Journal of Trauma and Injury

Original Articles

Vitamin D levels and bone mineral density: a prospective cross-sectional analysis of young orthopedic trauma patients at a rural United States trauma center: Michael Booth, Kenneth Sabacinski, Colleen Watkins, Erin Butcho, Emilie Kramer, Lukas Meadows, Michelle A. Bramer; J Trauma Inj. 2024;37(4):276-280. Published online December 26, 2024; DOI: https://doi.org/10.20408/jti.2024.0038

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Abstract PDF: Purpose
The goal of this cross-sectional study was to investigate the prevalence of vitamin D deficiency in young orthopedic trauma patients and its impact on bone mineral density (BMD) measured through computed tomography imaging of the lumbar spine.
Methods
Conducted at a level I trauma center, this prospective cross-sectional analysis included 100 patients aged 18 to 50 years with non-fragility fractures. Vitamin D levels and Hounsfield units of the lumbar spine were recorded from computed tomography scans. Exclusion criteria included fragility fractures, lumbar surgery history, or lumbar bony/metastatic lesions. The correlation between vitamin D levels and BMD was assessed; vitamin D deficiency was defined as below 30 ng/mL.
Results
Among the participants, 75% were vitamin D–deficient, with an average vitamin D level of 25.0 ng/mL. No patients had osteoporosis based on Hounsfield units; however, 5% of patients were in the osteopenic range. In patients with normal vitamin D levels, there was an inverse correlation between vitamin D levels and BMD measured by Hounsfield units (P=0.025). Higher lumbar spine Hounsfield unit measurements correlated with lower vitamin D levels in this nondeficient population.
Conclusions
This study highlights a high prevalence of vitamin D deficiency in young orthopedic trauma patients, and it suggests a potential inverse relationship with BMD in patients with vitamin D levels >30 ng/mL. The absence of osteoporosis in our population raises questions about the influence of vitamin D on BMD in this young trauma patient demographic. Future research should explore the impact of vitamin D replacement on fracture union and investigate the interaction between vitamin D levels and bone health in the younger orthopedic trauma population.; Summary

Management of cardiac trauma and penetrating cardiac injuries with severe hemorrhagic shock: a 5-year experience: Tran Thuc Khang; J Trauma Inj. 2024;37(4):268-275. Published online December 16, 2024; DOI: https://doi.org/10.20408/jti.2024.0063

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Abstract PDF: Purpose
The diagnosis and management of cardiac trauma and penetrating cardiac injuries pose significant challenges in emergency settings due to the rapid onset of life-threatening complications. This paper presents a narrative review to better describe the etiology, presentation, and management of penetrating cardiac trauma, offering insights and experiences related to performing emergency surgery for such cases.
Methods
We compiled cases of traumatic cardiac rupture and penetrating cardiac injuries accompanied by severe hemorrhagic shock that necessitated emergency surgery. Data were collected regarding the type of injury, causative agents, specific clinical features observed during emergency admission, intraoperative parameters, and treatment outcomes.
Results
Twenty-one patients (16 men, 5 women) with cardiac rupture or penetrating cardiac injuries were recorded. All patients presented in severe shock, and six cases (28.6%) experienced cardiac arrest upon arrival in the operating room. Cardiac rupture due to blunt chest trauma occurred in two cases (9.5%), and one case (4.8%) involved right atrial perforation due to complex open chest trauma. Penetrating injuries accounted for cardiac perforation in 18 cases (85.7%). Associated injuries were present in 11 cases (52.4%). The intraoperative mortality rate was 9.5%, and there was one postoperative death on the 11th day due to multiorgan failure.
Conclusions
Cardiac trauma and penetrating injuries are usually fatal unless promptly diagnosed and surgically treated. The timing and rapidity of emergency surgery—often foregoing ancillary tests and administrative procedures—are critical for patient survival. Emergency sternotomy, swift control of bleeding, and aggressive resuscitation are essential operative measures in saving lives. Factors that influence prognosis include the extent of blood loss, duration of cardiac arrest, acid-base imbalances, coagulopathy, multiorgan failure, and postoperative infections.; Summary

