Proximal Humerus Fractures in the Elderly: Concomitant Fractures and Management

Introduction. The purpose of this study was to identify additional injuries commonly seen with proximal humerus fractures experienced by patients 65 years or older and to evaluate discrepancies in the management of these patients with regard to provider type. Methods. A retrospective review was conducted of all patients 65 years or older who sustained a proximal humerus fracture. Patient data collected included demographics, injury details, hospital course, and discharge destination. Results. Patients with a concomitant fracture (45.5%, n = 65) had a slightly higher Injury Severity Score (ISS; 8.3 ± 3.0 vs. 6.4 ± 3.0, p < 0.001) and experienced one additional death than those with an isolated fracture (54.5%, n = 78). Slightly more patients were managed by a trauma provider (51.7%, n = 74) than by a non-trauma provider (48.3%, n = 69). Those managed by a trauma provider sustained the most pelvic fractures (12.2% vs. 2.9%, p = 0.038), were more likely to be injured in a motor vehicle collision (8.1% vs. 0%, p = 0.005), had a higher ISS (8.0 ± 3.3 vs. 6.4 ± 2.8, p = 0.003), and had more imaging performed than those treated by a non-trauma provider. There was, however, no difference in operative rates, concomitant injuries, length of stay or discharge disposition regarding provider type.  Conclusions. It is important to recognize proximal humerus fractures as a sign of fragility and to optimize hospital management of these patients

Demographics and Incident Location of Gunshot Wounds at a Single Level I Trauma Center

Introduction:  Little is known surrounding the demographic and geospatial factors of firearm-related traumas in the Midwest Region.  The purpose of this study was to describe the overall incidence of firearm-related traumas and examine any racial/ethnic disparities that may exist. Methods:  A retrospective review was conducted of all patients 14 years or older who were admitted with a gunshot wound (GSW) to a Level I trauma center between 2016 and 2017.  Results:  Forty-nine percent of patients were Caucasian, 26.5% African American, and 19.6% Hispanic/Latino.  Hispanic/Latino patients were the youngest (25.8 ± 8.8) and Caucasians were the oldest (34.3 ± 14.1, P = 0.002).  Compared to Caucasian patients, African American (42.0%) and Hispanic/Latino (54.1%) patients were more likely to be admitted to the intensive care unit (ICU) (P = 0.034) and experienced longer ICU lengths of stay (2.5 ± 6.3 and 2.4 ± 4.7, P = 0.031, respectively).  African American patients (96.0%) experienced more assaults while Caucasians were more likely to receive gunshot wounds accidentally (26.9%, P = 0.001).  More African American (86.0%) and Hispanic/Latino (89.2%) patients were injured with a handgun and Caucasians sustained the highest number of shotgun/rifle related injuries (16.1%, P = 0.012).  Most GSWs occurred in zip codes 67202, 67203, 67213, 67211, and 67214.  Geographical maps indicated that GSWs were concentrated in low-income areas and areas with high minority populations.                                                                                                                                                                                              Conclusions:  Racial differences were noted, however, unlike national trends, most of our patients were older Caucasian males

Evaluating the Long-Term Neurologic Sequelae Among Trauma Patients who Received Flexion-Extension Radiographs: Flexion-Extension Radiographs

Introduction. This study evaluated the presence of neurologic sequelae among trauma patients after flexion-extension (F/E) radiographs.  Methods. Authors of the study conducted a retrospective review of patients (age ≥ 14 years) with a Glasgow Coma Score of 15 who sustained a blunt traumatic injury and received F/E radiographs. Radiographic scans were defined as positive, negative, inconclusive, or incomplete. The neurologic status of each patient was assessed before and after the F/E radiographs, and at discharge and follow-up. Results. Of the 501 patients included in the analysis, 84.6% (n = 424) had negative F/E radiographs, and 3.2% (n = 16) had positive F/E radiographs. Ten percent (n = 51) of patients had incomplete F/E radiographs, and 2.0% (n = 10) were inconclusive due to the inability to rule out a ligamentous injury. Three patients (0.6%) had MRI-confirmed ligamentous injuries, all of which had initial incomplete F/E radiographs due to pain. No patient had a documented neurological deficit before or after the F/E exam. Three patients with an initial negative F/E radiograph returned to the clinic with symptoms of neurologic sequelae. Two of these patients had symptom resolution with no further issues at future follow-up appointments. The third patient was found to have chronic neurologic symptoms after further evaluation. Conclusions. The inclusion of F/E exams in cervical spine clearance protocols did not demonstrate any new long-term iatrogenic neurologic injuries. Consideration should be given to performing MRIs on patients with incomplete F/E radiographs that cannot rule out a ligamentous injury.

