Introduction: Sepsis is a frequent complication following traumatic injury. Early identification of trauma patients prone to develop sepsis remains challenging. Aberrant circulatory leukocyte numbers after insult have been linked with sepsis in critically ill patients. The goal of the study was to develop and test a novel immune parameter to predict sepsis: the 24hr-leukocyte gap (24hr-LCG), defined as the difference between blood leukocyte numbers on admission and after 24 hours.
Methods: During a 17-year period, adults patients with blunt trauma and an ISS ≥ 9 were selected from a prospectively trauma registry. We grouped and compared patients with and without septic complications first. Thereafter, a multivariable regression analysis was utilized to identify specific predictive immune parameters for sepsis after trauma. Subanalysis focussed on septic shock and mortality.
Results: 1592 patients have been included. Sepsis occurred in 251 individuals. Patients with sepsis were younger (p<0.002), had worse hemodynamics and higher ISS on admission (p<0.001). Multivariable analysis identified the 24hr-LCG as an independent immunological predictive parameter for sepsis. Moreover, patients with an 24hr-LCG ≥ 10, had significantly higher incidences of septic shock (12,4% vs. 4.3%, p<0.001) and related mortality 6.0 vs. 2.7%, p=0.036) than other individuals.
Conclusion: This study reveals that a novel parameter: the 24hr-leukocyte gap is an independent early predictor for sepsis in trauma patients. The 24hr-LCG is easy to calculate and is a promising tool for early identification of trauma patients prone to develop septic complications. This may guide future decision making and more specifically timing of surgery.

Introduction: The results after acetabular fracture are primarily related to the quality of articular reduction. Using the Universal large distractor can offer direct intra-articular view of the acetabular socket without dislocating the joint. Methods: Eighteen patients were included in this study with an average age of 30 years (range 18-50 years). Joint distraction was applied using the universal large distractor to apply controlled traction over the traumatic hip joint. Two Schanz pins (5mm) were placed; one in the dense supracetabular area of the iliac bone at least two centimeters above the joint proximally and the second in the back of proximal femur limited to the level of lesser trochanter distally. The sliding carriage was applied on the greater trochanter side for caudal directed distraction, ranging from 10 to 15mm. Intra-articular fragments were removed or disimpaction of the impacted articular fragments was done under vision to achieve congruent joint reduction. During the whole technique, flexion of the knee joint was maintained to relax and avoid excessive tension on the sciatic nerve. Results: None of these 18 surgeries were converted to other methods of joint exposure to achieve the required task of joint visualisation. There was no reported complications but one patient with partial sciatic nerve palsy that was completely recovered after 1 year of follow up. Conclusion: Use of universal large distractor seems to be a simple, safe and reproducible technique that can be applied to remove retained intra-articular fragments and assist reduction of marginally impacted acetabular fractures without joint dislocation.

Purpose: Occult hypoperfusion(OH) describes absence of sufficient microcirculation despite normal vital signs. Our study aims to identify causes for occult hypoperfusion after hemorrhagic shock (HS) in a porcine polytrauma model.

Methods: 25 male Pigs received a combined injury of blunt chest trauma, liver laceration, HS, and femoral shaft fracture. After 60 minutes, animals were resuscitated with crystalloid fluids and fractures were stabilized. Microcirculation was evaluated using near-infrared spectroscopy on the vastus lateralis of the fractured and uninjured site as well as liver, stomach and colon. Lactate was measured via blood gas analysis. Measurments were taken at baseline, during HS at 15/30/45/60 min, and after resuscitation at 2h,4h and 6h. OH was defined as persistent lactatemia (>2mmol/l) at 6h.

Results: Lactate normalized in 18 animals (72%) after resuscitation (control). Four animals (16%) were diagnosed with OH. Three animals (12%) died during the observation period. Vital parameters (HR, RR, SaO2, and Schock Index) didn’t differ significantly between groups. Lactate was significantly higher in OH at 3h and 6h (p = 0.039 and p = 0.001). Higher local bloodflow was noted during HS on the uninjured M. vastus lateralis at 30, 45, and 60 min (p = 0.012, p = 0.039 and p = 0.008) in OH compared to control. Oxygen delivery was significantly higher at 45 and 60 min (p = 0.044, and p = 0.004), but lower at 4h (p = 0.039).

Conclusion: Failure to centralize during hemorrhagic shock can lead to reduced local microcirculation and persistent lactatemia after resuscitation.