Review Article

Splenic artery embolization for trauma: a narrative review: Simon Roh; J Trauma Inj. 2024;37(4):252-261. Published online December 16, 2024; DOI: https://doi.org/10.20408/jti.2024.0056

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Abstract PDF: The management of traumatic splenic injuries has evolved significantly over the past several decades, with the majority of these injuries now being treated nonoperatively. Patients who exhibit hemodynamic instability upon initial evaluation typically require surgical intervention, while the remainder are managed conservatively. Conservative treatment for traumatic splenic injuries encompasses both medical management and splenic artery angiography, followed by embolization in cases where patients exhibit clinical signs of ongoing splenic hemorrhage. Splenic artery embolization is generally divided into two categories: proximal and distal embolization. The choice of embolization technique is determined by the severity and location of the splenic injury. Patients who retain functioning splenic tissue after trauma do not routinely need immunization. This is in contrast to post-splenectomy patients, who are at increased risk for opportunistic infections.; Summary

Case Reports

Reperfusion injury or cytokine storm? Utilizing plasmapheresis in severe trauma-induced multiorgan failure: a case report: Gun Woo Kim, Suyeong Hwang, Kyoung Hoon Lim, Sung Hoon Cho; J Trauma Inj. 2024;37(4):295-299. Published online December 4, 2024; DOI: https://doi.org/10.20408/jti.2024.0051

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Abstract PDF: Reperfusion injury can cause tissue damage due to ischemia, with severe cases potentially resulting in multiorgan failure. Cytokine storm, a life-threatening systemic inflammatory state characterized by elevated levels of circulating cytokines and hyperactive immune cells, can also lead to tissue damage and multiorgan failure. Reperfusion injury and cytokine storm sometimes exhibit similar clinical features, necessitating specific treatment in severe cases. A 31-year-old man sustained a stab wound to his left knee. Computed tomography angiography and surgical exploration revealed a transection of the left popliteal artery and vein. Both vessels were revascularized via end-to-end anastomosis approximately 3 hours after the injury. On postoperative day 2, marked increases were observed in levels of aspartate aminotransferase (8,600 U/L), alanine transaminase (6,690 U/L), creatine phosphokinase (26,817 U/L), and lactate dehydrogenase (7,398 U/L) levels. Elevated levels of interleukin 6 (178 pg/mL) and ferritin (41,079 ng/mL) were also noted. Given the possibility of either reperfusion injury or cytokine storm, plasmapheresis was initiated. Following two rounds of plasmapheresis, the patient’s condition rapidly improved, and he was discharged without complications. Reperfusion injury can arise when a target blood vessel is revascularized, particularly during severe stages of ischemia. Cytokine storm represents a life-threatening systemic inflammatory state characterized by high levels of circulating cytokines and overactive immune cells. Both reperfusion injury and cytokine storm can cause systemic inflammation and multiorgan failure. These two conditions may exhibit similar clinical features, necessitating supportive care primarily to prevent organ dysfunction. However, plasmapheresis may represent an effective treatment option in cases of severe progression.; Summary

Treatment of placental abruption following blunt abdominal trauma: a case report: Jinjoo Kim, Seokyung Kim, Dongwook Kwak, Donghwan Choi; Received July 23, 2024 Accepted October 7, 2024 Published online December 4, 2024; DOI: https://doi.org/10.20408/jti.2024.0050 [Epub ahead of print]

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Abstract PDF: Trauma during pregnancy poses a potentially tragic risk to both the fetus and mother, making its management particularly challenging. Here, we present the case of a 35-year-old woman at 34 weeks and 2 days gestation who was in a motor vehicle accident and subsequently suffered placental abruption and underwent an emergency cesarean section. We also present a review of traumatic placental abruption and its epidemiology. On arrival at the trauma bay, the patient showed no significant abdominal findings other than a seat belt sign. However, 2 hours after admission, the patient developed abdominal pain and vaginal bleeding. Ultrasonography revealed no clear evidence of placental abruption. This case demonstrates the necessity of close maternal and fetal monitoring with cooperation between the trauma and obstetric teams. Even in the absence of typical symptoms such as abdominal pain on initial presentation, a high-energy mechanism of injury should be suspected.; Summary

