Occurrence and prognostic effect of cervical spine injuries and cervical artery injuries with concomitant severe head injury.

BACKGROUND: Blunt cerebrovascular injuries (BCVIs) and cervical spinal injuries (CSIs) are not uncommon injuries in patients with severe head injury and may affect patient recovery. We aimed to assess the independent relationship between BCVI, CSI, and outcome in patients with severe head injury. METHODS: We identified patients with severe head injury from the Helsinki Trauma Registry treated during 2015-2017 in a large level 1 trauma hospital. We assessed the association between BCVI and SCI using multivariable logistic regression, adjusting for injury severity. Our primary outcome was functional outcome at 6 months, and our secondary outcome was 6-month mortality. RESULTS: Of 255 patients with a cervical spine CT, 26 patients (10%) had a CSI, and of 194 patients with cervical CT angiography, 16 patients (8%) had a BCVI. Four of the 16 BCVI patients had a BCVI-related brain infarction, and four of the CSI patients had some form of spinal cord injury. After adjusting for injury severity in multivariable logistic regression analysis, BCVI associated with poor functional outcome (odds ratio [OR] = 6.0, 95% CI [confidence intervals] = 1.4-26.5) and mortality (OR = 7.9, 95% CI 2.0-31.4). We did not find any association between CSI and outcome. CONCLUSIONS: We found that BCVI with concomitant head injury was an independent predictor of poor outcome in patients with severe head injury, but we found no association between CSI and outcome after severe head injury. Whether the association between BCVI and poor outcome is an indirect marker of a more severe injury or a result of treatment needs further investigations.

[Timing of surgical treatment of fractures of multiply iniured patients - from science to tactics]. / Monivammapotilaan murtumien leikkaus- hoidon ajoitus - tieteestä hoitostrategiaan.

Timing of the treatment of orthopaedic injuries in multiply injured patients has undergone changes. The timing of definitive fracture management has varied from several weeks to within hours of injury. In many studies a clear benefit has been identified from early definitive care of long bone fractures: early total care (ETC). The most seriously injured patients benefit from damage control orthopaedics, an approach employing primary external fixator stabilization followed by secondary intramedullary nailing. Debate over these approaches with enhanced understanding of biological response to injury has led to recent emphasis on the need for aggressive patient monitoring and continued multidisciplinary evaluation of the patient's physiological response to treatment.

Spine injuries among severely injured trauma patients: A retrospective single-center cohort study.

BACKGROUNDS AND AIMS: We aimed to determine the incidence and severity of spine injuries among severely injured trauma patients (Injury Severity Score (ISS)/New Injury Severity Score (NISS) > 15) treated in a single tertiary trauma center over 15 years. We also wanted to compare the demographics between patients with and without spine injuries and to determine the mortality of spine-injury patients. METHODS: Data from the years 2006-2020 from the Helsinki Trauma Registry (HTR), a local trauma registry of the trauma unit of the Helsinki University Hospital (HUH), were reviewed. We divided patients into two groups, namely those with traumatic spine injury (TSI) and those without traumatic spine injury (N-TSI). TSI patients were further subdivided into groups according to the level of injury (cervical, thoracolumbar, or multilevel) and the presence of neurological symptoms. RESULTS: We included 2529 patients: 1336 (53%) had a TSI and 1193 (47%) had N-TSI. TSI patients were injured more frequently by a high-fall mechanism (37% vs 21%, p < 0.001). Among TSI patients, 38% of high-fall injuries were self-inflicted. High falls, young age, and female gender were overrepresented in spine-injury patients with a self-inflicted injury mechanism. Cervical spine-injury patients were mostly elderly persons injured by a low-energy mechanism. CONCLUSIONS: Unlike other severely injured trauma patients, severely injured trauma patients with spine injuries are more frequently injured by a high-fall mechanism and self-injury.

Association of trauma classifications to long-term outcome in blunt trauma patients.

