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Clinical practice guidelines are being used as a means of reducing inappropriate care, controlling geographic variations in practice patterns, and making more effective use of health care resources. Developments at the national health policy level, as well as managed care imperatives, suggest that clinical practice guidelines will play an increasingly prominent role in the practice of medicine. These guidelines can contribute to medicine as an aid in clinical decision making and improving clinical practice [1,2] and as a research tool and an educational resource. We, as trauma surgeons, should participate in such endeavors in an effort to improve trauma care and guide future research. The Agency for Health Care Policy and Research (AHCPR) has led the way in guideline development methodology and currently has published 20 guidelines addressing a variety of topics. [3] Its initial work has led others to develop an evidence-based approach to care. Evidence-based guidelines have been published on intravenous analgesia, sedation, sustained neuromuscular blockade in the intensive care unit, and management of severe head injury. [4-6] Clinical computerized bedside protocols have improved outcome in adult respiratory distress syndrome and hypoxia. [7,8] National literature/consensus-based guidelines have also been published for stress ulcer prophylaxis and albumin transfusion and are currently in development for antibiotic use and fever workup in the intensive care unit. [9,10] The role of the Eastern Association for the Surgery of Trauma (EAST) and other national organizations will be to provide a series of national consensus-based guidelines from which institutionally specific clinical management protocols or pathways can be developed (see Figure 1).Figure 1: Guideline and protocol development.A step-by-step process of practice management guideline development, largely adapted from AHCPR recommendations, has been derived [11] to ensure a combination of rigorous methodology and practical feasibility that can be adapted to clinical decision making at any institution (Table 1). Key to guideline development is assessment of the scientific evidence and formulation of recommendations (Table 2).Table 1: Steps to practice management guideline developmentTable 2: Classification of scientific evidence and formulation of recommendationsA current limitation on the concept of guideline development is the paucity of prospective, randomized class I data for the development of more secure evidence-based guidelines. It is hoped that through the development of guidelines, a baseline can be created to direct future research and create more class I data. With these thoughts in mind, a consensus conference of 20 trauma surgeons interested in guideline development was held and initial topics were selected for development. Each member of the conference selected topics that he or she felt were important for development. Four topics were then selected by majority consensus. Each topic was assigned a chairperson, and the chairperson was then responsible for selecting his or her committee members. The individual committees were given latitude on how to approach their topics, but all were expected to conform to the process described above. Once completed, the guidelines were reviewed by the committee chairperson and the chairperson of the guideline committee and returned for revision. The revised guidelines were submitted to the EAST program chairman, the president of EAST, and the board members. The guidelines were presented at the annual meeting of EAST in 1997, and revisions were made based on comments and suggestions from the members. What follows is an abridged version of these guidelines. The unabridged version, which contains a more lengthy discussion of the scientific evidence, data classification, and evidentiary tables, as well as a complete bibliography, is available through the EAST web page (www.east.org) or by written request. Send requests to: EAST Guidelines, c/o Judith Schultz, Trauma Program Development Office, Lehigh Valley Hospital, Cedar Crest & I-78, P.O. Box 689, Allentown, PA 18105-1556. Practice Management Guidelines for Screening of Blunt Cardiac Injury Michael D. Pasquale, MD, Division of Trauma/Surgical Critical Care, Lehigh Valley Hospital, Allentown, Pa; Kimberly K. Nagy, MD, Department of Trauma, Cook County Hospital, Chicago, Ill; John R. Clarke, MD, Department of Surgery, Allegheny University Hospital, Philadelphia, Pa. Practice Management Guidelines for Identifying Cervical Spine Injuries after Trauma Donald W. Marion, MD, Chairman, Department of Neurosurgery, Presbyterian University Hospital, Pittsburgh, Pa; Robert Domeier, MD, Department of Emergency Medicine, St. Joseph Mercy Hospital, Ann Arbor, Mich; C. Michael Dunham, MD, St. Elizabeth Hospital Trauma Center, Youngstown, Ohio; Fred A. Luchette, MD, Division of Trauma/Critical Care, University of Cincinnati College of Medicine, Cincinnati, Ohio; Regis Haid, MD, Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Ga; Scott C. Erwood, MD, Emory Clinic, Atlanta, Ga. Practice Management Guidelines for Penetrating Intraperitoneal Colon Injuries C. Gene Cayten, MD, Institute for Trauma and Emergency Care, New York Medical College, Valhalla, NY; Timothy C. Fabian, MD, University of Tennessee College of Medicine, Memphis, Tenn; Victor F. Garcia, MD, Division of Pediatric Surgery, Children's Hospital Medical Center, Cincinnati, Ohio; Rao R. Ivatury, MD, Department of Surgery, New York Medical College/Lincoln Hospital, Bronx, NY; John A. Morris, Jr., MD, Division of Trauma and Surgical Critical Care, Vanderbilt University, Nashville, Tenn. Practice Management Guidelines for Venous Thromboembolism in Trauma Patients - The Use of Low-Dose Heparin (LDH) for Deep Venous Thrombosis/Pulmonary Embolus (DVT/PE) Prophylaxis - The Use of Sequential Compression Devices (SCDs) in the Prevention of DVT/PE - The Role of Low Molecular Weight Heparin in Venous Thromboembolism Prophylaxis in Trauma Patients - The Role of Arteriovenous Foot Pumps in the Prophylaxis of DVT/PE in the Trauma Patient - The Role of the Vena Cava Filter in the Prophylaxis and Treatment of PE - The Role of Treatment of Established DVT/PE with Anticoagulation in the Trauma Patient - The Role of Ultrasonography in Diagnostic Imaging for in Trauma - The Role of in Diagnostic Imaging for in Trauma - The Role of in the of in Trauma Patients MD, Department of Surgery, University of College of Medicine, D. 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The Journal of Bone and Joint Surgery. British volumeVol. 70-B, No. 1 ArticlesFree AccessPelvic ring fractures: should they be fixed?M TileM TileSearch for more papers by this authorPublished Online:1 Jan 1988https://doi.org/10.1302/0301-620X.70B1.3276697AboutSectionsPDF/EPUB ToolsAdd to FavouritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byPreoperative CT simulation of iliosacral screws for treating unstable posterior pelvic ring injury8 March 2022 | BMC Musculoskeletal Disorders, Vol. 23, No. 1Functional outcome of unstable pelvic fractures treated in a level III hospital in a developing country: a 10-year prospective observational study4 April 2022 | Journal of Orthopaedic Surgery and Research, Vol. 17, No. 1Percutaneous posterior transiliac plate versus iliosacral screw fixation for posterior fixation of Tile C-type pelvic fractures: a retrospective comparative study16 June 2022 | BMC Musculoskeletal Disorders, Vol. 23, No. 1Equestrian-Related Pelvic Trauma in Women of Childbearing Age — a Review of the Experience of a National Pelvic & Acetabular Referral Centre27 July 2022 | SN Comprehensive Clinical Medicine, Vol. 4, No. 1CT of Sacral Fractures: Classification Systems and ManagementRadioGraphics, Vol. 42, No. 7Moving forward with the management of minimally displaced lateral compression pelvic ring injuries18 June 2022 | European Journal of Orthopaedic Surgery & Traumatology, Vol. 32, No. 7Biomechanical Comparison of 4 Transsacral Fixation Constructs in a Type 61C, Zone II Pelvic Fracture ModelJournal of Orthopaedic Trauma, Vol. 36, No. 10Rami Comminution Is Associated With Displacement of Minimally Displaced Lateral Compression Type 1 Injuries on Lateral Stress