The management of complex orthopedic injuries

Virtual reality-enhanced rehabilitation for improving musculoskeletal function and recovery after trauma

Orthopedic trauma remains a critical challenge in modern healthcare, often resulting in severe mobility limitations, acute pain, and delayed recovery. Conventional rehabilitation techniques, though effective, fail to address the individualized, high-precision interventions needed for musculoskeletal injuries like fractures, joint instability, ligament tears, and muscular atrophy. Virtual reality (VR) technologies, such as Apple Vision Pro and HTC Vive Pro, offer a transformative approach by enhancing diagnostic precision, rehabilitation effectiveness, and patient engagement through interactive, immersive environments that improve clinical outcomes. These VR technologies provide real-time biomechanical data, such as joint mechanics, muscle coordination, and movement patterns, allowing clinicians to design personalized rehabilitation programs. These technologies can thus facilitate neuromuscular re-education, improve muscle proprioception, and enhance muscle coordination. Studies have shown that VR-based rehabilitation advances functional recovery, improves pain management, and reduces psychological barriers associated with immobility. VR also facilitates telemedicine, increasing accessibility for patients with geographic or mobility issues. However, while VR may provide biomechanical data, it is important to note that they fall short in accurate motion tracking, particularly in fine motor control tasks. This scoping review follows PRISMA guidelines to explore the potential of VR in orthopedic rehabilitation, analyzing its diagnostic capabilities, personalized interventions, and real-time feedback systems. Despite this, barriers remain, including regulatory challenges, limitations in haptic feedback, high cost, and patient compliance. By presenting a balanced perspective on the landscape of VR in orthopedic care, this paper emphasizes the need for rigorous clinical validation, regulatory advancements, and interdisciplinary collaboration. Ultimately, VR offers the potential to significantly improve recovery outcomes, enhance patient engagement, and streamline rehabilitation protocols, but its successful integration into clinical practice must be approached with both optimism and caution.

Regenerative Nanofat Membrane Development Process

INTRODUCTION

Chronic wounds present a significant challenge in clinical practice due to complications like infections and prolonged healing times. Conventional treatments often fall short, necessitating advancements in wound healing strategies. This article introduces a novel approach using a combination of adipose-derived stem cells (ADSCs) from fat and growth factors from platelet-rich fibrin (PRF) to enhance wound healing outcomes.

METHODS

The Fakih-Manay fat membrane device was utilized to prepare fat membranes. Microfat was harvested and emulsified to produce nanofat, which was then combined with PRF to create a Nanofat-PRF membrane. The resulting membrane was uniform, versatile, and suture-friendly, making it ideal for various medical and surgical applications.

RESULTS

Between April 2019 and April 2024, 172 patients received treatment using a nanofat membrane. The membrane showed significant improvement in wound healing in various cases including diabetic foot ulcers, cleft palate surgeries, facial dermabrasion, skin necrosis, revision rhinoplasties, and post-cosmetic surgery complications. Postoperative follow-up after healing ranged from 1 to 16 months, showing high patient satisfaction and significant improvements in wound healing and no reported complications.

CONCLUSION

The nanofat membrane presents a versatile and innovative approach to enhancing healing across a broad range of medical and surgical applications. This study provides the first evidence on the method for creating these membranes, demonstrating their clinical efficacy and safety, with no reported complications over a 5-year period.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Temporal evolution of postsurgical bone repair in a rabbit model: A [99mTc]Tc-MDP scintigraphic study

Bone regeneration is crucial for repairing bone tissue following various injuries. Research techniques that enable the study of metabolic changes in bone tissue under different conditions are important for understanding bone repair and remodeling. This study used bone scintigraphy to evaluate osteogenesis secondary to osteotomy in a preclinical model of New Zealand rabbits. For this purpose, we conducted a longitudinal, prospective, case-control study in which scintigraphic variables were measured in both the right forearm (case-operated) and the left forearm (control - non-operated). The study sample consisted of 10 rabbits subjected to osteotomy, followed by a 12-week postoperative evaluation period, divided into six imaging stages at 1, 2, 3, 4, 8, and 12 weeks. We observed that the operated forearm showed significantly higher external radiation than the control side, using the pinhole collimator, denoting an increase in the biodistribution and tropism of the radiopharmaceutical to the operated forearm. Among the three evaluated time points, osteoblastic activity was highest in the second week and presented a significant decline in the 8th and 12th weeks, denoting regeneration and resolution of the surgical injury; the control forearm was also influenced by the inactivity imposed by the operated forearm. This fact was notably evidenced by the reduction in the metabolic activity of osteoblasts in the left forearm. Our study suggested that bone scintigraphy was sensitive enough to semi-quantitatively differentiate the metabolic activity of osteoblasts in the operated forearm in the three temporal landmarks evaluated in the study.