PURPOSE: The impact of major trauma is long lasting. Although polytrauma patients are currently identified with the Berlin polytrauma criteria, data on long-term outcomes are not available. In this study, we evaluated the association of trauma classification with long-term outcome in blunt-trauma patients. METHODS: A trauma registry of a level I trauma centre was used for patient identification from 1.1.2006 to 31.12.2015. Patients were grouped as follows: (1) all severely injured trauma patients; (2) all severely injured polytrauma patients; 2a) severely injured patients with AIS ≥ 3 on two different body regions (Berlin-); 2b) severely injured patients with polytrauma and a physiological criterion (Berlin+); and (3) a non-polytrauma group. Kaplan-Meier survival analysis was performed to estimate differences in mortality between different groups. RESULTS: We identified 3359 trauma patients for this study. Non-polytrauma was the largest group (2380 [70.9%] patients). A total of 500 (14.9%) patients fulfilled the criteria for Berlin + definition, leaving 479 (14.3%) polytrauma patients in Berlin- group. Berlin + patients had the highest short-term mortality compared with other groups, although the difference in cumulative mortality gradually plateaued compared with the non-polytrauma patient group; at the end of the 10-year follow up, the non-polytrauma group had the greatest mortality due to the high number of patients with traumatic brain injury (TBI). CONCLUSION: Excess mortality of polytrauma patients by Berlin definition occurs in the early phase (30-day mortality) and late deaths are rare. TBI causes high early mortality followed by increased long-term mortality.

[Posterior dislocation of the sternoclavicular joint]. / Rintalasta-solisluunivelen posteriorinen sijoiltaanmeno.

Posterior dislocation of the sternoclavicular joint is a rare injury. It can be associated with life-threatening complications. Computed tomography is the imaging modality of choice with which possible associated injuries can be detected. Acute injuries are managed with closed reduction under general anaesthesia. A fracture-dislocation is inherently more unstable than an isolated dislocation. Surgical treatment is advocated in cases of delayed diagnosis or failed closed reduction. With early diagnosis and treatment, the long-term outcome of this injury is good.

Finnish translation and external validation of the Trauma Quality of Life questionnaire.

BACKGROUND AND AIMS: Major trauma impairs health-related quality of life (HRQoL). The aim of this study was the Finnish translation and external validation of the Trauma Quality of Life (TQoL) questionnaire. PATIENTS AND METHODS: The Finnish version of the TQoL questionnaire and the 15D, a generic HRQoL questionnaire, were sent by mail to 417 patients identified from the Helsinki Trauma Registry. RESULTS: Altogether 222 patients (53.2%) returned the questionnaires. Participants' mean age was 49.9 ± 18.1 years and 68.8% were males. The mean 15D score was significantly lower than that of the age- and sex-standardized general Finnish population (0.817 vs. 0.918, p < 0.001). The correlation between the Finnish translation and 15D scores was high (0.805). Factor analysis revealed that the Finnish TQoL questionnaire and the 15D have four common factors. Internal validation identified some differences between the Finnish and the original versions. CONCLUSIONS: The correlation between the Finnish TQoL questionnaire and the 15D was high. The factor structures of the original and Finnish versions of the TQoL questionnaire were not identical, which may be a consequence of cultural or patient population differences.Implications for rehabilitationTrauma causes a long-term decrease in health-related quality of life (HRQoL), and this impact should be assessed in rehabilitation.The Trauma-Specific Quality of Life (TQoL) questionnaire has many shared features with the generic HRQoL questionnaire, but it also contains features related to post-traumatic disorder syndrome.The TQoL questionnaire is a valid tool for monitoring HRQoL after trauma.

Injury incidence and prevalence in Finnish top-level football - one-season prospective cohort study.

OJECTIVE: To investigate the injury characteristics in Finnish male football players. DESIGN: One-season prospective epidemiological study. Data were collected via injury reports from the medical staff and directly from the players using the Olso Sports Trauma Research Center Health Questionnaire. PARTICIPANTS: The first team squads of Finnish football league (n = 12 teams, 236 players). MAIN OUTCOME MEASUREMENT: Injury incidence. RESULTS: A total of 541 injuries occurred during the exposure of 62 878 hours. Injury incidence per 1000 exposure hours was 8.6 (30.6 in matches and 3.4 in training). A player sustained on average 2.3 (median 2, range 0-13) injuries during the study. Thigh and ankle were the most commonly injured body parts for acute injuries and hip/groin were the most commonly injured body part for overuse injuries. The median absence time for all injuries was 12 (range 0-107) days, 12 (range 0-107) for acute, and 8 (range 0-61) for overuse injuries. Thigh injuries caused the greatest consequences in terms of absence from full participation (median 5 days, range 0-88). CONCLUSION: Lower limb muscle injuries were the most prevalent injuries in the study. Collecting data directly from the players enabled to report more injuries compared to what was reported only by the medical staff.