RadiographsJournal of Orthopaedic Trauma, Vol. 36, No. 10Surgical management of paediatric pelvic fractures: a prospective case series and early experience from a level one Egyptian trauma centre23 July 2022 | International Orthopaedics, Vol. 46, No. 10A Review on Management of Insufficiency Fractures of the Pelvis and AcetabulumOrthopedic Clinics of North America, Vol. 53, No. 4Lumbo-sacral Junction Instability by Traumatic Sacral Fractures: Isler’s Classification Revisited – A Narrative Review22 February 2022 | Global Spine Journal, Vol. 12, No. 8Prolonged ileus in traumatic pelvic ring injury patients who underwent arterial angio-embolization: A retrospective studyMedicine, Vol. 101, No. 39Surgical Versus Non-surgical Treatment of Unstable Lateral Compression Type I (LC1) Injuries of the Pelvis With Complete Sacral Fractures in Non-fragility Fracture Patients: A Systematic ReviewCureus, Vol. 15Analysis of Postoperative Gait, Hip Strength, and Patient-Reported Outcomes After OTA/AO 61-B and 61-C Pelvic Ring InjuriesJournal of Orthopaedic Trauma, Vol. 36, No. 9Dual-Energy CT and Cinematic Rendering to Improve Assessment of Pelvic Fracture InstabilityRadiology, Vol. 304, No. 2Mortality and functional outcomes of fragility fractures of the pelvis by fracture type with conservative treatment: a retrospective, multicenter TRON study1 December 2021 | European Journal of Trauma and Emergency Surgery, Vol. 48, No. 4Pelvic Fracture Urethral Distraction DefectUrologic Clinics of North America, Vol. 49, No. 3Paediatric pelvic fractures – an updated literature review3 July 2022 | ANZ Journal of Surgery, Vol. 36Sakrumfrakturen beim geriatrischen Patienten1 June 2022 | Zeitschrift für Gerontologie und Geriatrie, Vol. 55, No. 4Evolution of the AO Spine Sacral and Pelvic Classification System: a systematic reviewJournal of Neurosurgery: Spine, Vol. 78Nonoperative Management of Minimally Displaced Lateral Compression Type 1 Pelvic Ring Injuries With and Without Occult InstabilityJournal of Orthopaedic Trauma, Vol. 36, No. 6Reliability and reproducibility analysis of the AOSpine Sacral Fractures Classification System by spinal and pelvic surgeonsInjury, Vol. 53, No. 6Outcomes and complications of the INFIX technique for unstable pelvic ring injuries with high-velocity trauma: a systematic review and meta-analysis11 January 2021 | Archives of Orthopaedic and Trauma Surgery, Vol. 142, No. 5Anatomic reduction of the sacroiliac joint in unstable pelvic ring injuries and its correlation with functional outcome30 September 2020 | European Journal of Trauma and Emergency Surgery, Vol. 48, No. 2Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable17 December 2021 | Journal of Bone and Joint Surgery, Vol. 104, No. 4Ligaments stabilizing the sacrum and sacroiliac joint: a comprehensive review25 August 2021 | Neurosurgical Review, Vol. 45, No. 1Pelvic ring and acetabular fracture: Concepts of traumatological forensic interestInjury, Vol. 53, No. 2Danger zone - 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results of a prospective study13 August 2021 | BMC Musculoskeletal Disorders, Vol. 22, No. 1Comparison of lumbopelvic fixation and iliosacral screw fixation for the treatment of bilateral sacral fractures16 October 2021 | Journal of Orthopaedic Surgery and Research, Vol. 16, No. 1Minimally displaced acetabulum fractures in geriatric patients: a comparison of open, percutaneous and non-operative treatment from the German Pelvic Injury Register data8 April 2020 | European Journal of Trauma and Emergency Surgery, Vol. 47, No. 6Transarterial embolisation is associated with improved survival in patients with pelvic fracture: propensity score matching analyses19 September 2020 | European Journal of Trauma and Emergency Surgery, Vol. 47, No. 6A retrospective study about functional outcome and quality of life after surgical fixation of insufficiency pelvic ring injuries13 December 2021 | BMC Musculoskeletal Disorders, Vol. 22, No. 1Is Anterior Plating Superior to the Bilateral Use of Retrograde Transpubic Screws for Treatment of Straddle Pelvic Ring Fractures? A Biomechanical Investigation28 October 2021 | Journal of Clinical Medicine, Vol. 10, No. 21Verification of High-Rate Vertical Loading Laboratory Skeletal Fractures by Comparison with Theater Injury Patterns15 October 2021 | Annals of Biomedical Engineering, Vol. 49, No. 11Reproductibilité intra- et inter-examinateur de la classification AO/OTA 2018 des ruptures de l’anneau pelvien à haute énergie : une étude rétrospectiveRevue de Chirurgie Orthopédique et Traumatologique, Vol. 107, No. 6Inter- and intraobserver reliability assessment of the 2018 AO/OTA classification for high-energy pelvic ring injuries: A retrospective studyOrthopaedics & Traumatology: Surgery & Research, Vol. 107, No. 6Management and outcomes of open pelvic fractures: An updateInjury, Vol. 52, No. 10One sacroiliac screw for posterior ring fixation in unstable pelvic fractures1 November 2021 | Acta Orthopaedica Belgica, Vol. 87, No. 3Endovascular management of haemorrhage in pelvic traumaSurgery in Practice and Science, Vol. 6The FFP-classification: From eminence to evidenceInjury, Vol. 94The Influence of Surgeon Experience and Subspeciality on the Reliability of the AO Spine Sacral Classification SystemSpine, Vol. Publish Ahead of PrintAssociation Between Stability and Urologic Lesions in Pelvic Ring Fractures. A Case Series Report6 January 2020 | Journal of Investigative Surgery, Vol. 34, No. 7Pelvic Ring Fractures and Lower Urinary Tract Injuries8 January 2020 | Journal of Investigative Surgery, Vol. 34, No. 7Validation of the AO Spine Sacral Classification SystemJournal of Orthopaedic Trauma, Vol. Publish Ahead of PrintLateral compression type 1 (LC1) pelvic ring injuries: a spectrum of fracture types and treatment algorithms16 April 2021 | European Journal of Orthopaedic Surgery & Traumatology, Vol. 31, No. 5An independent inter- and intraobserver agreement assessment of the AOSpine sacral fracture classification systemThe Spine Journal, Vol. 21, No. 7Incidence and Clinical Features of Urethral Injuries with Pelvic Fractures in Males: A 6-Year Retrospective Cohort Study at a Single Institution in South KoreaJournal of Trauma and Injury, Vol. 34, No. 2Short-Term Functional Outcomes and Quality of Life after B2.1 Type Pelvic Fractures for Surgically and Non-Surgically Treated Young Patients21 May 2021 | Medicina, Vol. 57, No. 6Pelvic and acetabular trauma in amateur equestrian enthusiasts – A retrospective reviewThe Surgeon, Vol. 120Bilateral vertical shear sacroiliac joint dislocations treated with bilateral triangular Osteosynthesis in a young female: A case reportTrauma Case Reports, Vol. 61Factors Associated With Failure of Superior Pubic Ramus ScrewsJournal of Orthopaedic Trauma, Vol. 35, No. 4Medium-Term Patient-Reported Quality of Life and Activities of Daily Living in Surgically Treated Trauma Patients With Pelvic, Acetabular or Combined Pelvic and Acetabular Fractures in a Retrospective Single-Center StudyJournal of Orthopaedic Trauma, Vol. 35, No. 4Relevant Clinical Findings of Patients with Extraperitoneal Bladder Injury Associated with Pelvic Fracture Who Underwent Operative Management: A 6-Year Retrospective StudyJournal of Acute Care Surgery, Vol. 11, No. 1Comparison of One-Year Functional Outcomes and Quality of Life between Posterior Pelvic Ring Fixation and Combined Anterior-Posterior Pelvic Ring Fixation after Lateral Compression (B2 Type) Pelvic Fracture26 February 2021 | Medicina, Vol. 57, No. 3Patient-reported Outcome in Surgically Treated Pelvic Ring Injuries at 5 Years Post-surgery19 September 2019 | Scandinavian Journal of Surgery, Vol. 110, No. 1Application of Pelvic Circumferential Compression Devices in Pelvic Ring Fractures—Are Guidelines Followed in Daily Practice?21 March 2021 | Journal of Clinical Medicine, Vol. 10, No. 6Interobserver reliability of the Tile classification system for pelvic fractures among radiologists and surgeons8 September 2020 | European Radiology, Vol. 31, No. 3An Automated Deep Learning Method for Tile AO/OTA Pelvic Fracture Severity Grading from Trauma whole-Body CT21 January 2021 | Journal of Digital Imaging, Vol. 34, No. 1The ‘nightstick’ ischial fracture: a unique oddity of the pelvic injury family26 February 2021 | BMJ Case Reports, Vol. 14, No. 2Treatment of Pelvic Fractures15 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Journal of Palliative MedicineVol. 