Trauma

Chronic pain is a frequent and disabling complication following major trauma. Despite its high prevalence, it remains under-recognised and inconsistently managed. To review current evidence on the prevalence, risk factors and predictive models for chronic pain following major trauma, with comparison between musculoskeletal trauma, thoracic trauma, and spinal cord injury.

This narrative review follows PRISMA 2020 guidelines. Studies published between 2015 and March 2025 were included if they examined adults with major trauma and chronic pain. Thematic synthesis was performed and stratified by trauma sub-type.

Chronic pain occurs in 30–70% of trauma survivors, with prevalence varying by injury type. Key risk factors include female sex, younger age, pre-existing pain, psychological distress, and social disadvantage. Validated prediction models are available for musculoskeletal trauma, while preventive strategies remain inconsistently applied across trauma sub-types.

Chronic pain after major trauma is common. A trauma-informed, proactive approach is needed to improve outcomes.

Selective conservative management of asymptomatic patients with small pneumothorax (PTX) in the specific setting of thoracic stab wounds (SWs) remains controversial.

A prospective study was conducted over a 15-year period on patients with isolated thoracic SWs with small PTX on chest radiograph (CXR) (< 2 cm) and who were asymptomatic. These patients did not undergo tube thoracostomy (TT) but rather active clinical observation at a major trauma centre in South Africa.

Two hundred and eighty-four patients were included (91% male, mean age: 24 yrs). Eight (3%) eventually required TT: three deteriorated clinically and five demonstrated radiological progression of PTX on interval CXR. Of these eight patients who required TT, six (75%) had multiple SWs. All eight patients had uneventful recovery. All other patients who were managed successfully with clinical observation alone were discharged home. No patients represented to the hospital following discharge. There was no morbidity or mortality as a direct result of our selective conservative management approach.

Selective conservative management of patients with asymptomatic small PTX < 2 cm following thoracic SWs appeared to be safe. The vast majority of these patients do not require TT. Active clinical observation alone by an experienced clinician is sufficient.

Interprosthetic femoral fractures between ipsilateral total hip arthroplasty and total knee arthroplasty (TKA) represent an increasingly significant clinical challenge, reflecting the growing prevalence of periprosthetic fractures, rising arthroplasty rates, and an ageing population. Biomechanical studies have identified reduced interprosthetic distance and compromised cortical bone quality as key risk factors; however, clinical data guiding prophylactic management strategies—such as femoral bridge plating—remain limited.

A survey of 137 orthopaedic surgeons (118 consultants) was conducted to assess current practice and attitudes towards prophylactic femoral bridge plating. Respondents were asked about factors influencing their decision-making—such as interprosthetic distance, bone quality, and implant constraint—as well as their definitions and methods of measuring interprosthetic distance.

75% of surgeons would consider prophylactic plating when the interprosthetic distance was less than two cortical diameters. 62% would prophylactically plate if there was less than 60 mm between implants. 12% stated they would never bridge. Poor bone quality (60%), traumatic indications (52%), and higher TKA constraint (31%) increased the likelihood of bridging. Surgeons varied in how they measured implant distance and whether they considered intramedullary cementing an acceptable alternative. 88% of respondents agreed this is an important clinical question, with the majority supporting future research.

This survey reveals significant variation in current practice regarding prophylactic femoral bridge plating. While many surgeons favour plating in cases of short interprosthetic distances or compromised bone, decision-making is multifactorial. Further clinical research is essential to develop evidence-based guidelines in this challenging area.

Facial injuries are associated with significant morbidity and healthcare costs, yet data across all severity levels remain limited. This study aimed to examine demographics, incidence, injury characteristics, and outcomes of patients admitted with facial trauma across all age groups and injury severity in a health region of one million residents in New Zealand (NZ).

A retrospective analysis of admissions with traumatic facial injuries across the Te Manawa Taki (TMT) region from 1 January 2014 to 31 December 2023, using data from the TMT Trauma Registry, was conducted. Injuries were classified using the Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), and ICD-10-AM codes. Population-adjusted incidence rate ratios (aIRRs), corrected for age, gender, and ethnicity, were calculated.

A total of 4,020 facial injury incidents were documented. Māori individuals (65.9/100,000; aIRR 2.1, p < 0.001) and males (57.8/100,000; aIRR 2.3, p < 0.001) exhibited significantly higher rates compared to non-Māori (32.2/100,000) and females (25.3/100,000), respectively. Most injuries were of low severity (ISS 1–8; 82.5%), with blunt trauma representing 96.1%. Falls (27.4%) and assaults (26.7%) were the primary causes of mild injuries, while road traffic crashes and assaults were more common in moderate and severe cases. Mandible fractures (15.6%) and soft tissue injuries were the most frequent. The average hospital stay was 3.2 days (SD 4.7), and the case fatality rate was 0.7% (n = 27).