Making Sense of Electrical Stimulation: A Meta-analysis for Wound Healing

Electrical stimulation as a mode of external enhancement factor in wound healing has been explored widely. It has proven to have multidimensional effects in wound healing including antibacterial, galvanotaxis, growth factor secretion, proliferation, transdifferentiation, angiogenesis, etc. Despite such vast exploration, this modality has not yet been established as an accepted method for treatment. This article reviews and analyzes the approaches of using electrical stimulation to modulate wound healing and discusses the incoherence in approaches towards reporting the effect of stimulation on the healing process. The analysis starts by discussing various processes adapted in in vitro, in vivo, and clinical practices. Later it is focused on in vitro approaches directed to various stages of wound healing. Based on the analysis, a protocol is put forward for reporting in vitro works in such a way that the outcomes of the experiment are replicable and scalable in other setups. This work proposes a ground of unification for all the in vitro approaches in a more sensible manner, which can be further explored for translating in vitro approaches to complex tissue stimulation to establish electrical stimulation as a controlled clinical method for modulating wound healing.

Pattern of Orthopedic Injuries Related to Road Traffic Accidents Among Patients Managed at the Emergency Department in Black Lion Hospital, Addis Ababa, Ethiopia, 2021

Background

Studies showed that each year people lose their life on the road and many people are disabled. The majority of this disability was caused by orthopedic injury related to road traffic accidents. However, in the context of Ethiopia, studies ascribed to orthopedic injuries related to road traffic accidents are limited. The study aimed to assess the pattern of orthopedic injuries related to road traffic accidents among patients managed at the emergency department of Black Lion Hospital.

Methods

An institutional-based cross-sectional study was conducted on 354 victims of road traffic accidents with orthopedic injuries who were visiting the Emergency department of Black Lion Hospital. Patient charts were selected by systematic random sampling technique and the data was entered into Epi-data version 4.4.2.2 and exported to the static package for social science window version 26, and descriptive statistics were used for analysis.

Results

The study reveals that males were mostly injured persons (71.7%) with the age group of 13-24 were the most injured. Passenger car accounts 36.3% of causes of injury followed by motorbikes (27.4%) and lower limbs were the most common anatomic site of injuries (47.9). Of all injury types, a fracture is the most common one with 71.1%, especially lower limb fracture (42.1%). More than half victims (59.5%) had open wounds, and almost half of the study subjects (51.8%) experience Road traffic accidents while they are crossing or walking along the way.

Conclusion

Orthopedic injuries related to road traffic accidents are the main cause of death and disability in many individuals, especially in reproductive age groups. Therefore, policy-makers should be aware of different patterns of orthopedic injuries associated with a victim of road traffic accidents to have an appropriate and sustainable capacity to manage the orthopedic injuries.

Nanomaterials Versus The Microbial Compounds With Wound Healing Property

Age and diabetes related slow-healing or chronic wounds may result in morbidity and mortality through persistent biofilms infections and prolonged inflammatory phase. Nano-materials [metal/metal oxide NPs (39%), lipid vehicles (21%), polymer NPs (19%), ceramic nanoparticles (NPs) (14%), and carbon nanomaterials (NMs) (7%)] can be introduced as a possible next-generation therapy because of either their intrinsic wound healing activity or via carrying bioactive compounds including, antibiotics, antioxidants, growth factor or stem cell. The nanomaterials have been shown to implicate in all four stages of wound healing including hemostasis (polymer NPs, ceramic NPs, nanoceria-6.1%), inflammation (liposome/vesicles/solid lipid NPs/polymer NPs/ceramic NPs/silver NPs/gold NPs/nanoceria/fullerenes/carbon-based NPs-32.7%), proliferation (vesicles/liposome/solid lipid NPs/gold NPs/silver NPs/iron oxide NPs/ceramic NPs/copper NPs/self-assembling elastin-like NPs/nanoceria/micelle/dendrimers/polymer NPs-57.1%), remodeling (iron oxide NPs/nanoceria-4.1%). Natural compounds from alkaloids, flavonoids, retinoids, volatile oil, terpenes, carotenoids, or polyphenolic compounds with proven antioxidant, anti-inflammatory, immunomodulatory, or antimicrobial characteristics are also well known for their potential to accelerate the wound healing process. In the current paper, we survey the potential and properties of nanomaterials and microbial compounds in improving the process of wound and scar healing. Finally, we review the potential biocompounds for incorporation to nano-material in perspective to designate more effective or multivalent wound healing natural or nano-based drugs.