3, No. 1 Innovations in End-of-Life CareTaking a Spiritual History Allows Clinicians to Understand Patients More FullyDr. Christina Puchalski and Anna L. RomerDr. Christina Puchalski and Anna L. 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Maiko, Steven Ivy, Beth Newton Watson, Kianna Montz, and Alexia M. Torke27 March 2019 | Journal of Palliative Medicine, Vol. 22, No. 4Time to follow the evidence – Spiritual care in health careEthics, Medicine and Public Health, Vol. 9How and When Is Role Modeling Effective? The Influence of Mentee Professional Identity on Mentoring Dynamics and Personal Learning Outcomes18 April 2019 | Group & Organization Management, Vol. 44, No. 2Teenagers and Cannabis Use: Why It's a Problem and What Can Be Done About ItJournal of Psychosocial Nursing and Mental Health Services, Vol. 57, No. 3Haken und Ösen: Spiritualität in der klinischen PalliativversorgungWege zum Menschen, Vol. 71, No. 2Approaching Spirituality Using the Patient-Centered Clinical Method27 January 2018 | Journal of Religion and Health, Vol. 58, No. 1Medical Students’ (Dis)comfort with Assessing Religious and Spiritual Needs in a Standardized Patient Encounter10 October 2018 | Journal of Religion and Health, Vol. 58, No. 1Spirituality and Religiosity of Pharmacy Students1 February 2019 | American Journal of Pharmaceutical Education, Vol. 83, No. 1Interprofessional spiritual care in oncology: a literature review16 February 2019 | ESMO Open, Vol. 4, No. 1Physical, Psychological/Psychiatric, Social, and Spiritual Problems and Symptoms13 April 2019Spiritual Assessment in Healthcare: An Overview of Comprehensive, Sensitive Approaches to Spiritual Assessment for Use Within the Interdisciplinary Healthcare Team18 May 2019The Role of the Nurse in Providing Spiritual Care: A Case Study Approach to Exploring Specific Care Provision by Healthcare Workers in the Context of an Interdisciplinary Healthcare Team18 May 2019Teaching and Learning About Spirituality in Healthcare Practice Settings18 May 2019Religion and Spirituality Among Medical Students5 June 2019Spiritual Care: The Role of Health Care Chaplaincy4 September 2019End-of-life milieu of critically sick children admitted to a pediatric hospital: A comparative study of survivors versus nonsurvivorsIndian Journal of Palliative Care, Vol. 25, No. 4Incorporating and Teaching Spirituality into Medical Education: An Overview of the Field and Possible Educational Strategies4 September 2019Religion, Spirituality, and Stress6 March 2019Toward Comprehensive Medicine: Listening to Spiritual and Religious Needs of Patients26 April 2019 | Gerontology and Geriatric Medicine, Vol. 5Din ve Psikoloji Arasındaki Uçurum Gerçekten Ne Kadar Derin? Psikoterapilerdeki Dini İzler15 December 2018 | Cumhuriyet İlahiyat Dergisi, Vol. 22, No. 3Women's Perceptions of Using Short Films to Integrate Spirituality in TherapyJournal of Systemic Therapies, Vol. 37, No. 4Content Validation of Advanced Illness Criteria of a Palliative Care Screening Tool Lauren C. DiLello, Karen Mulvihill, Jennifer Delli Carpini, Riddhi Shah, Julia Hermanowski, and Damanjeet Chaubey29 October 2018 | Journal of Palliative Medicine, Vol. 21, No. 11Understanding, assessing, and in the spiritual of medical and October 2018 | Theology, Vol. 11, No. and of in Living with October 2018 | Journal of & Social Services, Vol. No. for the spirituality as October 2018 | Revista de Vol. 71, No. An of an aged psychiatry March 2018 | Psychiatry, Vol. 26, No. de de vida de de Vol. 25, No. support and with in Care in the Care A Narrative June | Journal of Care Medicine, Vol. No. Care in Cancer: in the of of Clinical Oncology Educational Vol. 3, No. religion/spirituality in clinical practice: A among social and and October | Journal of Clinical Psychology, Vol. 74, No. Spirituality in Care December | Journal of Religion and Health, Vol. 57, No. of to spiritual care at the of a phenomenological exploration from the of palliative care February 2018 | Journal for the Study of Spirituality, Vol. 8, No. Existential Distress in Pediatric Cancer December and Patient Spiritual in the through October of Spirituality in November Psychological/Psychiatric, Social, and Spiritual Problems and July and End-of-Life Care in Cancer in Oncology Nursing, Vol. No. Care in Hospice and Palliative Journal of Hospice and Palliative Care, Vol. 20, No. and Spirituality: Literature review and Journal of Counseling, Vol. 18, No. of the tool existential communication between and cancer August | European Journal of General Practice, Vol. 23, No. Education and of Christian Nursing, Vol. 34, No. Care Interventions in to and Therapy C. and D. September | Journal of Palliative Medicine, Vol. 20, No. in Patients with A Qualitative September | Journal of Research in Nursing and Vol. 14, No. theory on the and in an exploratory case study September | Vol. 69, No. of the of Spirituality and Palliative Care Research and of Pain and Symptom Management, Vol. No. of a spiritual care training program for staff on November | Palliative and Supportive Care, Vol. 15, No. 4Spiritual distress and spiritual care in advanced heart July | Reviews, Vol. and Spiritual Patient Simulation in Nursing, Vol. No. Vol. 42, No. 4The impact of a spiritual in patients with and and their support December | Vol. 26, No. 3The Importance of a Spiritual History in Healthcare Vol. No. About Substance Use DisordersJournal of Psychosocial Nursing and Mental Health Services, Vol. No. and Spiritual Beliefs of April | Journal of Religion and Health, Vol. No. Care Perceptions of and With of Hospice & Palliative Nursing, Vol. 19, No. in Substance Use What to Know to Practice30 November | in Mental Health Nursing, Vol. 38, No. End-of-Life Care to Religious and Vol. No. of Social Education, Vol. 53, No. Nursing Care and of Christian Nursing, Vol. 34, No. 1The of taking a religious and spiritual July | Psychiatry, Vol. 24, No. religion and spirituality in Vol. No. the role of religious in the at the of of Vol. No. care spiritual March | Supportive Care in Cancer, Vol. 24, No. Spiritual Care and the Role of An Review of Literature and April | Journal of Religion and Health, Vol. No. of the Spiritual Needs of of with Is in the June | Journal of Palliative Medicine, Vol. 19, No. Impact of a Tool for Comprehensive Assessment of Palliative Care on Assessment at and of Pain and Symptom Management, Vol. No. from Healthcare Students to Understand Spiritual Assessment in Clinical Practice29 October | Journal of Religion and Health, Vol. No. Spirituality in January | Journal of Religion and Health, Vol. No. 3Development and of to Assess Nurse Provision of Spiritual August 2014 | Journal of Holistic Nursing, Vol. 34, No. and Validation of the Practice Assessment September 2014 | Research on Social Practice, Vol. 26, No. and the Medical A of July | Journal of Health Care Chaplaincy, Vol. 22, No. history taking in palliative care: A controlled September | Palliative Medicine, Vol. 30, No. Is Is Using A and the Life With American in Spiritual March | Journal of in Mental Health, Vol. 11, No. and spiritual in September | International Journal of and Mental Health, Vol. No. 1The of Hospital to and Patients’ Spiritual A May | Journal for the Study of Spirituality, Vol. No. 1The and to March End-of-Life Spiritual March in Holistic Patient Journal of Nursing, Vol. No. of spiritual assessment for older September 2014 | and Vol. No. und der der Care, Vol. No. Spirituality and A for Holistic January | Journal of Religion and Health, Vol. No. and Belief, in Care spiritual history tool by C. M. Puchalski as an for an interdisciplinary in January | Journal for of and Social Vol. 21, No. the of Spiritual A Pain and Palliative Care Service Quality of Pain and Symptom Management, Vol. No. of Spiritual Assessment in September | Vol. No. the of Christian Nursing, Vol. 32, No. 4Spiritual care: is the assessment tool for palliative Journal of Palliative Nursing, Vol. 21, No. und Spiritualität in der September | Vol. 60, No. of September of spirituality assessment in palliative care patients in November 2014 | Progress in Palliative Care, Vol. 23, No. 4The for Spiritual A Mixed-Methods July | Oncology Nursing Vol. 42, No. 4The Integration of Religion and Spirituality in Social Practice: A May | Social Vol. 60, No. 3The and Educational of a Spiritual Life Review for Patients with and June 2014 | Journal of Cancer Education, Vol. 30, No. in Geriatric Palliative in Geriatric Medicine, Vol. No. An for Spiritual Well-Being May | Journal of Religion & Spirituality in Social Work: Social Thought, Vol. 34, No. Spiritual Assessment March | Journal of Health Care Chaplaincy, Vol. 21, No. American on Mental Health, and Help April | and Vol. 60, No. of Christian Nursing, Vol. 32, No. the Spiritual Needs and of Oncology Patients in Nursing Practice, Vol. 29, No. Care Training to Healthcare Professionals: A Systematic April | Journal of Pastoral Care & Counseling: Advancing theory and professional practice through scholarly and reflective publications, Vol. 69, No. analysis of spiritual

