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At long term follow-up, a male who sustains multiple traumatic injuries compared with a premenopausal female, who sustained similar polytrauma, is most likely to have which of the following?
Higher quality-of-life scores than females
Increased rates of complex regional pain syndrome
Require more psychiatric counseling and pharmacologic management than females
Take more absentee days at work as a result of illness than females
Decreased incidence of lower extremity amputation
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Ten or more years after severe polytrauma, premenopausal women, compared to men, demonstrate a higher incidence of posttraumatic stress disorder (PTSD) and take more sick leave time from work.
Depression following polytrauma should be screened for by treating orthopaedic surgeons. Depression commonly arises from a protracted injury and can compound the disability by increasing the perception of more physical illness.
Probst et al. present a Level 4 review of over 600 polytrauma patients. They found that quality-of-life was significantly lower in women (Short form-12 psychologic F = 48.6 +/- 10.8 vs. M = 50.8 +/- 9.4; p = 0.02), but the same rate of women (75.3%) and men (75.4%; p = 0.995) felt well rehabilitated.
Holbrook et al. report a Level 4 study of 1,048 polytrauma patients. They found that females had lower quality-of-life scores and were significantly more likely to develop early combined depression.
Answer 4: Females take more absentee days at work.
Answers 2, 3, 5: There is no data supporting these answer options.
Probst C, Zelle B, Panzica M, Lohse R, Sitarro NA, Krettek C, Pape HC.
J Trauma. 2010 Mar;68(3):706-11. PMID: 19996800 (Link to Abstract)
Probst, JTACS 2010
Holbrook TL, Hoyt DB
J Trauma. 2004 Feb;56(2):284-90. PMID: 14960969 (Link to Abstract)
Holbrook, JTACS 2004
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Average 1.0 of 48 Ratings
A patient sustains a severe lower extremity injury. What can be said about his outcome at 2 years if he chooses reconstruction over amputation?
He has a higher risk of rehospitalization
He has a higher chance of returning to work
He will have a higher overall SIP (Sickness Impact Profile) score
His psychosocial SIP score will improve with time
He will have a better SIP score if he did not complete high school
Severe lower extremity injury patients undergoing reconstruction have a higher rate of rehospitalization at 2 years. This question is based on data published by the LEAP study group, a multi-centered study of severe extremity injuries treated with either amputation or reconstruction.
Bosse et al found that at 2 years the SIP score and return to work were not statistically signficantly different between amputation and reconstruction groups. Reconstruction patients had a higher risk of rehospitalization. The psychosocial subscale of SIP did not improve with time. Risk factors for poorer SIP score were: rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), smoking, and involvement in disability-compensation litigation.
MacKenize et al evaluated factors influential in returning to work (RTW) after severe lower extremity injury. Characteristics that correlated with higher rates of RTW included younger age, higher education, higher income, the presence of strong social support, and employment in a white-collar job that was not physically demanding. Receipt of disability compensation had a strong negative effect on RTW.
Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Travison TG, Castillo RC
N. Engl. J. Med.. 2002 Dec;347(24):1924-31. PMID: 12477942 (Link to Abstract)
Bosse, NEJM 2002
MacKenzie EJ, Morris JA Jr, Jurkovich GJ, Yasui Y, Cushing BM, Burgess AR, DeLateur BJ, McAndrew MP, Swiontkowski MF.
Am J Public Health. 1998 Nov;88(11):1630-7. PMID: 9807528 (Link to Abstract)
Average 2.0 of 42 Ratings
A child in a MVA has a Glasgow Coma Scale score of 14. His injuries have been graded as severe but not life-threatening injury to the chest (3 points), moderate injury to the abdomen (2 points), and severe injuries but with probable survival injury to the the face or neck (4 points) using the criteria for the Modified Injury Severity Score (MISS). There are no injuries to extremities/pelvis . Based on this information, what is the child’s total MISS score?
The MISS for children categorizes injuries into five body areas: 1) neurologic, 2) face & neck, 3) chest, 4) abdomen & pelvic contents, 5) extremities & pelvic girdle. Each of these are scored 1-5 with 1 being minor, 2 moderate, 3 severe but not life threatening, 4 severe with probable survival, and 5 critical with uncertain survival. The total score for the MISS, like the Injury Severity Score (ISS), is the sum of the squares for the highest injury score grades in the three most severely injured body regions. Therefore, in this case: chest (3x3) + abdomen (2x2) + face/neck (4x4) = 9+4+16 = 29. The Glasgow coma scale would be 1, which is less than the scores of 3 of the other areas so it is excluded.
