The effect of shock duration on trauma-induced coagulopathy in a murine model

Background Trauma-induced coagulopathy (TIC) is a life-threatening condition associated with high morbidity and mortality. TIC can present with different coagulation defects. In this study, the aim was to determine the effect of shock duration on TIC characteristics. We hypothesized that longer duration of shock leads to a more hypocoagulable rotational thromboelastometry (ROTEM) profile compared to a shorter duration of shock. Methods Male B57BL/6J(c) mice (n = 5–10 per group) were sedated and mechanically ventilated. Trauma was induced by bilateral lower limb fractures and crush injuries to the liver and small intestine. Shock was induced by blood withdrawals until a mean arterial pressure of 25–30 mmHg was achieved. Groups reflected trauma and shock for 30 min (TS30) and trauma and shock for 90 min (TS90). Control groups included ventilation only (V90) and trauma only (T90). Results Mice in the TS90 group had significantly increased base deficit compared to the V90 group. Mortality was 10% in the TS30 group and 30% in the TS90 group. ROTEM profile was more hypocoagulable, as shown by significantly lower maximum clot firmness (MCF) in the TS30 group (43.5 [37.5–46.8] mm) compared to the TS90 group (52.0 [47.0–53.0] mm, p = 0.04). ROTEM clotting time and parameters of clot build-up did not significantly differ between groups. Conclusions TIC characteristics change with shock duration. Contrary to the hypothesis, a shorter duration of shock was associated with decreased maximum clotting amplitudes compared to a longer duration of shock. The effect of shock duration on TIC should be further assessed in trauma patients.

Multimorbidity Patterns and the Disablement Process among Public Long-Term Care Insurance Claimants in the City of Yiwu (Zhejiang Province, China)

This study aimed to identify multimorbidity patterns and explore the disablement process by utilizing the model raised by Verbrugge and Jette as a theoretical framework. This cross-sectional study used public Long-term Care Insurance (LTCI) claimants’ assessment data of Yiwu city in Zhejiang Province, China, for 2604 individuals aged 60 years and older, from September through December 2018. Latent Class Analysis (LCA) was conducted using 10 common chronic conditions. Structural Equation Modeling was used to examine the disablement process. The latent classes of multimorbidity patterns were the “coronary atherosclerotic heart disease” class (19.0%), the “lower limb fractures” class (26.4%), and the “other diseases” class (54.6%). The structural model results show that coronary atherosclerotic heart disease had a significant influence on incontinence, but it was not statistically significant in predicting vision impairment and mobility impairment. Lower limb fractures had significant effects on vision impairment, incontinence, and mobility impairment. Vision impairment, incontinence, and mobility impairment had significant effects on physical activities of daily living (ADLs). Our findings suggest that different impairments exist from specific patterns of multimorbidity to physical ADL disability, which may provide insights for researchers and policy makers to develop tailored care and provide support for physically disabled older people.

COVID-19 in Elderly Patients Surgically Treated for Lower Limbs Fracture

Background: The coronavirus disease 2019 (COVID-19) pandemic outbreak has posed new problems in the context of patients suffering from other diseases. In particular, musculoskeletal sequelae related to the state of debilitation associated with COVID-19 are important to consider in elderly patients undergoing surgery after lower limbs fracture, especially in the post-operative period. The objective of this study was to evaluate whether COVID-19 influenced biochemical parameter, recovery and mortality of surgically treated patients suffering from lower extremity fractures. Methods: Laboratory and clinical data of 30 patients were extrapolated and analyzed in the pre-operative and post-operative periods. Among these patients, 13 had COVID-19 infection (COVID-19 +), whereas 17 had no signs of COVID-19 infections (COVID-19 −). Long-term clinical and functional outcomes were also analyzed. Results: Lower calcium, slightly higher values of CRP and much higher values of CPK and AST were observed pre-operatively in COVID-19 + patients, who also showed higher prevalence of long-term sequelae than COVID-19 − patients. Conclusions: COVID-19 affects long-term outcome of elderly patients with lower limb fractures in a multifactorial way. First, the virus directly damages the muscle tissue. Secondly, the lung function impairment worsens the overall performance, making rehabilitation more challenging.