This is a recommended evaluation and management algorithm from the Western Trauma Association (WTA) Algorithms Committee focused on the management of pharmacologic prophylaxis for venous thromboembolism (VTE) prevention in trauma patients. Because there are few related published prospective, randomized clinical trials that have generated class I data on this topic in the trauma population, these recommendations are based primarily on published prospective and retrospective cohort studies, and expert opinion of the WTA members. The final algorithm is the result of an iterative process including an initial internal review and revision by the WTA Algorithm Committee members, and then final revisions based on input during and after presentation of the algorithm to the full WTA membership. Goals The algorithm (Fig. 1) and accompanying comments represent a safe and sensible approach to reducing VTE in trauma patients. The aim for this approach was to provide updated guidelines that apply to most patients, most of the time. We recognize that there will be multiple factors that may warrant or require deviation from any single recommended algorithm and that no algorithm can completely replace expert bedside clinical judgment. We encourage institutions and clinicians to use this algorithm as a general framework in the approach to trauma patients and to customize and adapt it to better suit the specifics of that program or location.Figure 1: The WTA algorithm for VTE prophylaxis after trauma. Circled letters correspond to sections in the associated article. Algorithm circle-bubbles represent patient criteria; algorithm square-bubbles represent expert recommendations. CrCl, creatinine clearance; Hb, hemoglobin; LMWH, enoxaparin; q8h, every 8 hours; q12h, every 12 hours; UFH, unfractionated heparin.Burden of Disease Venous thromboembolism, including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a potentially preventable complication after trauma. The focus of this algorithm is on optimizing the delivery of pharmacologic prophylaxis to prevent VTE and minimize any associated complications. For those trauma patients diagnosed with a DVT or PE, including distal upper extremity or calf thrombosis, specific treatments are addressed in other guidelines and will not be covered in this algorithm.1,2 Without pharmacologic prophylaxis, a 1994 study determined that the DVT rate was 58% in severely injured trauma patients who undergo serial impedance plethysmography with lower extremity contrast venography.3 In a landmark, 1996 New England Journal of Medicine publication 30 mg of subcutaneous enoxaparin twice daily performed better than 5,000 U of subcutaneous heparin twice daily at reducing DVT in moderate to severely injured trauma patients (31% vs. 44%, p = 0.04).4 The risk of major bleeding was low regardless of therapy, and importantly, the first dose of pharmacologic prophylaxis was initiated within 36 hours of the injury and continued through all surgical procedures except spinal fixation when a single preoperative dose was held.4 This study established that early, uninterrupted enoxaparin was superior to heparin at reducing VTE after trauma. In the last decade, a number of reviews and societal recommendations focused on improving the guidelines to reduce the rate of VTE and related complications after trauma.1,2,5–11 Despite this progress, debate persists regarding optimal dosing and timing of enoxaparin, including when to initiate, hold, and resume it before and after surgery or epidural placement. Trauma patients frequently receive a delayed, suboptimal dose of enoxaparin, which is then held for any potential surgical procedure despite substantial evidence that encourages early, uninterrupted pharmacologic prophylaxis. An updated algorithm on the appropriate management of VTE prophylaxis is therefore indicated. ALGORITHM The following lettered sections correspond to the letters identifying specific sections of the algorithm shown in Figure 1. In each section, we provide a brief summary of the important aspects and options that should be considered at that point in the evaluation and management process. A This algorithm is designed for adult trauma patients 18 years and older. Importantly, although younger children have a significantly lower VTE risk, older children and adolescents have a VTE risk that approaches their adult counterparts.12 Guidance for VTE prophylaxis in children can be found in the joint practice management guideline from the Pediatric Trauma Society and the Eastern Association for the Surgery of Trauma, which recommends, “pharmacologic prophylaxis be considered for children older than 15 years old and in younger postpubertal children with Injury Severity Score (ISS) greater than 25.”11 B Assessment of VTE risk will assist in determining which patients require pharmacologic prophylaxis. In general, an ISS of 10 or more suggests that pharmacologic prophylaxis should be initiated as soon as possible, whereas patients with an ISS of less than 10 are at lower VTE risk and may not require pharmacologic prophylaxis.13–15 Because ISS is not calculated in real time, the Greenfield Risk Assessment Profile or the Trauma Embolic Scoring System can assist with calculating VTE risk.13–15 Patients with spine or pelvic fractures, repair of venous injury, a history of VTE, or inherited clotting disorders have increased VTE risk and should be considered for pharmacologic prophylaxis.2,13,14 Among trauma patients with minor injuries, independent predictors of increased VTE risk are increased age, obesity, and lower extremity fractures; any combination of these three characteristics should encourage initiation of pharmacologic prophylaxis.13 C Patients with minor trauma may not require pharmacologic prophylaxis. Given the related pain with injection, potential for hematoma at the injection site, cost for the medication, and nursing costs for administration, avoiding pharmacologic prophylaxis may be indicated for select low-risk patients after minor trauma. The Trauma Embolic Scoring System can be used to assess VTE risk, as patients with a low score require no pharmacologic prophylaxis because of their low VTE rate.13 Ambulatory patients with minor injuries and short hospital stays may not require pharmacologic prophylaxis. Trauma patients capable of ambulation but confined to bed because of intoxication, restraints, or other reasons should receive pharmacologic prophylaxis. In general, trauma patients who require hospital admission for more than 24 hours require pharmacologic prophylaxis, whereas those hospitalized for less than 24 hours do not. For the patients who do not receive pharmacologic prophylaxis, mechanical prophylaxis and/or aspirin are low cost and low morbidity options, although their benefit is uncertain given the low VTE rate.13–16 D Appropriate delays in pharmacologic prophylaxis may occur for those patients with an active bleed, coagulopathy, hemodynamic instability, solid organ injury, traumatic brain injury (TBI), or spinal trauma. Quantifying the risk and benefit of initiating pharmacologic prophylaxis for each patient is a challenge that is best determined by the trauma team at bedside. Detailing every indication where a delay may be indicated is outside the scope of these guidelines; several are described below. However, it is important to note that the guidance in both