Loder in 1987 showed that in 78 polytrauma pediatric patients, no deaths were seen when the MISS is <40. Mortality was 50% for scores >40 and 75% for scores >50. The Mayer article is a good overview of the MISS.
Mayer T, Matlak ME, Johnson DG, Walker ML.
J Pediatr Surg. 1980 Dec;15(6):719-26. PMID: 7463271 (Link to Abstract)
J Orthop Trauma. 1987;1(1):48-54. PMID: 3506585 (Link to Abstract)
Loder, JOT 1987
Average 2.0 of 36 Ratings
The mangled extremity severity score (MESS) utilizes all of the following variables EXCEPT:
Skeletal and soft tissue injury
Time from admission to surgery
The MESS is a tool utilized to help predict limb salvage success versus primary amputation at the time of presentation. As a screening tool for amputation, this scoring system has a high specificity but low sensitivity, as scores lower than 7 may also ultimately need amputation. All of the variables except choice #5 are part of the scoring system.
The scoring system is as follows: 1. Skeletal / soft-tissue injury: Low energy = 1; Medium energy = 2; High energy = 3; very high energy = 4; 2. Limb ischemia: Pulse reduced or absent but perfusion normal = 1; Pulseless = 2; Cool, paralyzed, insensate = 3; 3. Shock: normotensive = 0; transient hypotension = 1; persistent hypotension = 2; 4. Age: < 30 = 0; 30-50 = 1; >50 = 2. Limb category scores are doubled for ischemia > 6 hours. The system's original designers reported a cutoff of 7 as predicting amputation.
The referenced study by Ly et al found that the scoring system did not predict functional outcomes at 6 or 24 months. They also found that the Limb Salvage Index; the Predictive Salvage Index; the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score; and the Hannover Fracture Scale-98 all did not predict outcomes at 6 or 24 months.
Ly TV, Travison TG, Castillo RC, Bosse MJ, MacKenzie EJ; LEAP Study Group.
J Bone Joint Surg Am. 2008 Aug;90(8):1738-43 PMID: 18676906 (Link to Abstract)
Ly, JBJS 2008
Average 3.0 of 28 Ratings
What is the Injury Severity Score (ISS) for a patient with an open chest wound (Abbreviated Injury Scale, AIS=4), colon transection (AIS=4), femoral fracture (AIS=3), shoulder dislocation (AIS=2), and a thyroid gland contusion (AIS=1)
Injury Severity Score (ISS) scores are used to define injury severity for research purposes. The score is based on anatomic and severity indicies. Injury severity is based upon the AIS (abbreviated injury scale). AIS scores range from 1-6 where 1 is a minor laceration or contusion and 6 is a unsurvivable severe injury. An example of a 6 is a crushed head or brain whereas a 5 is a crushed larynx. Open pelvic fracture and femoral shaft fracture come in at 3 and large joint dislocations are a level 2 injury. ISS is the sum of the squares for the highest AIS grades in the three most severely injured ISS body regions. An ISS greater than 18 reflects multiply injured patients and that a transfer to a trauma center is indicated. So in this case, it would be (4x4)+(4x4)+(3x3)= 16+16+9=41. The AIS table can be found in Miller Review on page 699.
Recently, the New Injury Severity Score (NISS) has been developed and found by some authors (Lavoie et al & Balogh et al) to be more reliable indicator of length of stay and ICU stay. The NISS differs from the ISS in that the NISS sums the squares of the 3 most significant injuries (even if they occur in the same anatomic area). The ISS sums the 3 most significant injuries in 3 separate anatomic areas.
Lavoie A, Moore L, LeSage N, Liberman M, Sampalis JS.
Injury. 2005 Apr;36(4):477-83. Epub 2005 Jan 22. PMID: 15755427 (Link to Abstract)
Lavoie, INJURY 2005
Balogh ZJ, Varga E, Tomka J, Suveges G, Toth L, Simonka JA
J Orthop Trauma. 2003 Aug;17(7):508-12. PMID: 12902789 (Link to Abstract)
Balogh, JOT 2003
Average 3.0 of 43 Ratings