Cardiovascular parameters on computed tomography are independently associated with in-hospital complications and outcomes in level-1 trauma patients

Background: In-hospital complications after trauma may result in prolonged stays, higher costs, and adverse functional outcomes. Among reported risk factors for complications are pre-existing cardiopulmonary comorbidities. Objective and quick evaluation of cardiovascular risk would be beneficial for risk assessment in trauma patients. Studies in non-trauma patients suggested an independent association between cardiovascular abnormalities visible on routine computed tomography (CT) imaging and outcomes. However, whether this applies to trauma patients is unknown.Purpose: To assess the association between cardiopulmonary abnormalities visible on routine CT images and the development of in-hospital complications in patients in a level-1 trauma center.Methods: All trauma patients aged 16 years or older with CT imaging of the abdomen, thorax, or spine and admitted to the UMC Utrecht in 2017 were included. Patients with an active infection upon admission or severe neurological trauma were excluded. Routine trauma CT images were analyzed for visible abnormalities: pulmonary emphysema, coronary artery calcifications, and abdominal aorta calcification severity. Drug-treated complications were scored. The discharge condition was measured on the Glasgow Outcome Scale.Results: In total, 433 patients (median age 50 years, 67% male, 89% ASA 1–2) were analyzed. Median Injury Severity Score and Glasgow Coma Scale score were 9 and 15, respectively. Seventy-six patients suffered from at least one complication, mostly pneumonia (n = 39, 9%) or delirium (n = 19, 4%). Left main coronary artery calcification was independently associated with the development of any complication (OR 3.9, 95% CI 1.7–8.9). An increasing number of calcified coronary arteries showed a trend toward an association with complications (p = 0.07) and was significantly associated with an adverse discharge condition (p = 0.02). Pulmonary emphysema and aortic calcifications were not associated with complications.Conclusion: Coronary artery calcification, visible on routine CT imaging, is independently associated with in-hospital complications and an adverse discharge condition in level-1 trauma patients. The findings of this study may help to identify trauma patients quickly and objectively at risk for complications in an early stage without performing additional diagnostics or interventions.</p

Functional Outcomes and Quality of Life in Patients With Post-Traumatic Arthrosis Undergoing Open or Arthroscopic Talocrural Arthrodesis—A Retrospective Cohort With Prospective Follow-Up

Fusion remains the gold standard for post-traumatic osteoarthritis after ankle fractures in many institutes. Patient-reported outcomes on long-term quality of life and functionality of talocrural arthrodesis remain relatively unknown. In literature, low patient numbers and inadequate outcome measures provide a poor foundation for patient expectation management. Additionally, the surgical approach is often omitted. This study presents a retrospective cohort of patients who underwent open or arthroscopic talocrural arthrodesis for post-traumatic arthritis between 2008 and 2019 with prospective follow-up by questionnaire. Participants completed the EuroQol 5-dimensional 3-level questionnaire (EQ-5D-3LTM), EuroQol Visual Analogue Scale (EQ-VASTM), Foot and Ankle Outcome Score Dutch Language Version (FAOS-DLV), and 4 additional questions. Thirty-five patients were included in the cohort and 32 were included for follow-up. Trauma mechanism was mainly a low fall or motor vehicle accident causing a talocrural fracture-dislocation in most cases. For open versus arthroscopic treatment respectively, patients reported a median EQ-5D-3LTM index of 0.775 and 0.775, EQ-VASTM of 80 and 88, FAOS-DLV of 57.0 and 63.9, and satisfaction of 90 and 88 out of 100 after a median of 6.0 and 6.5 years. This study is unique as it is the largest series on patient-reported outcomes in patients with post-traumatic arthrosis with validated questionnaires. In general, patients were satisfied with relatively high questionnaire scores, especially concerning pain and daily living. These functional scores are of importance when setting patient expectations regarding talocrural arthrodesis and recovery. Additionally, the subscale values may help preoperatively in weighing the intervention's advantages and disadvantages for individual patients

Epidemiology and outcomes of traumatic chest injuries in children: a nationwide study in the Netherlands

