Journal of Trauma and Injury最新文献

We present the case of a 55-year-old man with an AO/OTA 43-C3 pilon fracture in whom initial uniplanar external fixation failed to relieve persistent medial skin tenting, resulting in focal ischemic necrosis. Within 72 hours, the patient developed bullae and violaceous discoloration, which progressed to full-thickness skin breakdown. Despite staged open reduction and internal fixation and fasciocutaneous flap coverage, the patient developed chronic osteomyelitis, ultimately requiring segmental bone resection to control the infection. The patient underwent serial debridement procedures and placement of antibiotic-loaded cement spacers. Definitive reconstruction was achieved with salvage tibiotalocalcaneal arthrodesis using the Expert Tibial Nail system on postoperative day 319. Twelve months after fusion and bone grafting, radiographs confirmed solid union, and the patient was ambulating independently, albeit with considerable long-term functional limitations. This case underscores the importance of early and meticulous soft tissue evaluation in high-energy pilon fractures. Prompt repositioning of fracture fragments or the use of adjunctive decompression is essential. Delayed or inadequate decompression can lead to a cascade of complications, beginning with soft tissue necrosis and progressing to deep infection and limb salvage fusion, even when standard fixation protocols are followed.

Purpose: Traumatic brain injuries (TBIs) are a leading cause of morbidity, mortality, socioeconomic loss, and diminished quality of life among survivors of all injury types. The Glasgow Coma Scale (GCS), though commonly used in the intensive care unit (ICU), has limitations that may be addressed by the Full Outline of Unresponsiveness (FOUR) score. We compared the ability of the FOUR and GCS scores to predict outcomes in patients with TBI.

Methods: This prospective observational study included all patients presenting with head injury who survived beyond 24 hours between 2020 and 2022. Basic demographic data, prehospital care details, and neurological findings were collected. TBI severity was assessed using both the GCS and FOUR scores, and outcomes were graded using the Glasgow Outcome Score (GOS).

Results: Among 225 patients (mean age, 42.4±19.7 years; male sex, 77.8%) with TBIs, the mortality rate was 4.4%, and 15.1% experienced a poor outcome (GOS ≤2). Receiver operating characteristic curve analysis showed good predictive ability for both the FOUR score (area under the curve [AUC], 0.85) and GCS (AUC, 0.88). FOUR score ≤12 and GCS ≤10 were identified as optimal cutoff values for predicting poor outcomes (P<0.001), with the FOUR score demonstrating sensitivity and specificity of 79.4% and 77.5%, respectively. A FOUR score ≤12 at admission was significantly associated with intubation (odds ratio [OR], 8.2; 95% confidence interval [CI], 4.6-14.4; P<0.001), tracheostomy (OR, 21.8; 95% CI. 6.9-68.8; P<0.001), and neurological complications, including mental function deficits (OR, 7.5; 95% CI, 3.2-17.7; P<0.001), cranial nerve palsy (OR, 4.1; 95% CI, 1.6-10.4; P=0.002), and motor deficits (OR, 9.4; 95% CI, 4.6-19.2; P<0.001). A strong correlation was observed between the FOUR score and GOS (r=0.7).

Conclusions: The FOUR score is a reliable tool for assessing TBI severity and predicting outcomes, with performance comparable to the GCS. An admission FOUR score ≤12 was associated with poor neurological outcomes, increased need for advanced airway management, and long-term disability. By capturing additional neurological parameters beyond the GCS, the FOUR score may offer clinical advantages in ICU settings for early prognostication and management of patients with TBI.

Purpose: This study aimed to examine 13-year changes in the injury mechanisms of orbital blowout fractures (OBFs) in Korea and to determine how those changes influenced preoperative ocular motility deficits, while also assessing whether apparent intercenter differences persisted after covariate adjustment.

Methods: A retrospective cohort was assembled from two level I trauma centers: a historical 2011 series from Inje University Sanggye Paik Hospital (n=150) and a pooled 2019-2023 series from Pusan National University Hospital (n=50). Eligibility required computed tomography-confirmed medial and/or inferior wall fracture with an intact orbital rim; patients with rim involvement or penetrating ocular trauma were excluded. Injury mechanism, fracture site, and diplopia and/or extraocular movement (EOM) limitation at presentation were abstracted from electronic medical records. Categorical comparisons used the chi-square test, and trends across calendar years were assessed using logistic regression (with year as a continuous predictor). Multivariable logistic modeling estimated adjusted odds ratios (aORs) for preoperative ocular motility deficit according to age, sex, mechanism, fracture site, calendar year, and center, with robust clustering.