Evolution of high-energy pelvic trauma in southern Finland: a 12-year experience from a tertiary trauma centre.

PURPOSE: We compared incidence, demographics, and injury mechanisms in severely injured patients with and without a pelvic ring fracture treated at a tertiary trauma centre. We also analyzed the changes in injury mechanisms that lead to high-energy pelvic trauma. METHODS: Data on severely injured adult patients (New Injury Severity Score [NISS] ≥16) from Helsinki Trauma Registry over the years 2006-2017 were reviewed. Patients with a pelvic ring fracture (PRF) and those without (N-PRF) were analyzed. Further subgrouping regarding time of the accident (2006-2009, 2010-2013, 2014-2017) was made. A comparison between groups was performed according to age, age > 60, gender, American Society of Anesthesiologists classification, injury scoring and mechanism, and 30-day in-hospital mortality. RESULTS: We included 545 PRF and 1048 N-PRF patients. Pelvic ring fracture patients were more likely to be female (39% vs 22%, p < 0.001), to be more severely injured (NISS 35.2 vs 30.4, p < 0.001), injured due to a high fall (41% vs 25%, p < 0.001), to have self-inflicted injuries (23% vs 8%, p < 0.001), and to have higher 30-day in-hospital mortality (13% vs 9%, p = 0.005). During the study period, we noted increasing mean age and proportion of patients aged > 60, improvement in outcome (shown by decreasing 30-day in-hospital mortality rate) in both groups, and a decrease in motor vehicle accidents (MVAs) leading to pelvic trauma (30-16%). CONCLUSIONS: High-energy pelvic trauma can no longer be characterized as traffic accident injuries among young men. MVAs leading to pelvic trauma are decreasing and the most common injury mechanism is high fall. The patients are older and often female. Every fourth high-energy pelvic trauma was due to attempted suicide.

Surgical strategy for femoral shaft fractures in severely injured patients: A 13-year experience from a tertiary trauma centre.

BACKGROUND: The treatment strategy of femoral shaft fractures in polytraumatised patients has evolved over the years and led to improved outcomes for these patients. However, there is still controversy regarding the optimal treatment strategy and surgical care can differ markedly from one country to another. We investigate the surgical treatment strategy (Early Definitive Care (EDC) or Damage Control Orthopaedics (DCO)) implemented in the care of severely injured patients with femoral shaft fractures treated at a single tertiary trauma centre in southern Finland and factors affecting decision making. METHODS: The Helsinki Trauma Registry (HTR) was used retrospectively to identify severely injured patients (New Injury Severity Score [NISS] ≥ 16) treated from 2006 through to 2018 with concomitant femoral shaft fractures. Patients <16 years old, with isolated head injuries, dead on arrival and those admitted >24 h following the injury were excluded. Based on their initial surgical management strategy, femoral fracture patients were divided into EDC and DCO groups and compared. RESULTS: Compared to other trauma-registry patients, those with femoral shaft fractures are younger (30.9 ± 15.9 vs. 47.0 ± 19.7, p<0.001) and more often injured in road traffic accidents (64.1% vs. 34.4%, p<0.001). The majority (78%) of included patients underwent EDC. Patients who underwent DCO were significantly more severely injured (NISS: 40.1 ± 11.5 vs. 27.8 ± 10.1, p<0.001) with longer lengths of stay in ICU (15.4 ± 9.8 vs. 7.5 ± 6.1 days, p<0.001) and in hospital (29.9 ± 29.6 vs. 13.7 ± 11.4 days, p<0.001) than patients treated with EDC. Decision making was based primarily on injury related factors, while non-injury related factors may have contributed to choosing a DCO approach in a small number of cases. CONCLUSION: Early definitive care is the prevailing treatment strategy in severely injured femoral shaft fracture patients treated at a tertiary trauma centre. Patients treated with DCO strategy are more severely injured particularly having sustained worse intracranial and thoracic injuries. In addition to injury related factors, treatment strategy decision making was influenced by non-injury related factors in only a minority of cases.