Evaluation of Outcomes and Treatment Options Among Trauma Patients with Abdominal Vascular Injuries: Abdominal Vascular Injuries

Introduction.  Abdominal vascular injuries are rare and are associated with significant morbidity and mortality. Treatment options include nonoperative management, open repair, and endovascular procedures. This study aimed to characterize patients and detail treatment modalities among those who sustained a traumatic abdominal vascular injury. Methods.  A 6-year descriptive retrospective study was conducted at an American College of Surgeons-verified level 1 trauma center and included all adult patients who sustained an abdominal vascular injury. Results.  Most vascular injuries were to the iliac artery (27.9%), abdominal aorta (25.6%), and inferior vena cava (25.6%). Twenty-seven percent of patients sustained an injury to more than one vascular structure. Thirty-four percent of patients died before treatment of the abdominal vascular injury. Among the 28 patients (65.1%) treated for their vascular injuries, 46.4% were treated with open surgery, 32.1% were treated nonoperatively and 21.4% with coil embolization. The most common vascular injuries treated were lacerations (56%) and transections (21%). Sixty-four percent of the patients who survived to discharge presented for follow-up care with a mean follow-up period of 3 ± 4.1 months. There were no vascular reinterventions after discharge for patients who followed up with our hospital.  Conclusions.  Study findings suggests that appropriately selected cases of traumatic vascular injuries may be safely managed nonoperatively, as there were no mortalities, complications, or reinterventions among these patients.

A Case Series of Concomitant Falls and COVID-19 Infection Among Older Adults: Falls and COVID-19 Among Older Adults

Introduction.  Few studies have examined the hospital course and patient outcomes among elderly trauma patients with COVID-19 and traumatic fall-related injuries. This study aimed to describe patient characteristics and hospital outcomes for older adults who sustained fall-related injuries and were concurrently infected with COVID-19. Methods. A retrospective chart review was conducted of patients 65 years or older admitted to a level 1 trauma center between March 3, 2020 and March 3, 2021 with fall-related injuries. Results. Of the 807 patients who presented for fall-related injuries during the study timeframe, 16% (n=128) were tested for COVID-19, with 17% (n=22) testing positive. One patient was excluded, resulting in 21 patients included for analysis. Common presenting comorbidities were hypertension (86%, n=18), dyslipidemia (57%, n=12), or diabetes (43%, n=9). On admission, 62% (n=13) of patients had respiratory symptoms such as cough, shortness of breath, and hypoxemia. Approximately one-fourth (n=5) of patients were asymptomatic for COVID-19 on presentation. Most overall complications included unplanned intensive care unit or operating room visits (29%, n=6). COVID-19-related complications included acute hypoxic respiratory failure (67%, n=14) and pneumonia (43%, n=9). Nineteen percent of patients (n=4) patients died in hospital. Conclusions. Study findings suggest that elderly fall patients admitted with COVID-19 experienced a high frequency of complications and in-hospital mortality. Therefore, it is important to recognize COVID-19 as a severe and potentially lethal comorbidity among older adults who experience fall-related injuries

Demographics and Incident Location of Traumatic Injuries at a Single Level I Trauma Center: Traumatic Injury Mapping

Introduction: Traumatic injuries are preventable and understanding determinants of injury, such as socio-economic and environmental factors, is vital.  This study evaluated traumatic injuries and identified areas of high trauma incidence.                                                                                               Methods:  A retrospective review was conducted of all patients 14 years or older who were admitted with a traumatic injury to a Level I trauma center between 2016 and 2017.  Descriptive analyses were presented and maps of high injury areas were generated.                                Results:  The most frequent mechanisms of injury were falls (58.3%), motor vehicle crashes (22.3%), and motorcycle crashes (5.7%).  Fall patients were more likely to be female (59.6%) and were the oldest age group (72.1 ± 17.2) compared to motor vehicle and motorcycle crash patients.  Severe head (22.1%, P = 0.007) and extremity (35.7%, P = 0.001) injuries were most frequent among fall patients, however more motorcycle crash patients required mechanical ventilation (16.1%, P < 0.001) and experienced the longest intensive care unit length of stay (5.3 ± 6.8, P < 0.001) and mechanical ventilation days (6.6 ± 8.5, P < 0.036).  Motorcycle crash patients also had the most number of deaths (7.5%, P < 0.001).  The generated maps of all traumatic suggest that most injuries occur near our hospital and are located in several of the most population-dense zip codes.                                                                                                       Conclusions:  Falls, motor vehicle crashes, and motorcycle crashes were the most common mechanisms of injury.  The use of Geographic Information System aided in the identification of high injury incidence location.                          &nbsp

Traumatic Brain Injury in Older Adults: Characteristics, Outcomes, and Considerations. Results From the American Association for the Surgery of Trauma Geriatric Traumatic Brain Injury (GERI-TBI) Multicenter Trial.