Results: Interpersonal violence decreased from 34.7% of OBFs in 2011 to 14.0% in 2019-2023, representing an 11% annual decline (OR, 0.89; 95% confidence interval [CI], 0.81-0.97, P=0.007). Preoperative diplopia or EOM limitation was observed in 23 of 200 patients (11.5%): 14% in 2011 versus 4% in 2019-2023. Independent predictors of EOM limitation were interpersonal violence (aOR 3.84; 95% CI, 1.38-10.65; P=0.010) and male sex (aOR, 4.78; 95% CI, 1.49-15.49; P=0.009). Age showed a protective trend (aOR, 0.75 per decade; P=0.064); fracture extent and center were not significant after adjustment. Calendar year showed a borderline inverse association (aOR, 0.86; P=0.061), indicating a 14% annual reduction in presentation-time deficit.

Conclusions: Between 2011 and 2023, the Korean OBF landscape shifted from violent assault to accidental mechanisms, accompanied by a marked decline in preoperative ocular motility impairment. Assault mechanism and male sex remain strong risk indicators, while center-based differences appear largely explained by temporal composition. Public health efforts that reduce violence may therefore translate directly into better functional status at initial presentation.

Traumatic hemothoraces represent a readily available, normothermic, and ABO-compatible source of blood. As a resuscitation fluid, pleural blood presents a reduced risk of transmissible disease and hemolytic transfusion reactions, and it minimizes patient exposure to the storage lesion that affects allogeneic blood products. Pleural blood therefore retains more physiological concentrations of electrolytes and 2,3-diphosphoglycerate when compared to packed red blood cells. However, pleural blood also has a lower oxygen-carrying capacity than packed red blood cells and is largely depleted of coagulation factors. Yet, due to the presence of tissue factor and other proinflammatory mediators, it may paradoxically increase clot formation once transfused. Uncertainty remains regarding the clinical relevance of the supranormal levels of proinflammatory mediators and the effects of autotransfusion on coagulation in vivo. There is now a body of evidence suggesting that autotransfusion reduces the requirement for donor blood products, and small studies have not identified any signals of harm; however, any positive or negative effects on patient outcomes are yet to be conclusively demonstrated. Centers with access to a robust supply of allogeneic donor blood should continue with standard care until more comprehensive research is conducted to clarify both the clinical benefits and risks of autotransfusion. Nonetheless, autotransfusion retains a role in cases where there is a contraindication to allogeneic transfusion, and in low-resource centers where safe and reliable access to donor blood products is limited.

Purpose: In February 2024, a nationwide resident walkout in Korea caused a temporary shortage of medical professionals. This study investigated whether the walkout influenced trauma care, with a particular focus on scene-to-door time and patients' in-hospital course.

Methods: Trauma patients transported by emergency medical services between June 1, 2022, and March 31, 2025, were included if trauma team activation occurred upon emergency department arrival. Patients were divided into two groups: group 1 (post-COVID-19 normalization period) and group 2 (post-resident walkout period). The primary outcome was scene-to-door time.

Results: A total of 271 patients were analyzed: 117 in group 1 and 154 in group 2. The proportion of patients originating outside the primary service area increased from 16.7% to 31.3%. Intensive care unit admission rates decreased (65.0% vs. 22.1%), while interhospital transfers directly from the emergency department increased (7.7% vs. 18.8%). The median scene-to-door time rose from 28 to 44.5 minutes. Spline regression and locally estimated scatterplot smoothing analyses revealed no consistent temporal trend but showed greater variability during the walkout period. According to the generalized linear model, scene-to-door time was 42% longer during this period.

Conclusions: The resident walkout was associated with marked delays in scene-to-door time and shifts in in-hospital patient flow. These findings suggest that even temporary workforce shortages can disrupt both prehospital and in-hospital trauma care, underscoring the importance of response planning and adaptable system operations during workforce disruptions.

Purpose: Careful clinical assessment is essential for extubation in patients with acute respiratory failure, and decisions must weigh the potential benefits and risks related to the timing of extubation. This study aimed to characterize the population at high risk for extubation failure and to assess the interventions employed to prevent reintubation in head injury patients admitted to the trauma intensive care unit.

Methods: We retrospectively obtained data from the trauma registry database of traumatic brain injury patients who were intubated and admitted to a trauma intensive care unit in Qatar from January 2013 to December 2015. Regression analysis was performed to examine the association between successful extubation and in-hospital complications.