Purtscher retinopathy following isolated chest compression: a case report: Min Uk Jang, Ho Gil Jung, Youngwoong Kim; J Trauma Inj. 2024;37(4):291-294. Published online October 21, 2024; DOI: https://doi.org/10.20408/jti.2024.0032

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Abstract PDF: This case report describes the case of a 56-year-old man who developed Purtscher retinopathy following compressive chest trauma. During the tertiary survey, the patient was found to have a unilateral partial vision decline despite sustaining only mild rib fractures. The patient was diagnosed with a rare complication of Purtscher retinopathy. At a 2-week follow-up outpatient examination, improved visual acuity was observed. This case highlights the importance of conducting a tertiary survey not only on the directly impacted site, but also comprehensively across all sites, while attentively listening to and addressing the patient’s complaints.; Summary

Endoscopic transorbital approach for the removal of a frontal lobe foreign body: a case report: Charles Gervais, Conrad Pelletier, Mathieu Laroche, Pascal Lavergne; J Trauma Inj. 2024;37(4):281-285. Published online September 25, 2024; DOI: https://doi.org/10.20408/jti.2024.0002

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Abstract PDF: Low-velocity orbital penetrating injuries may result in an intracranial retained foreign body that requires surgical removal. We describe the endoscopic transorbital removal of a retained umbrella tip in the frontal lobe, which was secondary to trauma to the orbital roof. This technique facilitated the complete removal of the foreign body without causing additional damage to the surrounding tissue. The patient had a successful postoperative recovery. We also discuss the utility of the transorbital neuroendoscopic procedure in managing these traumatic injuries.; Summary

Review Article

Renal embolization for trauma: a narrative review: Peter Lee, Simon Roh; J Trauma Inj. 2024;37(3):171-181. Published online September 24, 2024; DOI: https://doi.org/10.20408/jti.2024.0021

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Abstract PDF: Renal injuries commonly occur in association with blunt trauma, especially in the setting of motor vehicle accidents. Contrast-enhanced computed tomography is considered the gold-standard imaging modality to assess patients for renal injuries in the setting of blunt and penetrating trauma, and to help classify injuries based on the American Association for the Surgery of Trauma injury scoring scale. The management of renal trauma has evolved in the past several decades, with a notable shift towards a more conservative, nonoperative approach. Advancements in imaging and interventional radiological techniques have enabled diagnostic angiography with angiographic catheter-directed embolization to become a viable option, making it possible to avoid surgical interventions that pose an increased risk of nephrectomy. This review describes the current management of renal trauma, with an emphasis on renal artery embolization techniques.; Summary

Original Articles

Predicting 30-day mortality in severely injured elderly patients with trauma in Korea using machine learning algorithms: a retrospective study: Jonghee Han, Su Young Yoon, Junepill Seok, Jin Young Lee, Jin Suk Lee, Jin Bong Ye, Younghoon Sul, Se Heon Kim, Hong Rye Kim; J Trauma Inj. 2024;37(3):201-208. Published online August 8, 2024; DOI: https://doi.org/10.20408/jti.2024.0024