Fibula Nail Outcomes in Soft Tissue Compromised Ankle Fractures

Background: To determine the clinical outcomes following fibula nail fixation and to identify the indication for the use of fibula nails in lower limb fractures. Methods: Retrospective study of adult patients from 2 major trauma centers (MTCs) and 9 trauma units (TUs) who underwent fibula nail fixation for AO/OTA 44 fractures between January 1, 2018, and October 31, 2020. Outcome measures included infection, metalwork complications, nonunion or malunion, time to union, and length of inpatient hospital stay. Results: Ninety-five patients were included, with a mean age of 66 years; 57.9% of patients were female. The average body mass index was 30. Sixty-nine patients (72.6%) sustained a Weber B and 24 (27.4%) sustained a Weber C fracture. In addition, 26.3% were open fractures and all patients had soft tissue compromise affecting the lateral malleolus. The calculated infection rate for fibula nail was 4.2% and metalwork complication rate was 5.2%. The nonunion and malunion rate was 8.4% and rate of removal of hardware was 2.1%. The average time to union was 12.5 weeks, and length of inpatient stay was 9.4 days (SD 10). Conclusion: This multicenter study demonstrates that use of a fibula nail appears to be a safe approach to treating patients who have a physiologically higher risk of surgery, poor skin condition, and a complex fracture pattern.

Trends in hospital admissions for childhood fractures in England

PurposeFractures to the axial and appendicular skeleton are common in children causing loss of opportunities and disability. There are relatively few studies available to quantify the number of children who have their fractures diagnosed in the emergency department and are then admitted to hospital for ongoing management. The purpose of this study is to explore trends of frequency, types and age of children sustaining fractures who were admitted for intervention to National Health Service (NHS) hospitals.DesignThe study uses data from the Hospital Episode Statistics and Office for National Statistics from 2012 to 2019 to calculate the annual incidence of hospital admission for limb, spine, facial and skull fractures per 100 000 children.ResultsDuring 2012–2019, 368 120 children were admitted to English NHS hospitals with a fracture. 256 008 (69.5%) were upper limb fractures, 85 737 (23.3%) were lower limb fractures and 20 939 (5.7%) were skull or facial fractures. The annual incidence of upper limb fractures was highest in children aged 5–9 (348.3 per 100 000 children) and the highest incidence of lower limb fractures was in children aged 10–15 (126.5 per 100 000 children). The incidence of skull and facial fractures in preschool (age 0–4) children has been increasing at a rate of 0.629 per 100 000 children per year.ImplicationsThe annual incidence of hospital admission for fractures in children has been shown to be consistent for several fracture types between 2012 and 2019. An increasing trend of admissions with preschool skull fractures was observed, though the study data do not have sufficient granularity to demonstrate if this is due to changes in practice or to accidental or non-accidental causes.

Incidence of Orthopedic Implant Removal, its Indications, and the Effect of the Covid-19 Pandemic

Aims & Objective. To assess the incidence and rate of implant removal among orthopedic patients, its indications, and the effect of COVID-19 pandemic. Material & Method: A retrospective study was done during the period from October 2017 to October 2020 included all patients admitted for removal of orthopedic implants. Results: One-hundred eleven patients with a mean age of 28 ± 10.9 years were included in this study. Most (83.8%) were males. The incidence rate of removal was 20.2%. The mean period between implant fixation and removal was 26 ± 20 months. Lower limb fractures constituted 85.6% of cases with about half of them as foot and ankle fractures. The most frequently presented fractures were femur and tibia (33.3% and 21.6%, respectively), while the most frequently removed implants were plate and screws (43.2%). Only 8.9% of surgeries were indicated for removal, and only 4.5% of all patients suffered post-removal complications. Conclusion: Non indicated implant removal occurs at a significantly high rate in Saudi Arabia. No real indications for such a procedure were found in the majority of patients. COVID-19 control strategies caused a significant decrease in this high rate. Keywords: COVID19; Orthopedics; Incidence Rate; Kingdom of Saudi Arabia; Bone Pins

Cycling-related orthopaedic fractures admitted to the Major Trauma Centre in the cycling capital of the UK

Introduction The popularity of cycling in the United Kingdom is increasing, with a further rise likely due to recent government cycling promotion schemes. This study aims to characterise fractures sustained due to cycling-related collisions in patients presenting to a Major Trauma Centre, in the region with the highest cycling rates in the United Kingdom. Methods A retrospective analysis of cycling injuries presenting to our centre between January 2012 and December 2020 was performed using a prospectively collected electronic database. Comparison of fracture characteristics was made according to patient age and mechanism of injury (collision with a motorised vehicle versus collision with a non-motorised object.). Results Of the 737 patients who suffered a cycling-related injury, 292 (39.6%) suffered at least 1 fracture to the appendicular skeleton. Overall, fractures were most commonly seen in those over 50 years of age. Upper limb fractures were more common than lower limb fractures. Fractures sustained during motorised injuries were more likely to require surgical intervention than those sustained during non-motorised collisions. Conclusion This study provides valuable information regarding the nature, epidemiology and treatment of fractures sustained following cycling-related accidents, adding to the paucity of similar literature in the field. Given the likely increase in future cycling uptake, our results are important to clinicians treating patients with cycling-related injuries and policymakers designing safety interventions.

