Magnetic Resonance Imaging Predictors of Chondral Lesions in Patients With Femoroacetabular Impingement: An Analysis of 545 Cases.

PURPOSE: A large prospective cohort was used (1) to evaluate the overall ability of magnetic resonance imaging (MRI) to detect Outerbridge grade III and IV cartilage defects found during surgery and (2) to identify the specific MRI findings most associated with these cartilage defects so that the practicing hip arthroscopist can better predict cartilage injury before surgery. METHODS: All patients undergoing hip arthroscopy between February 2015 and May 2017 at 1 institution were enrolled in a prospective cohort. Intra-articular findings were documented at the time of surgery. MRI reports were retrospectively reviewed for radiologist-reported articular cartilage, osseous, or synovial abnormalities. Sensitivity and specificity of MRI findings were calculated; multivariate logistic regression analysis determined which findings were associated with high-grade chondral damage at the time of arthroscopy and used to create an online risk calculator, https://orthop.washington.edu/hiprisk/. RESULTS: Of 598 patients who underwent hip arthroscopy, 550 had MRI reports available for review (92%). Grade III and IV cartilage injuries were reported on arthroscopy in 70 patients (13%) of average age 33 ± 13 years. On univariate analyses, individual MRI findings were not sensitive in detection of articular cartilage injury (mean 22%; range, 1.4%-46%), but positive findings were highly specific (mean 90%,; range, 76%-99%). Multivariate analysis revealed that older age (odds ratio [OR] 1.09 [1.06-1.11], P < .001) and osseous findings such as subchondral cyst or edema (OR 4.77 [2.51-9.05], P < .001) were most predictive of grade III and IV defects (P < .001). CONCLUSION: MRI was a specific but not sensitive tool in diagnosing articular cartilage injury. Surgeons should be aware that osseous findings such as cysts or edema are highly predictive of full-thickness cartilage loss in FAI. LEVEL OF EVIDENCE: Level III, development of diagnostic criteria (consecutive patients with consistently applied reference standard, no blinding).

Machete injuries to the upper extremity.

PURPOSE: We intend to describe and analyze the spectrum of upper extremity injuries that arises from both accidental and intentional machete injuries with a focus on associated complications and comorbidities. This review is the first from a United States institution, and the only from a designated level 1 trauma center. METHODS: A retrospective review of machete related upper extremity injuries admitted to a level 1 trauma center from 2008 to 2016. The following data was collected on admitted patients: demographics, mechanism of injury, surgical management, and complications. We assessed the data with Pearson Chi square analysis. RESULTS: This cohort consisted of 48 patients (mean = 42 ± 13 years old); the majority were men (96%) involved in an assault (81%). These patients had a high rate of documented psychiatric history, substance and tobacco abuse, and being underinsured. Patient follow-up was extremely variable: 75% of patients presented for follow-up care (mean = 149 ± 344 days; range 8-1846 days). 44% had complications (i.e., infection, tendon rupture, nerve palsy). We identified no associations when examining follow-up rates or complication rates regarding patient comorbidities, insurance status, mechanism of injury, or the need for a nerve, artery, or tendon repair. Patients with current tobacco use did have an increased risk for infection. The majority (52%) of injuries occurred on the ulnar side of the forearm and to the non-dominant extremity (66%). Patients assaulted by machetes are significantly more likely to have a history of psychiatric illness, substance abuse, tobacco use, and are more likely to be underinsured compared to those with accidental machete injuries. CONCLUSIONS: While machete injuries may be uncommon in most areas of the United States, physicians should give special attention to the patient comorbidities as many of these patients have complex medical and social issues which could complicate attempts of appropriate treatment. LEVEL OF EVIDENCE: IV; Prognostic Study.

Predictors of mortality in pediatric trauma: experiences of a level 1 trauma center and an assessment of the International Classification Injury Severity Score (ICISS).

OBJECTIVES: Injury severity scoring tools allow systematic comparison of outcomes in trauma research and quality improvement by indexing an expected mortality risk for certain injuries. This study investigated the predictive value of the empirically derived ICD9-derived Injury Severity Score (ICISS) compared to expert consensus-derived scoring systems for trauma mortality in a pediatric population. METHODS: 1935 consecutive trauma patients aged <18 years from 1/2000 to 12/2012 were reviewed. Mechanism of injury (MOI), Injury Severity Score (ISS), Revised Trauma Score (RTS), Trauma Score ISS (TRISS), and ICISS were compared using univariate and multivariate logistic regression analysis and receiver operator characteristic analysis. RESULTS: The population was a median age of 11 ± 6 year, 70 % male, and 76 % blunt injury. Median ISS 13 ± 12 and overall mortality 3.5 %. Independent predictors of mortality were initial hematocrit [odds ratio (OR) 0.83 (0.73-0.95)], HCO3 [OR 0.82 (0.67-0.98)], Glasgow Coma Scale score [OR 0.75 (0.62-0.90)], and ISS [OR 1.10 (1.04-1.15)]. TRISS was superior to ICISS in predicting survival [area under receiver operator curve: 0.992 (0.982-1.000) vs 0.888 (0.838-0.938)]. CONCLUSIONS: ICISS was inferior to existing injury scoring tools at predicting mortality in pediatric trauma patients.