Results: In total, 297 head injury patients (279 male and 26 female patients) at high risk of reintubation were included in the analysis. The prevalence of agitation and pneumonia in postextubated head injury patients were 10.8% and 4.7%, respectively. After adjusting for confounding variables, successful extubation with the use of a nasal cannula and continuous positive airway pressure was significantly associated with reduced agitation (P=0.001) and a lower incidence of in-hospital complications, including pneumonia (P=0.001) and sepsis (P=0.02).

Conclusions: This study suggests an association between successful extubation, reduced agitation, and a decreased incidence of in-hospital complications such as pneumonia and sepsis. Particular attention and further research should focus on optimizing extubation management for head injury patients.

Purpose: The acute care surgery (ACS) model establishes the capacity to immediately accommodate nontraumatic emergency surgery requiring urgent treatment while simultaneously elevating the existing trauma care system to the highest level. This study aims to evaluate the 4-year experience of operating after expanding the trauma surgery domain to ACS at this institution, which was designated as a lower-level trauma center by the local government in 2020.

Methods: A retrospective study was conducted using clinical records for patients who underwent surgery in the Division of Trauma and Acute Care Surgery over a 54-month period, from March 2021 to August 2025.

Results: Trauma volumes remained stable (10-20 cases semiannually) after ACS implementation, with surgical case numbers similar to those recorded before its introduction. Nontrauma volumes increased from 3 cases in March-August 2023 to 163 in March-August 2025.

Conclusions: The transition from the trauma surgery model to the ACS model successfully increased the efficiency of trauma and emergency general surgery within the level II low-volume environment, accomplishing without reducing the existing trauma caseload. These findings support the adoption of ACS in similar emergency medical institutions and offer insights relevant for national policy development concerning emergency general surgery in Korea.

Subclavian vessel injury concomitant with a closed clavicle fracture is rare, and challenges associated with exposure often make proximal control difficult. This paper presents the case of a 26-year-old man who presented to the emergency department after a fall from the sixth floor with multiple injuries, including closed clavicle fractures and a subclavian artery pseudoaneurysm. Proximal control was achieved with endovascular balloon occlusion rather than by performing cervical extension of median sternotomy. Subsequently, exposure was obtained through a subclavian incision, and the injury was treated with a bypass graft.

We report a case of iatrogenic injury to the lateral circumflex femoral artery following distal femoral nailing in a 72-year-old patient. Postoperatively, progressive thigh swelling developed, but initial contrast-enhanced computed tomography (CT) showed no evidence of vascular injury. The arterial injury was subsequently identified on a follow-up contrast-enhanced CT scan and was successfully treated with angiographic microcoil embolization. This case underscores the critical importance of meticulous awareness of the trajectories of the lateral circumflex and deep femoral arteries during proximal interlocking screw insertion. It also highlights that early postoperative imaging can fail to detect such vascular complications. Therefore, a high index of clinical suspicion is paramount, and repeated imaging should be strongly considered if clinical signs, such as progressive swelling, persist despite initial negative findings.

Subclavian artery injury is a rare complication of clavicular fracture. This condition most often results from penetrating trauma but may also occur after blunt injury, when bone fragments cause rupture, pseudoaneurysm, dissection, or arterial thrombosis. Subclavian artery injury associated with clavicular fracture occurs in less than 1% of cases and may lead to life-threatening hemorrhage or limb ischemia. We report a case of subclavian artery injury secondary to a clavicular fracture that was successfully managed with endovascular intervention. A 48-year-old man presented to the emergency department after a downhill bicycle crash with a right midshaft clavicle fracture and was scheduled for open reduction and internal fixation (ORIF) 11 days later. Intraoperatively, rupture of a subclavian artery pseudoaneurysm caused massive hemorrhage. Surgical dissection was complicated by severe perivascular inflammation and a high risk of iatrogenic subclavian vein injury. Immediate conversion to an endovascular approach allowed successful hemostasis through femoral artery access and covered stent deployment, after which ORIF was completed. The patient recovered without neurovascular complications and was discharged on postoperative day 5. At 12 weeks, he achieved full shoulder range of motion, and 2-year follow-up angiography showed no stent-related complications. This case underscores the effectiveness of emergent endovascular intervention for ruptured traumatic subclavian pseudoaneurysm when inflammation and risk of iatrogenic injury preclude safe open dissection. A hybrid or rescue endovascular strategy should be considered for similar complex trauma cases.