The optimal timing of surgical fracture stabilization in trauma patients

Research Doctorate - Doctor of Philosophy (PhD)Surgical interventions in trauma patients can amplify the initial systemic inflammatory response to injury. Aggressive early definitive surgical care could be detrimental in patients with physiological compromise or specific injury patterns. It has been shown, however, that early fracture fixation has a trend towards better outcome in patients with less severe injuries. Delaying all orthopedic surgery in critically injured patients can be a safe alternative but has several disadvantages. In the year 2000 the term Damage Control Orthopedics (DCO) was first described. It was derived from the general surgical concept of staged care in complex abdominal trauma. The concept involved initial temporary external fixation of all long bone fractures in critically ill patients. Following initial external fixation, IM nailing was performed in the next 10 days when the patient’s physiology had improved. The identified indication for DCO included traumatic brain injury, hemodynamic instability, severe thoraco-abdominal injuries and multiple long bone fractures. DCO is an attractive approach as it achieves early fracture stabilization without the risks of IMN or the need of traction devices, there are however, some potential downsides. There is no consensus in the literature in regards to optimal timing of fracture fixation for some patient groups. The main hypothesis explored in this body of work is that early definitive surgery in selected patients has superior results. To investigate this hypothesis a review article and five clinical studies were conducted. The research findings support the importance of physiological assessment of a trauma patient in decision making for initial and secondary surgeries. The decision between Damage Control Orthopaedics and Early Total Care is a dynamic process and needs an early multidisciplinary approach. Which modality is chosen is dependent on multiple modifiable and non-modifiable parameters

The Dilemma of Reconstructive Material Choice for Orbital Floor Fracture: A Narrative Review

The aim of this study is to present a narrative review of the properties of materials currently used for orbital floor reconstruction. Orbital floor fractures, due to their complex anatomy, physiology, and aesthetic concerns, pose complexities regarding management. Since the 1950s, a myriad of materials has been used to reconstruct orbital floor fractures. This narrative review synthesises the findings of literature retrieved from search of PubMed, Web of Science, and Google Scholar databases. This narrative review was conducted of 66 studies on reconstructive materials. Ideal material properties are that they are resorbable, osteoconductive, resistant to infection, minimally reactive, do not induce capsule formation, allow for bony ingrowth, are cheap, and readily available. Autologous implants provide reliable, lifelong, and biocompatible material choices. Allogenic materials pose a threat of catastrophic disease transmission. Newer alloplastic materials have gained popularity. Consideration must be made when deliberating the use of permanent alloplastic materials that are a foreign body with potential body interactions, or the use of resorbable alloplastic materials failing to provide adequate support for orbital contents. It is vital that surgeons have an appropriate knowledge of materials so that they are used appropriately and reduce the risks of complications

Open tibia fractures: timely debridement leaves injury severity as the only determinant of poor outcome

Background: Recent retrospective studies suggest that the time to debridement of open tibia fractures is not a major determinant of outcome. The aim of this prospective study was to determine the modifiable independent predictors of poor outcomes. Methods: A 36-month prospective observational study ending in December 2009 was performed on consecutive open tibia shaft fracture patients (age >18 years) admitted to a Level 1 trauma center. Demographics, mechanism, Injury Severity Score, fracture type/grade, local contamination, time to debridement, time to antibiotics, and interventions were prospectively recorded. Outcome measures were as follows: length of stay, deep infection, secondary procedures, and presence of union at 6 months and 12 months. Univariate, multivariate, and logistic regression analyses were performed. Results: Eighty-nine consecutive patients (74% male, age 41 years ±17 years, Injury Severity Score 15 ±3, and 37% multiple injured) met inclusion criteria. The mean time to surgical debridement and operative stabilization was 8 hours ±4 hours (48% within 6 hours). The average length of stay was 21 days ±13 days. Fifteen patients (17%) had deep infection and 5 (6%) required amputation (1 acute and 4 late because of the infection). The 6-month and 12-month union rates were 39% and 67%, respectively. Fifty-six patients (63%) required further procedures (a total of 312). The multivariate regression model (18 variables) showed no independent significant predictors for deep infection or nonunion at 6 months and 12 months (multiple injuries and smoking were closest to reach significance, p = 0.08). Conclusion: Timely management of open tibia fractures (mean, 8 hours) eliminates time to debridement and contamination as predictors of poor outcome. Patient factors and local and general injury severity determine the outcomes. Aiming for the earliest safe time to debridement minimizes the negative effects of modifiable factors on the outcome

Tissue oxygen saturation changes during intramedullary nailing of lower-limb fractures

