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.

Assessment of bicycle-car accidents under four different types of collision.

Bicycle riders are among the highest risk group in traffic. A cyclist simulation study captured kinematics and injuries to legs, pelvis, neck, and head for one human body size. We analyzed the number of parameters (forces acting on left and right tibia, head injury criterion, neck tensile force, neck shear force, and pelvic acceleration) for each of the four different cases: bicyclist ride out-residential driveway, motorist overtaking-undetected bicyclist, bicyclist left turn-same direction, and bicyclist right turn-opposite direction. The comparison of simulation outcomes for leg injuries with official hospital records has shown a very good correlation in terms of injury severity prediction. This study concludes that if countermeasures to prevent fatal cyclist injury in car impacts were to be concentrated on mitigating head and neck impact to the windscreen of the car, a dominant share of fatal cyclist crashes and severe traumatic head injury cases at collision speeds exceeding 40 km/h could be prevented.

Patient Experiences of Life Years After Severe Civilian Lower Extremity Trauma With Vascular Injury.

OBJECTIVE: Severe lower limb trauma with arterial injury is often devastating for the individual. Many studies describe how to manage these injuries when they occur. Short-term functional outcome is quite well described, but the patients are often young, and their suffering is physical, mental, and social from a lifelong perspective. The aim of this study was to report patient experiences of their lives several years after their accidents, and to explore mechanisms of how to improve management. METHOD: The Swedvasc registry was searched for participants from 1987 to 2011, living in the region of Uppsala, Sweden. Some amputated participants were added from the Walking Rehabilitation Center. There were five reconstructed patients with an intact limb, and three with amputations. In depth interviews were conducted and systematically analyzed, using A Giorgi's descriptive phenomenological method. RESULTS: Eight patients participated, five with reconstructed and three with amputated limbs. Life affecting functional impairments were described by all patients. The patients undergoing amputation had received more structured follow up and support through the Walking Rehabilitation Center. The satisfaction with the cosmetic result was poorer than expected. All patients had developed strategies of how to cope with their impairments and stated they now lived "normal lives." CONCLUSIONS: Despite substantial physical, psychological, and cosmetic impairments years after severe lower limb trauma, the participants described life as "normal" and mainly satisfactory. Transition to the new situation could have been facilitated by more frequent and continuous follow up after discharge from hospital, in particular among the non-amputated patients who tend to be lost to follow up. Findings also indicate that family members have to be acknowledged, strengthened, and supported.

Assessment of Compensated Turnout Characteristics and their Relationship to Injuries in University Level Modern Dancers.

Dancers may compensate alignment at the spine, hip, knees, ankles, and feet to achieve a greater turnout than is available at the hip alone. Such compensations are believed to lead to many of the musculoskeletal injuries experienced by dancers, especially overuse injuries. The aim of this study was to explore the relationship between compensated turnout and injury of the lower extremities and low back. Twenty-two university level modern dancers age 19 to 23 participated. Measurements were taken of active hip external rotation (AHER) prone and functional turnout (FTO) in first position. The difference between FTO and AHER was designated as compensated turnout (CTO). A questionnaire was conducted to gather information about dancers' injuries within the past 2 years. A total of 17 participants (77%) reported experiencing at least one injury in the 24 month period. All dancers compensated turnout. Results revealed a large variability in CTO among participants, ranging from 3° to 72°. Statistical analysis showed a significant relationship (r = 0.45, N = 22, p = 0.04) between CTO and the number of injuries experienced, especially as related to low back pain (r = 0.50, N = 22, p = 0.02). Students with no injury had a CTO mean of 26°, while those with two or more injuries had a CTO mean of 43°. Results contribute to previous studies that have examined the effects of CTO in ballet dancers and further indicate that compensatory patterns of turnout may increase the risk of experiencing more than one injury in university level modern dancers.

Lameness and hock injuries improve on farms participating in an assessment program.