the literature and clinical practice supports very short delays to the initiation of pharmacologic prophylaxis, even among these cohorts. Active Bleeding, Coagulopathy, or Hemodynamic Instability Control of active bleeding is necessary before starting pharmacologic prophylaxis. In the presence of hemodynamic instability, a hemoglobin drop of greater than 2 g/dL in under 12 hours or ongoing blood transfusion is an appropriate indication to delay the initiation of pharmacologic prophylaxis.2,4 Systemic coagulopathy was previously proposed as a reason to delay pharmacologic prophylaxis with one study holding pharmacologic prophylaxis for an elevated prothrombin time of more than 3 seconds above control or a platelet count of less than 50,000 per cubic millimeter.4 More recent studies indicate that prothrombin time and platelet count are not as reliable at predicting systemic coagulopathy as viscoelastic hemostatic assays, which may demonstrate hypocoagulability and hypercoagulability after trauma.2,17–19 The hypocoagulability due to trauma largely resolves within 24 hours, after which hypercoagulability becomes prevalent. In this setting, pharmacologic prophylaxis may be considered after the initial resuscitation is complete.17,20 Deferring the initiation of pharmacologic prophylaxis during trauma-induced coagulopathy is associated with an increased VTE rate such that the initiation of pharmacologic prophylaxis is encouraged if the hypocoagulable state is expected to resolve and there are no signs of ongoing bleeding.17 Solid Organ Injury Delays occur in the initiation of pharmacologic prophylaxis for patients with solid organ injury. Several studies indicate that patients with solid organ injury who received early pharmacologic prophylaxis had lower DVT and PE rates without increased risk of failure of nonoperative management, bleeding complications, or mortality; these risks did not increase when pharmacologic prophylaxis was started within 24 hours compared with within 48 hours.20–23 Early pharmacologic prophylaxis within 12 to 24 hours appeared to be safe across moderate American Association for the Surgery of Trauma injury grade and type of solid organ injury (liver, spleen, and/or kidney), without an increased risk of bleeding that necessitated intervention or blood transfusion.21 Although those with grade IV and V injuries should be approached with caution, pharmacologic prophylaxis may be initiated within 24 hours for most patients with solid organ injury.21–23 Traumatic Brain Injury Concern for progression of TBI is a common reason for the delay in initiation of pharmacologic prophylaxis. This delay is dependent on the type of TBI; those with “cerebral contusion, localized petechial hemorrhages, or diffuse axonal damage” may safely receive pharmacologic prophylaxis without delay.4 When pharmacologic prophylaxis is appropriately delayed, the follow-up computed tomography (CT) after TBI diagnosis is an important indicator for when to initiate pharmacologic prophylaxis.24 For patients with TBI progression on the follow-up CT, exposure to pharmacologic prophylaxis is a predictor for further progression, and it should be held until a follow-up CT demonstrates no progression.24 In contrast, if the follow-up CT demonstrates no TBI progression, then pharmacologic prophylaxis should be initiated.24 Importantly, progression of TBI occurs in about 10% of patients with a stable follow-up CT, regardless of whether pharmacologic prophylaxis is provided or not.24 Those trauma centers that provide pharmacologic prophylaxis within 24 hours after TBI have significantly lower rates of VTE with no difference in rates of late neurosurgical intervention.23,25–30 Even in the setting of combat related penetrating TBI, initiating pharmacologic prophylaxis 24 hours after injury for those patients with a stable CT was safe, with similar progression rates regardless of pharmacologic prophylaxis.29 The majority of TBI patients with a stable CT may be initiated on enoxaparin within 24 hours, and nearly all TBI patients should receive pharmacologic prophylaxis within 72 hours of the time of injury.23,28,31 Spinal Trauma In the absence of pharmacologic prophylaxis, patients who undergo spine surgery or those with spine trauma, fracture, or cord injury have a of and delays than 72 hours to a substantial increase in the VTE prophylaxis be initiated as soon as after spine surgery or any spine that provide pharmacologic prophylaxis or after fixation are considered When a was that pharmacologic prophylaxis or the of spine the VTE rate and the rate of spinal hematoma was pharmacologic prophylaxis initiated within 48 hours of fixation of traumatic spine did not increase the risk of progression of injury, or complications including spinal prophylaxis for moderate to VTE risk patients is encouraged regardless of pharmacologic prophylaxis. For patients who are not started on pharmacologic prophylaxis, mechanical prophylaxis with and when possible, should be the DVT if no pharmacologic prophylaxis is initiated and therefore is recommended for patients with a to pharmacologic In contrast, the of in patients who received pharmacologic prophylaxis did not to a in the DVT although the study had a low DVT rate and of the trauma mechanical prophylaxis with pharmacologic prophylaxis is therefore encouraged for moderate to VTE risk patients in because those who received the combination had a lower of do not to reduce the VTE rate in the presence of pharmacologic but may provide a benefit to those trauma patients who be started on pharmacologic is an important for VTE as early to a in A is safe in trauma patients and may reduce patient the rate of of spinal is associated with an increased DVT rate and should be to early venous should be considered in patients at VTE risk who be started or on pharmacologic prophylaxis. Although debate with venous is not indicated or for all trauma after trauma not the risk of PE or PE, and to In trauma patients at low VTE risk, the cost and low of that the practice may be institutions for in low-risk trauma patients to both and which may and the related complications such as venous venous or pain with For trauma patients at VTE risk, is associated with a PE The Greenfield Risk Assessment Profile can which trauma patients may benefit from may be in VTE risk patients who be started or on pharmacologic prophylaxis. the of DVT should not be a that all trauma patients have rates of and those centers with that do not will have DVT rates because of a lower for a venous prophylaxis be initiated as soon as and for most trauma patients may be initiated within 24 When VTE risk trauma patients who receive enoxaparin within 24 hours of admission are compared with those who receive mechanical prophylaxis, minor and major bleeding do not in appropriate delays may occur in the initiation of pharmacologic prophylaxis because of active coagulopathy, hemodynamic instability, solid organ injury, TBI, or spinal trauma. In most pharmacologic prophylaxis may be started in less than 24 hours, and in every pharmacologic prophylaxis may be started in less than 72 prophylaxis is held because of surgery despite the evidence that it may be initiated before most surgical Trauma patients who require an are in that their first may occur within of or the pharmacologic prophylaxis is or for which to an increased VTE dosing of pharmacologic prophylaxis is not to trauma. In other patient at risk for VTE, the use of preoperative pharmacologic prophylaxis the DVT rate without the complication for in should be initiated and continued Patients who surgery who received low heparin hours before surgery had a lower rate of DVT without or bleeding This benefit was not when low heparin was provided 12 hours or more We that the common and process of pharmacologic prophylaxis for 12 to 24 hours before surgical procedures is and will result in an increased VTE risk without an accompanying in the risk of bleeding to pharmacologic prophylaxis, the specific and initial dose should be determined for each is the recommended for most trauma patients with considered the of The for pharmacologic prophylaxis is the low heparin enoxaparin because of increased and more and compared with unfractionated less with which may reduce bleeding complications