Occipital condyle fracture-A rare but severe injury in cranial fracture patients.

We clarified occurrence, severity, and associated injuries of occipital condyle fractures (OCFs) in a cranial fracture population. Retrospective data of cranial fracture patients were analyzed. The outcome variable was presence of OCF in cranial fracture patients. Predictor variables were type of associated injury, Glasgow Coma Scale (GCS) value under 6, and death during hospital care. In addition, occurrence of OCF was assessed according to cranial fracture subtypes. Explanatory variables were age, sex, injury mechanism, involvement of alcohol, and high-energy injury. Treatment and outcome of OCFs were analyzed. Of 637 cranial fracture patients, 19 (3.0%) sustained an OCF, eight of whom had no other cranial fractures. In the multivariate adjusted model, increased risk for OCF was detected in patients with cervical injuries (OR 18.66, 95% CI 5.52, 63.12; p < 0.001) and facial fractures (OR 5.99, 95% CI 1.01, 35.45; p = 0.049). Patients with fractures not extending to the skull base were less likely to have OCF (OR 0.01, 95% CI 0.001, 0.25; p = 0.004), and fractures localized solely to the base of the skull offered a protective effect for OCF (OR 0.19, 95% CI 0.06, 0.58; p = 0.003). All OCFs were treated non-operatively with a cervical collar without complications. OCF patients typically sustain other severe injuries, particularly cervical injuries and facial fractures. Careful screening for associated injuries is therefore crucial when examining a patient with OCF. The classification scheme of Mueller et al. seems to be useful in guiding the treatment of OCFs, at least type 1 and 2 fractures.

Severe head injury in elderly: 6-year comparison of treatment and outcome between southern Finland and Navarra (Spain).

PURPOSE: To compare the profile, treatment and outcome of elderly patients with severe traumatic brain injuries (TBI) between southern Finland and Navarra (Spain). METHODS: Data collected from, 2010 to 2015, in the Major Trauma Registry of Navarra (MTR-N) and the Helsinki Trauma Registry (HTR) were compared. Patients with New Injury Severity Score (NISS) ≥ 16 and age ≥ 65 with isolated severe TBI were considered. Patients who had been admitted to the hospital ≥ 24 h after the trauma, had been pronounced dead before hospital arrival, or had been injured by hanging, drowning or burns, were excluded. Outcome was defined by 30-day hospital mortality. The expected mortality was calculated using the Revised Injury Severity Classification score II (RISC II). Other compared data included demographics, injury mechanism, pre-hospital and hospital treatment, and time intervals. RESULTS: A total of 305 (MTR-N) and 137 (HTR) patients were included in the outcome analysis. The standardized mortality ratio with 95% confidence interval was for MTR-N 1.4 (1.1-1.6) and for HTR 0.8 (0.6-1.1). Patients in Navarra were older (average 79.7 vs. 75.0) while in southern Finland the percentage of pre-hospital intubation in patients with GCS ≤ 8 (75.0% vs 50.0%) and ICU admission (72.2% vs 22.0%) were higher. CONCLUSION: The better adjusted outcome of elderly patients with severe TBI in southern Finland in comparison to Navarra could be due to higher rate of pre-hospital intubation and/or higher rate of ICU admissions in southern Finland. Increasing number of elderly patients with severe TBI necessitate uniformly accepted protocols in pre- and in-hospital management.

Cervical spine injuries in facial fracture patients - injury mechanism and fracture type matter.