Lameness and hock injuries are recognized welfare and production problems in the dairy industry. The objective of this study was to describe changes in the prevalence of these ailments in 15 freestall herds in the Northeastern United States that participated in an on-farm assessment program. Prevalence was assessed in a high-producing pen in each herd. A confidential report was delivered to each of the farms showing prevalence in relation to other herds assessed within the same region. The average (±SD) period between visits was 11.5 ± 4.4 months (range, 8-25 months). The prevalence of lameness decreased in most herds after the first assessment (mean difference ± SE [range] = -17 ± 4 % [-43 to 6]). An even larger improvement was seen in the prevalence of hock injuries with all farms showing a decrease (-38 ± 6% [-1 to -87]). The degree of improvement observed at the second assessment was greatest for those farms that had higher lameness prevalence when first assessed, but this was not the case for hock injuries. The changes in prevalence of clinical lameness and overall hock lesions were, however, correlated (ρ = 0.62). These results suggest that monitoring and reporting the prevalence of lameness and hock injuries to farmers can motivate changes in facilities and management targeted to address these ailments.

Safety assessment characteristics of pedestrian legform impactors in vehicle-front impact tests.

This study investigated the characteristics of safety assessment results of front-area vehicle impact tests carried out using the Transport Research Laboratory (TRL) legform impactor and a flexible legform impactor (FLEX legform impactor). Different types of vehicles (sedan, sport utility vehicle, high-roof K-car, and light cargo van) were examined. The impact locations in the study were the center of the bumper and an extremely stiff structure of the bumper (i.e., in front of the side member) of each tested vehicle. The measured injury criteria were normalized by injury assessment reference values of each legform impactor. The test results for center and side-member impacts indicated that there were no significant differences in ligament injury assessments derived from the normalized knee ligament injury measures between the TRL legform impactor and the FLEX legform impactor. Evaluations made using the TRL legform impactor and the FLEX legform impactor are thus similar in the vehicle safety investigation for knee ligament injury. Vehicle-center impact test results revealed that the tibia fracture assessments derived from the normalized tibia fracture measures did not significantly differ between the TRL legform impactor and the FLEX legform impactor. However, for an impact against an extremely stiff structure, there was a difference in the tibia fracture assessment between the FLEX legform impactor and the TRL legform impactor owing to their different sensor types.

Can RSScan footscan(®) D3D™ software predict injury in a military population following plantar pressure assessment? A prospective cohort study.

BACKGROUND: Injury in initial military training is common with incidences from 25 to 65% of recruits sustaining musculoskeletal injury. Risk factors for injury include extrinsic factors such as rapid onset of high volume training, but intrinsic factors such as lower limb biomechanics and foot type. Prediction of injury would allow more effective training delivery, reduce manpower wastage and improve duty of care to individuals by addressing potential interventions. Plantar pressure interpretation of footfall has been shown to reflect biomechanical intrinsic abnormality although no quantifiable method of risk stratification exists. OBJECTIVE: To identify if pressure plate assessment of walking gait is predictive of injury in a military population. METHOD: 200 male subjects commencing Naval Officer training were assessed by plantar pressure plate recording, of foot contact pressures. A software interpretation, D3D™, stratified the interpretation to measure 4 specific areas of potential correction. Participants were graded as to high, medium and low risk of injury and subsequently followed up for injury through their basic training. RESULTS: Seventy two percent of all injuries were attributed to subjects in the high and medium risk of injury as defined by the risk categorization. 47% of all injuries were sustained in the high-risk group. Participants categorized in the high-risk group for injury were significantly more likely to sustain injury than in medium or low groups (p<0.001, OR 5.28 with 95% CI 2.88, 9.70). CONCLUSIONS: Plantar pressure assessment of risk for overuse lower limb injury can be predictive of sustaining an overuse injury in a controlled training environment.

Costs and outcome for serious hand and arm injuries during the first year after trauma - a prospective study.

BACKGROUND: To study costs and outcome for serious hand and arm injuries during the first year after the trauma. METHODS: In patients with a Hand Injury Severity Score (HISS) > 50, DASH and EQ-5D scores as well as factors related to costs within the health care sector, costs due to lost production and total costs were evaluated. Cox-regression analysis stratifying for mechanism of injury was used to analyse return to work. RESULTS: The majority of the 45 included patients (median 42 years 16-64) were men with severe (n = 9) or major (n = 36) injuries with different type of injuries (amputations n = 13; complex injuries n = 18; major nerve injuries/full house n = 13; burn injury n = 1). DASH and EQ-5D decreased and increased, respectively, significantly over time during one year. Total costs (+34%) and costs of lost production were highest for persons injured at work. Factors associated with higher health care costs were age >50 years (+52%), injury at work (+40%) and partial labour market activity (+66%). Costs of lost production had a significant role in total costs of injury. Patients with major injuries had longer duration of sick leave. Patients with severe injuries were more likely to return to work [(RR 3.76 (95% CI 1.38-10.22) from Cox regression, controlling for age, gender and presence of nerve injury]. CONCLUSIONS: Despite the fact that work environments have constantly improved over the last decades, we found that hand injuries at work were most costly both in terms of health care and costs of lost production, although the severity, i.e. HISS, did not differ from injuries occurring at home or during leisure.