Tissue Augmentation in Wound Healing: the Role of Endothelial and Epithelial Cells

INTRODUCTION

Wounds and their complications present a frequent cause of morbidity and mortality in everyday clinical practice. In order to reduce the wound burden, much effort has been directed into the physiology of healing and new therapeutic approaches.

AIM

This paper provides an overview from the literature about the role of endothelial and epithelial cells in tissue filler employment for wound healing.

MATERIAL AND METHODS

The scientific literature was reviewed through PubMed, Medline and Science Direct. The articles were chosen in correlation with the study objective and their scientific relevance.

RESULTS

Successful wound healing depends on many diverse processes, cell types and molecular mediators. The definitive aim of wound healing is a properly healed wound. Tissue fillers are becoming an important alternative in wound management, although augmentation of soft tissue can present a demanding problem due to the difficulties in tissue survival. In order to prevent its failure, an optimal vascular network needs to form from wound edges into the filler.

CONCLUSIONS

Because of the importance of chemotaxis and angiogenesis in various physiological and pathological processes, both events present an extensive area of intense research. Additionally, epithelial cells are needed to cover the wound defect and sealing the wound environment from outer world.

Novel fibrous collagen-based cream accelerates fibroblast growth for wound healing applications: in vitro and in vivo evaluation

The present study reports the development of a novel film-forming bovine collagenous cream (BCC) based on bovine collagen (BC). In this study, collagen was isolated from bovine forestomach tissue, a novel source, and a cream formulation was prepared using some other bioactive ingredients. The electrophoretic pattern of the BC was found to be similar to type I collagen. The purity of BC was examined by amino acid analysis, which confirmed the presence of atelocollagen. The physicochemical properties of BCC such as rheology, spreadability, and temperature stability were characterized. The antimicrobial activity was examined against Bacillus subtilis, Staphylococcus aureus, and Escherichia coli, and BCC displayed excellent inhibitory effect. In vitro biocompatibility studies using NIH 3T3 fibroblast cells showed enhanced cell viability. FACS analysis revealed the non-toxic nature of BCC toward cells. The cell morphology and proliferation on the BCC matrix was studied using SEM and fluorescence microscopy. The in vivo wound healing efficacy of the BCC as a topical wound dressing was demonstrated on full thickness excision wounds in rat models. The healing profile showed that the BCC significantly enhanced re-epithelialization, collagen deposition, and contraction in the wound healing process. The findings of this study provide a new opportunity for the utilization of the untapped byproducts of the meat industry for valorization. We expect that this kind of topical healing cream could be a potential candidate in wound management and future clinical needs.

Traumatic Multiple Fractures Associated with Blunt Diaphragmatic Rupture and Diaphragmatic Hernia: A Case Report

Traumatic multiple fractures are a serious, infrequent and potentially life-threatening medical emergency. In addition, traumatic blunt diaphragmatic rupture and diaphragmatic hernia are rare and potentially life-threatening clinical entities associated with injuries. A case of traumatic multiple fractures associated with blunt diaphragmatic rupture and diaphragmatic hernia is reported. The operative management of this type of injury and clinical experience are discussed. (Hong Kong j.emerg.med. 2011;18:424-427)

Vacuum assisted closure technique: a short review

The management of difficult to heal wounds has always been a cause of concern for the treating clinicians. There has been a tremendous increase in the number patients presenting with difficult to heal wounds. The conventional techniques have been in use since the long time for the management of these wounds, yet desired results are not achieved always. Thus a newer novel technique which might be useful in the difficult to heal wounds and delivering at par or better results as compared to the conventional techniques is the need of the hour.

Complex knee injury scenario in tertiary level care in North India: An epidemiological study

Floating knee injury has been considered as one of the severe orthopedic injury, and is often associated with major systemic trauma involving other organs.

OBJECTIVE

To identify the incidence of floating knee injury, severity of injury and associated orthopaedic and non-orthopaedic injury.

