Introduction:Occult hypoperfusion (OH) is a condition marked by normal vital signs coupled with inadequate tissue oxygenation.OH is often linked with adverse outcomes, especially in older individuals.This study aims to evaluate how OH affects the outcomes of polytrauma patients across different age groups.
Materials:A prospective trauma registry was examined up to 2019, comprising adult patients with an Injury Severity Score (ISS) exceeding 16.Two groups were compared: ADULts (30-59 years) and ELDerly (60 years and above).OH was defined as Lactate >2 mmol/l with SBP >90 mmHg and PR <120 bpm, while shock was defined as SBP <90 or PR >120.The study compared outcomes between normal, OH and shock patients within each age group.
Results: 1,067 patients were classified as ADULts, and 715 selected for Gr.ELD. Among Gr. ADUL, ICU stay and hospital stay did not significantly differ between shock and OH.Mortality was notably higher in shock patients (39%) and upon OH (20%) compared to normal patients (8%). Conversely, among ELD-patients, hospital stay was longer after shock compared to OH (16 vs. 10 days, P=0.004). Mortality was higher after shock compared to OH, with no significant difference observed between normal and OH patients in this group.
Conclusions: This study is the first to demonstrate that OH is linked with increased mortality, especially in polytrauma patients aged between 30 and 59 years. Conversely, in older patients, there was no significant difference in morbidity or mortality between OH and normal patients.These findings diverge from literature on less severely injured patients and this requires further research.

Introduction: bone defect because of trauma, infection or war injury requires bone reconstruction the most effective method is external fixation system comfortable, stable, less painful, hinged; correct any angular deformity in addition to lengthening. Methods: the external arc fixation system Salamehfix1 assembled from three small arcs for one segment lengthening and 4 arcs for two segments of lengthening depending on patient size, for every patient a special size arranged. The arcs are deferring in diameter and perimeter depending on the extremity shape so that the fixator will take the shape of the extremity on which it applies and the mostly used half pins for bone fixation which transfix the bone in different angels and levels and lead to stable fixation also existing simple hinges between arcs can correct any angular deformity. Results ; from 2000 to 2023, 239 patients was treated mean age 43 years (range: 21 -68 years) with mean bone loose of 7.8 cm (range : 2- 17 cm )with various reasons and locations in upper and lower extremities, mean duration follow up 37 months, mean external fixation time 294 days , 102 excellent, 59 good , 38 fair, 5 poor there where 6 problems , 7 obstacles according to Paley,s classification of complication , there was one persisting nonunion which required additional grafting .Conclusion ;the external arc fixation system Salamehfix 1 is effective in bone defect treatment and more comfortable to the patient in size, stability and correction of combined angular deformities.

Introduction: Polytrauma presents a devastating event with great impact on the patient’s life. While we are taking great care of improving our treatment algorithms, the rehabilitation often takes place outside of our direct field of vision. Yet, adequate rehabilitation is crucial for the patients to regain their former lives. The aim of this study on behalf of the SICOT Trauma research group was to identify rehabilitation strategies and standards in existing scientific literature. Methods: A systematic literature search of MEDLINE and Embase from 2000-2023 was conducted. Inclusion criteria was the description of polytrauma rehabilitation strategies in the acute, post-acute or long-term stage. Reported treatment aims, conducted therapies and challenges were extracted and stratified to either of the stages. Results: A total of 5212 studies were identified and 7 reviews were included in our study but no original study met our inclusion criteria. In the acute rehabilitation, the focus seems to be on the physical recovery, prevention of complications and preparation for the following rehabilitation stages whereas in the later stages, the main aim is to integrate the patient back into his former life. In every stage, a multidisciplinary approach is mandatory. Multiple challenges, such as the “rehabilitation gap” or psychological obstacles are described. Conclusion: This study highlights the need for standardized polytrauma rehabilitation algorithms. Whereas we could identify important information about each rehabilitation stage, we did not encounter specific evidence for prioritization of different therapies or algorithms of treatment. Polytrauma rehabilitation needs to shift from eminence to evidence.

