Session 17: Trauma

Lonnie Froberg


Background: Orthopedic surgeons are not necessarily aware of patients who gradually derange, until the patient experiences a severe event (cardiac arrest, admit to ICU or dies). Early warning score (EWS) is a part of the early recognition and response to patient deterioration. The system allocate points based on the derangement of patients’ vital signs variables. The sum of the allocated points is used to direct care, e.g. to increase vital signs monitoring, involve more experienced staff or call a rapid response team. Our department discovered several problems in the use of early warning score: Vital signs were not measured, nurses did not orientate the surgeons of increased score, the surgeon did not initiate or initiated insufficient care. .
Aim: To prevent severe events in orthopaedic patients.
Materials and Methods: From June to August 2020 an increased focus on EWS including education in measuring of vital signs, orientation in case of increased EWS, examination and treatment of acute medical conditions were initialized. The number of patients experiencing severe event in a 5 months period before intervention (January-May 2020) and a 5 month period 1 year after implementation (August- December 2021) were analyzed.
Results: The majority of patients experiencing severe events suffered from low energy fractures. Before intervention, 947 patients were hospitalized and 28 (3.0%) experienced a severe event. Thirteen patients died, for 8 patients (62%) a decision had been taken not to start cardiopulmonary resuscitation (CPR) and 1 patient was found dead without initiating CPR. Two patients succeeded CPR but had a new cardiac arrest, 2 patients had unsuccessful CPR. Fifteen patients were admitted to ICU. One year after intervention 1.058 patients were hospitalized and 17 patients (1.6%) experienced a severe event. Fifteen patient died, in all cases (100%) a decision not to start CPR had been taken. Two patients were admitted to ICU.
Interpretation / Conclusion: A significant reduction of severe events (p=0.04) one year after implementation of a simple intervention was found. Furthermore, active decision on whether to start CPR or not before cardiac arrest occurred was done in all cases.

Christian Pean¹², Michael Gustin¹², Michael Weaver¹, Thuan Ly², Arvind von Keudell¹
Brigham and Women's Hospital, Boston, MA¹; Massachusetts General Hospital, Boston, MA ²

Background: Pelvic ring and acetabular fractures are commonly seen and treated by orthopaedic surgeons. Surgical treatment is associated with a 1.5-14% and 4.8% mortality rate for pelvic ring and acetabular fractures, respectively. There is limited data with regards to the effect of congenital, acquired and anticoagulant induced bleeding disorders on post-operative complications and mortality in surgically managed pelvic ring and acetabular fractures, which may contributed to associated morbidity and mortality.
Aim: To assess and compare short-term (=30 days) outcomes of pelvis and acetabulum fractures in patients with and without bleeding disorders.
Materials and Methods: Patients with operatively managed pelvis and acetabulum fractures were identified from the National Surgical Quality Improvement Program database from 2012 to 2019 using CPT codes 27215, 27217, 27218, 27226, 27228, and 27254. Major complications, readmission, length of stay, and reoperation were compared as primary outcomes between those with and without bleeding disorders.
Results: A total of 1,449 patients underwent pelvis and acetabulum ORIF during the study period assessed and 10.7% had a bleeding disorder. Patients with bleeding disorders were at higher risk for discharge location other than home ( OR 4.49, CI 2.68-7.53), major complications (OR 2.13, CI 1.38-3.28), reoperation (CI 2.03, CI 1.03-4.00), mortality (OR 2.34, CI 1.17-4.64), postoperative blood transfusion (OR 1.97, CI 1.40-2.77). In a logistic regression analysis controlling for multiple comorbidities, smoking, race, obesity and age, bleeding disorder remained significantly associated with major complications (B=1.60, CI 1.02-2.51, p=0.04) and intraoperative or postoperative blood transfusion (B=1.46, CI 1.02-2.08). Patient with bleeding disorders also exhibited a longer length of stay (8.05 +- 5.43 vs 6.88 +- 6.96, p=0.044) than patients without a bleeding disorder.
Interpretation / Conclusion: Patients with bleeding disorders undergoing ORIF for pelvis and acetabular fractures have higher rates of major complications, mortality, and readmission. Surgeons can use this to guide patient expectations and inform future interventions to mitigate the deleterious effects of bleeding disorders post- operatively.