METHODS

Epidemiologic study conducted from 1 Jan 2014 to 31 Dec 2014.

RESULTS

A total of 136 cases with floating knee injury were registered. Modified Fraser classification showed 58 patients had type 1, 74 had type 2 and 4 had type 3 floating knees. 119(87.5%) patients had open fractures and Gustilo-Anderson type IIIA(29.4%) being the commonest. No Mortality was found. 16 (11.76%) of floating knees had to undergo amputation of afflicted limb.

CONCLUSION

Statics of such data would be helpful in planning and preparing ourselves as healthcare professionals to prevent high mortality and morbidity/disability in floating knee injury.

STUDY DESIGN

Retrospective Epidemiological.

LEVEL OF EVIDENCE

Level 4 (Case Study).

Cox-2 inhibition potentiates mouse bone marrow stem cell engraftment and differentiation-mediated wound repair

BACKGROUND

Engraftment of transplanted stem cells is often limited by cytokine and noncytokine proinflammatory mediators at the injury site. We examined the role of Cyclooxygenase-2 (Cox-2)-induced cytokine-mediated inflammation on engraftment of transplanted bone marrow stem cells (BMSCs) at the wound site.

METHODS

BMSCs isolated from male C57/BL6J mice were transplanted onto excisional splinting wounds in syngenic females in presence or absence of celecoxib, Cox-2 specific inhibitor (50 mg/kg, body weight [b wt]), to evaluate engraftment and wound closure. Inflammatory cell infiltration and temporal expression of inflammatory cytokines at the wound bed were determined using immunohistochemical and quantitative-real time polymerase chain reaction (qPCR) analysis, respectively. Mechanistic studies were performed on a murine macrophage cell line (J774.2) to evaluate the effect of interleukin (IL)-17A.

RESULTS

Celecoxib administration led to a significantly high percent of wound closure, cellular proliferation, collagen deposition, BMSCs engraftment and re-epithelialization at the wound site. Interestingly, recruitment of CD4⁺T cells and F4/80⁺ macrophages as well as BMSC transplantation induced up-regulation of Cox-2 and IL-17A gene expression levels were reverted by celecoxib administration. Exogenous supplementation of recombinant interleukin (rIL)-17 to J774.2 cells significantly increased proliferation and gene expression of cytokines -IL-1β, IL-6, IL-8, IL-18 and tumor necrosis factor (TNF)-α via nuclear translocation of nuclear factor kappa B (NFκB)p65/50 subunit. Conditioned media of rIL-17 treated J774.2 cells when supplemented to BMSCs depicted a dose-dependent increase in the number of apoptotic cells and proapoptotic protein expression that was perturbed by celecoxib or IL-17 neutralizing antibody. Finally, celecoxib led to a dose-dependent increase in BMSC differentiation into keratinocyte-like cells in vitro.

CONCLUSION

Celecoxib protects transplanted BMSCs from Cox-2/IL-17-induced inflammation and increases their engraftment, differentiation into keratinocytes and re-epithelialization thereby potentiating wound tissue repair.

Platelet gel: a new therapeutic tool with great potential

Chronic wounds, such as diabetic foot ulcers, represent a serious clinical problem for patients and clinicians. Management of these wounds has a strong economic impact worldwide. Complications resulting from injuries are a frequent cause of morbidity and mortality. Chronic wounds lead to infections, painful dressings and prolonged hospitalisation. This results in poor patient Quality of Life and in high healthcare costs. Platelet concentrates (PC) are defined as autologous or allogeneic platelet derivatives with a platelet concentration higher than baseline. PC are widely used in different areas of Regenerative Medicine in order to enhance wound healing processes; they include platelet-rich plasma (PRP), platelet gel (PG), platelet-rich fibrin (PRF), serum eye drops (E-S), and PRP eye drops (E-PRP). This review highlights the use of platelet-rich plasma (PRP) and platelet gel (PG) preparation for clinical use.

Predictors of early versus late mortality in pelvic trauma patients

Background

Risks of predicting time-related in-hospital mortality varies in pelvic trauma patients. We aim to identify potential independent risks predictive of time-related (early versus late) mortality among pelvic trauma patients.

Methods

Local trauma registry data from 2004 through 2013 were reviewed. Mortality causes and timing of death were investigated. Multivariate logistic regression identified independent risks predictive of early versus late mortality in pelvic trauma patients while adjusting for patient demographics (age, sex, race), clinical variables (initial vital signs, mental status, injury severity, associated injuries, comorbidities), and hospital outcomes (surgical interventions, crystalloid resuscitations, blood transfusions).

