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Femoral fractures are an indicator of increased severity of injury for road traffic collision victims: an autopsy–based case–control study on 4895 fatalities

  • Trauma Surgery
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Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

The course of road traffic collision (RTC) victims with femoral fractures (FFx) from injury to death was reviewed. We sought to correlate the presence of femoral fractures with the overall severity of injury from RTCs using objective indices and to identify statistically significant associations with injuries in other organs.

Patients and methods

A case–control study based on forensic material from 4895 consecutive RTC-induced fatalities, between 1996 and 2005. Injuries were coded according to the Abbreviated Injury Scale-1990 Revision (AIS-90), and the Injury Severity Score (ISS) was calculated. Victims were divided according to the presence of femoral fractures in all possible anatomic locations or not. Univariate comparisons and logistic regression analysis for probabilities of association as odds ratios (OR) were performed.

Results

The FFx group comprised 788 (16.1%) victims. The remaining 4107 victims constituted the controls. The FFx group demonstrated higher ISS (median 48 vs 36, p < 0.001) and shorter post-injury survival times (median 60 vs 85 min, p < 0.001). Presence of bilateral fractures (15.5%) potentiated this effect (median ISS 50 vs 43, p = 0.006; median survival time 40 vs 65, p = 0.0025; compared to unilateral fractures). Statistically significant associations of FFx were identified with AIS2-5 thoracic trauma (OR 1.43), AIS2-5 abdominal visceral injuries (OR 1.89), AIS1-3 skeletal injuries of the upper (OR 2.7) and lower limbs (OR 3.99) and AIS2-5 of the pelvis (OR 2.75) (p < 0.001). In the FFx group, 218 (27.7%) victims survived past the emergency department and 116 (53.2%) underwent at least one surgical procedure. Complications occurred in 45.4% of hospitalized victims, the most common being pneumonia (34.8%).

Conclusion

This study has documented that femoral fractures are associated with increased severity of injury, shorter survival times and higher incidence of associated thoracic, abdominal and skeletal extremity injuries, compared to controls. These findings should be considered for an evidence-based upgrading of trauma care.

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References

  1. World Health Organization (2020) Global health estimates: Leading causes of death, cause specific mortality, 2000–2019. https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death/. Accessed 16 Jan 2021

  2. European Transport Safety Council (2020) 14th Road Safety Index Report (June 2020). https://etsc.eu/wp-content/uploads/14-PIN-annual-report-FINAL.pdf/. Assessed 29 Apr 2021

  3. Agarwal-Harding KJ, Meara JG, Greenberg SL, Hagander LE, Zurakowski D, Dyer GS (2015) Estimating the global incidence of femoral fracture from road traffic collisions: a literature review. J Bone Jt Surg Am 97(6):e31. https://doi.org/10.2106/JBJS.N.00314

    Article  Google Scholar 

  4. Rastogi S, Wild BR, Duthie RB (1986) Biomechanical aspects of femoral fractures in automobile accidents. J Bone Jt Surg Br 68(5):760–766

    Article  CAS  Google Scholar 

  5. Adili A, Bhandari M, Lachowski RJ, Kwok DC, Dunlop RB (1999) Organ injuries associated with femoral fractures: implications for severity of injury in motor vehicle collisions. J Trauma 46(3):386–391. https://doi.org/10.1097/00005373-199903000-00006

    Article  CAS  PubMed  Google Scholar 

  6. Lefaivre KA, Starr AJ, Stahel PF, Elliott AC, Smith WR (2010) Prediction of pulmonary morbidity and mortality in patients with femur fracture. J Trauma 69(6):1527–1535. https://doi.org/10.1097/TA.0b013e3181f8fa3b (discussion 35-6)

    Article  PubMed  Google Scholar 

  7. Kwong Y, Chong M, Hassan A, Kelly R (2006) Severity of injuries associated with femoral fractures as a result of motor vehicle collisions. Arch Orthop Trauma Surg 126(7):454–457. https://doi.org/10.1007/s00402-006-0151-4

    Article  PubMed  Google Scholar 

  8. Willett K, Al-Khateeb H, Kotnis R, Bouamra O, Lecky F (2010) Risk of mortality: the relationship with associated injuries and fracture treatment methods in patients with unilateral or bilateral femoral shaft fractures. J Trauma 69(2):405–410. https://doi.org/10.1097/TA.0b013e3181e6138a

    Article  PubMed  Google Scholar 

  9. Nikolaou VS, Stengel D, Konings P, Kontakis G, Petridis G, Petrakakis G et al (2011) Use of femoral shaft fracture classification for predicting the risk of associated injuries. J Orthop Trauma 25(9):556–559. https://doi.org/10.1097/BOT.0b013e318206cd06

