Background
German hospitals are classified as basic, standard and maximum care facilities within the German trauma networks. The Municipal Hospital Dessau was upgraded in 2015 as a maximum care provider. The aim of this study is to investigate whether a change in treatment management and outcome of polytraumatized patients has occured afterwards.
Methods
The study compared polytraumatized patients, treated in the Dessau Municipal Clinic as a standard care facility (DessauStandard) from 2012-2014 vs. those treated in the Dessau Municipal Clinic as a maximum care facility (DessauMax) from 2016-2017. Data of the German Trauma Register were analysed using the chi-square test, t-test and odds ratios with 95% confidence intervals.
Results
In DessauMax (238 patients, Ø 54 years ± 22.3; ♂ 160, ♀ 78), the shock room time with 40.7 ± 21.4 min was shorter than in DessauStandard (206 patients, Ø 56.1 years ± 22.1; ♂ 133, ♀ 73 ) with 49 ± 25.1 min (p=0.001). The transfer rate of 1.3% (n=3) to another hospital was lower in DessauMax (p=0.01). DessauStandard had 9 (4%) thromboembolic events and DessauMax 3 (1.3%) (p=0.7). Multiorgan failure was more common in DessauStandard, (16%) than in DessauMax (1.3%; p=0,000). DessauStandard showed a mortality of 13.1% (n=27), and DessauMax 9.2% (n=22) (p=0.22; OR=0.67, 95% CI, 0.37-1.23). The GOS in DessauMax (4.5 ± 1.2) was higher than in DessauStandard (4.1 ± 1.3; p=0.002).
Conclusions
The Dessau Municipal Clinic as a maximum care facility has achieved improved shock room time, fewer complications, lower mortality and an improved outcome.

Objective
To evaluate the characteristics of polytrauma patients with or without severe traumatic brain injury (TBI) compared to patients with isolated severe TBI.
Methods
Retrospective data analysis of 266 consecutive patients treated at a Level 1 Trauma center between 2012 and 2015.
Results
Of all included patients 27.1% were female. The mean age was 50.63±20.90 (18-97) years. The main mechanisms of injury were traffic accidents (47.7%, n=127) followed by falls from lesser height (23.3%, n=62) and falls from greater height (18%, n=48). A significantly higher mean age was documented in patients with isolated severe TBI compared to polytrauma patients with severe TBI and polytrauma patients without severe TBI. In patients with isolated severe TBI a fall from lesser height was the main cause of injury in contrast to polytrauma patients with or without severe TBI in whom traffic accidents and falls from greater height were the main cause of injury (p<0.001). Significantly higher mortality rates were seen in patients with isolated severe TBI (37.6%) compared to polytrauma patients with severe TBI (34.8%) and polytrauma patients without severe TBI (13.6%; p=0.001).
Conclusion
Polytrauma patients without severe TBI show significantly higher survival rates compared to polytrauma patients with severe TBI and patients with isolated severe TBI. Patients with severe TBI are significantly older and have significantly different injury mechanisms compared to polytrauma patients with or without severe TBI reflecting the frailty of this increasingly aging population.

Objectives: While the exact indications and interventions for thoracic and abdominal damage control have been consented, this information is not available for musculoskeletal injuries. We therefore performed a series of consensus meetings and an expert opinion survey to evaluate the appropriateness of orthopedic interventions.
Methods: Part I: Systematic review and development of the questionnaire. Systematic review. Publications were screened for abbreviated surgeries in spinal, pelvic, extremity and soft tissue injuries, if published between Jan 1, 2000 and Jan 1, 2019. Inclusion criteria: English language, publications dealing with isolated injuries and multiply injured patients with early temporary fixation by external fixation or comparable abbreviated surgical interventions. A standardized questionnaire was developed. Part 2: Twelve certified experts in trauma management, participated in the consensus process. These experts were subjected to the questionnaire. Consensus meetings were held (9/2018, 2/2019, 5/2019, 9/2019).
Results: Based on the literature review, 12 surgical interventions and 79 indications for DCO were identified. In spinal trauma, percutaneous interventions have been determined beneficial in both mono- and polytrauma. External fixation of pelvis or long bones are considered as standard procedures in DCO. Strong disagreement amongst the experts was observed for percutaneous screw fixation of the anterior pelvic ring. Traction for temporary stabilization was considered harmful by the panelists.
Conclusion. This review demonstrates a detailed description of management consensus for DC indications of the spine, the pelvis, extremities and soft tissues. Moreover, the authors propose a distinct terminology to separate local (isolated: MuST Surgery) versus systemic (polytrauma: DCO) scenarios.