compared with unfractionated a lower of and not have the associated with heparin When the initial mg of enoxaparin twice daily should be considered the for most trauma patients, as 30 mg twice daily frequently in pharmacologic patients 18 to years with of more than and a creatinine of more than should be started on mg of enoxaparin twice as this dose is safe and the VTE Patients who are older than less than or who have a creatinine of 30 to should to receive initial dosing at 30 mg of enoxaparin twice The initial enoxaparin dose for trauma patients with a may be based on twice twice or 30 mg for to patients, mg for to patients, and mg for patients greater than Patients who are initiated on of enoxaparin based should be by because of the in creatinine after trauma that to in the enoxaparin Although enoxaparin is to heparin for pharmacologic prophylaxis, institutions to dose unfractionated heparin at 5,000 U three daily based in on a randomized that that this be and compared with 30 mg of enoxaparin twice This practice should be as the was because of an DVT rate of for unfractionated heparin for enoxaparin, and a 10% for the The difference in the VTE rate was which enoxaparin without vs. enoxaparin, p = In the study was not to a difference in the rate of PE or both of which the complication rate and More 30 mg of enoxaparin twice daily was established as superior to U of unfractionated heparin three daily at the prevention of VTE and for Quantifying the risk and benefit of the type and initial dose of pharmacologic prophylaxis for each patient is a challenge best determined by the trauma team at bedside. mg of enoxaparin twice daily is the recommended initial pharmacologic prophylaxis for most trauma patients. Detailing every indication where an or dose may be indicated is outside the scope of these guidelines; several are described below. In the presence of or a creatinine of subcutaneous unfractionated heparin at U every 8 hours may be Because enoxaparin is by the to patients with failure may to increased bleeding complications and should be not and for use in patients. lower enoxaparin in the setting of a creatinine of may be in the but is necessary before this can be In most other enoxaparin is to unfractionated as enoxaparin to lower VTE rates without increased bleeding Brain and Trauma For TBI patients, enoxaparin is associated with less VTE and than unfractionated heparin with no difference in the progression of brain regardless if the dose was in less than 24 hours after 24 to 48 hours, or after 48 those patients with spine trauma should receive early Patients with brain and spine trauma should be initiated on 30 mg of enoxaparin twice daily and considered for dose by Patients patients require specific dose recommendations for pharmacologic prophylaxis after trauma because of the as as the increase in and that occur the of require enoxaparin with more unfractionated heparin enoxaparin the and both are considered safe to use in during an admission for trauma, patients should receive 30 mg of enoxaparin twice daily by a of to or a of to For patients who more than initiating mg of enoxaparin twice daily is recommended with similar and prophylaxis with or aspirin should not be a for pharmacologic prophylaxis for most trauma patients because of the of related clinical The use of or aspirin may be considered in the setting of injuries, but if the patient injection with enoxaparin or unfractionated are for pharmacologic prophylaxis after 10 mg of and mg of twice both which are trials that or to enoxaparin demonstrate that have to better VTE rates with similar to bleeding In contrast, other that enoxaparin a lower VTE and a lower bleeding Because retrospective have the use of for pharmacologic prophylaxis after trauma, randomized trials are necessary before a for trauma The use of low dose aspirin may be considered for pharmacologic prophylaxis in trauma patients with injuries who For those trauma patients started on a for pharmacologic prophylaxis, aspirin may replace the after with similar prevention of I trauma patients require dose after initiating Because of the in and enoxaparin by is In one of trauma patients of mg or and of mg or enoxaparin by or to lower the VTE rate without bleeding complications in moderate to severely injured patients, trauma patients who require injuries, and surgical Although debate on the appropriate for suggests to for or to for should be considered for those patients who receive Although not for pharmacologic prophylaxis, with platelet may assist with platelet A randomized that used as an to enoxaparin did not lower rates of VTE with the enoxaparin In contrast, with platelet may if a hypercoagulability is due to platelet which encourages the of aspirin to the pharmacologic prophylaxis aspirin is the initial recommended dose is mg daily with the of the dose to mg daily on with platelet The uninterrupted dosing of pharmacologic prophylaxis should be the for most trauma patients their hospital Although the and benefit of uninterrupted pharmacologic prophylaxis established more than of trauma patients A is the number of and DVT risk such that patients who to have DVT risk compared with those with no For TBI patients who are started on pharmacologic prophylaxis, dosing an increase in the VTE The following are common reasons for pharmacologic procedure patient was from the for bleeding epidural and When holding pharmacologic prophylaxis, the rate of bleeding with pharmacologic prophylaxis is no than without VTE are compared with bleeding complications, the pharmacologic should focus on pharmacologic prophylaxis without The appropriate for holding or pharmacologic prophylaxis spinal epidural or and these are below. Although VTE is not indicated for all trauma may be in those at VTE venous should be performed for evidence of DVT such as or For those trauma patients with injuries and in pharmacologic prophylaxis, venous may be a DVT or PE is then is necessary per and if it is then an should be considered as in Surgery in holding pharmacologic prophylaxis because of surgery is with few for brain or spine Given the delays and of that may occur during trauma patient holding pharmacologic prophylaxis can of pharmacologic prophylaxis. pharmacologic prophylaxis is safe for trauma and to a lower VTE The preoperative of pharmacologic prophylaxis is encouraged for surgical patients in other who have a VTE risk and to a lower DVT rate without the complication The lower VTE rate is if pharmacologic prophylaxis is provided more than 12 hours reduce morbidity and in trauma patients injuries and are a of pain Patients who require an epidural have in pharmacologic such that epidural is associated with an increased VTE whereas previously this was not the a enoxaparin dose and epidural by a to before enoxaparin is at 10 and 10 the dose may be held for 10 epidural to for the necessary without prophylaxis. 10 the enoxaparin dosing may one dose is of enoxaparin are for pharmacologic prophylaxis, a for enoxaparin before epidural by a to before at of enoxaparin should be for any enoxaparin enoxaparin are encouraged with to the VTE rate associated with epidural For unfractionated a to is recommended before epidural by a before unfractionated heparin is which for uninterrupted platelet should be considered for those trauma patients who receive pharmacologic prophylaxis because of the risk of is recommended for patients who are considered risk for every 3 from to or until pharmacologic prophylaxis is Trauma patients who are to enoxaparin may be considered low risk for and may not require platelet as the rate of clinical was with heparin compared with with The clinical diagnosis of may be by that thrombosis, and the heparin be with such as the which can for trauma patients for because of the of these and the with dosing and their may be considered in the setting of DVT or PE when there is a to appropriate The use of is among trauma centers although their is without a in PE is not In a randomized of VTE risk trauma patients who to receive pharmacologic prophylaxis during the first 72 hours of a did not lower the of PE or which established the of of early of an in this The of an not regardless of whether a DVT is or guidelines provide recommendations and most studies have among patients