Inger Birgitta Schipper

Purpose: This study compares the syndesmosis congruity and functional outcomes after syndesmotic reconstruction by open reduction and internal fixation (ORIF) of posterior malleolar fractures (PMFs) sized > 5% versus no fixation in type C ankle fractures. Methods: This multicenter prospective cohort study compared ORIF of PMFs (FIX) with no fixation (NO-FIX). Both groups underwent fibular and medial malleolus fixation according to AO principles, with trans-syndesmotic stabilization screws in case of instability. The primary outcome was syndesmotic alignment assessed on post-operative bilateral CT scans. The main secondary outcome measures were patient-reported functional outcome up to 1 year assessed with AAOS and OMAS questionnaires, and complications. Results: 26 patients (17 FIX, 9 NO-FIX) were included, with a median PMF size of 20%. Syndesmotic stabilization with fib-tib screws was used in 6% of FIX vs 44% of NO-FIX ( p = 0.03). Anatomical reduction (primary outcome) was achieved in 85% (FIX) versus 29% (NO-FIX, p = 0.02). AAOS and OMAS scores during follow-up were superior in FIX (linear mixed models, p < 0.01). The complication rate was higher in NO-FIX (55% vs. 0%, p  < 0.001). Conclusion: in this study, ORIF of the PMF resulted in a higher rate of anatomically reduced syndesmosis, lesser need for syndesmotic stabilization screws, better functional outcome and fewer complications compared to no fixation. Fixation of PMFs in suprasyndesmotic fibula fractures with PMFs > 5% may be valuable, but more studies are needed to confirm this hypothesis due to study limitations.

Background: Distal radial fractures (DRFs) and malleolar fractures (MFs) represent almost one-third of Dutch emergency room fractures. The WARRIOR trials showed that routine follow-up radiographs obtained >2 weeks post-injury were unnecessary in most cases and safe to omit. This study evaluated 2 strategies to reduce such imaging: dissemination of WARRIOR evidence and a tailored de-implementation strategy. Methods: This multicenter retrospective observational study included adults with a DRF (OTA/AO 23A to 23C) or MF (Lauge-Hansen SA 2, SE 2 to 4, PE 1 to 4, or PA 1 to 3) treated at 5 hospitals in the West Netherlands region. Centers 1 and 2 (Level I) were participants in the WARRIOR trials; Centers 3 to 5 (Level II) were not. Exclusion criteria were open, pathological, high-energy, or SA 1 fractures. Three cohorts were compared: historical controls (n = 846; at Centers 1 and 2), after dissemination (n = 337; at Centers 1 to 5), and after de-implementation (n = 314; at Centers 1 to 5). The mean age was 55 years, and 67% were female. The de-implementation strategy included educational sessions, performance feedback, and updated guidelines. The primary outcome was the number of routine follow-up radiographs per patient; secondary outcomes were the number of treatment-phase radiographs, the total number of radiographs, and the proportion of patients without routine follow-up imaging. Operative and nonoperative fractures were analyzed jointly. Results: In Centers 1 and 2, the mean number of routine radiographs per patient decreased by 1.41 (95% confidence interval, 1.10 to 1.72) after dissemination and by a further 0.26 (0.07 to 0.46) after de-implementation for MFs, and decreased by 0.71 (0.49 to 0.94) after dissemination but by only a nonsignificant further 0.09 (−0.08 to 0.26) after de-implementation for DRFs. The probability of no routine follow-up imaging increased by 44.2% (37.1% to 51.3%) after dissemination and by a further 13.2% (3.6% to 22.8%) after de-implementation for MFs, and increased by 41.9% (36.5% to 47.3%) after dissemination but changed by a nonsignificant −3.0% (−10.2% to 4.2%) after de-implementation for DRFs. In Centers 3 to 5, the mean number of routine radiographs per patient decreased after active de-implementation by 0.38 (0.18 to 0.57) for MFs, and by 0.30 (0.16 to 0.43) for DRFs, compared with the number after dissemination. The probability of no routine follow-up imaging increased after de-implementation by 11.4% (4.8% to 18.0%) for MFs, and by 21.9% (13.8% to 30.1%) for DRFs, compared with the rate after dissemination. Conclusions: Both research dissemination and a tailored de-implementation strategy substantially reduced routine follow-up radiographs for DRFs and MFs, supporting their use to decrease low-value radiographs in trauma care. Level of Evidence: Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Fracture non-union cause chronic pain, dysfunction, and high healthcare costs. Treatment consists of revitalizing the nonhealed fracture site through debridement, bone resection, grafting, or stabilization if indicated. Adequate bone perfusion is essential for healing, but current intraoperative assessments are subjective. This study explores the feasibility of using quantitative near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) to assess bone perfusion in non-union surgery. This technique allows real-time visualization of tissue perfusion through tracing intravascular injected ICG. Methods: This prospective, multicenter feasibility study was conducted in 2 Dutch academic hospitals. Intraoperative ICG NIRF imaging was performed in non-union patients after debridement and before osteosynthesis. Time-intensity curves were derived from intraoperative data, and 3 time-related perfusion parameters were extracted to quantify the perfusion in various osseous structures. Demographic data included patient's age, sex, race, and body mass index. Results: ICG NIRF measurement was successfully performed in 20 patients (median age 50.5 years, 65% female, and 90% White) at 7 fracture locations. Three distinct perfusion patterns were observed. (1) rapid ingress and egress, (2) rapid ingress with a plateau phase, and (3) prolonged ingress with no egress within the measurement. The median Tmax was 214 s (inter-quartile range [IQR]): 69-246 s. The normalized maximum ingress slope was 4.4%/s (IQR: 2.4-6.5), and the median Egress-60 was 84.7% (IQR: 77.4-94.8). Conclusion: ICG NIRF imaging is a feasible and reproducible method for intraoperative bone perfusion assessment in fracture non-union, potentially offering an objective measure of bone vitality. Perfusion parameters and time-intensity curves were successfully quantified across various bone structures, revealing patterns similar to those linked with clinical outcomes in other studies. Future research should evaluate how these perfusion patterns relate to bone healing. Level of Evidence: Level II . See Instructions for Authors for a complete description of levels of evidence.