Results

We retrospectively collected data on 1566 pelvic trauma patients with a mortality rate of 9.96 % (156/1566). Approximately 74 % of patients died from massive hemorrhage within the first 24 h of hospitalization (early mortality). Revised trauma score (RTS), injury severity score (ISS), initial hemoglobin, direct transfer to operating room, and blood transfusion administration in the Emergency Department were considered independent risk factors predictive of early mortality. Age, ISS, and Glasgow Coma Scale (GCS) were deemed risk factors predictive of death after 24 h (late mortality).

Discussion

Given the fact of a substantial number of patients died within the first 24 h of hospital arrival, it is reasonable to consider the first 24 h of hospitalization as the appropriate window within which early mortality may be expected to occur in pelvic trauma patients. The risk factors associated with massive hemorrhage were strong predictors of early mortality, whereas late mortality predictors were more closely linked with comorbidities or in-hospital complications.

Conclusions

While risk factors predictive of early versus late mortality vary, ISS seems to predict both early and late mortality accurately in pelvic trauma patients.

Wound Healing Concepts in Clinical Practice of OMFS

BACKGROUND

Wound healing is a complex and dynamic process and a thorough knowledge of the basics of physiology of wound healing is a must to implement principles of chronic wound care. Understanding wound healing at multiple levels-biochemical, physiologic, cellular and molecular provides the surgeon with a framework for basing clinical decisions aimed at optimizing the healing response.

OBJECTIVE

This review article describes the classification of wounds and aims to highlight the fundamentals of wound repair, enumerating the dressings used commonly and also, the newer concepts of wound healing.

MATERIALS AND METHODS

Search engines and medical databases were tapped to gather information on the subject. Search words employed were "Wounds", "wounds in OSMF", "Wound healing", "Repair", "Dressings in OMFS".

RESULTS

The search resulted in total of 153 articles which we reviewed to add to the literature the concepts of wound healing and to throw some light on recent advances in wound care.

CONCLUSIONS

Wound healing remains a challenging clinical problem and correct, efficient wound management is essential to positively influence the wound healing course and reduce potential complications.

BIOMATERIAL IMPLANTS IN BONE FRACTURES PRODUCED IN RATS FIBULAS

To evaluate the importance of collagen and hydroxyapatite in the regeneration of fractures experimentally induced in the fibulas of rats. Method: 15 rats were used. These were subjected to surgery to remove a fragment from the fibula. This site then received a graft consisting of a silicone tubes filled with hydroxyapatite and collagen. Results: Little bone neoformation occurred inside the tubes filled with the biomaterials. There was more neoformation in the tubes with collagen. Conclusion: The biomaterials used demonstrated biocompatibility and osteoconductive capacity that was capable of stimulating osteogenesis, even in bones with secondary mechanical and morphological functions such as the fibula of rats.

Is tissue augmentation a reality in biosurgery? An experimental study of endothelial cell invasion into tissue filler

New therapeutic approaches for wound treatment are evolving. Non healing wounds in oncology and after trauma may be cured by a novel technique of tissue augmentation with soft tissue fillers. The principle resides in filling the wound with collagen filler in order to seal the defect and promote healing. Successful angiogenesis forms the basis of tissue filler survival and determines the outcome of the healing process. During this study, basic data about endothelial cell invasion into collagen-made substratum was collected that could be used for neoangiogenesis studies in tissue augmentation techniques for large wound defect treatment. In the in vitro assay, the human umbilical vein endothelial cells (HUVEC) grow into a three-dimensional framework of collagenous tissue fillers, forming the basic step for angiogenesis. After heparins were used as chemotactic agents, a typical bell-shaped relationship between chemotaxis and agent concentrations was found. Significant cell infiltration was present in the assays with chemotactic agents. These observations support the potential for tissue augmentation with soft tissue fillers that could be used in acute and chronic non healing traumatic and oncology wounds after extensive surgical resections and radiotherapy.

Comparison between the effects of platelet-rich plasma and bone marrow concentrate on defect consolidation in the rabbit tibia

OBJECTIVE

To perform a comparative analysis of the effects of platelet-rich plasma and centrifuged bone marrow aspirate on the induction of bone healing in rabbits.