Thoracic injuries are infrequent among children, but still represent one of the leading causes of pediatric mortality. Studies on pediatric chest trauma are dated, and little is known of outcomes in different age categories. This study aims to provide an overview of the incidence, injury patterns, and in-hospital outcomes of children with chest injuries. A nationwide retrospective cohort study was performed on children with chest injuries, using data from the Dutch Trauma Registry. All patients admitted to a Dutch hospital between January 2015 and December 2019, with an abbreviated injury scale score of the thorax between 2 and 6, or at least one rib fracture, were included. Incidence rates of chest injuries were calculated with demographic data from the Dutch Population Register. Injury patterns and in-hospital outcomes were assessed in children in four different age groups. A total of 66,751 children were admitted to a hospital in the Netherlands after a trauma between January 2015 and December 2019, of whom 733 (1.1%) sustained chest injuries accounting for an incidence rate of 4.9 per 100,000 person-years. The median age was 10.9 (interquartile range (IQR) 5.7–14.2) years and 62.6% were male. In a quarter of all children, the mechanisms were not further specified or unknown. Most prevalent injuries were lung contusions (40.5%) and rib fractures (27.6%). The median hospital length of stay was 3 (IQR 2–8) days, with 43.4% being admitted to the intensive care unit. The 30-day mortality rate was 6.8%. Conclusion: Pediatric chest trauma still results in substantial adverse outcomes, such as disability and mortality. Lung contusions may be inflicted without fracturing the ribs. This contrasting injury pattern compared to adults underlines the importance of evaluating children with chest injuries with additional caution.What is Known:• Chest injuries are rare among children, but represent one of the leading causes of pediatric mortality.• Children show distinct injury patterns in which pulmonary contusions are more prevalent than rib fractures.What is New:• The proportion of chest injuries among pediatric trauma patients is currently lower than reported in previous literature, but still leads to substantial adverse outcomes, such as disabilities and death.• The incidence of rib fractures gradually increases with age and in particular around puberty when ossification of the ribs becomes completed. The incidence of rib fractures among infants is remarkably high, which is strongly suggestive for nonaccidental trauma

The use of patient-reported outcome measures in the literature on traumatic foot fractures: A systematic review

Introduction: Adequate foot function is paramount in daily activities, yet the incidence of foot fractures shows a rising trend. Patient-reported outcome measures are increasingly used for research; however, the use of a wide variety of available instruments is undesirable. In the current study, an overview is provided of patient-reported outcome measures used in clinical research evaluating outcomes of foot fractures. Tools are provided to choose the most adequate instrument in future research. Methods: To identify the instruments, a systematic review was performed using PubMed, Embase, and the Cochrane Library. Articles published since 2000, reporting on traumatic foot fractures and/or their posttraumatic sequelae, and using a minimum of one condition- or region-specific patient-reported outcome measure were included. Forty-nine instruments were identified, used 636 times collectively. These instruments were evaluated on frequency of use, bones or joints analyzed with the instruments, the type and amount of contained items, and existing literature on their psychometric properties. Results: The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale was used predominantly (AOFAS Ankle-Hindfoot Scale; n = 243, 38.2%), followed by the Maryland Foot Score (n = 90, 14.2%). Twenty-seven instruments were included for further analysis. The majority included questions on mobility (27/27) and pain (24/27). Tools to select an adequate instrument for new research are presented in the appendices. Discussion: Controversy surrounds the AOFAS Ankle-Hindfoot Scale as other authors have found that its psychometric properties, indicating it measures what it is supposed to measure adequately, are flawed. Conclusion: A multitude of specific patient-reported outcome measures concerning foot fractures exists. Furthermore, the predominantly used instrument is deemed insufficient regarding quality as found by other studies. A valid, reliable, and responsive patient-reported outcome measure for clinical research on foot fractures is necessary. The most adequate existing ones for future research on different topics can be found through the tools provided

Is a chest radiograph indicated after chest tube removal in trauma patients? A systematic review