Evidence supports the notion that craniofacial fractures are significant predictors of cervical spine injuries (CSIs), but some debate remains on the injury mechanism of co-existing CSIs in craniofacial fractures and the relationship between CSI and specific facial fractures. In this retrospective study, we aim to assess the incidence rates of specific facial fracture types as well as other important variables and their relationship with CSIs. The primary outcome variable, CSI, and several predictor variables, including facial fracture type, were evaluated with logistic regression analyses. Of 2919 patients, the total CSI incidence rate was 3.0%. Rates of CSI in patients with isolated mandibular fractures (OR 0.26 CI 0.10, 0.63; p = 0.006) were lower than those previously reported, whereas isolated nasal fractures were strongly associated with CSI (OR 2.67 CI 1.36, 5.22; p = 0.004). Patients with concomitant cranial injuries were twice as likely to have CSI (OR 2.00, CI 1.22, 3.27; p = 0.006). Even though there is a strong occurrence rate of CSIs in patients with cranial injuries, clinicians should be aware that patients presenting with isolated facial fractures are at significant risk for sustaining CSIs also.

Achilles Tendon Reconstruction with Semitendinous Tendon Grafts Is Associated with a High Complication Rate.

BACKGROUND: In the presence of a large gap where end-to-end repair of the torn Achilles tendon is difficult and V-Y advancement would likely be insufficient, augmentation is sometimes required. At our institute we have used primarily the hamstring autograft augmentation technique for the past two decades. The aim of this study was to analyze the complications after surgical treatment of Achilles tendon rupture with semitendinous tendon augmentation. METHODS: We retrospectively analyzed 58 consecutive patients treated with semitendinous tendon autograft augmentation at the Helsinki University Hospital between January 1, 2006, and January 1, 2016. RESULTS: During the study period, 58 patients were operated on by six different surgeons. Of 14 observed complications (24%), seven were major and seven were minor. Most of the complications were infections (n = 10 [71%]) The infections were noted within a mean of 62 days postoperatively (range, 22-180 days). Seven patients with a complication underwent repeated operation because of skin edge necrosis and deep infection (five patients), hematoma formation (one patient), and a repeated rupture (one patient). CONCLUSIONS: In light of the experience we have had with autologous semitendinous tendon graft augmentation, we cannot recommend this technique, and, hence, we should abandon reconstruction of Achilles tendon ruptures with autologous semitendinous tendon grafts at our institute. Instead, other augmentation techniques, such as flexor hallucis longus tendon transfer, should be used.

Severe blunt trauma in Finland and Estonia: comparison of two regional trauma repositories.

PURPOSE: Evolving trauma system of Estonia has undergone several reforms; however, performance and outcome indicators have not been benchmarked previously. Thus, we initiated a baseline study to compare demographics, management and outcomes of severely injured patients between Southern Finland and Northern Estonia utilizing regional trauma repositories. METHODS: A comparison of data fields of the Helsinki University Hospital trauma registry (HTR) and trauma registry at the North Estonia Medical Centre in Tallinn (TTR) between 1/1/2015 and 31/12/2016 was performed. The inclusion criterion was Injury Severity Score > 15. Transferred patients, patients with penetrating injuries, and pediatric patients were excluded. The data for comparison included demographics, Trauma Score-Injury Severity Score (TRISS), mortality, and standardized mortality ratio (SMR). Primary outcome was mortality and SMR per TRISS methodology. RESULTS: During the 2-year study period, 324 patients from the HTR and 152 from the TTR were included. Demographic profile was similar between the repositories with the exception of severe abdominal injuries being more prevalent at the TTR (25.0% vs. 13.3%, p = 0.002). Predominant injury mechanism was non-ground level fall in both repositories. Mortality was similar at 14.5% and 13.6% at the TTR and HTR, respectively (adj. p = 0.762; OR 1.13, 95% CI 0.64-1.99). SMR was lower at the HTR compared to the TTR (0.65 vs. 0.77, p > 0.05), however, the difference did not reach statistical significance. CONCLUSION: Benchmarking trauma repositories at a national level provides opportunities for quality and performance improvements. We observed comparable demographic profile and outcome indicators in the compared regional trauma systems.

Major blunt trauma causes increased mortality up to 12 years: Long-term survival in 3 557 patients compared to 35 502 control persons.

