Purpose:
The number of severely injured patients exceeding the age of 60 has shown a steep increase within the last decades. Today, they make up almost 40% of our polytrauma population. This is an over-view of changes in demographics of geriatric severe trauma patients from 2002 to 2017.
Methods:
A descriptive analysis of the data from the TraumaRegister DGU® was performed. Patients admitted between 2002-2017, aged 60 years or older and with ISS over 15 were included. Patients were stratified into four subgroups: 2002-2005, 2006-2009, 2010-2013 and 2014-2017. Trauma and patient characteristics, diagnostics, treatment, and outcome were compared between subgroups.
Results:
In total 27,049 patients were included. Average age was 73.9 years. The majority were males (64%), mean ISS was 27.4. Motorvehicular trauma cases decreased from 52.0% to 38.1%, whereas incidences of low falls (< 3m) rose from 17.6% to 40.1%. Spinal injuries became more frequent (29.2% to 35.8%) as extremity injuries (54.9% to 46.5%) and abdominal trauma rates dropped (17.3% to 13.4%).
The average length of stay decreased from 28.9 days to 19.5 days and on ICU from 17.1 days to 12.7 days. Intubation rates decreased from 59.8% to 39.5 and blood transfusions decreased from 31.1% to 11.8%. Mortality decreased from 40.5% to 31.8%.
Conclusion:
We saw a decrease of length of stay and mortality despite an increase in patient age. Besides changing injury patterns, we ascribe these observations mainly to increased use of diagnostic tools, improved treatment algorithms and implementation of specialized geriatric trauma centers.

Introduction: The COVID-19 pandemic has had a significant impact on the management of ambulatory trauma patients over the last year. Our trust has restructured the management of these patients throughout the waves of the pandemic. We report our experience managing this patients at this challenging time whilst analysing the effects of the waves of the pandemic on patient numbers and delays to theatre. Materials and Methods: We conducted an observational cohort study on consecutive NHS attending three NHS hospitals with ambulatory trauma warranting surgery between 1/4/20 and 1/2/21. Results: A total of 867 patients underwent surgery for ambulatory trauma during the study period. The vast majority were upper limb cases (>65%) and the overall distribution of case mix remained constant throughout. During the first National COVID-19 lockdown the number of cases presenting to our trust with ambulatory trauma over halved but this trend was not repeated during the 2nd and 3rd subsequent lock downs. Despite the challenges the NHS faced, the overall time to surgery was maintained throughout the period without significant delays (mean 5.6 days). Conclusions: The number of ambulatory trauma case was reduced during the first National Lockdown but this did not appear to be impacted by subsequent lockdowns. The overall time to theatre was maintained despite significant pressures.

Background: Management of open fractures is challenging and requires a multidisciplinary team approach. This study aims
to evaluate outcomes of open Gustilo–Anderson IIIB fractures managed at a single Ortho-Plastic centre following One-stage
“Fix and Flap” approach. Methods: Prospective data review for patients presenting with Gustilo–Anderson IIIB Fractures to our centre and managed with one-stage “Fix and Flap” approach. Postoperative outcomes are presented only for the patients who had a minimum of 12 months postoperative follow-up. Results: 120 patients were included (83 males and 37 females). Mean age was 43 years (10–96). Tibia diaphysis was the most common site of injury (60%). 55.9% of injuries were road trafc accidents (RTA). 102 out of 120 patients had a minimum of 12 months follow-up (mean follow-up duration 25 months). Meantime from injury until defnitive surgery was 7.71 days. Primary union achieved in 86.73%. Delayed union was encountered in 10.20%. 3.06% of patients had non-union. Limb salvage rate was 97.05% and Deep infection rate was only 0.98%. Conclusion: Our results showed that low infection rate, high limb salvage rate, and high union rate can be achieved in these complex injuries with meticulous technique, combined Ortho-Plastic (Fix and Flap) approach, and MDT input.