Nomogram for Predicting Deep Venous Thrombosis in Lower Extremity Fractures

Deep venous thrombosis (DVT) is a common complication in patients with lower extremity fractures, causing delays in recovery short-term and possible impacts on quality of life long-term. Early prediction and prevention of thrombosis can effectively reduce patient pain while improving outcomes. Although research on the risk factors for thrombosis is prevalent, there is a stark lack of clinical predictive models for DVT occurrence specifically in patients with lower limb fractures. In this study, we aim to propose a new thrombus prediction model for lower extremity fracture patients. Data from 3300 patients with lower limb fractures were collected from Wuhan Union Hospital and Hebei Third Hospital, China. Patients who met our inclusion criteria were divided into a thrombosis and a nonthrombosis group. A multivariate logistic regression analysis was carried out to identify predictors with obvious effects, and the corresponding formulas were used to establish the model. Model performance was evaluated using a discrimination and correction curve. 2662 patients were included in the regression analysis, with 1666 in the thrombosis group and 996 in the nonthrombosis group. Predictive factors included age, Body Mass Index (BMI), fracture-fixation types, energy of impact at the time of injury, blood transfusion during hospitalization, and use of anticoagulant drugs. The discriminative ability of the model was verified using the C-statistic (0.676). For the convenience of clinical use, a score table and nomogram were compiled. Data from two centers were used to establish a novel thrombus prediction model specific for patients with lower limb fractures, with verified predictive ability.

Measuring recovery after open lower limb fractures: combined objective functional tests and global perceived recovery outperform narrower metrics and a standard generic patient reported outcome measure

Background Open lower limb fractures are serious injuries requiring combined ortho-plastic surgery and have significantly worse outcomes than similar closed fractures. There is little objective published data to determine which functional outcome measures best reflect progress or completeness of physical recovery. Our hypothesis was that objective measures combining strength, mobility and balance would better reflect recovery than isolated parameters (e.g. range of motion ROM) and would compare well to patients’ perceived recovery. Methods Adult open lower limb fracture patients were reviewed 6 and 12 weeks, 6, 9 and 12 months post-injury. The mechanism, injury pattern, age, gender and treatment were recorded. Isolated parameter objective functional outcome measures (OFOMs) (ROM and MRC strength grade) were compared to combined OFOMs (timed up and go, comfortable gait speed and fast gait speed, Edgren Side Step Test (TUAG, CGS, FGS, ESST) and Single Leg balance. Patient reported outcomes were recorded (Global Perceived Effect (GPE) score and Disability Rating Index (DRI)). Statistical analysis used non-parametric tests (e.g. Spearman correlation) compared each with time since injury. Results Sixty-eight patients (54 male) with a median age of 45(20–75) years. Of the 19 isolated OFOMs, only knee flexion and ankle plantar flexion ROM and strength improved with time (Spearman correlation p = 0.042, 0.008, 0.032, 0.036 respectively). TUAG, ESST, CGS, FGS and GPE scores showed significant improvement (Spearman correlation p < 0.001). Patients’ estimation of recovery paralleled these measures (Spearman correlation p < 0.001) with all but 2 patients achieving the minimum clinical important difference in DRI by 12 months compared to baseline. However, the GPE score had a higher proportion of improving responses than DRI at each time-point. Discussion Functional recovery is a key determinant in patients returning to work, providing for themselves and their family or resuming independent living for older patients. This study has demonstrated time-related improvements in combined OFOMs measuring mobility, strength, agility and balance paralleling patients’ perception of recovery in the 12 months after open lower limb fractures. Over the same time-frame, the simple GPE score compared favourably with the DRI. Such parameters could become part of a defined core outcomes set. Focussing rehabilitation towards these combined OFOMs may help hasten recovery. Trial registration South West Wales REC 06/WMW02/10).