    Article  PubMed  Google Scholar 

  10. Anyaehie UE, Ejimofor OC, Akpuaka FC, Nwadinigwe CU (2015) Pattern of femoral fractures and associated injuries in a Nigerian tertiary trauma centre. Niger J Clin Pract 18(4):462–466. https://doi.org/10.4103/1119-3077.151761

    Article  CAS  PubMed  Google Scholar 

  11. Prionas A, Tsoulfas G, Tooulias A, Papakoulas A, Piachas A, Papadopoulos V (2020) Evaluating trauma care, outcomes and costs in a system in crisis: the necessity of a Greek National Trauma Database. Trauma Surg Acute Care Open 5(1):e000401. https://doi.org/10.1136/tsaco-2019-000401

    Article  PubMed  PubMed Central  Google Scholar 

  12. Prionas A, Toulias A, Tsoulfas G, Papadopoulos VN (2018) Measuring the impact of trauma in Greece: a systematic review of Greek Trauma Registries. Is Quality Improvement Achievable? Hellenic J Surg 90:75–84. https://doi.org/10.1007/s13126-018-0444-4

    Article  Google Scholar 

  13. Papadopoulos IN, Kanakaris N, Bonovas S, Triantafillidis A, Garnavos C, Voros D et al (2006) Auditing 655 fatalities with pelvic fractures by autopsy as a basis to evaluate trauma care. J Am Coll Surg 203(1):30–43. https://doi.org/10.1016/j.jamcollsurg.2006.03.017

    Article  PubMed  Google Scholar 

  14. Papadopoulos IN, Bonovas S, Kanakaris NK, Konstantiadou I, Nikolopoulos G, Konstantoudakis G et al (2010) Motor vehicle collision fatalities involving alcohol and illicit drugs in Greece: the need for management protocols and a reassessment of surveillance. Addiction 105(11):1952–1961. https://doi.org/10.1111/j.1360-0443.2010.03072.x

    Article  PubMed  Google Scholar 

  15. Papadopoulos IN, Bonovas S, Kanakaris NK, Nikolopoulos G, Kotsilianou O, Konstantoudakis G et al (2012) Alcohol and psychoactive drugs increased the pre-hospital mortality in 655 fall-related fatalities in Greece: a call for management protocols. Injury 43(9):1522–1526. https://doi.org/10.1016/j.injury.2010.11.056

    Article  PubMed  Google Scholar 

  16. Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast SL, Bain LW et al (1990) The Major Trauma Outcome Study: establishing national norms for trauma care. J Trauma 30(11):1356–1365

    Article  CAS  Google Scholar 

  17. World Health Organization (1980) Manual of the international classification of diseases, injuries and causes of death, 9th rev., Athena, Athens Greece

  18. Association for the Advancement of Automotive Medicine (1990) The Abbreviated Injury Scale, 1990 rev., Association for the Advancement of Automotive Medicine, Des Plaines Ill

  19. Baker SP, O’Neill B, Haddon W, Long WB (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14(3):187–196

    Article  CAS  Google Scholar 

  20. Papadopoulos IN, Bukis D, Karalas E, Katsaragakis S, Stergiopoulos S, Peros G et al (1996) Preventable prehospital trauma deaths in a Hellenic urban health region: an audit of prehospital trauma care. J Trauma 41(5):864–869. https://doi.org/10.1097/00005373-199611000-00018

    Article  CAS  PubMed  Google Scholar 

  21. Papadopoulos IN, Kanakaris N, Triantafillidis A, Stefanakos J, Kainourgios A, Leukidis C (2004) Autopsy findings from 111 deaths in the 1999 Athens earthquake as a basis for auditing the emergency response. Br J Surg 91(12):1633–1640. https://doi.org/10.1002/bjs.4752

    Article  CAS  PubMed  Google Scholar 

  22. Papadopoulos IN (2007) Report of preventable prehospital trauma deaths in a Greek health care region: importance of editorial comments. J Trauma 62(5):1316. https://doi.org/10.1097/TA.0b013e3180343056

    Article  PubMed  Google Scholar 

  23. Christodoulou C, Papadopoulos IN, Douzenis A, Kanakaris N, Leukidis C, Gournellis R et al (2009) Seasonality of violent suicides in the Athens greater area. Suicide Life Threat Behav 39(3):321–331. https://doi.org/10.1521/suli.2009.39.3.321

    Article  CAS  PubMed  Google Scholar 

  24. Papadopoulos IN, Kanakaris NK, Bonovas S, Konstantoudakis G, Petropoulou K, Christodoulou S et al (2011) Patients with pelvic fractures due to falls: a paradigm that contributed to autopsy-based audit of trauma in Greece. J Trauma Manag Outcomes. https://doi.org/10.1186/1752-2897-5-2