Both floating knee, floating hip and open pelvic ring fractures are rare. These conditions are caused by high-energy trauma and relate with high complication rate and mortality. A recent study reviewed 8 cases in literature of double floating extremity and shows the difficulties in managing these situations. A 22 year-old man suffered a motorcycle accident and was approached according to the ATLS algoritm. Active inguinal hemorrhage was managed with inguinal packing to allow CT-scan study. His injuries included open-type IIIB-GA fracture of pelvic ring(Young-Burguess APC-II), comminuted fracture of the right femoral shaft, open-type II-GA fracture of right tibial+fibular shaft and multiple lacerations of the limbs, perineum and abdomen. He underwent surgical reduction of pubic symphysis with C-Clamp and external fixation of the femur and tibia fractures. There was no peritoneal penetration, but due to testicular hematoma, orchidopexy was preformed. The patient was then admitted to the ICU. He underwent placement of external fixator to stabilize the pelvic ring and definitive right sacroiliac joint osteosynthesis, with an ilio-sacral screw(percutaneous). After 10days, intramedullary nailing of the femur and tibia was performed. Due to dehiscence of the inguinal wound, debridement was performed. After discharge, the evolution was favorable and after finish the rehabilitation treatment, the patient regained total independence and was able to walk without walking aids, only with a deficit in hallux extension(G4/5–MRC). The approach to the polytraumatized patient with simultaneous ipsilateral floating hip and knee is complex, particularly with open fractures. The multidisciplinary approach was essential to guarantee the good results.

Determination of the level and dynamics of the D-dimer diagnostic marker, which will allow characterizing the course of COVID-19 in patients with limb fractures and their impact on the early diagnosis of thromboembolic complications in this category of patients. The main group included 157 cases of skeletal fractures against the background of COVID-19, the control group included 132 cases of skeletal fractures in which there was no COVID-19 infection. On the first day of treatment, 45.9% of patients in the main group had a high level of D-dimer, while among patients in the control group, this result was registered more than four times less often. On the third day of treatment, 53.5% of patients in the main group had a high level of D-dimer, which is 5.5 times more often than in the control group. On the tenth day of treatment, normal and subnormal D-dimer levels were observed in 44.0% of the main group, but this was more than twice as common as in the control group. A high level of D-dimer was determined in 49.8% of patients of the main group, while in the control array it was found in only 3.3% of patients. Peak values of D-dimer on the third day of treatment tend to decrease on the tenth day of treatment

Introduction: It is widely accepted that major trauma leads to systematic dysregulation with concomitant metabolic derangement. While metabolomics measurements are already used in other medical fields such as oncology, we still know little about the specific effects of trauma on human metabolism. The impetus for our study was to identify relevant components of the metabolic pathway in the existing literature. Methods: A systematic literature search of MEDLINE and Embase from 2000 to 2022 was performed. Original publications reporting metabolomics measurements after severe trauma in human studies were included. All significant parameters were extracted and evaluated. The metabolites were stratified according to their time point of measurement to either group: acute (baseline/0h after trauma), intermediate (6-24h after trauma) or late (>24h-7days). Results: A total of 3878 publications were identified in the databases. Nine publications met our criteria. In the acute phase, metabolites that are involved in the energy providing pathways, detoxification and excretion as well as biosynthesis are significantly elevated. These pathways present a dynamic over the following time course. Overall, ornithine, succinate and lactate were the most frequently reported metabolites. Conclusion: There is great heterogeneity in the existing literature between study designs, groups and time-points. As far as these discrepancies allow, a specific metabolic dysregulation can be observed, with a particular impact on energy-providing and detoxification/excretion pathways with a time-dependent dynamic. Especially in the acute phase after trauma, a highly catabolic metabolism with increased oxidative stress is visible. Identified metabolites and pathways may be of particular interest for future research.