Purpose: Preinjury use of antithrombotic medication (PAM) may increase bleeding risk and adverse outcomes in older trauma patients. PAM is not routinely recorded in the Dutch trauma registry, leaving its impact on outcomes unclear. This study describes PAM among older trauma patients and assesses its association with injury patterns and patient outcomes, thereby informing whether routine documentation in trauma registries would be useful. Methods: Data from trauma patients aged ≥ 65 years admitted to hospitals within the West-Netherlands trauma region in June-September 2024 were obtained from the regional trauma registry. PAM was additionally documented during this period. Poor outcome was defined as in-hospital mortality and Glasgow Outcome Scale (GOS) score ≤ 3 at hospital discharge. Associations between PAM and outcomes were analyzed using multivariable logistic regression. Results: Of 1,112 patients, 50% used antithrombotic medication, most commonly platelet aggregation inhibitors (47%) or direct oral anticoagulants (37%). Users were older, more often male, had more comorbidities, and more frequently sustained low-energy falls and minor head injuries. PAM was not associated with higher ISS (median 9 in both groups, p = 0.80), more intracranial hemorrhages (74% vs. 71%, p = 0.85), increased mortality (adjusted odds ratio [OR], 0.79; 95% Confidence Interval [CI], 0.41–1.53), or poor GOS at discharge (OR, 1.06; 95% CI, 0.79–1.43). Conclusion: PAM is common among older trauma patients. In this exploratory study, PAM did not seem to be associated with more severe injuries or poorer short-term outcomes. To evaluate the in-depth and long-term effects structured documentation of PAM in trauma registries is advocated.

Rehabilitation after musculoskeletal trauma is globally acknowledged as essential for restoring function and improving quality of life; however, significant variation exists in rehabilitation frameworks and services worldwide. Although certain principles—such as early intervention, structured care pathways, and multidisciplinary approaches—are universally recognized as important determinants of outcomes in trauma patients, their implementation and effectiveness vary considerably due to differences in health care infrastructure, economic resources, policy frameworks, and cultural contexts. Drawing on comparative analyses of rehabilitation frameworks across regions, including North America, Latin America, Europe, Asia-Pacific, and Africa, this paper identifies structural variations, systemic challenges, and innovations that can inform global rehabilitation efforts. Strategic international collaboration focusing on shared learning, standardized protocols, technology integration, and targeted investments is key to creating equitable and sustainable rehabilitation models, especially in resource-limited settings and aging populations.

Introduction: Pancreatic trauma is rare, accounting for only 0.2% of all trauma cases, and reports on long‐term endocrine outcomes are scarce. Patients who undergo pancreatic resection may develop diabetes mellitus. Objectives: To summarize the available literature reporting the incidence of diabetes mellitus (DM) after pancreatic trauma and to evaluate potential influences on the incidence rates. Patients and Methods: We searched in PubMed and Embase for studies published between 1990 and July 2025 that enrolled patients with trauma of the pancreas and reported data on new‐onset DM. Results: Out of 906 identified records, six studies with a total of 297 patients with pancreatic trauma. The overall cumulative incidence of new‐onset DM is 5.7% (95% confidence interval [CI]: 3.4%–9.0%). DM developed in 8.2% (95% CI: 4.4%–13.6%) of patients who underwent (partial) pancreatic resection and in 2.9% (95% CI: 0.8%–7.4%) of patients treated nonoperatively. For low‐grade injuries, the incidence of DM was 5.5% (95% CI: 2.0%–11.5%) compared to 11.1% (95% CI: 4.9%–20.7%) for high‐grade injuries. The time until new‐onset diabetes mellitus was detailed in one study with 15 patients. Conclusion: Based on the available literature, the estimated overall incidence of DM after pancreatic trauma is 5.7%. High‐grade pancreatic injury seems to increase the risk of developing new‐onset DM, which is possibly influenced by their frequent surgical treatment.