Mechanism and mortality of pediatric aortic injuries.

BACKGROUND: Aortic injuries are rare, but have a high mortality rate in children and adolescents. We sought to investigate mechanisms of injury and predictors of survival. MATERIALS AND METHODS: The Kids' Inpatient Database (1997-2009) was used to identify cases of thoracic and abdominal aortic injury (International Classification of Diseases, ninth Revision, Clinical Modification codes 901.0, 902.0) occurring in children aged <20 y. Bivariate and risk-adjusted multivariate analyses were used to reveal associated diagnoses and procedures and to identify predictors of in-hospital mortality, respectively. Cases were limited to emergent or urgent admissions. RESULTS: A total of 468 cases were identified. Survival was 65% overall, 63% for boys and 68% for girls. The most common mechanism of injury was motor vehicle-related (77%), followed by other penetrating trauma (10%) and firearm injury (8%). On multivariate modeling, boys (odds ratio, 0.15 [95% confidence interval, 0.05, 0.45]) and Hispanic children (0.17 [0.05, 0.60]) had lower associated mortality versus girls and Caucasians, respectively. Self-pay patients (6.47 [1.94, 21.6]) had higher mortality versus privately insured patients. Children in the fourth income quartile had lower mortality versus all income quartile patients. Patients admitted to urban nonteaching hospitals (0.15 [0.04, 0.59]) had lower mortality versus those admitted to urban teaching hospitals. Patients with traumatic shock (47.9 [12.3, 187]) or necessitating exploratory laparotomy (13.7 [2.06, 91.4]) had the highest associated mortality overall. Survival increased over the study period between 1997 and 2009. CONCLUSIONS: Motor vehicle-related injuries are the predominant mechanisms of aortic injury in the pediatric population. Gender, race, payer status, income quartile, and hospital type, along with associated procedures and diagnoses, are significant determinants of mortality on multivariate analysis.

Limited Return to Preinjury Performance in NCAA Division I American Football Players With Hamstring Injuries.

Background: Hamstring strains are common among elite athletes, but their effect on return to the same level of play in American football has been incompletely characterized. Purpose: Data on National Collegiate Athletics Association Division I college football players with acute hamstring strains were gathered to identify the effects these injuries have on both return to play and athletic performance regarding velocity, workload, and acceleration. Study Design: Case Series; Level of evidence, 4. Methods: Injury data for a single Division I football team were prospectively recorded over a 4-year period. Players wore global navigation satellite system and local positioning system (GNSS/LPS) devices to record movement data in practices and games. The practice and game data were cross-referenced to evaluate players with isolated acute hamstring strains. Comparisons were made regarding players' pre- and postinjury ability to maintain high velocity (>12 mph [19.3 kph]), maximal velocity, triaxial acceleration, and inertial movement analysis (IMA). There were 58 hamstring injuries in 44 players, of which 25 injuries from 20 players had GNSS/LPS data. Results: Players were able to return to play from all 25 injury incidences at a mean of 9.2 days. At the final mean follow-up of 425 days, only 4 players had reached preinjury function in all measurements; 12 players were able to return in 2 of the 4 metrics; and only 8 players reached their preinjury ability to maintain high velocity. For those who did not achieve this metric, there was a significant difference between pre- and postinjury values (722 vs 442 m; P = .016). A total of 14 players were able to regain their IMA. Players who returned to prior velocity or acceleration metrics did so at a mean of 163 days across all metrics. Conclusion: While players may be able to return to play after hamstring strain, many players do not reach preinjury levels of acceleration or velocity, even after 13.5 months. Further studies are needed to confirm these findings, assess clinical relevance on imaging performance, and improve hamstring injury prevention and rehabilitation.

Patient Outcomes After Transolecranon Fracture-Dislocation.