    Article  PubMed  PubMed Central  Google Scholar 

  25. Papadopoulos IN, Kanakaris NK, Danias N, Sabanis D, Konstantudakis G, Christodoulou S et al (2013) A structured autopsy-based audit of 370 firearm fatalities: Contribution to inform policy decisions and the probability of the injured arriving alive at a hospital and receiving definitive care. Accid Anal Prev 50:667–677. https://doi.org/10.1016/j.aap.2012.06.018

    Article  PubMed  Google Scholar 

  26. Theodorou D, Toutouzas K, Drimousis P, Larentzakis A, Kleidi E, Georgiou G et al (2009) Emergency room management of trauma patients in Greece: preliminary report of a national study. Resuscitation 80(3):350–353. https://doi.org/10.1016/j.resuscitation.2008.10.015

    Article  PubMed  Google Scholar 

  27. Anagnostou E, Larentzakis A, Vassiliu P (2018) Trauma system in Greece: Quo Vadis? Injury 49(7):1243–1250. https://doi.org/10.1016/j.injury.2018.05.022

    Article  PubMed  Google Scholar 

  28. Stevenson M, Segui-Gomez M, Lescohier I, Di Scala C, McDonald-Smith G (2001) An overview of the injury severity score and the new injury severity score. Inj Prev 7(1):10–13. https://doi.org/10.1136/ip.7.1.10

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Copes WS, Champion HR, Sacco WJ, Lawnick MM, Keast SL, Bain LW (1988) The Injury Severity Score revisited. J Trauma 28(1):69–77. https://doi.org/10.1097/00005373-198801000-00010

    Article  CAS  PubMed  Google Scholar 

  30. Wyatt JP, O’Donnell J, Beard D, Busuttil A (1999) Injury analyses of fatal motorcycle collisions in south-east Scotland. Forensic Sci Int 104(2–3):127–132. https://doi.org/10.1016/s0379-0738(99)00104-8

    Article  CAS  PubMed  Google Scholar 

  31. Hellenic Statistical Authority (2021) Road Traffic Accidents–Timeseries: Number of road traffic accidents and persons injured therefrom (1991–2019).xls. http://www.statistics.gr/el/statistics/-/publication/SDT04/. Accessed 29 Apr 2021

  32. Trunkey DD (1983) Trauma. Accidental and intentional injuries account for more years of life lost in the U.S. than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further research. Sci Am 249(2):28–35

  33. Demetriades D, Kimbrell B, Salim A, Velmahos G, Rhee P, Preston C et al (2005) Trauma deaths in a mature urban trauma system: is “trimodal” distribution a valid concept? J Am Coll Surg 201(3):343–348. https://doi.org/10.1016/j.jamcollsurg.2005.05.003

    Article  PubMed  Google Scholar 

  34. Ray JJ, Meizoso JP, Satahoo SS, Davis JS, Van Haren RM, Dermer H et al (2016) Potentially preventable prehospital deaths from motor vehicle collisions. Traffic Inj Prev 17(7):676–680. https://doi.org/10.1080/15389588.2016.1149580

    Article  PubMed  Google Scholar 

  35. Chiara O, Scott JD, Cimbanassi S, Marini A, Zoia R, Rodriguez A et al (2002) Trauma deaths in an Italian urban area: an audit of pre-hospital and in-hospital trauma care. Injury 33(7):553–562. https://doi.org/10.1016/s0020-1383(02)00123-7

    Article  PubMed  Google Scholar 

  36. Kwon AM, Garbett NC, Kloecker GH (2014) Pooled preventable death rates in trauma patients: meta analysis and systematic review since 1990. Eur J Trauma Emerg Surg 40(3):279–285. https://doi.org/10.1007/s00068-013-0364-5

    Article  CAS  PubMed  Google Scholar 

  37. Sampalis JS, Boukas S, Nikolis A, Lavoie A (1995) Preventable death classification: interrater reliability and comparison with ISS-based survival probability estimates. Accid Anal Prev 27(2):199–206. https://doi.org/10.1016/0001-4575(94)00056-r

    Article  CAS  PubMed  Google Scholar 

  38. Copeland CE, Mitchell KA, Brumback RJ, Gens DR, Burgess AR (1998) Mortality in patients with bilateral femoral fractures. J Orthop Trauma 12(5):315–319. https://doi.org/10.1097/00005131-199806000-00003

    Article  CAS  PubMed  Google Scholar 

  39. Morshed S, Miclau T, Bembom O, Cohen M, Knudson MM, Colford JM (2009) Delayed internal fixation of femoral shaft fracture reduces mortality among patients with multisystem trauma. J Bone Jt Surg Am 91(1):3–13. https://doi.org/10.2106/JBJS.H.00338