Damage Control Orthopaedics (DCO) is a widely accepted strategy in the treatment of polytraumatized patients. Country-specific factors and influences on trauma-systems have impacts on implementation and its execution. The aim of this study was to assess current standards of fracture-management in polytraumatized patients in Europe.
A survey was sent online via SurveyMonkey®, between July and November 2020, to surgical disciplines participating in trauma care in Europe. Participation was voluntarily and anonymity was granted. The questionnaire consisted of demographic data, the definition of "polytrauma” and local standards for DCO.
Overall, questionnaires of 87 participants (12 women) were included. The majority of participants were senior consultants (50.57%). The mean work experience was 19 years and on average, 17 multiple-injured patients were treated monthly. The majority of participants stated that polytraumatized patients were defined by ISS ≥ 16 (44.16%), followed by the “Berlin Definition” (25.97%). BPsys <90 mmHg, Tachycardia or vasopressor administration (86.84%), pH-deviation, base excess-shift (48.68%) and lactate >4mmol (40.79%) or coagulopathy defined by ROTEM (40.79%) were the three mostly stated indicators for shock. Local guidelines (33.77%) and the S-3 Guideline by the DGU® (23.38%) were mostly stated as a reference for the treatment of polytraumatized patients. Normal coagulation (79.69%), missing administration of catecholamines (62.50%) as well as missing clinical signs of “SIRS” (67.19%) were stated as criteria for definite secondary surgery.
Different definitions of polytrauma are used in the clinical setting. Indications for DCO are mainly dependent on the patient`s physiology. The «Window of Opportunity» plays a lesser role in decision-making.

South Africa has the 11th highest gun related mortality in the world. Furthermore, many patients are injured by gunshots. Gunshot related injury has been recognised as a highly costly healthcare problem by individual treating centres, however no ‘national picture’ exists. This study sought to explore the burden of gunshot related orthopaedic injuries across South Africa.

A network was established across South Africa and 37 orthopaedic units representing 9 provinces joined. A snap shot cohort study was conducted which ran over two weeks. Data was captures by the local orthopaedic teams. Patients were eligible if they had at least one acute gunshot related orthopaedic injury. Follow up was at 6-8 weeks after injury.

Thirty-seven centres enrolled 135 patients over the study period. The Western Cape had the highest number of cases (52), followed by Gauteng (35) and KwaZulu-Natal (29). The median age of patients was 32.5 years and the overwhelming majority were male (89%). Forty three percent of patients had been either shot or stabbed before.
The femur was the most commonly affected bone (n=29). Most patients were discharged back to their community, however 37% of patients didn’t return for routine clinical follow up.

Gunshot related orthopaedic injuries amounts a major burden on healthcare resources. The true burden is most likely grossly underestimated. There is significant variation is management of the gunshot related fractures. In comparison to other countries, there is a greater tendency to non-operative treatment. However, challenges with follow up preclude determining effectiveness of these alternative treatment options.

Introduction: Incidence of Open Fractures is estimated at 30.7 per 10,000 population/ year. There are several ways to classify these fractures based on severity. Gustilo-Anderson classification is widely used for open fracture grading and it describes a higher risk of complications including infections and non-union with progressively higher grading. In the UK, BOAST and NICE guidelines advocate early administration of antibiotics, with BOAST guidance recommending it within 1 hour of injury. There is, however, a paucity of evidence describing the correlation between Antibiotic administration timing and wound infections. The purpose of this study was to evaluate this correlation. Materials and Methods: Retrospective non-randomized patient data collected from electronic patient record system (EPR) in a Major Trauma Centre in the UK from January 2019 to October 2019. Patients with Open Fractures (N=25) were identified. Primary outcome studied was the occurrence of wound infections, and it was correlated with the timing of Antibiotic administration, physiological status (ASA grading), and Gustilo-Anderson (GA) grade. Results: 25 patients were studied between the ages of 17 and 69, classified into ASA 1 & 2 (24%), ASA 3 (28%), and ASA 4 & 5 (24%). 48% of the fractures were GA III, 36% were identified as GA II, and 16% were GA I. Mean delay in Antibiotic administration from the time of injury was 3 hours and 55 minutes. There was no statistically significant correlation between Wound infections and delay in Antibiotic administration.