Christian Pean, Steven Rivero, Michael Weaver, Mark Fleming, Arvind von Keudell a,b,c
aHarvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts, USA bDepartment of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA cDepartment of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

Background: The modified frailty index has yet to be studied in patients undergoing surgical treatment of pelvic and acetabular fractures.
Aim: We hypothesized that patients with a modified frailty index greater than 2 will be subject to an increased rate of infection, readmission, length of stay, mortality and overall complications after surgical treatment of pelvic and acetabular fractures.
Materials and Methods: Hospitals participating in American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database were included for analysis of outcomes. Patients: Patients undergoing open reduction internal fixation (ORIF) of pelvic and acetabular fractures were identified from the NSQIP database between 2012 to 2019. Intervention: ORIF for pelvic and acetabular fractures. Main Outcome Measurements: Major complications, mortality, readmission, length of stay, and reoperation were primary outcome measures in this study.
Results: A total of 1,449 patients underwent pelvis and acetabulum ORIF during the study period assessed and 24.3% had a mFI-5 of two or greater. In a multivariate regression analysis controlling for numerous patient comorbidities including, race, BMI, preoperative hypoalbuminemia, and ASA greater than 2, patients with a mFI-5 of two or greater were at higher risk for discharge other than home (OR=1.96, CI=1.32-2.91), infectious complications (OR =1.56, CI 1.03- 2.37), and readmission (OR=1.72, CI 1.10- 2.69). Patients with a mFI-5 greater than two also had a significantly longer length of stay compared to other patients (8.4 vs. 6.6, p<0.001)
Interpretation / Conclusion: In this study, the mFI-5 was seen to correlate with 30-day postoperative incidence of infectious complications, readmission, and discharge other than home in patients undergoing ORIF for pelvis and acetabular fractures. Orthopedic trauma surgeons can use this information in concert with geriatricians to influence surgical decision making, improve perioperative management and anticipate complications in this patient population.

Miao Wang, Carina Wulff Greve Andersen, Maj Alexandra Ambrosiussen , Karen Toftdahl Bjørnholdt
Orthopedic Department, Horsens Regional Hospital

Background: Images and charts from emergency departments are typically evaluated the following weekday at a radiographic conference, in some cases leading to re-contact of the patients: when there is a change of diagnosis and treatment plan or need for additional examinations.
Aim: To evaluate the quality of trauma center service by retrospectively investigating the incidence and reasons for re-contact of patients after initial treatment for minor trauma in the emergency department at Horsens Regional Hospital
Materials and Methods: A random sample of 1000 patient charts from 1 October 2021 to 31 December 2021 from the trauma center were reviewed. Re-contacts were identified, and time of visit, diagnosis, treatment, and patient age and gender were compared to the cohort. Reasons for re-contacts were counted and explored qualitatively.
Results: The overall incidence of re-contacts was 33 (3.3%). Reasons for re-contact were missed injury 11 (1.1%), need for additional examinations 6 (0.6%), diagnostic error 5 (0.5%), change of treatment plan without change of diagnosis 5 (0.5%), uncertainty about treatment or diagnosis 5 (0.5%), other 1 (0.1%). The most common site for missed injury and diagnostic error was hand/wrist (n=6), followed by foot (n=3), shoulder (n=2) and elbow (n=2) cases. The re-contact rate varied throughout the day: day time 08:00- 18:00: 2.1%, evening 18:00-23:00: 4.6%, and night 23:00-08:00: 5.4%. This could be a reflection of the availability of a specialist orthopedic surgeon (08:00-18:00 on site, 18:00-08:00 on call), a newly graduated doctor (on site 08:00-23:00), and an orthopedic doctor in training (on call 08:00- 18:00, on site 23:00-08:00).
Interpretation / Conclusion: The incidence of re-contacts was 3,3 %. The missed injury rate was 1.1%, which is relatively low compared with misse dinjury rates in other studies (ranges from 1.39 to 14.5%). The missed injury and diagnostic errors are mainly due to misinterpretation of radiological images, which can be improved by training. In the day time, when 60% of patients vists the trauma center, we found a 50% lower re-contact rate compared to evening and night. The working system at trauma center Horsens Denmark is well functional and can achieve a low missed injury rate.

Christian Pean, Amy Steele, Abigail Sagona, Arvind von Keudell a,b,c
aHarvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts, USA bDepartment of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA cDepartment of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