INTRODUCTION: There are few small case series that discuss patient outcomes after a transolecranon fracture-dislocation, and they suggest that patients have reasonable function after injury. The purpose of this study was to describe the injury pattern and clinical outcomes of transolecranon fracture-dislocations. METHODS: After Institutional Review Board approval, transolecranon fracture-dislocations treated at two academic level 1 trauma centers between 2005 and 2018 were retrospectively reviewed. Fracture characteristics and postsurgical complications were recorded. Radiographs were reviewed for arthrosis, and Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) scores were obtained at a minimum of 12 months after injury. RESULTS: Thirty-five patients with a mean follow-up of 28 months (range, 12 to 117 months) were included. Nine patients had associated radial head fracture, 23 patients had associated coronoid fracture, four patients had ligamentous injury, and two patients had capitellum fracture. Four patients (11%) developed infection and required irrigation and débridement with intravenous antibiotics. Thirteen patients (13 of 35, 37%) developed radiographic arthrosis with most (11 of 13) having grade 2 or three changes. Patients who had associated radial head fracture, coronoid fracture, capitellum fracture, and/or ligamentous injury had significant arthrosis (10 of 24, 42%) more commonly than patients with olecranon fracture alone (1 of 11, 9%) (P = 0.05). Twenty-eight patients completed patient outcomes instrument and achieved a mean QuickDASH score of 9 (range, 0 to 59). Patients with isolated transolecranon fracture had a significantly better QuickDASH score (0.93, 0 to 4) than patients with transolecranon fracture variant with associated coronoid fracture, radial head fracture, distal humeral fracture, or ligamentous injury (11.74, 0 to 59) (P = 0.04). DISCUSSION: Patients with transolecranon fracture-dislocation had excellent return to function based on the QuickDASH outcome assessment. Patients with transolecranon fracture with associated radial head fracture, coronoid fracture, humeral condyle fracture, and/or ligamentous injury tend to have worse functional outcome than patients with simple transolecranon fracture. LEVEL OF EVIDENCE: Level IV-case series.

Recent Advances in Forward Surgical Team Training at the U.S. Army Trauma Training Department.

U.S. Army Forward Surgical Teams (FSTs) are elite, multidisciplinary units that are highly mobile, and rapidly deployable. The mission of the FST is to provide resuscitative and damage control surgery for stabilization of life-threatening injuries in austere environments. The Army Trauma Training Center began in 2001 at the University of Miami Ryder Trauma Center under the direction of COL T. E. Knuth, MC USA (Ret.), as a multimodality combination of lectures, laboratory exercises, and clinical experiences that provided the only predeployment mass casualty and clinical trauma training center for all FSTs. Each of the subsequent five directors has restructured the training based on dynamic feedback from trainees, current military needs, and on the rapid advances in combat casualty care. We have highlighted these evolutionary changes at the Army Trauma Training Center in previous reviews. Under the current director, LTC J. M. Seery, MC USA, there are new team-building exercises, mobile learning modules and simulators, and other alternative methods in the mass casualty exercise. This report summarizes the latest updates to the state of the art training since the last review.

Causes of death differ between elderly and adult falls.

BACKGROUND: As the population ages, mortality from falls will soon exceed that from all other forms of injury. Tremendous resources are focused on this problem, but how these patients die is unclear. To fill this gap, we tested the hypothesis that falls among the elderly are related to patient, rather than to injury factors when compared with falls among younger adults. METHODS: From January 2002 to December 2012, 7,293 fall admissions were reviewed. Data are reported as mean ± SD if normally distributed or median (interquartile range) if not. RESULTS: In 2002 to 2007, 25% of all falls were in elderly patients (≥65 years), but in 2008 to 2012, this proportion increased to 30% (p < 0.001). When comparing adult (n = 5,216) with elderly (n = 2,077) admissions, characteristics were as follow: Injury Severity Score (ISS) of 8 (4-13) versus 9 (5-17), length of stay (in days) of 3 (1-7) versus 6 (2-11), and mortality of 3.8% versus 13.7% (all p < 0.001). After controlling for variables associated with mortality using multiple logistic regression, elderly age was the strongest independent predictor of mortality (odds ratio, 8.18; confidence interval, 4.88-13.71). When comparing adult (n = 198) with elderly (n = 285) fatalities, ground-level falls occurred in 31% versus 91%, ISS was 27 (25-41) versus 25 (16-36), and length of stay (in days) was 2 (0-6) versus 4 (1-11) (all p < 0.001). Death occurred directly from fall in 82% versus 63%, from complications in 10% versus 20%, and from a fatal event preceding the fall in 8% vs. 17% (all p < 0.001). CONCLUSION: The proportion of fall admissions in the elderly is growing in this trauma system. Elderly age is the strongest independent predictor of mortality following a fall. In those who die, death is less likely a direct effect of the fall. LEVEL OF EVIDENCE: Epidemiologic study, level III.