diagnosed with an DVT or PE who receive an should be considered to reduce the rate of PE without the Trauma patients with TBI, or spine injuries, and those who undergo major surgery are at VTE risk and should be considered for pharmacologic prophylaxis. prophylaxis after for VTE risk trauma patients is by evidence that demonstrates the practice is safe, and and may be considered for patients with TBI, or spine injuries, and those who undergo major The VTE risk occurs during the first 3 after injury with until the VTE rate to that of the general Venous for of trauma at a cost of pharmacologic prophylaxis with enoxaparin is associated with a low rate of bleeding complications, and is in patients at VTE The of pharmacologic prophylaxis following or pelvic surgery for or was associated with a in VTE Because the optimal dose and of enoxaparin after trauma are not more than 30 mg twice daily should be and the of pharmacologic prophylaxis may be considered for to after the of For those who undergo major pharmacologic prophylaxis may be to from the of may be initiated for pharmacologic prophylaxis for VTE risk trauma patients, as it shown to be as as enoxaparin with less bleeding complications and better and is not by the of may be considered for pharmacologic prophylaxis after This algorithm was designed to provide and guidance at reducing the VTE rate after trauma. Although there are multiple factors that will to from the most trauma patients should be initiated on early and of enoxaparin that should be by For most trauma patients, pharmacologic prophylaxis should uninterrupted the hospital and at after preventable and delays to the initiation and of pharmacologic prophylaxis should be a focus of all trauma and it associated with rates of VTE

Foreword Dear Colleague We would like to introduce you to the 2018 OTA/AO (or AO/OTA) Fracture and Dislocation Classification Compendium. This is the second revision of the compendium which was first published in 1996 as a cooperative effort of the AO Foundation and the Orthopaedic Trauma Association (OTA). Both organizations were committed to assuring that there was a standardized and rational methodology of describing fractures and dislocation as well as a mechanism to code data for future recall. These principles were absolutely necessary to establish a consistent system for clinical interaction and research. After 20 years of use, the current revision addresses the many suggestions to help improve the application of the system, correct errors, and add new classifications. The process was under the direction of a committee of four individuals representing both organizations, with experience in the day to day application of the compendium and fracture coding. The process was supervised and funded by the Classification Committee of the OTA and AOTrauma International Board (AOTIB). An ongoing agreement between both organizations to assure the ongoing collaborative support of the revision process of the compendium was also developed. Importantly, copyright will remain with both organizations so that its reproduction and promulgation will be unencumbered. This establishes not only mutual ownership but also responsibility and ensures continued collaboration and support. We believe that this is an important step forward in the process of clinical research as well as standardizing day to day clinical communication. However, change is inevitable and both the OTA and the AOTIB encourage comment and criticisms so that the next revision process can continue to improve the compendium. John H. Wilber MD Chairman, AOTrauma International Board Professor and Chair Department of Orthopaedic Surgery MetroHealth Medical Center Hansjoerg Wyss Professor Orthopaedic Trauma Case Western Reserve University Cleveland, Ohio William M. Ricci MD President, Orthopaedic Trauma Association Chief, Combined HSS/NYP Trauma Service Hospital for Special Surgery New York Presbyterian Hospital New York, NY Compedium introduction The AO Foundation/Orthopaedic Trauma Association (AO/OTA) fracture classification was published as a compendium to the Journal of Orthopaedic Trauma (JOT) in 1996.1 Using the principles of the Comprehensive Classification of Fractures of the Long Bones (CCF) developed by Müller and collaborators, the OTA classification committee classified and coded the remaining bones.2,3 This helped bring order to the state of fracture classification with its multiple systems that had thwarted any possibility of a standardized language and accumulation of uniform data. Since the compendium was published in 1996, the classification has resided on the OTA and AO Foundation websites and has been regularly used in trauma databases, scientific journals, and textbooks worldwide. It is the official classification of the OTA, the AO, and JOT. It has gained wide acceptance and its use has dramatically improved the way information about fractures is communicated, stored, and used to advance knowledge. In some anatomical areas, this classification has largely supplanted multiple options achieving one of the original intentsion.1,2,3 The classification is intended to be a flexible evolving system in which changes are made based on user feedback, criticism, and appropriate clinical research, thus serving the needs of the orthopedic community for both clinical practice and research. In 2007, the AO and OTA classification committees undertook a revision to address issues of reliability, reproducibility, and need. This revision was based on the premise that changes needed to be validated prior to being implemented. The validation process was expensive and not practical so a decision was made to not validate all edits. The 2007 revision standardized the two different alphanumeric codes into one agreed-upon scheme, thus developing an internationally recognized uniform system for clinical research on fractures and dislocations. The validated AO Pediatric Classification of Fractures developed by Slongo was also included in the compendium.4,5 The two committees confirmed the original premise that the revision process needed to be undertaken every 10 years. Ongoing concerns about terminology, the relevancy of certain classification schemes, and the need to streamline codes provided the impetus to undertake the 2018 review.6–12 To make this an effective, economical, and efficient process, the AOTrauma International Board (AOTIB) and OTA appointed five persons to form the International Comprehensive Classification of Fractures and Dislocations Committee (ICCFC). The process began with the aims to address editorial errors, criticisms of the proximal humerus and proximal femur classification, and to simplify the coding process based on fracture pattern occurrence and complexity using a modified Delphi approach. A priority for this revision was to maintain the original principles of the CCF with regard to definitions and the basic coding system. It became apparent that many of the fracture patterns occurred so infrequently that there was no need to have a unique code for them, as they could easily be coded by a shortened generic system. Frequency plots of a large registry that uses these codes confirmed this. It became evident that it would be more accurate to code radius and ulna fractures separately and to align the system with ICD-10 terminology.13 The same was done for the other two-bone system by adding a new coding system for fibula fractures. The former editions had many qualifications and sub-qualifications for each fracture pattern, many of which were duplications. The committee decided to group these into a universal modifier list that could be applied to every fracture as desired by the end user, who codes the fracture. All fracture specific modifiers were maintained with their specific fracture or dislocation. As this classification system provides standard terminology and codes, it also felt appropriate to combine, insert, or reference other commonly accepted classifications (eg, Neer) into the AO/OTA descriptions and codes. This would assure consistency and greater clinical utility in fracture and dislocation classification. The 2018 compendium revision The compendium is branded as the AO/OTA or OTA/AO Fracture and Dislocation Classification Compendium. In publications, it will be cited as