METHOD

Twenty adult, male New Zealand rabbits were randomly separated into two equal groups, and surgery was performed to create a bone defect (a cortical orifice 3.3 mm in diameter) in the proximal metaphysis of each rabbit's right tibia. In the first group, platelet-rich plasma was implanted in combination with β-tricalcium phosphate (platelet-rich plasma group), and in the second group, centrifuged bone marrow in combination with β-tricalcium phosphate (centrifuged bone marrow group) was implanted. After a period of four weeks, the animals were euthanized, and the tibias were evaluated using digital radiography, computed tomography, and histomorphometry.

RESULTS

Seven samples from each group were evaluated. The radiographic evaluation confirmed the absence of fractures in the postoperative limb and identified whether bone consolidation had occurred. The tomographic evaluation revealed a greater amount of consolidation and the formation of a greater cortical bone thickness in the platelet-rich plasma group. The histomorphometry revealed a greater bone density in the platelet-rich plasma group compared with the centrifuged bone marrow group.

CONCLUSION

After four weeks, the platelet-rich plasma promoted a greater amount of bone consolidation than the bone marrow aspirate concentrate.

The wound healing process: an overview of the cellular and molecular mechanisms

Wound healing remains a challenging clinical problem and correct, efficient wound management is essential. Much effort has been focused on wound care with an emphasis on new therapeutic approaches and the development of technologies for acute and chronic wound management. Wound healing involves multiple cell populations, the extracellular matrix and the action of soluble mediators such as growth factors and cytokines. Although the process of healing is continuous, it may be arbitrarily divided into four phases: (i) coagulation and haemostasis; (ii) inflammation; (iii) proliferation; and (iv) wound remodelling with scar tissue formation. The correct approach to wound management may effectively influence the clinical outcome. This review discusses wound classification, the physiology of the wound healing process and the methods used in wound management.

Avaliação de centrifugado osteogênico de medula óssea na consolidação de fratura em coelhos

OBJETIVO: Avaliar a eficácia de um centrifugado osteogênico de medula óssea em estimular a consolidação de osteotomias da fíbula em coelhos. MÉTODOS: Foram utilizados dez coelhos machos adultos da raça Nova Zelândia albino. Realizou-se uma osteotomia transversa médio-diafisária da fíbula direita, seguida da adição local de uma esponja de colágeno absorvível embebida em um centrifugado osteogênico, obtido pela centrifugação de aspirado de medula óssea do osso ilíaco ipsilateral. A fíbula esquerda foi utilizada como controle, sendo feita a mesma osteotomia, porém neste caso adicionando-se somente a esponja de colágeno absorvível. Após quatro semanas os animais foram sacrificados para estudo dos calos ósseos formados. Os critérios de avaliação foram a mensuração da densidade mineral utilizando-se a densitometria óssea com DEXA, do volume do calo com tomografia computadorizada multi-slice e dos tecidos formados por meio de histomorfometria. RESULTADOS: A utilização do centrifugado osteogênico resultou em um aumento médio na densidade mineral óssea dos calos de 40,3% e da quantidade relativa de tecido ósseo de 9,4%, sem aumento significativo nas quantidades relativas de cartilagem ou fibrose nem no volume do calo ósseo. CONCLUSÃO: A administração do centrifugado osteogênico de medula óssea utilizado neste estudo favoreceu a consolidação óssea de osteotomias experimentais em coelhos.

Missed injuries in trauma patients: A literature review

BACKGROUND

Overlooked injuries and delayed diagnoses are still common problems in the treatment of polytrauma patients. Therefore, ongoing documentation describing the incidence rates of missed injuries, clinically significant missed injuries, contributing factors and outcome is necessary to improve the quality of trauma care. This review summarizes the available literature on missed injuries, focusing on overlooked muscoloskeletal injuries.

METHODS

Manuscripts dealing with missed injuries after trauma were reviewed. The following search modules were selected in PubMed: Missed injuries, Delayed diagnoses, Trauma, Musculoskeletal injuires. Three time periods were differentiated: (n = 2, 1980-1990), (n = 6, 1990-2000), and (n = 9, 2000-Present).

RESULTS

We found a wide spread distribution of missed injuries and delayed diagnoses incidence rates (1.3% to 39%). Approximately 15 to 22.3% of patients with missed injuries had clinically significant missed injuries. Furthermore, we observed a decrease of missed pelvic and hip injuries within the last decade.