PURPOSE The aim of this systematic review was to assess the necessity of routine chest radiographs after chest tube removal in ventilated and nonventilated trauma patients. METHODS A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, and CINAHL on May 15, 2020. Quality assessment was performed using the Methodological Index for Nonrandomized Studies criteria. Primary outcome measures were abnormalities on postremoval chest radiograph (e.g., recurrence of a pneumothorax, hemothorax, pleural effusion) and reintervention after chest tube removal. Secondary outcome measures were emergence of new clinical symptoms or vital signs after chest tube removal. RESULTS Fourteen studies were included, consisting of seven studies on nonventilated patients and seven studies on combined cohorts of ventilated and nonventilated patients, all together containing 1,855 patients. Nonventilated patients had abnormalities on postremoval chest radiograph in 10% (range across studies, 0-38%) of all chest tubes and 24% (range, 0-78%) of those underwent reintervention. In the studies that reported on clinical symptoms after chest tube removal, all patients who underwent reintervention also had symptoms of recurrent pathology. Combined cohorts of ventilated and nonventilated patients had abnormalities on postremoval chest radiograph in 20% (range, 6-49%) of all chest tubes and 45% (range, 8-63%) of those underwent reintervention. CONCLUSION In nonventilated patients, one in ten developed recurrent pathology after chest tube removal and almost a quarter of them underwent reintervention. In two studies that reported on clinical symptoms, all reinterventions were performed in patients with symptoms of recurrent pathology. In these two studies, omission of routine postremoval chest radiograph seemed safe. However, current literature remains insufficient to draw definitive conclusions on this matter, and future studies are needed. LEVEL OF EVIDENCE Systematic review study, level IV

The association of radiologic body composition parameters with clinical outcomes in level-1 trauma patients

Purpose: The present study aims to assess whether CT-derived muscle mass, muscle density, and visceral fat mass are associated with in-hospital complications and clinical outcome in level-1 trauma patients. Methods: A retrospective cohort study was conducted on adult patients admitted to the University Medical Center Utrecht following a trauma between January 1 and December 31, 2017. Trauma patients aged 16 years or older without severe neurological injuries, who underwent a CT that included the abdomen within 7 days of admission, were included. An artificial intelligence (AI) algorithm was used to retrieve muscle areas to calculate the psoas muscle index and to retrieve psoas muscle radiation attenuation and visceral fat (VF) area from axial CT images. Multivariable logistic and linear regression analyses were performed to assess associations between body composition parameters and outcomes. Results: A total of 404 patients were included for analysis. The median age was 49 years (interquartile range [IQR] 30–64), and 66.6% were male. Severe comorbidities (ASA 3–4) were seen in 10.9%, and the median ISS was 9 (IQR 5–14). Psoas muscle index was not independently associated with complications, but it was associated with ICU admission (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.65–0.95), and an unfavorable Glasgow Outcome Scale (GOS) score at discharge (OR 0.62, 95% CI 0.45–0.85). Psoas muscle radiation attenuation was independently associated with the development of any complication (OR 0.60, 95% CI 0.42–0.85), pneumonia (OR 0.63, 95% CI 0.41–0.96), and delirium (OR 0.49, 95% CI 0.28–0.87). VF was associated with developing a delirium (OR 1.95, 95% CI 1.12–3.41). Conclusion: In level-1 trauma patients without severe neurological injuries, automatically derived body composition parameters are able to independently predict an increased risk of specific complications and other poor outcomes

Outcome of severely injured patients in a unique trauma system with 24/7 double trauma surgeon on-call service

Background: The presence of in-house attending trauma surgeons has improved efficiency of processes in the treatment of polytrauma patients. However, literature remains equivocal regarding the influence of the presence of in-house attendings on mortality. In our hospital there is a double trauma surgeon on-call system. In this system an in-house trauma surgeon is 24/7 backed up by a second trauma surgeon to assist with urgent surgery or multiple casualties. The aim of this study was to evaluate outcome in severely injured patients in this unique trauma system. Methods: From 2014 to 2021, a prospective population-based cohort consisting of consecutive polytrauma patients aged ≥ 15 years requiring both urgent surgery (≤ 24h) and admission to Intensive Care Unit (ICU) was investigated. Demographics, treatment, outcome parameters and pre- and in-hospital transfer times were analyzed. Results: Three hundred thirteen patients with a median age of 44 years (71% male), and median Injury Severity Score (ISS) of 33 were included. Mortality rate was 19% (68% due to traumatic brain injury). All patients stayed ≤ 32 min in ED before transport to either CT or OR. Fifty-one percent of patients who needed damage control surgery (DCS) had a more deranged physiology, needed more blood products, were more quickly in OR with shorter time in OR, than patients with early definitive care (EDC). There was no difference in mortality rate between DCS and EDC patients. Fifty-six percent of patients had surgery during off-hours. There was no difference in outcome between patients who had surgery during daytime and during off-hours. Death could possibly have been prevented in 1 exsanguinating patient (1.7%). Conclusion: In this cohort of severely injured patients in need of urgent surgery and ICU support it was demonstrated that surgical decision making was swift and accurate with low preventable death rates. 24/7 Physical presence of a dedicated trauma team has likely contributed to these good outcomes

