European Journal of Trauma and Emergency Surgery最新文献

Purpose: This study aimed to investigate practice variation in non-operative treatment methods and immobilisation duration for metacarpal fractures, and to evaluate patient-reported outcomes.

Methods: Conducted in 12 Dutch hospitals over three months in 2020, this study included adult patients with non-operatively treated solitary metacarpal fractures. Fractures were classified into intra-articular base, extra-articular base, shaft, neck, and intra-articular head fractures. The treatment methods (functional treatment allowing digit mobilisation or immobilisation) and immobilisation duration were assessed. Patient-reported outcomes were evaluated using the Michigan Hand Outcomes Questionnaire (MHQ) at three months post-trauma.

Results: Of 389 included patients, shaft fractures were most common (n = 150, 39%), with 93% immobilised, followed by fifth metacarpal neck fractures (n = 93, 24%), with 75% immobilised. Immobilisation rates for fifth metacarpal neck fractures varied between hospitals, ranging from 29% (95% CI 0.10-0.58) to 100% (95% CI 0.78-1.00). The median immobilisation duration for all fractures was 23 days (IQR: 20-28), and hospital setting was independently associated with this duration. Patients with metacarpal shaft fractures immobilised for less than 21 days had higher MHQ scores compared to those immobilised for 21 days or more (median (IQR) 83 (76-100) versus 71 (57-89), p = 0.026).

Conclusions: The results showed practice variation in the treatment of metacarpal fractures, especially in the treatment of fifth MC neck fractures, with some hospitals following the Dutch guideline that advocates functional treatment while others did not. There are suggestions that prolonged immobilisation of metacarpal shaft fractures may lead to a worse MHQ score. These findings underscore the need for adherence to treatment protocols and emphasize functional treatment to potentially improve patient outcomes and cost-effectiveness.

Introduction

Advances in trauma care have attributed to a decrease in mortality and change in cause of death. Consequently, exsanguination and traumatic brain injury (TBI) have become the most common causes of death. Exsanguination decreased by early hemorrhage control strategies, whereas TBI has become a global health problem. The aim of this study was to investigate trends in injury severity,physiology, treatment and mortality in the last decade.

Methods

In 2014, a prospective cohort study was started including consecutive severely injured trauma patients > 15 years admitted to a Level-1 Trauma Center ICU. Demographics, physiology, resuscitation, and outcome parameters were prospectively collected.

Results

Five hundred and seventy-eight severely injured patients with predominantly blunt injuries (94%) were included. Seventy-two percent were male with a median age of 46 (28–61) years, and ISS of 29 (22–38). Overall mortality rate was 18% (106/578) with TBI (66%, 70/106) being the largest cause of death. Less than 1% (5/578) died of exsanguination. Trend analysis of the 10-year period revealed similar mortality rates despite an ISS increase in the last 2 years. No significant differences in demographics,and physiology in ED were noted. Resuscitation strategy changed to less crystalloids and more FFP. Risk factors for mortality were age, brain injury severity, base deficit, hypoxia, and crystalloid resuscitation.

Discussion

TBI was the single largest cause of death in severely injured patients in the last decade. With an aging population TBI will increase and become the next epidemic in trauma. Future research should focus on brain injury prevention and decreasing the inflammatory response in brain tissue causing secondary damage, as was previously done in other parts of the body.

Purpose

Nonoperative management (NOM) for blunt splenic injuries (BSIs) is supported by both international and national guidelines in Germany, with high success rates even for severe organ injuries. Angioembolization (ANGIO) has been recommended for stabilizable patients with BSI requiring intervention since the 2016 German National Trauma Guideline. The objectives were to study treatment modalities in the adult BSI population according to different severity parameters including NOM, ANGIO and splenectomy in Germany.

Methods

Between 2015 and 2020, a retrospective registry-based cohort study was performed on patients with BSIs with an Abbreviated Injury Score ≥ 2 in Germany using registry data from the TraumaRegister DGU® (TR DGU). This registry includes patients which were treated in a resuscitation room and spend more than 24-h in an intensive care unit or died in the resuscitation room.

Results

A total of 2,782 patients with BSIs were included in the analysis. ANGIO was used in 28 patients (1.0%). NOM was performed in 57.5% of all patients, predominantly those with less severe organ injuries measured by the American Association for the Surgery of Trauma Organ Injury Scale (AAST) ≤ 2. The splenectomy rate for patients with an AAST ≥ 3 was 58.5%, and the overall mortality associated with BSI was 15%.

Conclusions

In this cohort splenic injuries AAST ≥ 3 were predominantly managed surgically and ANGIO was rarely used to augment NOM. Therefore, clinical reality deviates from guideline recommendations regarding the use of ANGIO and NOM. Local interdisciplinary treatment protocols might close that gap in the future.

Purpose

Ulnar styloid process (USP) fractures are present in 40–65% of all distal radius fractures (DRFs). USP base fractures can be associated with distal radioulnar joint (DRUJ) instability and ulnar sided wrist pain and are treated by conservative management and surgical fixation, without consensus. This systematic review and meta-analysis compares operative to non-operative treatment of concomitant ulnar styloid base fractures in patients with distal radius fractures.