Background: The University Hospital of Wales initiated a Quality Improvement Project aimed at boosting the efficacy of the Massive Haemorrhage Protocol (MHP) among its Trauma and Orthopaedic staff. This study investigated the effects of targeted educational interventions on improving staff familiarity and operational efficiency with the MHP, a critical factor for patient safety and survival.
Methods: A comprehensive evaluation involved structured educational sessions and the distribution of laminated reference cards to bridge knowledge gaps. The project assessed improvements in staff's MHP activation knowledge, focusing on the activation process and essential contact numbers, through pre- and post-intervention surveys.
Results: Significant improvements were noted following the interventions: understanding of the MHP activation number rose from 14.8% to 70%, knowledge of the out-of-hours bleep number increased from 30% to 95%, and familiarity with the blood bank bleep number improved from 18.52% to 85%. Usage of PORTERTRAC for MHP activation surged, with feedback suggesting the need for a unified activation number.
Conclusion: This Quality Improvement Project demonstrated that integrating educational sessions and practical tools significantly enhances MHP activation within trauma settings. It highlighted the synergistic effects of theoretical learning and practical aids in improving patient outcomes, emphasising the importance of clear communication and continuous education in trauma care. The study advocates for continued educational initiatives and simplification of the MHP activation process to maintain high standards of patient care and safety.

The choice of tactics and the final result of treatment depend not least on the adequate, effective and timely diagnostic measures, their completeness and comprehensive interpretation. The aim was to determine the possibilities of procalcitonin for early diagnosis of infectious complications in victims with gunshot fractures of the lower extremities. The entire array of research consisted of 86 victims with gunshot fractures of the lower extremities. The main group included 38 victims with gunshot fractures, the control group included 48 victims with household fractures. Among a large group of inflammatory markers, we used procalcitonin. Depending on the content of this hormone in the victim's blood, it is possible to talk about an existing infectious process developing in the victim's body. In patients with a threat of infectious complications, the level of procalcitonin was 0.9±0.03 ng/ml, and in control patients it was only 0.4±0.01 ng/ml. Determining the blood procalcitonin level is a fairly informative method of early diagnosis of infectious complications in victims with gunshot wounds of the lower extremities. Among the victims with gunshot fractures of the lower extremities, a higher blood procalcitonin level was determined compared to the victims with fractures caused by other factors

Introduction
Efficient patient flow management in trauma centres is crucial for enhancing healthcare outcomes. The Trauma and Spine Hub (TSHUB) at the University Hospital of Wales was established to improve treatment efficiency, reduce wait times, and ensure timely, specialised care for GP-referred patients, aiming to elevate patient care standards.
Methods
In an eleven-week retrospective study, the TSHUB's effectiveness, safety, and efficiency were evaluated. Data was collected from the Welsh Clinical Portal and admission records, analysing key metrics such as hospital length of stay, time to radiography, and blood test timing to assess patient flow. A staff survey involving doctors, nurse practitioners, and ward nurses identified operational challenges, offering a comprehensive view of the TSHUB's functionality.
Results
During the study, 49 patients were admitted to the TSHUB, primarily with query infections (79.6%). A significant portion, 67.3%, were discharged on the day of admission, while 12.2% were discharged on Day 1, and 8.16% on Day 2. The longest stay was 75 days. Challenges included non-compliance with unit criteria, capacity limitations, radiograph delays, and staff venipuncture training gaps.
Conclusion
The TSHUB significantly improved patient flow in the tertiary care environment, optimising referrals and access to specialised care. Despite its success, operational issues highlight the need for ongoing refinement to sustain the TSHUB's effectiveness. Further research is encouraged to explore the TSHUB model's long-term viability and potential to enhance orthopaedic and spine care delivery in various settings.

Deltopectoral (DP) approach is the most used approach for proximal humerus fractures. But it provides inadequate access to the posteriorly displaced fragments. These disadvantages can be addressed by a direct lateral deltoid splitting (DS) approach. However, there is always a concern about the possibility of axillary nerve injury in DS group. Purpose of this study is to assess whether there is increased possibility of post operative axillary nerve palsy in DS group or not.
Between 2015 to 2023, 38 patients having Neer 2- and 3-part fractures were operated for proximal humerus fracture with proximal humerus locking plate. Among them 17 were operated through deltoid splitting (DS) approach while 21 patients were operated through classic deltopectoral (DP) approach M:F ratio was 9:10 with average age of 56.6 years. The mean follow-up period was 52 weeks (range 18-82 weeks). There were no case of nonunion while 3 cases had malunion in DS group and 2 cases in DP group. There were no cases of axillary nerve palsy or deltoid weakness in any group. Mean Constant- Murley score of shoulder function was 80.3 (range 57-92). DS group had a significantly short operation time (62.5 min vs 79.8 min). So, it can be concluded that deltoid splitting approach allows a feasible way to treat proximal humerus fractures with excellent results in most of the patients without increased chance of peri-operative axillary nerve palsy.