This study provides a comprehensive analysis of facial trauma in NZ, incorporating all ages and injury severities. Facial injuries impose a substantial burden in the TMT region, disproportionately affecting people of Māori ethnicity and males.

Trauma within older people is increasingly recognised as a different entity, with different management and outcomes to younger people. We aim to compare the 30-day survival and length of stay of splenic injury patients in English major trauma centres in an elderly trauma (65+) cohort in comparison to under 65.

Data were obtained from the Trauma Audit Research Network of all Grade 2–5 American Association of Surgery in Trauma (AAST) splenic injuries admitted to English Major Trauma Centres between 01/01/17 and 31/12/21. End-points of mortality and length of stay were compared between the under 65 and 65+ groups according to treatment using descriptive statistics and multi-variable regression analysis.

In total, 802/3958 (20.2%) of admissions were 65+ and 2926/3958 (73.9%) were male. The proportion of AAST grades 3–5 was 41.3% (331/802) for 65+ and 52.3% (1652/3156) for under 65. A total of 12.8% (103/802) received embolisation in the 65+ group and 13.1% (413/3156) within the under 65 group. In total, 6.9% (55/802) in the 65+ group received splenectomy compared to 10.1% (319/3156). Within the 65+ group, 30-day mortality in the splenectomy group was 14.5% (8/55) compared to embolisation (18/103, 17.5%) and conservative (141/644, 21.9%). The 30-day mortality was (10.3%, 33/319) in those having a splenectomy as first treatment in the under 65's, compared with embolisation (26/413, 6.3%) and conservative management (197/2424, 8.1%). Embolisation failure was 3.9% (4/103) in the 65+ group and 7.3% (30/413) in the under 65 group. Splenectomy is associated with an increased length of stay at 1.20 (confidence interval (CI) 1.06, 1.37) times longer; however, this was not affected by age group.

Mortality was higher in the over 65 cohort regardless of treatment. Splenectomy is associated with an increased length of stay compared to embolisation, however there is no clear interaction demonstrated between age and first treatment.

Trauma is the third largest contributor to the global burden of disease with 90% of the trauma-related mortality occurring in low to middle income countries (LMICs) such as South Africa. The Acute Physiology and Chronic Health Evaluation (APACHE) II is widely used, but was developed in a first-world setting. This study sought to evaluate the APACHE II's ability to predict intensive care unit (ICU) mortality among trauma patients in a LMIC and to identify predictors of mortality within this population.

This retrospective study was conducted by analysing data records of 284 ICU patients over 2 years. Performance of the APACHE II was assessed with calibration and receiver operator characteristic curves. Survivors and non-survivors were compared using descriptive statistics, and logistic regression identified independent risk factors.

An overall mortality rate of 18.8% was observed. Sensitivity of the APACHE II was 0.74, and specificity 0.68. The model showed good discrimination (area under receiver operating curve (AUROC) 0.82, 95% confidence interval) and calibration (Hosmer–Lemeshow p > 0.3). The cut-off value for APACHE II was 20.2. Community assault and intubation were more common in the demised cohort (p < 0.01, odds ratio (OR) 4) although the APACHE II remained the strongest predictor of mortality when adjusting for confounders (p < 0.001).

APACHE II is a valid mortality prediction tool in polytrauma patients. Patients with scores above 20 were at highest risk of mortality. Intubation and community assault were significant risk factors of mortality, however, they aren’t included in the APACHE II score, highlighting the need to consider additional risk factors in the trauma population.

Distal radius fractures are the most common fractures among adolescents and young adults. In addition to Kirschner wires, after growth plate closure anatomical volar or dorsal radius plates may also be used for fixation. Current volar plates have been designed to fit the wrist of an average adult patient. The aim of this article was to review the use and the suitability of anatomical plates in the treatment of teenagers.

Retrospective data from patient records was collected on 59 patients, aged from 13 to 19 years, who underwent a plate fixation of distal radius at a tertiary center (level one university trauma hospital). An anatomical plate had been used in 32/59 (54.2%) of the patients. We reviewed and analyzed patient characteristics, injury mechanisms and types, post-operative complication, and pre- and post-operative radiological parameters.

29 wrists were operated using volar and 3 using a dorsal anatomical plate. Anatomical plates had not been used in patients aged ≤14 years. Out of the 29 cases, in 17 (58.6%) wrists the plate positioning corresponded to Soong gr II. In our follow-up period, the incidence of the post-operative complications was not greater than reported among adults. The plate was removed post-operatively in two cases. One removal was done due to inadequate plate positioning causing tendon irritation, and the other due to superficial wound infection.