Methods

PubMed/Medline/Embase/CENTRAL databases were searched identifying RCTs and comparative observational studies. Effect estimates were extracted and pooled using random effect models to account for heterogeneity across studies. Results were presented as (standardized) mean differences (SMD or MD) or odds ratios (OR) and corresponding 95% confidence intervals (95%CI).

Results

Two RCTs (161 patients) and three observational studies (175 patients) were included. Tension band wiring was used for surgically treated USP fractures. Results were comparable across the different study designs and hence pooled across studies. Non-surgically treated patients had better wrist function at 6 months (SMD 0.57, 95%CI 0.30; 0.90, I² = 0%). After 12 months there was no observed difference (MD 2.31, 95%CI −2.57; 7.19, I² = 91%). Fewer patients had USP non-unions in the operative group (OR 0.08, 95%CI 0.04; 0.18, I² = 0%). More patients suffered complications in the operative group (OR 14.3; 95%CI 1.08; 188, I² = 89%).

Conclusion

Routinely fixating USP base fractures as standard of care is not indicated. Surgery may be considered in selective cases (e.g. persistent DRUJ instability during ballottement test after fixation of the radius).

Purpose

Postinjury multiple organ failure (MOF) is the sequela to the disease of polytrauma. We aimed to describe the contemporary population-based epidemiology of MOF within a mature trauma system, to analyse the time taken for MOF to develop, and to evaluate the temporal patterns and contributions of the individual constituent organ failures.

Methods

Prospective observational study conducted across five Level-1 trauma centers in New South Wales, Australia. Trauma patients at-risk of MOF (Denver > 3 from 48 h post-admission), aged > 16 years, ISS > 15, and who stayed in ICU for ≥ 48 h were eligible for inclusion.

Results

From May 2018–February 2021, 600 at-risk polytrauma patients were prospectively enrolled (mean(SD)age = 49(21)years, males = 453/600(76%),median(IQR)ISS = 26(20,34)). MOF incidence was 136/600(23%) among at-risk patients, 142/6248(2%) among major trauma patients (ISS > 12 per Australian definition), and 0.8/100,000 in the general population. The mortality rate was 55/600(11%) in the overall study population, and 34/136(25%) in MOF patients. 82/136(60%) of MOF patients developed MOF on day-3. No patients developed MOF after day-13. Among MOF patients, 60/136(44%) had cardiac failures (mortality = 37%), 39/136(29%) had respiratory failures (mortality = 23%), 24/136(18%) had renal failures (mortality = 63%), and 12/136(9%) had hepatic failures (mortality = 50%).

Conclusion

Although a rare syndrome in the general population, MOF occurred in 23% of the most severely injured polytrauma patients. When compared to previous risk-matched cohorts, MOF become more common, but not more lethal, despite a decade older cohort. The heart has superseded the lungs as the most common organ to fail. Cardiac and respiratory failures occurred earlier and were associated with lower mortality than renal and hepatic failures.

Introduction

Patients sustaining pulmonary contusion (PC) have a higher risk of complications and long-term respiratory difficulty. Computed tomography (CT) scans have a high sensitivity for PC. However, since PC develops over time, CT scans made directly post-trauma may underestimate the full extent of PC. This creates a need to better define in which PC-patients complications are more likely. The aim of this systematic review was to identify different classification systems of PC, and investigate the association between amount of PC and in-hospital outcomes.

Methods

A systematic review was conducted in accordance with PRISMA guidelines. Studies reporting a classification system for PC after blunt thoracic trauma based on a CT scan were included. Outcomes were classification method of PC and the relation between classification and pulmonary complications and in-hospital outcomes.

Results

Twenty studies were included. Total number of patients ranged from 49 to 148,140 patients. The most common classification system used was calculating the percentage of contused lung volume. Other classification methods were based on Blunt Pulmonary Contusion score-6 and -18, Abbreviated Injury Score and Thoracic Trauma Severity scores. Worse outcomes were generally associated with between > 18 to > 24% contusion volume.

Discussion

The heterogeneity of currently available literature makes comparing classification methods challenging. The most common classification of PC was based on volumetric analysis. Calculating a percentage of PC as part of the total volume allows for the highest level of segmentation of lung parenchyma as compared to using BPC-6, BPC-18, or AIS. Contusion volume exceeding 18–24% was generally associated with worse outcomes.

In this review, we provide recommendations as well as summarize available data on the optimal time to initiate venous thromboembolism chemoprophylaxis after severe trauma. A general approach to the severe polytrauma patient is provided as well as in-depth reviews of three high-risk injury subgroups: patients with traumatic brain injury, solid organ injury, and pelvic fractures.

Due to increasing life expectancy, the prevalence of fractures caused by osteoporosis is raising. These fractures significantly reduce the quality of life in the elderly population. They represent both a disease and an injury simultaneously. While they were once treated solely with conservative methods, new techniques and implants are expanding the indications for surgical treatment. This article presents the current treatment options.