OBJECTIVES: Describe the epidemiology of a large cohort of older adults with isolated traumatic brain injury (TBI) and identify predictors of mortality, palliative interventions, and discharge to preinjury residence in those presenting with moderate/severe TBI. DESIGN: Prospective observational study of geriatric patients with TBI enrolled across 45 trauma centers. SETTING AND PARTICIPANTS: Inclusion criteria were age ≥40 years, and computed tomography (CT)-verified TBI. Exclusion criteria were any other body region abbreviated injury scale score \u3e2 and presentation at enrolling center \u3e24 hours after injury. METHODS: The analysis was restricted to individuals aged ≥65 and stratified into 3 age groups: young-old (65-74), middle-old (75-84), and oldest-old (≥85). Demographic, clinical, and injury data were collected. Predictors of mortality, palliative interventions, and discharge to preinjury residence in the moderate/severe TBI group were identified using Classification and Regression Tree and Generalized Linear Mixed Models. RESULTS: Of the 3081 subjects enrolled in the study, 2028 were ≥65 years old. Overall, 339 (16.7%) presented with a moderate/severe TBI and experienced a 64% mortality rate. A Glasgow Coma Scale (GCS) scoremortality, CT worsening (odds ratio [OR] = 1.7, P \u3c .04), cerebral edema (OR = 2.4, P \u3c .04), GCS CONCLUSION AND IMPLICATIONS: In this prospective study of a large cohort of older adults with isolated TBI, comparisons across the older age groups with moderate/severe TBI revealed that survival and favorable discharge disposition were influenced more by severity of injury rather than age itself. Indicating that chronological age alone maybe insufficient to accurately predict outcomes, and increased representation of older adults in TBI research to develop better diagnostic and prognostic tools is warranted

Factors associated with receipt of intracranial pressure monitoring in older adults with traumatic brain injury.

BACKGROUND: The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injury (TBI) include intracranial pressure monitoring (ICPM), yet very little is known about ICPM in older adults. Our objectives were to characterize the utilization of ICPM in older adults and identify factors associated with ICPM in those who met the BTF guidelines. METHODS: We analyzed data from the American Association for the Surgery of Trauma Geriatric TBI Study, a registry study conducted among individuals with isolated, CT-confirmed TBI across 45 trauma centers. The analysis was restricted to those aged ≥60. Independent factors associated with ICPM for those who did and did not meet the BTF guidelines were identified using logistic regression. RESULTS: Our sample was composed of 2303 patients, of whom 66 (2.9%) underwent ICPM. Relative to Glasgow Coma Scale (GCS) score of 13 to 15, GCS score of 9 to 12 (OR 10.2; 95% CI 4.3 to 24.4) and GCS score of \u3c9 \u3e(OR 15.0; 95% CI 7.2 to 31.1), intraventricular hemorrhage (OR 2.4; 95% CI 1.2 to 4.83), skull fractures (OR 3.6; 95% CI 2.0 to 6.6), CT worsening (OR 3.3; 95% CI 1.8 to 5.9), and neurosurgical interventions (OR 3.8; 95% CI 2.1 to 7.0) were significantly associated with ICPM. Restricting to those who met the BTF guidelines, only 43 of 240 (18%) underwent ICPM. Factors independently associated with ICPM included intraparenchymal hemorrhage (OR 2.2; 95% CI 1.0 to 4.7), skull fractures (OR 3.9; 95% CI 1.9 to 8.2), and neurosurgical interventions (OR 3.5; 95% CI 1.7 to 7.2). DISCUSSION: Worsening GCS, intraparenchymal/intraventricular hemorrhage, and skull fractures were associated with ICPM among older adults with TBI, yet utilization of ICPM remains low, especially among those meeting the BTF guidelines, and potential benefits remain unclear. This study highlights the need for better understanding of factors that influence compliance with BTF guidelines and the risks versus benefits of ICPM in this population. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III

Predictors of Retained Hemothorax in Trauma: Results of an EAST Multi-Institutional Trial.

BACKGROUND: The natural history of traumatic hemothorax (HTX) remains unclear. We aimed to describe outcomes of HTX following tube thoracostomy drainage and to delineate factors that predict progression to a retained hemothorax (RH). We hypothesized that initial large volume HTX predicts the development of an RH. METHODS: We conducted a prospective, observational multi-institutional study of adult trauma patients diagnosed with a HTX identified on CT scan with volumes calculated at time of diagnosis. All patients were managed with tube thoracostomy drainage within 24 hours of presentation. RH was defined as blood-density fluid identified on follow-up CT scan or need for additional intervention after initial tube thoracostomy placement for HTX. RESULTS: 369 patients who presented with a HTX initially managed with tube thoracostomy drainage were enrolled from 17 trauma centers. RH was identified in 106 (28.7%) patients. Patients with RH had a larger median [IQR] HTX volume on initial CT compared to no RH (191 [48-431] mL vs. 88 [35-245] mL, p = 0.013) and were more likely to be older with a higher burden of thoracic injury. After controlling for significant differences between groups, RH was independently associated with a larger HTX on presentation, with a 15% increase in risk of RH for each additional 100 mL of HTX on initial CT imaging (OR 1.15, 95% CI 1.08-1.21; p \u3c 0.001). Patients with an RH also had higher rates of pneumonia and longer hospital length of stay than those with successful initial management. RH was also associated with worse functional outcomes at discharge and first outpatient follow-up. CONCLUSION: Larger initial HTX volumes are independently associated with RH and unsuccessful initial management with tube thoracostomy is associated with worse patient outcomes. Future studies should use this experience to assess a range of options for reducing the risk of unsuccessful initial management. LEVEL OF EVIDENCE: III, therapeutic/care management study