Nonoperative treatment of multiple rib fractures, the results to beat: International multicenter prospective cohort study among 845 patients

BACKGROUND Optimal treatment (i.e., nonoperative or operative) for patients with multiple rib fractures remains debated. Studies that compare treatments are rationalized by the alleged poor outcomes of nonoperative treatment. METHODS The aim of this prospective international multicenter cohort study (between January 2018 and March 2021) with 1-year follow-up, was to report contemporary outcomes of nonoperatively treated patients with multiple rib fractures. Including 845 patients with three or more rib fractures. Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), (pulmonary) complications, and quality of life. RESULTS Mean age was 57.7 ± 17.0 years, median Injury Severity Score was 17 (13-22) and the median number of rib fractures was 6 (4-8). In-hospital mortality rate was 1.5% (n = 13), 112 (13.3%) patients had pneumonia and four (0.5%) patients developed a symptomatic nonunion. The median HLOS was 7 days (4-13 days), and median intensive care unit length of stay was 2 days (1-5 days). Mean 5-Level Quality of Life Questionnaire index value was 0.83 ± 0.18 1 year after trauma. Polytrauma patients had a median HLOS of 10 days (6-18 days), a pneumonia rate of 17.6% (n = 77) and mortality rate of 1.7% (n = 7). Elderly patients (≥65 years) had a median HLOS of 9 days (5-15 days), a pneumonia rate of 19.7% (n = 57) and mortality rate of 4.1% (n = 12). CONCLUSION Overall, nonoperative treatment of patients with multiple rib fractures shows low mortality and morbidity rate and good quality of life after 1 year. Future studies evaluating the benefit of operative stabilization should use contemporary outcomes to establish the therapeutic margin of rib fixation. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III

Epidemiology and outcomes of traumatic chest injuries in children: a nationwide study in the Netherlands

Thoracic injuries are infrequent among children, but still represent one of the leading causes of pediatric mortality. Studies on pediatric chest trauma are dated, and little is known of outcomes in different age categories. This study aims to provide an overview of the incidence, injury patterns, and in-hospital outcomes of children with chest injuries. A nationwide retrospective cohort study was performed on children with chest injuries, using data from the Dutch Trauma Registry. All patients admitted to a Dutch hospital between January 2015 and December 2019, with an abbreviated injury scale score of the thorax between 2 and 6, or at least one rib fracture, were included. Incidence rates of chest injuries were calculated with demographic data from the Dutch Population Register. Injury patterns and in-hospital outcomes were assessed in children in four different age groups. A total of 66,751 children were admitted to a hospital in the Netherlands after a trauma between January 2015 and December 2019, of whom 733 (1.1%) sustained chest injuries accounting for an incidence rate of 4.9 per 100,000 person-years. The median age was 10.9 (interquartile range (IQR) 5.7–14.2) years and 62.6% were male. In a quarter of all children, the mechanisms were not further specified or unknown. Most prevalent injuries were lung contusions (40.5%) and rib fractures (27.6%). The median hospital length of stay was 3 (IQR 2–8) days, with 43.4% being admitted to the intensive care unit. The 30-day mortality rate was 6.8%. Conclusion: Pediatric chest trauma still results in substantial adverse outcomes, such as disability and mortality. Lung contusions may be inflicted without fracturing the ribs. This contrasting injury pattern compared to adults underlines the importance of evaluating children with chest injuries with additional caution.What is Known:• Chest injuries are rare among children, but represent one of the leading causes of pediatric mortality.• Children show distinct injury patterns in which pulmonary contusions are more prevalent than rib fractures.What is New:• The proportion of chest injuries among pediatric trauma patients is currently lower than reported in previous literature, but still leads to substantial adverse outcomes, such as disabilities and death.• The incidence of rib fractures gradually increases with age and in particular around puberty when ossification of the ribs becomes completed. The incidence of rib fractures among infants is remarkably high, which is strongly suggestive for nonaccidental trauma