Introduction: Technological advances in orthopedic and trauma surgery persist, but drilling proficiency still relies heavily on surgeon technique. Despite its critical role, access to specific drilling skills training is lacking. Spatial awareness and psychomotor skills are crucial in drilling accuracy, but evidence of practice improving proficiency is scant. Methods: This prospective study, representing level II therapeutic evidence, aimed to assess if repeated drill practice improves accuracy. Participants used standardized SawBone models to drill varying trajectories toward predefined targets. The control group conducted initial drilling, followed by a second round after 8 weeks with no regular practice. Meanwhile, the intervention group engaged in weekly self-directed drilling practice over 8 weeks, followed by a final round of standardized drilling. Results: A total of 17 orthopaedic staff at 2 hospital locations completed the study. Results showed no significant change in drilling accuracy of the control group from the initial round (Mean 3.8, SD 0.65, 95% CI 2.93-4.49) compared to the second round (Mean 4.0, SD 0.82, 95% CI 3.19-4.83) with a t-test p-value of 0.61. In the intervention group there was a significant improvement in accuracy from the initial round (Mean 4.4 SD 0.88 95% CI 3.52-5.03) compared to the final round after regular practice (Mean 2.9 SD 0.49 CI 2.39-3.38, p-value <0.01). Conclusion: There is a significant improvement in drilling accuracy with regular practice and no significant difference in a cohort that undertake only standard clinical work. This provides evidence for implementation of supplementary drilling practice as a standard orthopaedic training tool.

Objectives: The Integrated Military Partnerships and Civilian Trauma Systems (IMPACT) Study was initiated to examine and address the challenges faced in establishing integrated systems of trauma care. Methods: Through a survey, this study comprehensively gathered data on trauma system capabilities and the current degree of military-civilian integration of 77 individual countries. Our research collaborative developed a scoring method based on participant responses; countries were classified into three distinct integration types, ranging from minimal (Type I) to robust (Type III). Results: The survey collected a total of 246 responses. Improvements in resource availability with increased integration status were assessed in different aspects of trauma care delivery. Ambulance personnel availability was found to be improved with increased integration status (Type I: 48%, Type II: 69.2%, Type III: 84.6%), demonstrating a statistically significant correlation (Tau-b=0.299, p<0.05). A positive correlation with rehabilitation provider and therapist availability was also noted with increased integration status (Tau-b=0.230, p<0.05); Type I: 40%, Type II: 80.8%, Type III: 96.2%. Conclusion: Our comprehensive dataset allows us to understand not only factors surrounding resource availability, but also patient-care, communication, finances, and other components of trauma care. This analysis helps us understand the global landscape of military-civilian trauma system integration. From this foundation, our group aims to build an adaptable framework for implementation of trauma system integration that can significantly reduce the burden of traumatic disease globally.

A retrospective single-center study was performed to determine the impact of earthquakes during the COVID-19 lockdown on pediatric injury pattern referrals at a tertiary care facility. The investigated group included a period during the COVID-19 lockdown right after the earthquakes until the end of the confinement period, and the control group included the corresponding period one year before the pandemic. All consecutive pediatric patients who presented to the Emergency Department due to urgent care requirements for trauma were identified. Demographical data, type, region, and treatment of leading injury were investigated. Overall, data on 1166 patients were collected and analyzed. The investigated group's median age was lower than the control group but without sex differences. During the post-earthquake COVID-19 lockdown period, we observed a reduction in Emergency Department presentations and a decreased proportion of trauma presentations.
Furthermore, in the investigated group, we observed an increase in the proportion of head and shoulder/elbow injuries and a decrease in the proportion of foot/ankle injuries compared to the control group. The proportion of hospital admissions and the need for surgical treatment in the observed groups remained similar in both periods. Therefore, in the initial response to similar future scenarios, centers with pediatric emergency departments need to be prepared for an increased number of head and upper limb trauma cases.