The use of intramedulalary nails on unstable transtrochanteric fractures, is associated with a lower cut-out rate and material failure, however the size of the nail is still a topic of debate.
We conducted a retrospective observational study, in patients with reverse obliquity transtrochanteric fractures treated with cephalomedullary nail between January 2017 and May 2018. 45 patients were divided into 2 groups: 29 patients treated with short nail (180mm) and 16 patients with long nail (> 300mm).
Most patients underwent surgery before 48h (66.7%), with 44.4% before 24h on admission.
A tip-apex <25mm was obtained in 84.4% of the cases (n = 38). We had complications in 6 patients: 3 cut-out’s, 2 vicious consolidation in varus and 1 material failure. Complications were statistically more frequent in patients with a short nail(p <0.001).
The average hospital stay was 21 days in patients with a short nail and 18 days with a long nail. Transfusions were required in 51% of patients, with no statistically significant differences between the 2 groups. Mortality rate at 1 year was 16%, and we obtained an average function score of 4.6 on the Parker Palmer Mobility Score, with no statistically significant differences between the 2 groups.
In conclusion, the use of long nails on reverse obliquity transtrochanteric fractures, is recommended to reduce the likelihood of complications and new surgical interventions. However, no additional benefit was observed for the ability to walk, mortality rate, hospital stay and need for transfusion.

Introduction:

Open and closed reduction are the two treatment options used for the fixation of femoral shaft fractures. The aim and objective of the study is to assess the clinical and functional outcomes of the open v closed nailing of closed femoral shaft fractures.

METHODLOGY:

A total of 398 patients underwent intermedullary nailing fixation of nonpathological femoral shaft fracture between January 2016 to December 2019 were reviewed retrospectively. 274 underwent closed nailing and 124 were considered for open nailing.

RESULTS:

Primary outcome reviewed was union rate of fracture, other outcomes analysed were complication, intraoperative blood loss, time to union and duration of procedure. Patients in open group who had union of fracture, did so in 15.71 weeks, close reduction group had union in 15.53 weeks (p-value 0.495).Patients in open nailing had mean RUST score of 11.435 vs closed nailing group had mean of 11.664(p-value 0.187).Operative time was higher in open group , when compared to closed reduction group (p-value 0.000).However, Intraoperative blood loss was more in open nailing as compared to closed nailing .However ,15 patients in closed nailing had non-union , whereas 11 had non-union after going through open nailing. Superficial infection and deep infection requiring debridement was equally observed among two treatment groups.

CONCLUSION

Open nailing used to fix closed femoral shaft fractures have similar outcomes in rates of union, time to union, and rates of significant complication similar to those of close nailing.

Introduction: Conventional lateral column locking plate are found to have high rates of varus collapse and implant failure in comminuted metaphyseal and articular fractures. This systematic review evaluates the pros and cons of dual plating in distal femoral fractures.
Material and methods: totally 913 articles were identified, of which 12 articles were included after screening. There were one randomized-controlled, four prospective and seven retrospective studies. A total of 260 patients with 264 knees were evaluated (dual plating group-185, single plating group-76, lost to follow up-3). Three studies compared the single plate with dual plate; remaining seven studies evaluated the outcome of dual plating only.
Results: The non-union rate following dual plating in distal femur fracture was ranging from 0 to 12.5%, and the incidence of the delayed union was up to 33.3%. The mean healing time for the distal femur fracture using dual plates ranged from 11 weeks to 18 months. There was no difference between the single plate and dual plate fixation with regards to the functional outcome (VAS score, Neer’s Score and Kolmert’s standard) and complications. The infection rate and stiffness have been reported up to 16.7% and 25% of patients respectively.
Conclusion: Dual plating in distal femur leads to a better union in comminuted distal femur fractures, low supracondylar periprosthetic fractures and non-union., the findings are limited by heterogeneity in the studies with different fracture pattern, medial implant and outcome assessment methods.