Purpose: Low intensity pulsed ultrasound therapy has been used for bone healing since 1970s. EXOGEN® was granted FDA approval in 1994 and NICE issued guidelines in 2013 and 2019. We conducted a retrospective review of EXOGEN® therapy at a major trauma centre. We believe this is the largest single centre case series on EXOGEN® in the world. Methods: We audited all cases undergoing EXOGEN® therapy at Barts Health NHS Trust from 01/01/2012 to 31/12/2017 and collected data on 201 patients, with delayed union or non-union, for twenty different patient, intervention and injury parameters including, but not limited to, site and type of fracture, method of fixation, co-morbidities and associated injuries. This was then analysed to ascertain and compare union and non-union rates for each parameter using the Chi-squared test for p<0.05. Results: The mean union rate for all fractures (delayed union/non-union) over six years was 76.62% (range 60%-94%). There was no significant difference between union rates for any parameter. Taking absolute values into account, union was favoured by female gender, age 20-40, open fractures, undisplaced fractures, intra- articular fractures, primary fixation, upper limb fractures, no infection, no vascular injury, polytrauma, diabetics and the use of NSAIDs. Conclusion: The mean union rate is comparable to case series mentioned in the NICE guidelines. We believe the wide variation was due to absence of robust patient selection criteria and compliance data. This dataset adds to the current body of evidence and is unique due to the variety of fractures from a single centre.

Introduction: The majority of pelvic ring fractures are a result of a high energy injury such as motorcycle and motor vehicle pedestrian accidents. Although many stable fractures can be managed nonoperatively, unstable fractures usually require surgical intervention. Objectives: To evaluate the outcome of ORIF of unstable pelvic fractures. Methods: ORIF of unstable pelvic fractures performed at our institution between 2012 and 2018 were reviewed. A minimum of 12-month follow-up was necessary. Image evaluation was performed according to the Tile classification. The functional outcome was assessed using the Short Form Survey (SF-36), Majeed pelvic score and Iowa pelvic score. Results and Discussion: Fifteen patients (8 men, 7 women, mean age 48 years) underwent an ORIF for an unstable pelvic fracture were included. The mean follow-up time was 31 months. Six patients had a Tile B and nine a Tile C fracture. The mean time between admission and surgery was 13 days. The mean score for physical SF-36v2 was 68% and emotional SF36v2 was 54%. The mean Majeed pelvic score was 81% and Iowa pelvic score was 70.5%. Conclusion: Despite the magnitude of the injury, patients with unstable pelvic fractures managed with ORIF had mild disability as stated by the good functional scores. More studies with larger samples are necessary to confirm these conclusions.

Introduction: Traumatic spinopelvic dissociation (TSD) is a transverse fracture of the sacrum with a longitudinal transforaminal bilateral fracture, which causes a dislocation of the spine and the upper sacrum from the pelvis. Triangular lumbopelvic fixation (LPF) is a popular fixation in the treatment of TSD and can be applied in unilateral or bilateral fashion.
Patient and Methods:A prospective cohort study conducted at Level I trauma center between January 2017 and July 2019 including twenty patients with TSD treated surgically with lumbopelvic fixation and sacral decompression in cases with neurological deficit, with a minimum follow up period of one year. two equal groups with ten patients each, Group (A) and (B) were fixed by unilateral LPF and bilateral LPF respectively, both groups were compared to each other regarding fracture reduction, complications and functional outcome.
Results: both groups revealed that 90 % of injuries were due to fall from height (FFH), with average Injury Severity Score (ISS) = 27, as regard Gibbon`s score, 50 % of patients with neurological deficit improved after fixation and decompression. the preoperative delay, the average operative time, radiation exposure and soft tissue complications were less in the unilateral group compared to bilateral group with no statistically significant difference between both groups.
Conclusion: The unilateral triangular fixation is a good surgical construct option with added benefit of less operative time, radiation exposure, mean blood loss and most importantly reduced post-operative soft tissue complication.
Key words: Spinopelvic dissociation, lumbopelvic fixation.