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Abstract PDF: Purpose
The number of elderly patients with trauma is increasing; therefore, precise models are necessary to estimate the mortality risk of elderly patients with trauma for informed clinical decision-making. This study aimed to develop machine learning based predictive models that predict 30-day mortality in severely injured elderly patients with trauma and to compare the predictive performance of various machine learning models. Methods: This study targeted patients aged ≥65 years with an Injury Severity Score of ≥15 who visited the regional trauma center at Chungbuk National University Hospital between 2016 and 2022. Four machine learning models—logistic regression, decision tree, random forest, and eXtreme Gradient Boosting (XGBoost)—were developed to predict 30-day mortality. The models’ performance was compared using metrics such as area under the receiver operating characteristic curve (AUC), accuracy, precision, recall, specificity, F1 score, as well as Shapley Additive Explanations (SHAP) values and learning curves. Results: The performance evaluation of the machine learning models for predicting mortality in severely injured elderly patients with trauma showed AUC values for logistic regression, decision tree, random forest, and XGBoost of 0.938, 0.863, 0.919, and 0.934, respectively. Among the four models, XGBoost demonstrated superior accuracy, precision, recall, specificity, and F1 score of 0.91, 0.72, 0.86, 0.92, and 0.78, respectively. Analysis of important features of XGBoost using SHAP revealed associations such as a high Glasgow Coma Scale negatively impacting mortality probability, while higher counts of transfused red blood cells were positively correlated with mortality probability. The learning curves indicated increased generalization and robustness as training examples increased. Conclusions: We showed that machine learning models, especially XGBoost, can be used to predict 30-day mortality in severely injured elderly patients with trauma. Prognostic tools utilizing these models are helpful for physicians to evaluate the risk of mortality in elderly patients with severe trauma.; Summary

Traumatic peripheral nerve injuries in young Korean soldiers: a recent 10-year retrospective study: Chul Jung, Jae-hyun Yun, Eun Jin Kim, Jaechan Park, Jiwoon Yeom, Kyoung-Eun Kim; J Trauma Inj. 2024;37(3):192-200. Published online August 8, 2024; DOI: https://doi.org/10.20408/jti.2024.0001

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Abstract PDF: Purpose
Traumatic peripheral nerve injury (PNI), which occurs in up to 3% of trauma patients, is a devastating condition that often leads to permanent disability. However, knowledge of traumatic PNI is limited. We describe epidemiology and clinical characteristics of traumatic PNI in Korea and identify the predictors of traumatic complete PNI. Methods: A list of enlisted soldier patients who were discharged from military service due to PNI over a 10-year period (2012–2021) was obtained, and their medical records were reviewed. Patients were classified according to the causative events (traumatic vs. nontraumatic) and injury severity (complete vs. incomplete). Of traumatic PNIs, we compared the clinical variables between the incomplete and complete PNI groups and identified predictors of complete PNI. Results: Of the 119 young male patients who were discharged from military service due to PNI, 85 (71.4%) were injured by a traumatic event; among them, 22 (25.9%) were assessed as having a complete injury. The most common PNI mechanism (n=49, 57.6%), was adjacent fractures or dislocations. Several injury-related characteristics were significantly associated with complete PNI: laceration or gunshot wound, PNI involving the median nerve, PNI involving multiple individual nerves (multiple PNI), and concomitant muscular or vascular injuries. After adjusting for other possible predictors, multiple PNI was identified as a significant predictor of a complete PNI (odds ratio, 3.583; P=0.017). Conclusions: In this study, we analyzed the characteristics of enlisted Korean soldiers discharged due to traumatic PNI and found that the most common injury mechanism was adjacent fracture or dislocation (57.6%). Patients with multiple PNI had a significantly increased risk of complete injury. The results of this study contribute to a better understanding of traumatic PNI, which directly leads to a decline in functioning in patients with trauma.; Summary

Case Report

Use of helicopter emergency medical services with a physician on board in severe pediatric trauma in Korea: a case report: Yoonsuk Lee, Gunwoo Kim, Pil Young Jung; J Trauma Inj. 2024;37(3):224-227. Published online June 14, 2024; DOI: https://doi.org/10.20408/jti.2023.0080

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Abstract PDF: In Korea, helicopter emergency medical services (HEMS) with a physician on board were introduced in September 2011, funded by both central and regional governments. HEMS was integrated into the Korean emergency medical system to address the need for EMS in remote rural areas. The present report describes 16-month-old twins who fell from the fifth floor of an apartment building, located approximately 100 km from the nearest level I trauma center. Utilizing HEMS along with initial emergency management by an emergency physician, the patients were transported to the level I trauma center within the critical “golden hour.” The children had sustained multiorgan injuries. Without intervention at the scene by an emergency physician, a fatal outcome was anticipated for both children. With the use of HEMS, one patient died, but the other survived with a good prognosis. The use of HEMS flights with an emergency physician on board may improve outcomes for pediatric patients with severe trauma in medically underserved rural areas.; Summary