Injuries increase the amputee burden at the prosthesis centre: a 2-year retrospective survey of amputees in a low-income setting.

The aim of this study is to survey different types of injuries as the cause for prosthesis fitting in the Institute of Physical Medicine and Rehabilitation (IPM&R). This retrospective chart review was conducted at the IPM&R at the Dow University of Health Sciences, from the year 2007 till 2009. We selected all amputees who got enrolled in our institute for prosthesis fitting with major amputations, during the above mentioned period of time. Informed verbal consent was taken from each patient before recording their data at the IPM&R. Anonymity has been maintained. Data for this study was collected through a structured questionnaire, variables included: gender, age, town of origin, cause of amputation, level of amputation, limb involvement (unilateral or bilateral), level and causes of amputations. The data entry and analysis were done on SPSS (Statistical Package of Social Sciences) version 16.0. Of the amputee burden of our study, 55.9% was due to trauma, which is a preventable cause of disability. This is mostly affecting men in the productive age group. New strategies need to be devised in order to alleviate the burden of amputations resulting from preventable injuries.

Shin pain in athletes - assessment and management.

BACKGROUND: Shin pain is a common complaint among running athletes and can be caused by bony, muscular, vascular or neural pathology. OBJECTIVE: This article discusses the likely causes, assessment and management of shin pain in athletes presenting in the general practice setting. DISCUSSION: Accurate diagnosis is important as treatment differs depending on the cause. The characteristics of the pain and examination findings after exercise give strong clues to the diagnosis; further investigation may be unnecessary. Bony stress reactions and fractures are the most common cause of shin pain; patients describe a 'jarring' sensation along the bone margin with heel strike. Other causes include recurrent exertional compartment syndrome (RECS), tenosynovitis, neurological entrapment and rarely, vascular entrapment. Symptoms of vascular entrapment may be similar to RECS and this may cause diagnostic confusion. Increased bone stress in athletes is largely due to inappropriate training program design and can usually be alleviated by reducing impact loading until pain resolves.

Assessment of risk factors for osteoporosis and fractures in children with meningomyelocele.

PURPOSE: Our objective was to assess bone and muscular mass in children with meningomyelocele (MMC), and to analyze risk factors for osteoporosis and fractures based on densitometric examination. MATERIAL AND METHODS: The study group included 30 patients (15 girls and 15 boys) with MMC, aged 6-17 years, treated in the Department of Pediatric Rehabilitation, University Hospital. Physiotherapeutic assessment and laboratory tests (serum parathormone, alkaline phosphatase levels, calcium, and phosphate levels, and urine calcium levels) were performed. Densitometry was measured by dual energy X-ray absorptiometry using a Lunar DPX-L apparatus. Lean mass (fat-free tissue content) and fat mass (% fat content) was evaluated. RESULTS: Femur fractures were the most common 12/30 (40%); 5/30 (17%) of the children with MMC had multiple fractures. The incidence of fractures correlated significantly with BMI and body fat content (p = 0.03) Children with MMC and fractures had a tendency toward higher BMI, despite the same absolute value of body mass, compared to those without fractures. Body fat levels were higher in MMC patients with fractures than in those without fractures (BMI R = 0.393, p = 0.03). Children with MMC and fractures had significantly higher 24 h calcuria values, despite normal renal function indices (p = 0.03). CONCLUSIONS: Low-energetic fractures in MMC children may result from metabolic disturbances that are a consequence of excessive renal calcium loss or excessive fatty tissue content.

[The anaesthetist's liability and bullfights]. / Responsabilité de l'anesthésiste et corrida.

