian environments. Treatment with modern ring external fixation may reduce complications common in these patients. However, no study has rigorously compared outcomes of modern ring external fixation with commonly used internal fixation approaches. The FIXIT study is a prospective, multicenter randomized trial comparing 1-year outcomes after treatment of severe open tibial shaft fractures with modern external ring fixation versus internal fixation among men and women of ages 18-64. The primary outcome is rehospitalization for major limb complications. Secondary outcomes include infection, fracture healing, limb function, and patient-reported outcomes including physical function and pain. One-year treatment costs and patient satisfaction will be compared between the 2 groups, and the percentage of Gustilo IIIB fractures that can be salvaged without soft tissue flap among patients receiving external fixation will be estimated.

The use of secure anonymised data linkage to determine changes in healthcare utilisation following severe open tibial fractures.

Severe open fractures of the lower limbs are complex injuries requiring expert multidisciplinary management in appropriate orthoplastic centres. This study aimed to assess the impact of open fractures on healthcare utilisation and test the null hypotheses that there is no difference in healthcare utilisation between the year before and year after injury, and that there is no difference in healthcare utilisation in the year post-injury between patients admitted directly to an orthoplastic centre in keeping with the joint BOA/BAPRAS standards and those having initial surgery elsewhere. This retrospective cohort study utilising secure anonymised information linkage (SAIL), a novel databank of anonymised nationally pooled health records, recruited patients over 18 years of age sustaining severe open lower limb fractures managed primarily or secondarily at our centre and who had data available in the SAIL databank. 101 patients met inclusion criteria and 90 of these had records in the SAIL databank. The number of days in hospital, number of primary care attendances, number of outpatient attendances and number of emergency department attendances in the years prior and subsequent to injury were recorded. Patients sustaining open fractures had significantly different healthcare utilisation in the year after injury when compared with the year before, in terms of days spent in hospital (23.42 vs. 1.70, p=0.000), outpatient attendances (11.98 vs. 1.05, p=0.000), primary care attendances (29.48 vs. 11.99, p=0.000) and emergency department presentations (0.2 vs. 0.01, p=0.025). Patients admitted directly to orthoplastic centres had significantly fewer operations (1.78 vs. 3.31) and GP attendances (23.6 vs. 33.52) than those transferred in subsequent to initial management in other units. There is a significant increase in healthcare utilisation after open tibial fracture. Adherence to national standards minimises the impact of this on both patients and health services.

Emergency department visits with facial fractures among children and adolescents: an analysis of profile and predictors of causes of injuries.

PURPOSE: The objectives of this study were to provide nationally representative estimates of hospital-based emergency department (ED) visits for facial fractures in children and adolescents, examine the burden associated with such visits, identify common types of facial fracture, and examine the role of patient-related demographic factors on the causes of facial fractures. MATERIALS AND METHODS: The Nationwide Emergency Department Sample for 2008 to 2010 was used. All ED visits with a diagnosis of facial fractures in those no older than 21 years were selected. Demographic characteristics, types of facial fracture, causes of injuries, and hospital charges were examined. RESULTS: During the study period, 336,124 ED visits were for facial fractures in those no older than 21 years. Late adolescents (18 to 21 yr old) and middle adolescents (15 to 17 yr old) comprised 45.6% and 26.6% of all ED visits, respectively. Male patients comprised 74.7% of ED visits. The most common facial fractures were those of the nasal bones and mandible. Younger children were more likely to have falls, pedal cycle accidents, pedestrian accidents, and transport accidents, whereas older groups were more likely to have firearm injuries, motor vehicle traffic accidents, and assaults (P < .05). Female patients were more likely to have falls, motor vehicle traffic accidents, and transport accidents, whereas male patients were more likely to have firearm injuries, pedal cycle accidents, and assaults (P < .05). Those residing at low annual income household levels were at a high risk for having firearm injuries, motor vehicle traffic accidents, and transport accidents (P < .05). CONCLUSIONS: Late adolescents, middle adolescents, and male patients comprise a significant proportion of these ED visits. Age, gender, and household income levels are significantly associated with the causes of facial fracture injuries.

The cost of after-hours operative debridement of open tibia fractures.

OBJECTIVES: The aim of this study was to evaluate the additional cost associated with performing after-hours operative debridement of open fractures within 6 hours of injury. DATA SOURCES: The economic model is based on population estimates obtained from the National Trauma Database and the National Inpatient Sample on the number of open tibia fractures that occur annually in the United States and the number that present after-hours (between 6 PM and 2 AM) that undergo operative debridement within 6 hours. This model estimates incremental cost for after-hours surgery based on overtime wages for on-call personnel (nurses and surgical technicians) required to staff after-hours cases as published by the US Department of Labor and data from our own institution. As many level 1 hospitals are capable of performing after-hours cases without additional cost, a sensitivity analysis was performed to determine the effect of designated level of care of the trauma hospital. DATA EXTRACTION AND SYNTHESIS: A total of 17,414 open tibia fractures were recorded in the National Inpatient Sample for 2009, and an estimated 7485 open tibia fractures presented after-hours, 4242 of which underwent operative debridement within 6 hours of presentation. Based on wage statistics from the US Department of Labor and our own institution, the estimated total additional cost for after-hours operative debridement of open tibia fractures within 6 hours is from $2,210,895 to $4,046,648 annually, respectively. For level 2 hospitals and below, the cost of performing after-hours operative debridement of open tibia fractures is calculated as from $1,532,980 to $2,805,846 annually. CONCLUSIONS: The data indicated an increased overall financial cost of performing after-hours operative debridement of open tibia fractures. Given that there is minimal documented benefit to this practice, and with increased pressure to practice cost containment, elective delay of operative debridement of open fractures and/or transfer to a higher level of care trauma hospital may be an acceptable way to address these issues. LEVEL OF EVIDENCE: Economic analysis level III. See instructions for authors for a complete description of levels of evidence.