    Article  Google Scholar 

  40. Dischinger PC, Cushing BM, Kerns TJ (1993) Injury patterns associated with direction of impact: drivers admitted to trauma centers. J Trauma 35(3):454–458. https://doi.org/10.1097/00005373-199309000-00020 (discussion 458-9)

    Article  CAS  PubMed  Google Scholar 

  41. Markogiannakis H, Sanidas E, Messaris E, Koutentakis D, Alpantaki K, Kafetzakis A et al (2006) Motor vehicle trauma: analysis of injury profiles by road-user category. Emerg Med J 23(1):27–31. https://doi.org/10.1136/emj.2004.022392

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Salminen ST, Pihlajamäki HK, Avikainen VJ, Böstman OM (2000) Population based epidemiologic and morphologic study of femoral shaft fractures. Clin Orthop Relat Res 372:241–249. https://doi.org/10.1097/00003086-200003000-00026

    Article  Google Scholar 

  43. TraumaRegister DGU (2000) Allgemeine Jahresberichte seit 2000. www.traumaregister-dgu.de/infos-downloads. Assessed 29 Apr 2021

  44. Brundage SI, McGhan R, Jurkovich GJ, Mack CD, Maier RV (2002) Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries. J Trauma 52(2):299–307. https://doi.org/10.1097/00005373-200202000-00016

    Article  PubMed  Google Scholar 

  45. Nahm NJ, Como JJ, Wilber JH, Vallier HA (2011) Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries. J Trauma 71(1):175–185. https://doi.org/10.1097/TA.0b013e3181fc93a2

    Article  PubMed  Google Scholar 

  46. Saar E, Bugeja L, Ranson DL (2017) National coronial information system: epidemiology and the coroner in Australia. Acad Forensic Pathol 7(4):582–590. https://doi.org/10.23907/2017.049

  47. Bartolomeos K, Kipsaina C, Grills N, Ozanne-Smith J, Peden M (eds) (2012) Fatal injury surveillance in mortuaries and hospitals: a manual for practitioners. World Health Organization, Geneva

    Google Scholar 

  48. Martin BT, Fallon WF, Palmieri PA, Tomas ER, Breedlove L (2007) Autopsy data in the peer review process improves outcomes analysis. J Trauma 62(1):69–73. https://doi.org/10.1097/TA.0b013e31802d08e5 (discussion 73)

    Article  PubMed  Google Scholar 

  49. Leth PM, Ibsen M (2010) Abbreviated injury scale scoring in traffic fatalities: comparison of computerized tomography and autopsy. J Trauma 68(6):1413–1416. https://doi.org/10.1097/TA.0b013e3181b251b8

    Article  PubMed  Google Scholar 

  50. Osler T, Baker SP, Long W (1997) A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma 43(6):922–925. https://doi.org/10.1097/00005373-199712000-00009 (discussion 5-6)

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

The authors would like to acknowledge the contribution of the memorable Dr. Christos Leukidis MD DMJ (Path) (RIP) of the forensic medical officers of the Athens Forensic Medical Service, Ministry of Justice, Athens, Greece, for facilitating the forensic data collection process. The authors would also like to acknowledge the contribution of Dr. Fillipos Koutsaftis MD Ph.D., former Director of the Athens Forensic Medical Service, Ministry of Justice, Athens, Greece, for facilitating the forensic data collection process.

Funding

The authors did not receive support from any organization for the submitted work.

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Authors and Affiliations

  1. 4th Department of Surgery, School of Medicine, National and Kapodistrian University of Athens, University General Hospital “Attikon”, Athens, Greece

    Leonidas Roumeliotis, Nikolaos Danias, Georgios Konstantoudakis & Iordanis N. Papadopoulos

  2. Leeds Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Leeds, Yorkshire, UK

    Nikolaos K. Kanakaris

  3. 2nd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, “Konstantopouleio” General Hospital, Athens, Greece

    Leonidas Roumeliotis & Vasileios S. Nikolaou

  4. Private Orthopaedic Practice, 25 Daskalogianni Street, 11471, Athens, Greece

    Leonidas Roumeliotis

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  1. Leonidas Roumeliotis
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by LR, NKK and INP. The first draft of the manuscript was written by LR and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Leonidas Roumeliotis.

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Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethics approval

This study was approved by the Ethics Committee of the University General Hospital ‘Attikon’, Athens, Greece (No.313/9-7-14). Approval for the use of forensic data has been obtained from the Athens Forensic Medical Service, Hellenic Ministry of Justice, Athens, Greece.

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Roumeliotis, L., Kanakaris, N.K., Nikolaou, V.S. et al. Femoral fractures are an indicator of increased severity of injury for road traffic collision victims: an autopsy–based case–control study on 4895 fatalities. Arch Orthop Trauma Surg 142, 2645–2658 (2022). https://doi.org/10.1007/s00402-021-03997-8

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