Whether you are an aficionado or completely uninitiated, everyone has an opinion on bull-fighting. The bull-fighter is in constant risk of injury. A medical team made up of surgeons, anesthetists, emergency physicians and nurses remains present throughout the show. For the anaesthetist and surgeon, a wounded bullfighter is an emergency because the vital and functional prognosis are engaged. The team must act in conformity with normal practice and the Code of Medical Ethics because any lack of coordination between the practitioners is punishable by law in the same way as technical fault. Several specific aspects of this type of medical procedure should be highlighted: firstly, the legal restrictions within the corrida, and secondly, the nature of the medical team, which may be comprised of doctors normally based within a public health institution and others who practice in a private health establishment. The particularity of the situation reveals differences in the system of liability, and civil liability must be distinguished from administrative liability: both of these allow the victim to obtain compensation for harm caused, but the consequences of each are different according to doctor status. The fact that the anaesthetists frequently work on a voluntary and benevolent basis does not exonerate them from liability. Lastly, a question frequently addressed is whether or not the doctor is covered by his professional insurance when he is on ringside duty.

Biomechanical evaluation of dancers and assessment of their risk of injury.

Professional dancers have a 90% risk of injury during their career. The lower extremity is involved in approximately 75% of the injuries sustained by dancers. Proper biomechanical evaluation, risk assessment, and prevention-oriented treatment are necessary to minimize future problems and promote a full and lasting recovery when an injury is sustained. This article outlines the in-office evaluation process and discusses backstage care.

Comparison of injury rates between cadets with limb length inequalities and matched control subjects over 1 year of military training and athletic participation.

OBJECTIVES: To compare lower-limb overuse injury and low back pain incidence among cadets with and without limb length inequality (LLI) over 1 year of military training and athletic participation. METHODS: A total of 1,100 cadets were screened for LLIs; 126 of 1,100 were identified to have a LLI of > 0.5 cm and were assigned a matched control cadet. Injury rates, numbers of visits to sick call, and numbers of days spent on medical excusal during a 1-year period were then compared for the 252 cadets. RESULTS: There was no difference in prevalence of injury between the groups and no significant differences (p > 0.05) between the groups in injury rates, visits to sick call, or number of days spent on medical excusal. CONCLUSIONS: These findings do not support any increased incidence of injuries in a young, healthy, athletic, military population with mild LLIs, compared with matched control subjects without LLIs, over 1 year.

Derivation and theoretical assessment of a set of biomechanics-based, AIS2+ risk equations for the knee-thigh-hip complex.

A set of risk equations was derived to estimate the probability of sustaining a moderate-to-serious injury to the knee-thigh-hip complex (KTH) in a frontal crash. The study consisted of four parts. First, data pertaining to knee-loaded, whole-body, post-mortem human subjects (PMHS) were collected from the literature, and the attendant response data (e.g., axial compressive load applied to the knee) were normalized to those of a mid-sized male. Second, numerous statistical analyses and mathematical constructs were used to derive the set of risk equations for adults of various ages and genders. Third, field data from the National Automotive Sampling System (NASS) were analyzed for subsequent comparison purposes. Fourth, the fidelity of the resulting set of risk equations was assessed by using the risk equations to transform the axial compressive femur loads from simulated, full-engagement, frontal crashes into event risks, and the resulting model-based injury rates were compared with the field-based injury rates. The results were promising: For unbelted drivers in towaway frontal crashes involving 1985-1997 model year passenger cars whose speed changes were less that 58 km/h, the model-based average injury rate was 1.10%; the field-based rate was 1.30%. Moreover, some of the trends in the field were confirmed with the model (e.g., there were more KTH-injured males than KTH-injured females). The risk equations demonstrated better fidelity for lower-speed crashes than high-speed crashes.

Snowdome, skiers and boarders: accident and emergency experience.

A prospective case series was compiled of all people presenting to the accident and emergency department with an injury caused by snowboarding or skiing, during the first year of opening of the Milton Keynes snowdome. The aim was to analyse the types of injuries associated with recreational snowboarding and to compare these with the injuries seen in skiing. Of the snowboarders, 23 (86%) were males, and the mean age was 24 years. Of the skiers, 13 (81%) were males, and the mean age was 34 years. Forty-three injuries required orthopaedic review, and 12 were admitted for further management. Significant differences were noted between the patterns of injuries in snowboarding and skiing. The snowboarders had a higher incidence of upper limb injuries (96 vs. 62%) and a lower incidence of lower limb injuries (4 vs. 38%) compared to the skiers. This study demonstrates that the opening of a leisure facility has a significant impact on the local accident and emergency department. Snowboarding is associated with a unique pattern of injuries, the knowledge of which should influence education and accident prevention.