BACKGROUND: Trauma registries usually report 30-day or in-hospital mortality as an outcome measure. However, some studies criticize this measure as inadequate; the impact of a major trauma could last longer than 1 month after the injury. We studied the long-term mortality of patients who sustained a major trauma. METHODS: The Helsinki University Hospital's trauma registry was used for patient identification from 2006 to 2015 (New Injury Severity Score ≥ 16 and blunt mechanism of injury). For each trauma registry patient, 10 control persons matched by age, sex, and county of residency were obtained from the Population Register Center of Finland. Cause of death information was obtained from Statistics Finland. RESULTS: We included 3 557 trauma registry patients and 35 502 control persons. Follow-up ranged from 1 year 7 months to 11 years 7 months. The 1-year mortality was 11 times higher in the trauma-patient group (22% vs. 2%). The long-term (approximately 12 years) mortality after the injury was 2.6 times higher in the trauma-patient group (46% vs. 18%). For patients surviving at least 1 year post-trauma, the mortality at 12 years was 2.2 times higher than in the control group (31% vs. 14 %). The cause of death was a disease in 73.3% of the trauma patients and 93.6% of the controls. Accidents were more often a cause of death in the patient population than in the control population (21.2% vs. 4.1%). Suicide was the cause of death in 3.0% of patients and 1.1% in controls. Several factors associated with increased mortality were identified. CONCLUSIONS: Major trauma patients had significantly higher long-term mortality compared to controls. To the best of our knowledge, this is the first study on this subject with a follow up of this duration with patients this severely injured and a cohort this large.

Resource use and clinical outcomes in blunt thoracic injury: a 10-year trauma registry comparison between southern Finland and Germany.

PURPOSE: Serious thoracic injuries are associated with high mortality, morbidity, and costs. We compared patient populations, treatment, and survival of serious thoracic injuries in southern Finland and Germany. METHODS: Mortality, patient characteristics and treatment modalities were compared over time (2006-2015) in all patients with Abbreviated Injury Scale (AIS) thorax ≥ 3, Injury Severity Score (ISS) > 15, age > 15 years, blunt trauma mechanism, and treatment in Intensive Care Unit (ICU) in Level 1 hospitals included in the Helsinki Trauma Registry (HTR) and the TraumaRegister DGU® (TR-DGU). RESULTS: We included 934 patients from HTR and 25 448 patients from TR-DGU. Pre-hospital differences were seen between HTR and TR-DGU; transportation in the presence of a physician in 61% vs. 97%, helicopter use in 2% vs. 42%, intubation in 31% vs. 55%, and thoracostomy in 6% vs. 10% of cases, respectively. The mean hospital length of stay (LOS) and ICU LOS was shorter in HTR vs. TR-DGU (13 vs. 25 days and 9 vs. 12 days, respectively). Our main outcome measure, standardised mortality ratio, was not statistically significantly different [1.01, 95% confidence interval (CI) 0.84-1.18; HTR and 0.97, 95% CI 0.94-1.00; TR-DGU]. CONCLUSIONS: Major differences were seen in pre-hospital resources and use of pre-hospital intubation and thoracostomy. In Germany, pre-hospital intubation, tube thoracostomy, and on-scene physicians were more prevalent, while patients stayed longer in ICU and in hospital compared to Finland. Despite these differences in resources and treatment modalities, the standardised mortality of these patients was not statistically different.

Does arrival time affect outcomes among severely injured blunt trauma patients at a tertiary trauma centre?

BACKGROUND AND AIMS: We aimed to determine whether the outcome of severely injured patients differs based on admission time (office hours vs. non-office hours) at a tertiary trauma centre without an in-house trauma surgeon consultant available at all times. We also studied subgroups of patients presenting with a New Injury Severity Score (NISS) ≥ 25 and patients experiencing major bleeding. PATIENTS AND METHODS: This trauma registry study consisted of severely injured patients (NISS > 15) with blunt trauma treated between 2006 and 2017 at a single institute. Causes of deaths were obtained from autopsy reports and classified as resulting from brain injury; exsanguination; multi-organ failure, adult respiratory distress syndrome, or sepsis; or other. RESULTS: Among 1853 patients, 497 (27%) were admitted during office hours (OH) and 1356 (73%) during non-office hours (NOH). Further subgroup analysis consisted of 211 OH and 611 NOH patients with NISS ≥ 25, and 51 OH and 154 NOH patients experiencing major bleeding. The 30-day in-hospital mortality was 3.8%-7.4% lower in the NOH groups. We found no significant differences between the study groups in neither the standardised mortality ratio (SMR, defined as the ratio of observed to expected mortality) nor in the causes of death. In both groups, the primary cause of death resulted from brain injury. CONCLUSIONS: We found that arrival time did not affect mortality among patients with severe blunt trauma treated at a tertiary trauma centre without an in-house trauma surgeon consultant available at all times. Thus, this type of unit can maintain a standard of care during non-office hours by investing in precise treatment protocols and continuous education. However, our results do not apply to penetrating trauma injury patients.