Open pelvic fractures: epidemiology, current concepts of management and outcome.

Open pelvic fractures constitute one of the most devastating injuries in musculo-skeletal trauma and must be treated aggressively, incorporating a multidisciplinary approach. Early treatment, focusing on prevention of haemorrhage and sepsis, is essential. The management of associated soft tissue injuries must also be aggressive, including early administration of broad-spectrum antibiotics and repeated, meticulous wound debridement and irrigation. Selective faecal diversion, based on wound location, is compulsory and safe, minimising the risk of sepsis and reducing mortality rates.

Diagrama de flujo para el tratamiento de las fracturas expuestas en urgencia. Revisión epidemiológica y determinación de costos / An algorithm for treatment of open fractures in an emergency department

Se presenta un serie de 1,210 fracturas expuesta atendidas entre enero de 1991 y diciembre de 1993. Los segmentos más frecuentemente afectados fueron la pierna (tibia y peroné) con 486 casos (40.1 por ciento) y en segundo lugar antebrazo (radio y cúbito) con 295 casos (24.3 por ciento). Los pacientes se trataron mediante el procedimiento establecido en nuestro servicio. El costo promedio del tratamiento por paciente fue de 13,673.44 pesos

Epidemiology and management of open fractures of the lower limb.

Epidemiological analysis indicates that 40% of open fractures occur in the lower limb and that the tibial and femoral diaphyses are most commonly affected. Recent advances in fracture stabilization and soft tissue reconstruction technique have improved the outcome of these fractures.

[Epidemiology of supracondylar fractures of the humerus in children in Bangui, Central African Republic]. / Epidémiologie des fractures supra-condyliennes de l'humerus chez l'enfant à Bangui, Centrafrique.

The purpose of this retrospective study was to evaluate the epidemiological, clinical, and anatomical aspects of supracondylar fractures of the humerus in children treated at the National University Hospital Center (NUHC) of Bangui, Central African Republic. Between January 1992 and March 1995 a total of 119 documented cases involving children between the ages of 0 and 15 years were treated. Most patients were boys (62%) between 3 and 8 years of age. Fracture occurred during play in 74% of cases on the left side (92 cases) more often than the right. The mechanism of fracture was extension in 115 of the 119 cases with only four open fractures. Most fractures (68.1%) were severe (Lagrange Grade 3 and 4). These findings which are comparable to those reported in other countries confirm the high incidence of supracondylar fracture of the humerus and need for appropriate treatment in African orthopedic facilities.

The relationships of skeletal injuries with trauma score, injury severity score, length of hospital stay, hospital charges, and mortality in children admitted to a regional pediatric trauma center.

Thirty-four-hundred and seventy-two children were consecutively admitted for acute traumatic injuries over a 34 month period to the Children's National Medical Center. The study comprised 805 patients who sustained 953 fractures and dislocations. The male to female ratio was 2:1. Age at the time of admission was evenly distributed over 16 years, with a mean of 8.3 years. Pedestrian accidents and falls each accounted for 34% of the musculoskeletal injuries, whereas motor vehicle accidents accounted for an additional 13%. The femur was the most commonly fractured bone, representing 22% of all fractures and dislocations, followed by the humerus (16%), tibia/fibula (12%), ankle/foot (13%), and radius/ulna (8%). Nine percent of the fractures were open. The average length of hospital stay was 8.6 days, and the average cost per hospital admission was $8,765. The mortality rate was 3%. Central musculoskeletal injuries (spine, clavicle/scapula, and pelvis) in our hospitalized patients were associated with the longest hospital stays and intensive care unit admissions, and lowest Trauma Scores, as well as the highest Injury Severity Scores, hospital charges, and mortality rates.

[A three-year aid program for plastic surgery in Peshawar (Pakistan). Ongoing management of severely injured patients of the Afghanistan war: 1,528 large operations, 5,171 smaller interventions, 15,932 patients examined]. / Ein dreijähriges Hilfsprogramm für Plastische Chirurgie in Peshawar (Pakistan). Kontinuierliche Versorgung schwerverletzter Patienten des afghanischen Krieges: 1528 grosse Operationen, 5,171 kleinere Eingriffe, 15,932 untersuchte Patienten.

Since 1980 Interplast Germany has sent many plastic surgeons to developing countries. In 1989 a new Interplast Germany program for helping Afghan refugees in Pakistan's Peshawar was started. The Federal Republic of Germany financed the first two years; thereafter, the European Community and Help supported the project. Twenty-four teams with 123 nurses, surgeons and anesthesiologists operated on 1,528 patients in two hospitals. In the same period 5,171 smaller operations have been performed and 15,932 patients have been examined. Low expense for the teams, good support by officials, and professional administration have made this project highly effective for 3 years.

Infection after intramedullary nailing of the tibia. Incidence and protocol for management.

There is concern about the incidence and serious nature of infection after intramedullary nailing of the tibia, especially for open injuries. We have reviewed 459 patients with tibial fractures treated by primary reamed nailing. The incidence of infection was 1.8% in closed and Gustilo type I open fractures, 3.8% in type II, and 9.5% in type III fractures (5.5% in type IIIa, 12.5% in type IIIb). These incidences appear to be acceptable in comparison with other published results. We describe the different modes of presentation of infection in these cases, and suggest a protocol for its management, which has been generally successful in our series.