CONCLUSION

The lack of standardized studies using comparable definitions for missed injuries and clinically significant missed injuries call for further investigations, which are necessary to produce more reliable data. Furthermore, improvements in diagnostic techniques (e.g. the use of multi-slice CT) may lead to a decreased incidence of missed pelvic injuries. Finally, the standardized tertiary trauma survey is vitally important in the detection of clinically significant missed injuries and should be included in trauma care.

Impact of timing of pelvic fixation on functional outcome

Pelvic fractures are the third most common cause of death in motor vehicle accidents. Recent improvements in mortality can be attributed to the progress made in modern critical care medicine, multidetector CT, ATLS principles, multidisciplinary protocols and early fracture stabilisation. Currently, the timing of pelvic fixation is often based on the haemodynamic status and response of the patient to resuscitation, the fracture pattern, the presence of associated injuries and the immuno-inflammatory status of the patient. The purpose of this review is to focus on the impact of timing of reconstruction of pelvic fractures on the functional outcome of the patients. Thirty seven scientific studies on the outcome of pelvic and acetabular injuries were reviewed. Four on pelvic ring fractures, and one study on pelvic and acetabular fractures met our second inclusion criterion of prospective or retrospective studies investigating the outcome after early or late pelvic and acetabular fixation. These five studies suggested early pelvic and acetabular fixation for optimal outcome but their main difference was the definition of the length in time of that early period. In polytrauma patients, the "damage control orthopaedics" principle should be applied for haemodynamic and skeletal stabilisation (and faecal diversion, if indicated in cases of open fractures of the pelvis). The definitive fixation should be performed after the fourth post-injury day, when the physiological state of the patient is conducive to surgery.

Three-Dimensional Finite Element Models of the Human Pubic Symphysis with Viscohyperelastic Soft Tissues

Three-dimensional finite element (FE) models of human pubic symphyses were constructed from computed tomography image data of one male and one female cadaver pelvis. The pubic bones, interpubic fibrocartilaginous disc and four pubic ligaments were segmented semi-automatically and meshed with hexahedral elements using automatic mesh generation schemes. A two-term viscoelastic Prony series, determined by curve fitting results of compressive creep experiments, was used to model the rate-dependent effects of the interpubic disc and the pubic ligaments. Three-parameter Mooney-Rivlin material coefficients were calculated for the discs using a heuristic FE approach based on average experimental joint compression data. Similarly, a transversely isotropic hyperelastic material model was applied to the ligaments to capture average tensile responses. Linear elastic isotropic properties were assigned to bone. The applicability of the resulting models was tested in bending simulations in four directions and in tensile tests of varying load rates. The model-predicted results correlated reasonably with the joint bending stiffnesses and rate-dependent tensile responses measured in experiments, supporting the validity of the estimated material coefficients and overall modeling approach. This study represents an important and necessary step in the eventual development of biofidelic pelvis models to investigate symphysis response under high-energy impact conditions, such as motor vehicle collisions.

Early versus Delayed Fixation of Pelvic Ring Fractures

This retrospective study reports outcomes, after early and delayed surgical stabilization of fractures of the pelvic ring, in terms of pulmonary complications, length of hospital stay, and cost of hospitalization. The hospital course of 151 patients admitted to an academic teaching hospital who sustained acute fractures of the pelvic ring between June 1996 and December 2000 was reviewed. Patient demographics, Injury Severity Score (ISS), timing of operative fixation, and the incidence of pulmonary complications were analyzed. Radiographs were reviewed and fractures classified according to the modified Tile system. Tile fracture types B and C patients who underwent fixation within 1 week of injury (n = 71) were compared to those in whom surgery was delayed (n = 28). Adjusting for the ISS, early-repair patients had a lower risk of pulmonary complications (RR = 0.49, 95% CI = 0.25-0.96), a reduced length of hospital stay (12.2 vs. 20.5 days; P = 0.0005), and overall reduced cost of care ($57,084 vs. $158,625; P = 0.0317). Pelvic ring fixation within the first week of injury results in significantly reduced incidence of pulmonary complication, hospital stay, and cost of care regardless of injury severity. The coordinated team approach to insure prompt resuscitation, stabilization, and operative fixation results in more optimal patient outcomes.