Recommendation of use of checklists in tibial intramedullary nail removal: Retrospective study of mechanical complications related to nail removal.

BACKGROUND: The removal of implants such as intramedullary nails is one of the most common operations in orthopedic surgery. The indications for orthopedic implants removal will always remain a subject of conversation and hardly supported by literature. The aim of this study to report injuries of treatment in tibial nail removal and to determine if there are fracture characteristics, patient demographics, or surgical details that may predict a complication. METHODS: This is a retrospective seven-year (2010-2016) study including a total of 389 tibial intramedullary nail removals at the Helsinki University Hospital's orthopedic unit. Patients with tibial fracture and removal of intramedullary nail were identified from the hospital discharge register and analyzed. RESULTS: A total of 21 (5,4%) nail removal related mechanical complications (iatrogenic fractures, nerve injuries, failures to remove the nail) were noted. The most common complication was iatrogenic fracture (n = 15, 3,8%). In 6/15 cases the fracture was caused by broken interlocking screws, In 5/15 cases the iatrogenic fracture was caused accidentally by extracting the nail without prior removal of all distal interlocking screws. In one case, new condensed bone had formed around the nail's distal end and case the forced nail extraction caused a re-fracture in both tibia and fibula. CONCLUSION: Nail removal can be a challenging operation which does not always receive the necessary preoperative planning or operative expertise. Iatrogenic fractures were most often caused by inadequate preoperative planning or assuming that a broken interlocking screw tilts during the extraction. We suggest the use of checklists in preoperative planning to avoid fractures caused by broken or undetected interlocking screws.

Validation of the revised injury severity classification score in patients with moderate-to-severe traumatic brain injury.

INTRODUCTION: By analysing risk-adjusted mortality ratios, weaknesses in the process of care might be identified. Traumatic brain injury (TBI) is the main cause of death in trauma, and thus it is crucial that trauma prediction models are valid for TBI patients. Accordingly, we assessed the validity of the RISC score in TBI patients by internal and external validation analyses. METHODS: Patients with moderate-to-severe TBI admitted to the TraumaRegister DGU® (TR-DGU) and the trauma registry of Helsinki University Hospital (TR-THEL) in 2006-2011 were included in this retrospective open cohort study. Definition of moderate-to-severe TBI was head abbreviated injury scale of 3 or higher. Subgroup analysis for patients with isolated and polytrauma TBI was performed. The performance of the RISC score was evaluated by assessing its discrimination (area under the curve, AUC) and calibration (Hosmer-Lemeshow [H-L] test). RESULTS: Among the 9106 and 809 patients with moderate-to-severe TBI admitted to TR-DGU and TR-THEL, unadjusted mortality was 26% and 23%, respectively. Internal and external validation of the RISC score showed good discrimination (TR-DGU AUC 0.89, 95% confidence interval [CI] 0.88-0.90 and TR-THEL AUC 0.84, 95% CI 0.81-0.87), but poor calibration (p<0.001) in patients with moderate-to-severe TBI. Subgroup analysis found the discrimination only to be modest in isolated TBI (AUC 0.76) and calibration to be particularly poor in polytrauma TBI (TR-DGU H-L=4356, p<0.001; TR-THEL H-L 112, p<0.001). CONCLUSION: The RISC score was found to be of limited predictive value in patients with moderate-to-severe TBI. A new general trauma scoring system that includes TBI specific prognostic factors is warranted.