Background: Metabolic syndrome is an increasingly prevalent condition affecting 1 out of 3 Americans and has been tied to elevated risk of poor surgical outcomes. Pelvis and acetabular fractures are inherently challenging fractures fraught with a higher risk of complications than many injuries. As shifts to value-based care occur, it is critical to properly risk-stratify patients to develop policy and prevent patient complications when possible.
Aim: This study sought to assess the impact of metabolic syndrome on short term outcomes of pelvis and acetabulum ORIF.
Materials and Methods: Patients who underwent ORIF for pelvis and acetabular fractures from 2012 to 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients with metabolic syndrome (MetS) were compared to other patients for rates of adverse events and readmission in the 30- day postoperative period for the overall cohort. All statistical analyses were conducted using SPSS (IBM SPSS Statistics for Windows, Version 26.0, Armonk, NY: IBM Corp). Paired student t- tests were used to assess continuous variables. Pearson’s Chi-square and odds ratios were used for categorical variables.
Results: A total of 1,005 patients met inclusion criteria for this study. In total, 51 MetS patients were identified in the cohort. MetS patients were more likely to have a history of congestive heart failure (OR 3.39, CI 1.62-7.10) and pre-operative kidney disease (OR 9.69, CI 1.73-54.22), MEtS patients did not have significantly different rates of infectious complications, major complications, or readmission than other patients.
Interpretation / Conclusion: Patients undergoing ORIF for pelvis and acetabular fractures with MetS are not at higher risk of 30-day major complications, infection, and readmissions. Although other comorbidities are often considered in isolation as risk factors for patients with pelvis and acetabular fractures, MetS patients do not appear to have an increased risk for poorer outcomes in the 30-day postoperative period.

Kristian Kjærgaard, Jens Lauritsen
Accident Analysis Group, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital. Department of Clinical Medicine, University of Southern Denmark

Background: We found no formal guideline to assist in clinical decision on driving ability following immobilization due to orthopaedic acute injury or fractures. Few studies mention simple metrics like brake force or reaction time. A more realistic assessment could be a driving simulator, where obstacles and sudden situations arise based on analysis of injury statistics. Analysis of a larger number of traffic injury situations is hypothesized to reveal a classification potential, which could then allow driving simulator developers to implement high- risk situations in virtual driving.
Aim: To propose a list of traffic incidents that occur frequently (Fx) or result in severe personal injury (Sx) based on empirical traffic incident data the basis for implementation for driving simulation and estimate variation of this with sex and age.
Materials and Methods: We included patients injured in traffic incidents while driving a passenger car and treated at the emergency department at Odense University Hospital between Jan 2014 and Jun 2021. Key variables were extracted from the routine registration (age, sex, severity of injury, and incident variables: counterpart, direction of counterpart, place of incident) and grouped into scenarios according to resemblance.
Results: We analyzed 4,017 incidents for 2074 male and 1943 female drivers with age grouped as 18-24 (n=1,138), 25-49 (n=2,009), 50-64 (n=550), 65-74 (n=167), or 75+ years (n=153). Six Fx scenarios and seven Sx scenarios were extracted from the dataset, covering 89% and 81% of respective incidents. The rank order was markedly different between Fx and Sx scenarios, between age groups for Fx and Sx scenarios, and between sexes for Sx scenarios.
Interpretation / Conclusion: The variation of ranking between Fx and Sx scenarios with age and sex indicates that incorporation of real life traffic situations in driving simulators is not simple. Developers of a screening tool for individual guidance in driving ability after orthopaedic surgery should take this into consideration.

Thomas Falstie-Jensen¹, Anne Kathrine Belling Sørensen¹, Ilja Ban², Mette Rosenstand²
¹DSSAK;²DOT

Background: Displaced fractures of the middle-third of the clavicle are a common injury. This type of injury is commonly treated non-operatively. However, with the development of anatomical plates an increase in operative treatment was seen. In 2017 Dansk Ortopædisk selskab released “Korte Kliniske Retningslinjer” (KKR) based on current knowledge to guide Danish orthopaedic surgeons in the choice of treatment.
Aim: To update the current KKR with evidence published after 2017.
Materials and Methods: All relevant databases and grey literature were searched for metanalyses and randomized clinical trials (RTC) published from 2017 to 2022 comparing plate fixation of displaced midclavicular fractures with non-operative treatment. RCTs were assessed for bias using the Cochrane Risk-of-bias tool and metanalyses were assessed using the AMSTAR tool. Finally, the level of evidence was assessed using the GRADE tool. Using the prior PICO (Population, Intervention, Comparator, Outcome) question, the new evidence was evaluated.
Results: The search revealed 92 new metanalyses of which 2 network metanalyses covered the PICO question and were included. Similarly, 146 new RTCs were identified. After assessment 2 RCT, not included in the metanalyses and with low risk of bias, were included. Three studies found a statistical and just clinically relevant increase in Disabilities of the hand and shoulder score (DASH) among the operated patients after six weeks. This effect diminished over time and all studies showed no significant difference in functional outcome measured by Constant Score or DASH after one year. All studies found a significant higher risk of non-union after non-operative treatment (˜16%) compared to ORIF (˜1,5%).
Interpretation / Conclusion: Displaced middle-third clavicular fractures should mainly be treated non-operatively since no difference in functional outcome is found after one year. Plate fixation reduce the risk of non-union and may lead to a minimal and temporary functional improvement after six weeks. Consequently, plate fixation should only be performed in selected cases and after thorough consideration.