Introduction: Comminuted distal femoral fractures with bone loss represent a very challenging surgical problem. Single lateral plate fixation may be inadequate in cases with medial wall comminution and may be complicated with varus collapse and nonunion. The retrograde nail may be difficult to provide adequate fixation if the distal fragment is comminuted or short. Nail plate combination may provide a biomechanical stable construct for comminuted distal femoral fractures, allowing for early range of motion and rehabilitation. This study aimed to evaluate the functional outcome of nail plate combination augmented by bone graft in a synthetic scaffold in a single-stage operation. Methods: 12 patients were involved in this prospective study from 2016 to 2020. All patients with comminuted distal femoral fractures more than 18 years old were involved. The age ranged from 20 to 58 years old with an average of 29 years. Open fractures in 9 cases (75%). A defect ranged from 3 to 8 cm. All cases were managed by retrograde nail augmented by lateral plate and bone graft in a Surgicel® scaffold. Results: All cases were united without further procedures with an average of 7 months ranging from 4 to 12 months with a good range of knee motion. One case developed a deep infection that needed surgical debridement. Conclusion: Nail plate combination augmented by bone graft in a synthetic scaffold is a good option for the management of complex distal femoral fractures in a single-stage operation.

Introduction: The ideal form of fixation for displaced, extra-articular fractures of the distal tibia remains controversial. Operative fixation with intramedullary nail and plate osteosynthesis are mainstay of treatment. The purpose of the study is to assess the treatment outcome of distal tibia fracture treated by intramedullary nail and plate osteosynthesis. Methods: The results of the management for 44 patients with closed extra-articular distal tibia fracture by intramedullary nailing and plating were reviewed retrospectively. The variables include, the mean duration of union, malunion, and nonunion. Results: eighteen patients were treated with intramedullary nail and twenty six patients were treated with plating. The mean radiological union duration in nailing group was 10 weeks and 13 weeks in plating group. Four patients (22%) out of eighteen nailing group and five patients (19%) of twenty six in plating group had nonunion. Seven patients (39%) of nailing group and three patients (12%) of plating group had malunion. Four patients from plating group and one patient from nailing group had infection. Conclusion: the plating technique in comparison to nailing has satisfactory outcome. This technique has lower incidence of nonunion and malunion and it should be recommended for closed distal tibia fractures.

Aim: To examine the clinical and functional outcome of bridge plating for complex (severely comminuted) femoral fractures. Introduction: Complex femoral fractures present a special magnificent problem. With a diversity of treatment options; there is an enthusiasm to use minimally invasive plate osteosynthesis (MIPO) which is gaining popularity for the last decade. Preserving fracture hematoma and periosteal vascularity. Finally resulting in small, more cosmetic scars. Principles: Manipulation at a distance to fracture site, preserving soft tissues (Indirect reduction techniques). Plate osteosynthesis is particularly advantageous in certain situations where an intramedullary nail may be contraindicated or technically not feasible. Method: Between 2014 and 2020 Eighteen patients (15 males and 3 females) aged 15-72 years having severely comminuted femoral fractures had been treated with submuscular plating via minimally invasive approach. Then the fractures were manipulated and anatomically aligned under image intensifier. The patients were monthly followed up for clinical and radiological union. Full weight bearing started 12-14 weeks post operatively. Results: Solid union achieved in all fractures of our series (100%). shortening of 1 cm and 5-degree external malrotation (two cases each). Limitation of complete knee flexion (one case). implant failure treated conservatively (one case).
Conclusion: MIPO technique provides a good alternative method for fixing comminuted femoral fracture. It is reliable, accepted by the patients, with a high union rate and a minimal complication rate.
Keywords: MIPO (Minimally Invasive Plate Osteosynthesis), Comminuted Femoral Fractures.

Background: The Covid-19 crisis quickly led to changes in social structures. Economic anxiety and living together in confined spaces with the obligation to stay at home led to an increase in domestic violence as reported worldwide. Methods: All patients who came to the Division of Trauma Surgery with domestic violence injuries 15 months before and after the beginning of the pandemic, were compared. The relative frequency of such patients in comparison to all other trauma patients, as well as age, sex, citizenship, injury pattern, mechanism of injury, and other parameters were analyzed. Results: An increase in patients reporting injuries associated with domestic violence in relation to all trauma patients from 0.465% to 0.548% after the onset of the pandemic was observed. Also, a significant increase of Austrian patients from 51.2% to 60.6% (p = .016) could be examined. The other parameters showed no significant changes. Conclusion: The Covid-19 crisis led to a relative increase in patients with domestic violence injuries at one of the largest trauma surgery units in Austria. The proportion of Austrian citizens also increased significantly. The remaining study parameters did not differ significantly, indicating that the frequency changed during the pandemic, but not the underlying pattern of domestic violence.