Elastic and viscoelastic properties of the human pubic symphysis joint: effects of lateral impact joint loading

The human pelvis is susceptible to severe injury in vehicle side impacts owing to its close proximity to the intruding door and unnatural loading through the greater trochanter. Whereas fractures of the pelvic bones are diagnosed with routine radiographs (x-rays) and computerized tomography (CT scans), non-displaced damage to the soft tissues of pubic symphysis joints may go undetected. If present, trauma-induced joint laxity may cause pelvic instability, which has been associated with pelvic pain in non-traumatic cases. In this study, mechanical properties of cadaveric pubic symphysis joints from twelve normal and eight laterally impacted pelves were compared. Axial stiffness and creep responses of these isolated symphyses were measured in tension and compression (perpendicular to the joint). Bending stiffness was determined in four primary directions followed by a tension-to-failure test. Loading rate and direction correlated significantly (p<0.05) with stiffness and tensile strength of the unimpacted joints, more so than donor age or gender. The impacted joints had significantly lower stiffness in tension (p <0.04), compression (p<0.003), and posterior bending (p<0.03), and more creep under a compressive step load (p<0.008) than the unimpacted specimens. Tensile strength was reduced following impact, however, not significantly. We concluded that the symphysis joints from the impacted pelves had greater laxity, which may correlate with post-traumatic pelvic pain in some motor vehicle crash occupants.

Dynamic helical computed tomography scan accurately detects hemorrhage in patients with pelvic fracture

BACKGROUND

The purpose of this study was to evaluate the use of dynamic helical computed tomography (CT) scan for screening patients with pelvic fractures and hemorrhage requiring angiographic embolization for control of bleeding.

METHODS

Patients admitted to the trauma service with pelvic fractures were identified from the trauma registry. Data retrieval included demographics, hemodynamic instability, Injury Severity Score, blood transfusion requirement, length of stay, and mortality. CT scans obtained during the initial evaluation were reviewed for the presence of contrast extravasation and correlated with angiographic findings. Data are reported as mean +/- SEM, with P<.05 considered significant.

RESULTS

Seven thousand seven hundred eighty-one patients were admitted from June 1994 to May 1999. A pelvic fracture was diagnosed in 660 (8.5%). Two hundred ninety (44.0%) dynamic helical CT scans were performed, of which 13 (4.5%) identified contrast extravasation. Nine (69%) were hemodynamically unstable and had pelvic arteriography performed. Arterial bleeding was confirmed in all and controlled by embolization. Patients with contrast extravasation had significantly greater Injury Severity Score, blood transfusion requirement and length of stay. Sensitivity, specificity, and accuracy of CT scan for identifying patients requiring embolization were 90.0%, 98.6%, and 98.3%, respectively.

CONCLUSIONS

Early use of dynamic helical CT scanning in the multiply injured patient with a pelvic fracture accurately identifies the need for emergent angiographic embolization.

Prevention and treatment of venous thromboembolism after major trauma

In prospective studies the incidence of deep venous thrombosis, documented by venography, is between 35% and 63% in patients with major trauma. Five independent risk factors for deep vein thrombosis have been identified in these patients: older age, fracture of the femur or tibia, surgery, spinal cord injury and blood transfusion. Mechanical antithrombotic methods and low-dose unfractionated heparin administered subcutaneously moderately decrease the risk of venous thromboembolism but are less effective than a fixed dose of subcutaneous unmonitored low molecular weight heparin. Prophylaxis with oral anticoagulants (International Normalized Ratio 2.0-3.0) is also effective but is much less used because of the bleeding risk. This is particularly the case in patients with intracranial neurosurgery and acute spinal cord injury. Only a few clinical studies have evaluated the treatment of venous thromboembolism in patients with major trauma. If the condition of a patient with major injury allows, the treatment of venous thromboembolism recommended after hip replacement is cautiously applied.

Relationship between foot length and the inter anterior superior iliac distance

Reduction of unstable pelvic fracture by external fixator might be over or under corrected as there is no proper estimation from the surgical landmark. Radiographic evaluation after reduction must be carried out and improper reduction is found in a certain number. To find a better guide by normal surgical landmark the study was carried out as a survey research in 600 volunteers aged from 10 to 70 years. Simple caliper and tape were used to measure the height, foot length and inter anterior superior iliac spine distance. In 376/420 male volunteers (89%), the length between right heel and tip of the fourth toe was equal to the inter anterior superior iliac spine distance. In 173/180 female volunteers (96%), the length between right heel and tip of big toe was equal to the inter anterior superior iliac spine distance. The length of the right foot can be used as a reference in reducing unstable fractured pelvis by external fixation. These data were used in the management of 36 patients with unstable fractured pelvis with external fixation for reduction and stabilization. All had good results.