Original Articles

Implementation of structured trauma training for first-year surgical residents in Ethiopia: a novel pilot program in a low income country: Segni Kejela, Meklit Solomon Gebremariam; J Trauma Inj. 2024;37(2):132-139. Published online June 12, 2024; DOI: https://doi.org/10.20408/jti.2024.0010

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Abstract PDF: Purpose
Curricula for surgical residents should include training in trauma care; however, such training is absent in many low income countries. At the largest surgical training institution in Ethiopia, a trauma training program was developed, integrated into the existing surgical curriculum, and implemented. This study was conducted to evaluate the trainees’ response to the new program.
Methods
Over a 5-month period, 35 first-year surgical residents participated in weekly trauma care training sessions. The program included journal clubs, practical sessions, didactic sessions, and case-based discussions. Six months after the conclusion of the training, changes in knowledge, attitude, and practices were evaluated through a self-report survey.
Results
For knowledge-based items, the survey data revealed reported improvements in 83.8% to 96.8% of students. Furthermore, 90.3% to 93.5% of participants indicated improvements in practice, while 96.7% exhibited a change in attitude. Respondents reported that attending didactic courses improved their presentation skills and facilitated the acquisition of knowledge. They suggested the inclusion of additional practical sessions.
Conclusions
Training structures that are simple to implement are crucial for residency programs with limited resources. Such programs can be developed using existing academic staff and can aid residents in delivering improved care to trauma patients.; Summary

A predictive nomogram-based model for lower extremity compartment syndrome after trauma in the United States: a retrospective case-control study: Blake Callahan, Darwin Ang, Huazhi Liu; J Trauma Inj. 2024;37(2):124-131. Published online May 22, 2024; DOI: https://doi.org/10.20408/jti.2023.0077

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Abstract PDF Supplementary Material: Purpose
The aim of this study was to utilize the American College of Surgeons Trauma Quality Improvement Program (TQIP) database to identify risk factors associated with developing acute compartment syndrome (ACS) following lower extremity fractures. Specifically, a nomogram of variables was constructed in order to propose a risk calculator for ACS following lower extremity trauma.
Methods
A large retrospective case-control study was conducted using the TQIP database to identify risk factors associated with developing ACS following lower extremity fractures. Multivariable regression was used to identify significant risk factors and subsequently, these variables were implemented in a nomogram to develop a predictive model for developing ACS.
Results
Novel risk factors identified include venous thromboembolism prophylaxis type particularly unfractionated heparin (odds ratio [OR], 2.67; 95% confidence interval [CI], 2.33–3.05; P<0.001), blood product transfusions (blood per unit: OR 1.13 [95% CI, 1.09–1.18], P<0.001; platelets per unit: OR 1.16 [95% CI, 1.09–1.24], P<0.001; cryoprecipitate per unit: OR 1.13 [95% CI, 1.04–1.22], P=0.003).
Conclusions
This study provides evidence to believe that heparin use and blood product transfusions may be additional risk factors to evaluate when considering methods of risk stratification of lower extremity ACS. We propose a risk calculator using previously elucidated risk factors, as well as the risk factors demonstrated in this study. Our nomogram-based risk calculator is a tool that will aid in screening for high-risk patients for ACS and help in clinical decision-making.; Summary

Validation of chest trauma scoring systems in polytrauma: a retrospective study with 1,038 patients in Korea: Hongrye Kim, Mou Seop Lee, Su Young Yoon, Jonghee Han, Jin Young Lee, Junepill Seok; J Trauma Inj. 2024;37(2):114-123. Published online May 9, 2024; DOI: https://doi.org/10.20408/jti.2023.0087

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1 Web of Science
1 Citations