Purpose: Both the Glasgow Coma Scale (GCS) and Abbreviated Injury Scale (AIS) for head injuries quantify traumatic brain injury (TBI) severity. The GCS is based on brain physiology of consciousness, whereas the AIS is an anatomical injury scoring system. This study aimed to describe the correlation of GCS with maximal AIS-Head (maxAIS) and summative AIS-Head (sumAIS) in TBI patients. Methods: Data of 4996 adult TBI patients admitted to two level 1 trauma centers in the Netherlands between 2015 and 2021 were selected from the regional trauma registry. The association of GCS with maxAIS and sumAIS was quantified using Spearman rank correlation coefficients (r _s ). Results: For 39% of the patients, the GCS was not documented in the trauma registry. These patients had less severe head injuries than the 3051 patients with documented GCS scores, who were further analyzed. Among those with severe head injuries (AIS-Head ≥ 4), 53% had a GCS score ≥ 13. The GCS showed a weak inverse relationship with both maxAIS and sumAIS (r _s -0.33 and − 0.34, respectively, both p < 0.001). Conclusions: The correlation between physiological alterations (GCS) and anatomical brain damage (AIS) in patients with TBI patients, represented by the GCS and AIS respectively, is weak. Additionally, the GCS appears to underestimate the severity of AIS coded severe TBI. Recognizing this limited correlation is important for valid TBI research.

Traumatic injuries are a leading cause of global morbidity and mortality, with 40 million people permanently injured and nearly 6 million deaths every year. Approximately 90% of trauma-related deaths occur in low- and middle-income countries, and 50% of trauma-related deaths are believed to be preventable. Although effective trauma systems encompassing prehospital, hospital, and rehabilitative care are critical for improving outcomes, global documentation remains limited. This study provides a comparative analysis of trauma care systems across 8 countries—the United States, Canada, Brazil, Belgium, the Netherlands, Australia, Japan, and South Africa—spanning 5 continents. Each country's analysis includes demographic context, system organization (including prehospital, hospital, and posthospital care), clinical and systemic outcomes, and future directions. Trauma systems across countries vary significantly in the structure and regulation of trauma care, injury patterns, national data collection, and accessibility, reflecting diverse demographics and healthcare infrastructures. National trauma registries are well established in countries like the Netherlands, Japan, and Canada but are in early development stages in Brazil, South Africa, and Belgium. In some countries, such as the Netherlands and Canada, trauma from traffic collisions and falls dominates, whereas others, such as Brazil and South Africa, have higher rates of violence-related injuries like homicides. Accessibility in remote areas remains a challenge in countries with large landmasses such as Canada and Australia, where rural populations often face limited or delayed trauma care. Other countries, such as the United States and South Africa, face different challenges linked to disparities in quality of and access to care between public and private systems. Although centralization of trauma care, standardization of national trauma care systems, and investment in workforce and infrastructure are universal goals for improving outcomes, solutions tailored to each country are required to optimize trauma systems globally.

Trauma systems are vital components of healthcare infrastructure, addressing the significant burden of severe injuries across Europe. Effective trauma systems improve patient outcomes and reduce mortality by providing timely, specialised care. However, significant disparities remain between countries, with only a few well-structured and maintained systems currently operating in Europe. Developing trauma systems requires collaboration among healthcare providers, emergency services, and government agencies. Standardised protocols for triage, transport, and treatment are essential, supported by robust infrastructure, public education, and injury prevention initiatives. Trauma systems comprise four core components: • Injury Prevention. • Pre-Hospital Care. • Facility Care. • Post-Hospital Care/Rehabilitation. These components rely on key elements such as leadership, professional resources, education, quality improvement, and funding. Political commitment, geographical considerations, and the efforts of dedicated clinicians are crucial for ensuring system success. Trauma systems across Europe are evolving under diverse healthcare structures. Over recent decades, dedicated clinicians, often with support from national medical societies, have initiated and sustained these systems. Typically, trauma hospitals, or trauma centres (TCs), are categorised into two or three levels, with the highest being ‘Level I TC’ or ‘Major TC,’ capable of managing the most complex cases. This chapter outlines general requirements for these categories, leaving individual nations to tailor standards to their healthcare systems.