Introduction: Compartment syndrome is a common and severe medical condition that can lead to ischemia and ultimately tissue loss. The treatment of choice is emergent fasciotomy to lower the compartment pressure. Delayed primary closure is ideal, but because of skin edge retraction, the open wound must either heal secondarily or be closed with a split-thickness skin graft.The purse string suture technique allows for gradual closure of open fasciotomy wounds,encompassing all its levels, restoring normal anatomy and all containment and resistance functions of the skin layers.Aim: To perform fasciotomy wound closure by purse string suture technique which is a type of dermal apposition for gradual closure of fasciotomy wound.Materials and methods:The study included 30 patients who presented with compartment syndrome for which Decompression fasciotomy was done. Purse string suture was performed for closure of wound. Patients demographics, location of fasciotomy, time duration between injury and fasciotomy, number of tightening session, time to achieve closure, length of hospital stay, need for skin grafts and complications were recorded.Results:With this technique, none of the cases required new surgical interventions to close the wound. Closure was achieved in less time period, with less hospital stay and a low rate of complication.Conclusions:Gradual skin closure using purse string suture avoids the use of free skin grafts to close the fasciotomy wounds, reducing the need for anesthesia, nursing care, and hospital stays of patients resulting in lower morbidity and better aesthetic result. Because of the above-mentioned reasons, this technique is economically viable also.

Introduction: All orthopedic surgeons agree on the need for skeletal stabilization for the necessity for the compound fractures to heal, but whether to proceed with primarily definitive fixation or delayed definitive fixation is subject to debate. Objective: To assess and compare the rate of the bony union of the fracture, the duration of intravenous antibiotics, the wound healing capacity, duration of hospital stay, and the rate of postoperative infections among early and delayed definitive fixation of compound fractures. Methods: A prospective study consisting of 100 patients with compound fractures, out of which half were treated with primary definitive fixation while the other half were treated with delayed fixation in the form of external fixation initially followed by definitive surgery at a later date. The duration of the study is from 2015 to 2019 for all the patients followed up at our tertiary care center. These patients were serially followed up, radiographs and their outcomes were assessed and compared. Result: The study is a non-randomized cohort study with hundred patients with a mean age of 30.5 years with a predominance of men. 50 % of the fractures were Grade 3 b classification as per Gustillo Anderson classification. Conclusion: The outcome of primary definitive surgery has statistically significant better outcomes compared to delayed surgery. They had a faster bony union, shorter duration of limb immobilization, decreased duration of hospital stay, decreased requirement of intravenous antibiotics, and an early return to daily activities with a comprehensive decrease in the rate of infection.

Background: From the time “equivalents” of Monteggia lesion was described by Bado in 1967, there is a lot of confusion and varied interpretation of cases that fall into this category of rare injuries. The equivalent lesions are ones having the same mechanism of injury but the clinical and radiological presentation may differ from the classically described ones. Materials and Methods: A retrospective review was done for those Monteggia equivalent injuries presented into level 1 trauma centre between the year 2012-2019. These injuries maybe acute or chronic and had a minimum two-year follow-up. All these cases were surgically stabilized and the final functional outcome was evaluated using the Mayo elbow performance score (MEPS). Results: 10 children were diagnosed as Monteggia equivalent lesions during the study period. Mean age is 7.6 years and male: female ratio was 5:5. Six cases presented early and the remaining four cases presented late following trauma. In total, we had one type 1, four type 2, three type 3 and two inverted type 3 equivalent injuries. Of them one with type 3 equivalent injury was lost to follow-up and had to be excluded from the analysis describing the functional outcome. On final follow-up, MEPS was excellent in 8 children and good in one child. Conclusion: Monteggia equivalent lesions need precise diagnosis as it is easily missed and should be managed according to principles. The surgical planning and treatment should be individualized according to the fracture pattern for the best possible outcomes.

Introduction: Humerus head split fractures are rare subgroup of proximal humerus fractures and are often missed at initial outset. Simple head splits need to be addressed in young individuals as they often lead to early arthritis, stiffness of the shoulder and compromises the functionality of the joint. Methods: A prospective study done from 2010 to 2020, with all simple head split fractures treated by internal fixation, was carried out at our institution. Patients in the age group of 20 to 50 years were sub divided into two groups- one fixed with cancellous screws alone and the other fixed with plate-augmented-screw construct. Higher imaging was done in all patients pre-operatively. Functional (Visual Analogue Score and Oxford Shoulder Score) and radiological analysis (assessed by blinded analyzers) were done at regular follow-up visits, over the next 12 months. Results: A total of 22 patients were included in the study, of which 12 fractures were fixed by screws alone and 10 by plate-augmented-screw construct. The mean age of the study group was 34.5 years with 85% male patients. Bony union was achieved in all cases with average time to union being 28.5 weeks in screw group and 29.3 weeks in plate-augmented-screw construct group. Functional outcome assessment recorded Oxford shoulder scores of 51.6 and 42.9 in the two groups respectively. Mean VAS score was 9.2 and 8.7 respectively. Conclusion: We conclude that primary internal fixation of simple head split fractures with minimal comminution in young adults have an excellent radiological and functional outcome.