BACKGROUND: The systemic complications of acute intramedullary nailing (IMN) in trauma patients are well known. There are no reliable methods available to predict these adverse outcomes. Noninvasive near-infrared spectroscopy (NIRS) allows measurement of oxygen saturation within muscle tissue (StO2) and quantification of the potential metabolic and microcirculatory effects of IMN in real time. The aim of this study was to characterize tissue oxygenation changes occurring during reamed IMN. METHODS: Patients undergoing reamed IMN for fixation of a tibia or femur fracture and patients having an open reduction and internal fixation of the ankle (to control for potential effects of anesthesia) had a noninvasive NIRS probe attached to the thenar eminence of the hand. Tissue oxygenation was monitored continuously throughout the operation and digitally recorded for later analysis. Vascular occlusion tests, an established technique with the NIRS device, were performed before canal opening and after nail insertion (at equivalent times in the control group), to establish the presence and nature of changes in systemic microcirculation occurring during the duration of the operation. RESULTS: Tissue oxygenation data were collected on 23 patients undergoing 26 IMN. (mean [SD] age, 36 [19] years; median Injury Severity Score [ISS], 9; interquartile range, 9–12). The control group consisted of 19 patients (mean [SD] age, 41 [18] years; ISS, 4). Remote muscle tissue desaturated significantly faster after IMN compared with the control operation (mean [SD] difference in IMN desaturation rate, 1.8% per minute [2.6% per minute]; mean [SD] difference in control group desaturation rate, -0.6% per minute [1.5% per minute]; p = 0.014). Near infrared-derived muscle oxygen consumption (NIR VO₂) was significantly increased during the course of IMN compared with the control (mean [SD] difference in IMN NIR VO₂, 19.9 [32.1]; mean [SD] difference in control NIR VO₂, -4.2 [17.9]; p = 0.041). CONCLUSION: IMN causes significant remote microcirculatory changes. The responsiveness of the microcirculation could be a predictor of secondary organ dysfunction. LEVEL OF EVIDENCE: Epidemiologic study, level III

Patterns of CT use and surgical intervention in upper limb periarticular fractures at a level-1 trauma centre

Objectives: The universal availability of CT scanners has led to lower thresholds for imaging despite significant financial costs and radiation exposure. We hypothesised that this recent trend has increased the use of CT for upper limb periarticular fractures and led to more frequent operative management. Method: A 5-year retrospective study (01/07/2005–30/06/2010) was performed on all adult patients with upper extremity periarticular fractures (OTA: 11, 13, 21 and 23) admitted to a level-1 trauma centre. Patients were identified from the institution's prospectively maintained OTA classification database. Results A total of 1734 upper extremity periarticular fractures were identified in 1651 patients. 65% (1132/1734) were operated on. 32% (557/1734) had CT imaging and 78% (431/557) of these had operative management. CT use for all fractures and ages showed no change (0.56%/year, p = 0.210, r² = 0.457). Operative intervention increased at a rate of 2.17%/year (p = 0.004, r² = 0.959). Within each fracture type, CT rates showed no change. Operative management of proximal humerus and distal radius fractures became more frequent (6.30%/year, p = 0.002, r² = 0.969 and 0.96%/year, p = 0.046, r² = 0.784 respectively). Fractures around the elbow showed no change. In patients younger than 55 years, only proximal humerus fractures had more frequent imaging (3.17%/year, p = 0.023, r² = 0.866). In patients over 55 the frequency of CT scanning did not increase, but they were more frequently operated on (4.09%/year, p = 0.012, r² = 0.907). In older patients the rate of surgical intervention increased in all but the distal humerus region, Proximal humerus (6.19%/year, p = 0.015, r² = 0.894), proximal forearm (4.57%/year, p = 0.007, r² = 0.931) and distal radius (2.70%/year, p = 0.002, r² = 0.871). Conclusion: During the examined 5-year period no increases of in CT imaging frequency were observed. The significantly increased number of operations among older patients is unlikely to be driven by imaging frequency

The prevalence of smoking and interest in quitting among surgical patients with acute extremity fractures

Introduction and Aims: We studied the prevalence of smoking, the effect of hospital stay on motivation to quit and the exposure to smoking cessation advice in orthopaedic patients who required surgical intervention for acute extremity fractures. Design and Methods: This cross-sectional study involved a self-administered pen-and-paper survey assessing smoking status, interest and motivation to quit smoking, and current advice to quit among a consecutive cohort of patients aged 18-65 years old with acute extremity fractures. These patients were admitted to the John Hunter Hospital Level 1 trauma facility in New South Wales, Australia, for surgical intervention over a three month period. Results: A total of 183 patients (response rate 98%) completed the survey. Sixty-eight patients (37.2%) reported a current smoking habit. The prevalence of smoking was 42.2% among males and 25.5% among females. A total of 40% of smokers reported that they had not received advice to quit from medical staff during hospital admission. Prior to admission, 12.1% of smokers were interested in smoking cessation; this percentage increased to 26.8% post-admission. Discussion and Conclusions: The prevalence of smoking among surgical patients with extremity fractures was found to be more than twice the prevalence of the population of New South Wales. Hospital admission had a positive impact on the patient's interest in smoking cessation. Our study suggests that the identification of orthopaedic patients who smoke is suboptimal, and the opportunity to encourage smoking cessation during hospital admission is currently being overlooked

The definition of polytrauma: variable interrater versus intrarater agreement: a prospective international study among trauma surgeons