Aim – Complex limb injuries usually comprise of a combination of osseous, soft tissue, vascular and neural damage, necessitating prompt and accurate initial examination and decision-making to maximise optimal patient outcomes. Unfortunately, scant guidelines exist regarding the management of complex extremity injury – when to opt for primary amputation vs limb salvage? We present the factors affecting the decision-making as well as the outcomes following primary limb amputation or salvage of complex extremity injuries. Method: We performed the literature search on PubMed and Embase, and collated the relevant data comprising of demographics, injury, scoring system, primary and secondary outcome metrics and complications. Results: Many scoring systems, each with variable factors, have been proposed to predict limb salvage vs amputation in complex extremity injury (MESS, PSI, LSI, NISSSA, HFS-97), however the landmark LEAP trial concluded in its final analysis that they could not validate them. Whilst the scores were useful in predicting limb salvage, they were inaccurate and unreliable in predicting amputation with low sensitivities. Conclusion: Many scoring systems attempt to provide guidance regarding decision-making in limb salvage vs primary amputation, however the LEAP study has shown poor predictive standards of these systems. As such, there is no gold standard algorithmic approach or scoring system when making this difficult decision – instead the poor predictors of limb salvage have been identified, and the surgeons need to be judicious and make a joint decision considering these variables and other patient factors (social, economic and psychological status).

Introduction: Plate fixation in compound proximal and distal tibial articular (tibial plateau and plafond) fractures is not safe in acute setting due to risk of infection. This study was done to see the clinico-radiological outcome of these fractures wherein Ilizarov was applied in the acute setting as a definitive modality. Methods: 13 cases (8 tibial plateau and 5 plafond fractures), ageing 18-70 years, presenting within 7 days of injury having Gustilo-Anderson Grade 1,2,3A open fractures were operated by Ilizarov ring fixation and followed for 12-18 months. The parameters noted were time required for union, functional outcome by Johner and Wruh’s criteria and presence of any complications. Results: All the patients were operated within a week of hospitalization. Average duration of hospital stay was 7 days (Range:4-15 days). Ilizarov was retained for 84-170 days. Final results after a minimum of 12 months follow-up were excellent in 8 cases, good in 4 and fair in 1. None of the patients required secondary procedures like bone grafting. Pin tract infection, to varying degrees were found in almost all cases but only in 2 cases, oral antibiotics had to be continued beyond 2 weeks. There was a case each of wire loosening and of wire breakage. Limb-length discrepancy to the extent of 2.5 cm were seen in 2 cases. Conclusion: Application of Ilizarov ring fixator in acute compound fractures of proximal/ distal tibial is a safe and good option which avoids secondary surgery, has minimal complications, allows early patient ambulation and reduces hospital stay.

Introduction: Distal femur fractures are exceedingly rare with an estimated frequency of 0.4% of all fractures and 3% of femoral fractures. In the setting of medial comminution malunion, fracture shortening with extension and varus deformities of the distal articular surface is a typical presentation. Our hypothesis was that anatomical reduction of the articular and metaphyseal fracture with stable rigid fixation that allows early rehabilitation and mobilization may decrease the associated high rates of morbidity and mortality including prevention of varus collapse and accelerated arthritic changes. Materials and Methods: The study involved 20 patients with follow up period of 52 weeks. A standard Medial parapatellar incision was used to reduce the articular surface and bicolumnar plating was done in a U shaped fashion. Results: Average duration of surgery was 2.58hrs. Average blood loss was 460ml.At 2 weeks follow up, 50% of patients had 81-90º range of motion, 30% of patients had 61-70º and 20% had 71-80º range of motion. At 6 weeks follow up, 80% patients had >90º range of motion and at 6 months 75% patients had >110º range of motion. Clinical union was achieved in 85% within 6 months and all the patients achieved clinical union by 7 months. All except one patients achieved radiological union by 8 months. Functional outcome of patients was calculated at final follow-up with help of Functional Evaluation scoring system given by Sanders.et.al In our study we found excellent functional outcome in 50% patients, good in 40 percent and fair in 10% .

