Thoracic injuries in trauma patients: epidemiology and its influence on mortality

BACKGROUND

Thoracic injuries are common among trauma patients. Studies on trauma patients with thoracic injuries have reported considerable differences in morbidity and mortality, and there is limited research on comparison between trauma patients with and without thoracic injuries, particularly in the Scandinavian population. Thoracic injuries in trauma patients should be identified early and need special attention since the differences in injury patterns among patient population are important as they entail different treatment regimens and influence patient outcomes. The aim of the study was to describe the epidemiology of trauma patients with and without thoracic injuries and its influence on 30-day mortality.

METHODS

Patients were identified through the Karolinska Trauma Register. The Abbreviated Injury Scale (AIS) system was used to find patients with thoracic injuries. Logistic regression analysis was performed to evaluate factors [age, gender, ASA class, GCS (Glasgow Coma Scale), NISS (New Injury Severity Score) and thoracic injury] associated with 30-day mortality.

RESULTS

A total of 2397 patients were included. Of those, 768 patients (32%) had a thoracic injury. The mean (± SD, range) age of all patients (n = 2397) was 46 (20, 18-98) years, and the majority (n = 1709, 71%) of the patients were males. There was a greater proportion of patients with rib fractures among older (≥ 60 years) patients, whereas younger patients had a higher proportion of injuries to the internal thoracic organs. The 30-day mortality was 11% (n = 87) in patients with thoracic injury and 4.3% (n = 71) in patients without. After multivariable adjustment, a thoracic injury was found to be associated with an increased risk of 30-day mortality (OR 1.9, 95% CI 1.3-3.0); as was age ≥ 60 years (OR 3.7, 95% CI 2.3-6.0), ASA class 3-4 (OR 2.3, 95% CI 1.4-3.6), GCS 1-8 (OR 21, 95% CI 13-33) and NISS > 15 (OR 4.2, 2.4-7.3).

CONCLUSION

Thoracic injury was an independent predictor of 30-day mortality after adjustment for relevant key variables. We also found a difference in injury patterns with older patients having a higher proportion of rib fractures, whilst younger patients suffered more internal thoracic organ injuries.

Variables affecting functional outcome in floating knee injuries

BACKGROUND

The surgical outcome of floating knee injuries is difficult to predict. The high-velocity nature of the injury, complex fracture pattern and associated soft tissue/visceral injuries may have some impact on the functional outcome. The present study evaluates the variables affecting the clinical and radiological outcomes of floating knee injuries.

MATERIALS AND METHODS

The clinical, radiological and functional outcome (Karlstrom and Olegrud criteria) of 89 patients with 90 floating knee injuries were evaluated at the end of one year who were managed in our level 1 trauma center between January 2013 and December 2016. The details of the injury, fracture pattern, management and complications were collected retrospectively from their records.

RESULTS

There were 81 (91.1%) males and 8 (8.9%) females with mean age of 34.34 ± 12.28 years. The mean time for tibia and femur union was 9.52 (±6.6) and 10.5 (±7.37) months. There was significant delay (p < 0.005) in time taken for union in segmental femur fractures (14.3 ± 9.6 months) compared to nonsegmental femur fractures (8.68 ± 5.18 months). Such significant difference in time taken for union was not seen in tibial segmental (10.6 ± 4.62 months) and nonsegmental fractures (9.05 ± 7.27 months). As per the Karlstrom and Olegrud criteria, there were 22 (24.4%) excellent, 26 (28.9%) good, 24 (26.7%) fair and 11 (12.2%) poor outcome. There were 15 patients with malunited tibia, 6 with malunited femur, 10 with limb length discrepancy and 39 with knee stiffness. 28 (33.3%) patients underwent major additional procedures such as bone grafting, re-fixation or bone transport or tendon transfer. It was observed that open tibia fracture, segmental fracture, intra-articular fracture, additional surgical procedures, initial external-fixator (ex-fix) application were significantly associated with development of knee stiffness, limb shortening, malalignment and unsatisfactory (Karlstrom and Olegrud fair to poor) functional outcome.

CONCLUSION

Open tibial fractures, segmental fractures, intraarticular involvement, additional surgical procedures and initial external fixator application are the poor prognostic indicators of floating knee injuries.

Polytrauma patients in the Netherlands and the USA: A bi-institutional comparison of processes and outcomes of care

BACKGROUND

Modern trauma systems differ worldwide, possibly leading to disparities in outcomes. We aim to compare characteristics and outcomes of blunt polytrauma patients admitted to two Level 1 Trauma Centers in the US (USTC) and the Netherlands (NTC).

METHODS

For this retrospective study the records of 1367 adult blunt trauma patients with an Injury Severity Score (ISS) ≥ 16 admitted between July 1, 2011 and December 31, 2013 (640 from NTC, 727 from USTC) were analysed.

RESULTS

The USTC group had a higher Charlson Comorbidity Index (mean [standard deviation] 1.15 [2.2] vs. 1.73 [2.8], p<0.0001) and Injury Severity Score (median [interquartile range, IQR] 25 [17-29] vs. 21 [17-26], p<0.0001). The in-hospital mortality was similar in both centers (11% in USTC vs. 10% NTC), also after correction for baseline differences in patient population in a multivariable analysis (adjusted odds ratio 0.95, 95% confidence interval 0.61-1.48, p=0.83). USTC patients had a longer Intensive Care Unit stay (median [IQR] 4 [2-11] vs. 2 [2-7] days, p=0.006) but had a shorter hospital stay (median [IQR] 6 [3-13] vs. 8 [4-16] days, p<0.0001). USTC patients were discharged more often to a rehabilitation center (47% vs 10%) and less often to home (46% vs. 66%, p<0.0001), and had a higher readmission rate (8% vs. 4%, p=0.01).

CONCLUSION

Although several outcome parameters differ in two urban area trauma centers in the USA and the Netherlands, the quality of care for trauma patients, measured as survival, is equal. Other outcomes varied between both trauma centers, suggesting that differences in local policies and processes do influence the care system, but not so much the quality of care as reflected by survival.