Background: The international trauma community has recognized the lack of a validated consensus definition of “polytrauma.” We hypothesized that using a subjective definition, trauma surgeons will not have substantial agreement; thus, an objective definition is needed. Methods: A prospective observational study was conducted between December 2010 and June 2011 (John Hunter Hospital, Level I trauma center). Inclusion criteria were all trauma call patients with subsequent intensive care unit admission. The study was composed of four stages as follows: (1) four trauma surgeons assessed patients until 24 hours, then coded as either “yes” or “no” for polytrauma, and results compared for agreement; (2) eight trauma surgeons representing the United States, Germany, and the Netherlands graded the same prospectively assessed patients and coded as either “yes” or “no” for polytrauma; (3) 12 months later, the original four trauma surgeons repeated assessment via data sheets to test intrarater variability; and (4) individual subjective definitions were compared with three anatomic scores, namely, (a) Injury Severity Score (ISS) of greater than 15, (b) ISS of greater 17, and (c) Abbreviated Injury Scale (AIS) score of greater than 2 in at least two ISS body regions. Results: A total of 52 trauma patients were included. Results for each stage were as follows: (1) κ score of 0.50, moderate agreement; (2) κ score of 0.41, moderate agreement; (3) Rater 1 had moderate intrarater agreement (κ score, 0.59), while Raters 2, 3, 4 had substantial intrarater agreement (κ scores, 0.75, 0.66, and 0.71, respectively); and (4) none had most agreement with ISS of greater than 15 (κ score, 0.16), while both definitions ISS greater than 17 and Abbreviated Injury Scale (AIS) score of greater than 2 in at least two ISS body regions had on average fair agreement (κ scores, 0.27 and 0.39, respectively). Conclusion: Based on subjective assessments, trauma surgeons do not agree on the definition of polytrauma, with the subjective definition differing both within and across institutions

Epidemiology of acute transfusions in major orthopaedic trauma

Objectives: The orthopaedic trauma–related blood product usage is largely unknown. Aim of this study was to describe the epidemiology of early (<24 hours of arrival) blood component use in major orthopaedic trauma. Design: 12-month prospective observational study. Setting: John Hunter Hospital, Level 1 Trauma Center, New South Wales, Australia. Patients: 64 consecutive trauma admissions identified, who had an orthopaedic injury and required at least 1 unit of packed red blood cells (PRBC) <24 hours of arrival. Intervention: Epidemiological study. Main outcome measures: Demographics, orthopaedic injury type, procedure type, injury severity score, timing, place of first unit of transfusion, and blood component volumes were collected. Activation of the massive transfusion protocol was recorded. Primary outcome measures were intensive care unit admission and mortality. Results: From 965 major trauma admissions, 64 had one or more orthopaedic injuries and were transfused <24 hours. Forty-eight percent (31/64) required massive transfusion protocol activation. Average age was 41 ± 21 years, 73% (47/64) men. Eighty-four percent (54/64) required emergent orthopaedic intervention, 41% (22/54) having multiple procedures. Overall mortality was 13% (8/64). Twenty-five percent (16/64) required >=10 units of PRBC. Average PRBC use was 7.2 ± 6.6 units and fresh frozen plasma use 4.3 ± 5.2 units. Thirty-nine percent (25/64) had a pelvic ring injury or acetabular fracture. Thirty-seven percent (24/64) had at least one femoral shaft fracture. Twenty patients had a total of 23 tibia fractures. Conclusions: Orthopaedic trauma patients consume the majority of the blood products <24 hours among blunt trauma patients. This resource-intensive group requires frequent urgent surgical interventions and intensive care unit admission

Prehospital nausea and vomiting after trauma: prevalence, risk factors, and development of a predictive scoring system

BACKGROUND: Nausea and vomiting are common problems in trauma patients and potentially dangerous during trauma resuscitation. These symptoms are present in up to 10% of ambulance patients, but their prevalence in trauma patients is largely unknown. The aim of this study was to determine the prevalence of prehospital nausea and vomiting in trauma patients and evaluate antiemetic usage. METHODS: Prospective, cohort study of trauma resuscitation patients transported by ambulance to a major trauma centre. Patients with hemodynamic instability (systolic blood pressure <90, heart rate >120) or Glasgow Coma Scale score <14 on arrival were excluded. Nausea, vomiting, and antiemetic use were recorded. RESULTS: Convenience sample of 196 trauma resuscitation patients (68% men; age, 42 ± 18 years, mean Injury Severity Score 8 ± 7) were interviewed over the 5-month study period, of a total 369 admitted trauma patients (53%). Seventy-five (38%) patients reported some degree of nausea, 57 (29%) moderate or severe nausea, and 15 (8%) vomited. Older age and female gender were associated with vomiting (p < 0.01). Seventy-nine patients (40%) received a prophylactic antiemetic. Of these, four became nauseous (5%), compared with 71 of 117 (61%) for patients not given an antiemetic (p < 0.0001). CONCLUSIONS: Prehospital nausea and vomiting are more common in our cohort of trauma patients than the reported rates in the literature for nontrauma patients transported to hospital by ambulance. Only 40% of patients receive prophylactic antiemetics, but those patients are less likely to develop symptoms