Abstract PDF Supplementary Material

Purpose
Appropriate scoring systems can help classify and treat polytrauma patients. This study aimed to validate chest trauma scoring systems in polytrauma patients.
Methods
Data from 1,038 polytrauma patients were analyzed. The primary outcomes were one or more complications: pneumonia, chest complications requiring surgery, and mortality. The Thoracic Trauma Severity Score (TTSS), Chest Trauma Score, Rib Fracture Score, and RibScore were compared using receiver operating characteristic (ROC) analysis in patients with or without head trauma.
Results
In total, 1,038 patients were divided into two groups: those with complications (822 patients, 79.2%) and those with no complications (216 patients, 20.8%). Sex and body mass index did not significantly differ between the groups. However, age was higher in the complications group (64.1±17.5 years vs. 54.9±17.6 years, P<0.001). The proportion of head trauma patients was higher (58.3% vs. 24.6%, P<0.001) and the Glasgow Coma Scale score was worse (median [interquartile range], 12 [6.5–15] vs. 15 [14–15]; P<0.001) in the complications group. The number of rib fractures, the degree of rib fracture displacement, and the severity of pulmonary contusions were also higher in the complications group. In the area under the ROC curve analysis, the TTSS showed the highest predictive value for the entire group (0.731), head trauma group (0.715), and no head trauma group (0.730), while RibScore had the poorest performance (0.643, 0.622, and 0.622, respectively)
Conclusions
Early injury severity detection and grading are crucial for patients with blunt chest trauma. The chest trauma scoring systems introduced to date, including the TTSS, are not acceptable for clinical use, especially in polytrauma patients with traumatic brain injury. Therefore, further revisions and analyses of chest trauma scoring systems are recommended.

Summary

Citations

Citations to this article as recorded by

Clinical prediction models for the management of blunt chest trauma in the emergency department: a systematic review
Ceri Battle, Elaine Cole, Kym Carter, Edward Baker
BMC Emergency Medicine.2024;[Epub] CrossRef

The characteristics and clinical outcomes of trauma patients transferred by a physician-staffed helicopter emergency medical service in Korea: a retrospective study: Myung Jin Jang, Woo Sung Choi, Jung Nam Lee, Won Bin Park; J Trauma Inj. 2024;37(2):106-113. Published online February 23, 2024; DOI: https://doi.org/10.20408/jti.2023.0074

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Abstract PDF: Purpose
Helicopter transport with medical teams has been proven to be effective, with improvements in patient survival rates. This study compared and analyzed the clinical characteristics and treatment outcomes of trauma patients transported by doctor helicopters according to whether patients were transferred after a clinical evaluation or without a clinical evaluation.
Methods
This study retrospectively reviewed data from the Korean Trauma Data Bank of trauma patients who arrived at a regional trauma center through doctor helicopters from January 1, 2014, to December 31, 2022. The patients were divided into two groups: doctor helicopter transport before evaluation (DHTBE) and doctor helicopter transport after evaluation (DHTAE). These groups were compared.
Results
The study population included 351 cases. At the time of arrival at the trauma center, the systolic blood pressure was significantly lower in the DHTAE group than in the DHTBE group (P=0.018). The Injury Severity Score was significantly higher in the DHTAE group (P<0.001), and the accident to trauma center arrival time was significantly shorter in the DHTBE group (P<0.001). Mortality did not show a statistically significant between-group difference (P=0.094). Surgical cases in the DHTAE group had a longer time from the accident scene to trauma center arrival (P=0.002). The time from the accident to the operation room or from the accident to angioembolization showed no statistically significant differences.
Conclusions
DHTAE was associated with significantly longer transport times to the trauma center, as well as nonstatistically significant trends for delays in receiving surgery and procedures, as well as higher mortality. If severe trauma is suspected, air transport to a trauma center should be requested immediately after a simple screening test (e.g., mechanism of injury, Glasgow Coma Scale, or Focused Assessment with Sonography in Trauma), which may help reduce the time to definitive treatment.; Summary

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