Objective
There is limited research on the long-term psychiatric outcomes of severely injured patients. Those studies existing focus on the negative effects like post-traumatic stress disorder, anxiety and depression. Yet, also psychiatric improvements can be noticed in patients after severe trauma, mainly through post-traumatic growth. In our study, we investigated coping mechanisms in multiply injured patients at least 20 years after trauma.
Methods
631 patients, who suffered polytrauma between 1971 and 1990, were contacted 20 or more years later. 37 questions on posttraumatic growth were enquired via a questionnaire. Questions touched on 5 specific topics relating to growth and question quantified improvements in specific areas. Answers were correlated with patient demographics using ANOVA-Test and Pearson’s R.
Results
337 patients returned the questionnaire and could be included in our study. Gender distribution was 114 females (33,8%) to 223 males (66,8%). 96,5% of patients reported improvements regarding at least one of the 37 questions. Approximately a third of patients noticed distinct improvements regarding their relationship to others (29,2%) and their appreciation of life (36,2%). We found a number of statistically significant (p<0.05) correlations with patient demographics: Women and married patients showed a greater expression of post-traumatic growth, while we could also note a positive correlation between the expression of post-traumatic growth and patient age as well as injury severity (ISS).
Conclusion
20 years after polytrauma a large proportion of patients exhibit posttraumatic growth, with significant correlation with patient demographics. Those coping mechanisms should be identified and fostered in clinical practice.

Background: Elderly patients who suffer from hip fractures often use medications that affect the coagulation system. Operating on such patients may pose a risk of bleeding. The aim of this study is to assess blood loss and other morbidities and mortality rates in these patients.
Patients and methods: A total of 2,748 patients with hip fractures were included in this study. They were divided to 5 main groups according to the different medical regimens they received. Our main outcome was intraoperative blood loss, measured by the hemoglobin level difference. We also compared death within 365 days, hospitalization duration, infection within 30 days and any recurrent re-hospitalization. A propensity score was applied to adjust comorbidities.
Results: Mean hemoglobin change levels were higher in the Plavix group (2.11.5, p.value<0.001). Death within 365 days was significantly higher in the Plavix group compared to the other groups )33.3%, p.value 0.001). In addition, The use of non-Plavix single agent antiplatelet therapy was associated with an increased operative blood loss (Beta=-0.17, 95% CI [-0.32;-0.02], p.value 0.02).
Conclusions: Since we did not find an increased risk for bleeding in the Plavix group, we recommend operating within 48 hours. On the other hand, an increased risk for bleeding was found in the non-Plavix single agent antiplatelet group, which is why further consideration needs to be done in this group.

Objectives: To investigate differences in demographic, surgical, and outcome data in orthopaedic trauma patients. Methods: The American College of Surgeons National Surgical Quality Improvement Program was retrospectively reviewed to identify White or Black patients who underwent a primary orthopaedic trauma surgery between 2008 and 2016. Demographics, comorbidities, surgical data, and preoperative outcomes were compared between both cohorts. Results: A total of 56,319 patients were identified; 50,927 (90.4%) were White and 5,392 (9.6%) Black. Black patients had lower rates of chronic obstructive pulmonary disease, but were more frequently smokers and diabetic (all, p<0.05). They presented with lower American Society of Anesthesiologists Classification score and required emergency surgery less frequently (all, p<0.05). Higher frequencies of deep wound infection (0.5% vs 0.3%, p<0.01) and postoperative ventilator use for >48 hours (0.4% vs 0.2%, p=0.03) were noted in Black individuals, with decreased mortality (0.3% vs. 0.6%, p<0.01) and postoperative transfusion (2.7% vs. to 3.8%, p<0.01) rates. Conclusions: Clear differences exist in the demographic, surgical, and outcome data between Black and White orthopaedic trauma patients.