Kirschner wires should be considered the first line of treatment when operating distal radius fractures in teenagers. Hardware protrusion seems to be common when anatomical volar plates are used. Further research is required to assess the long-term safety and the cumulative rate of complications from the use of anatomical volar plates in teenagers.

Thoracic trauma accounts for a significant proportion of major injuries requiring intensive care. The Galway University Hospital (GUH) serves as a key regional trauma unit, and understanding historical trends is essential for planning trauma service. Thus, this review aimed to describe the demographics, injury patterns, interventions, complications, and outcomes of patients with thoracic trauma admitted to the GUH intensive care unit (ICU) between 2011 and 2020.

A retrospective observational study was conducted, including all adult patients admitted to the GUH ICU for thoracic trauma between January 2011 and December 2020. These cases were identified using the Metavision and NIMIS databases. The primary outcome was 30-day mortality, and the secondary outcomes included complication burden, ICU length of stay (LOS), and the need for thoracic surgery. Data were anonymised and analysed using Minitab Statistical Software.

A total of 250 patients were included in the study. The cohort was predominantly male (77.2%) with a mean age of 50.9 years old. Road traffic accidents were the leading mechanism of injury in patients aged < 65 years (60.2%), whereas falls predominated in those aged ≥ 65 years (48.8%). Rib fractures (66%) and pulmonary contusions (46%) were the most common injuries. Polytrauma occurred in 83% of the patients, and traumatic brain injury occurred in 36%. Only 1% of patients required thoracotomy. Thirty-day mortality was 12%, rising to 15.9% at one year. Complication-free survival was observed in 38% of the patients.

Thoracic trauma ICU admissions at GUH increased over the decade, with clear age-related injury patterns and low rates of thoracic surgical interventions. These findings support ongoing trauma service development aligned with the Trauma System Implementation Program (TSIP) to improve outcomes through standardised and specialised care.

Left ventricular pseudoaneurysms are uncommon but potentially life-threatening entities, often presenting with non-specific clinical symptoms and posing significant diagnostic challenges.

We report the case of a 31-year-old female who presented with recurrent palpitations, chest pain, and exertional dyspnea 9 years after a traumatic fall. Initial workup with echocardiography suggested a possible pericardial or epicardial cyst, while coronary angiography excluded obstructive coronary artery disease but revealed abnormal contrast filling at the left ventricular apex. Subsequent computed tomography demonstrated a calcified apical mass, and cardiac magnetic resonance imaging raised suspicion for either a pseudoaneurysm or an echinococcal cyst, highlighting the diagnostic uncertainty. Given the risk of rupture, the patient underwent surgical exploration, which confirmed a large calcified apical pseudoaneurysm with intraluminal thrombi. The lesion was resected and repaired with a modified Dor procedure, and the patient's postoperative course was uneventful. Histopathological examination demonstrated chronic remodeling with hyaline-sclerotic and ossified changes, consistent with a traumatic origin.

This case reflects the diagnostic complexity of apical pseudoaneurysms, which can mimic other cardiac or cystic pathologies. It emphasizes the critical role of multimodal imaging and histopathological analysis in distinguishing among traumatic, infectious, autoimmune, and congenital etiologies, and underlines the importance of timely surgical intervention to prevent catastrophic rupture.

Auto-resuscitation, also known as the ‘Lazarus phenomenon’, refers to the spontaneous return of circulation following the cessation of cardiopulmonary resuscitation (CPR). The phenomenon is rarely reported, and most involve cases of non-traumatic cardiac arrest, with only four cases having been previously described in trauma patients.

A young male trauma patient presented in extremis following a blunt assault by multiple assailants. Upon arrival to our level I trauma centre, the patient was bradycardic, acidotic, hyperkalaemic, hypoglycaemic and presenting with focal signs of traumatic brain injury. He progressed to pulseless electrical activity, and resuscitative efforts were ceased after being deemed futile. Approximately 5 minutes later, he was then observed to have resumed spontaneous but ineffective respiratory efforts and good cardiac contractility, prompting renewed resuscitation. Despite initial biochemical and haemodynamic improvement, he deteriorated several hours later, and was ultimately pronounced dead for a second time.

With the benefit of a post-mortem examination, the cause of death was likely crush syndrome in the context of mob assault. The precise mechanisms behind auto-resuscitation remain uncertain. Proposed explanations include intrinsic positive end-expiratory pressure (“auto-PEEP”) due to iatrogenic hyperventilation, and a delay in the pharmacological effects of adrenaline. The phenomenon poses a significant communication challenge for clinicians when it comes to informing next of kin of the patient's outcome.

This case reinforces the importance of continuing to observe patients for at least 10 minutes following termination of CPR in order to identify auto-resuscitation.