Meinberg E, Agel J, Roberts C, et al. Fracture and Dislocation Classification Compendium–2018, Journal of Orthopaedic Trauma. Volume 32: Number 1; Supplement, January 2018. Future publications related to the revised Compendium will be authored and referenced as determined by the International Comprehensive Classification of Fractures and Dislocations Committee (ICCFC), irrespective of its member composition. The mandates for the 2018 revision are the following: a) Editorial, terminology, and typographical changes and corrections: i. The terms "complex” and "multifragmentary” have created confusion in their application. The term "complex” did not describe a fracture pattern consisting of many fragments while "multifragmentary” does. Multifragmentary was previously used generically to refer to diaphyseal type B and C and did not have a specific alphanumeric code so was rarely used. Consequently, the committee felt that it is more concise to have three types of diaphyseal fractures: simple, wedge, and multifragmentary. "Multifragmentary” will no longer be used as a generic term for diaphyseal types B and C. A multifragmentary diaphyseal or end segment extraarticular fracture is one with many fracture fragments and after reduction there is no contact between the main fragments. A multifragmentary complete articular fracture is one with more than two fracture fragments of the articular surface. ii. The diaphyseal fracture classification has been made consistent for all bones. The diaphysis is defined as that part of the bone between the two end segments and is divided into three equal parts defining the location of the diaphyseal fracture. The fracture location within the diaphysis is a qualification as follows: a Proximal 1/3 b Middle 1/3 c Distal 1/3 iii. A more precise description of the intraarticular portion of proximal tibia fractures has been recommended.14,15 A modification to the proximal tibia classification as recommended by Mauricio Kfuri and Joseph Schaztker to better define the significant joint fragmentation or displacement is added as qualifications for type B and C proximal tibial intraarticular fractures.16 iv. The written description of fractures has been standardized so that each fracture is presented in a similar order highlighting the specific region or fracture morphology. v. To facilitate data entry and lessen the error rate in coding, the hyphen in the code has been removed. vi. A code for fibula fractures based on the principles of the CCF has been added. vii. The Neer classification has been integrated into the fracture description for proximal humeral fractures to facilitate the clinician comprehension of the terms unifocal and bifocal fractures. viii. The proximal femoral classification terminology has been a source of confusion as a variety of descriptive terms have been used to describe similar fractures. There has also been a problem defining fractures for group 31A2. Definitions have been added to help classify these fractures and the codes reorganized to better represent these fractures. The femoral neck fractures have been organized to better align the fracture types. By adding the Pauwels classification as a qualification for femoral neck fractures a more detailed evaluation of high-energy fractures is available. ix. The Young-Burgess Classification of Pelvic Ring Injuries has been integrated into the AO/OTA pelvic fracture classification. b) Addition of recently published validated classifications: i. OTA Open Fracture Classification17 ii. AO/OTA Scapular Fracture Classification18,19 iii. Unified Classification of Periprosthetic Fractures20 iv. AOSpine Subaxial Cervical and Thoracolumbar spine injury classification21 v. AOSpine Sacral Fracture Classification22 c) At the request of the AOTK Thoracic Surgery Expert Group, a preliminary classification of rib and sternal fractures has been included. Publication of this classification will allow interested groups to assess its validity and reproducibility so in the next revision, a validated modification will be available. d) Review of the codes with regards to frequency and applicability: i. Many of the qualifications and subqualifications of the first two compendiums were repetitious and on a survey of users were not routinely used. To simplify the usage, the common modifiers were placed in a list called Universal Modifiers. This simplifies the presentation of the codes and allows each clinician to use these as they see fit for their circumstances. ii. Certain qualifications were fracture-specific and were left as qualifications within the specific fracture types and groups. iii. Complex injuries such as the terrible triad of the elbow and a transolecranon fracture dislocation are difficult to code related to the fact that fractures of radius and ulna were placed into one code. The committee decided to separate the radius and ulna and classify fractures in each bone. This simplifies the process and when combined with the universal modifiers makes classification of complex injuries about the elbow more consistent and accurate. It also follows the ICD-10 system where each bone is coded separately. It was recognized by the committee that this revision must maintain the principles and definitions of the CCF and the prior two compendiums. This revision represents a streamlining of the 2007 version. The aim was to assure that the majority of fracture patterns were represented. This revision provides a more concise and clinically relevant compendium. The user will be able to choose the code that best meets their needs. It is hoped that with the recognition of other standard classifications being integrated into the codes that this compendium will be of increasing value to many other orthopedic subspecialities. Fundamentals of fracture classification Classification is the process by which related groups are organized based on similarities and differences.5 It provides the language necessary to convey information among individuals to ensure standardization. This classification process may be looked upon as the systematic methodology of describing a fracture or dislocation. It is critical to note that a fracture should be coded only after all the information is obtained. It must be remembered that if there is doubt, then waiting until the complete information is available is mandatory before determining the final classification.23–28 The final classification may be delayed until the operative procedure is completed and the fracture fully visualized. This system provides the clinician with standardized definitions so the verbal fracture description is precise and consistent from bone to bone and fracture to fracture. These standard definitions and guidelines for application assure consistency in the classification process.16,24–37 With the improved consistency of fracture descriptions, future investigations assessing treatment guidelines, prognosis, and risk of complications will be more reliable and meaningful. The system also provides a mechanism to convert the verbal description into an alphanumeric code to allow for data storage and future recall. The use of this alphanumeric coding scheme is absolutely necessary for multicenter collaboration, retrospective comparison of results, international communication, and to standardize recording information about all fractures in a trauma database. The classification offers several other benefits. It provides a hierarchy of severity as the descriptions generally proceed from simple to multifragmentary fractures. This hierarchy is based on the energy of injury or potential complexity of treatment. Ease of use is also an important aspect for a classification. This system allows the clinician to be as general or detailed as necessary according to their clinical or research needs. The classification is logical, comprehensible, and does not contain an unmanageable number of categories, a problem that ensures poor reliability. Principles of fracture and dislocation classification The principles of classification2 are based on understanding and applying standardized definitions. These definitions are universal and allow consistency in classification and communication. Although clinical decisions are sometimes made on incomplete information, this should be avoided as much as possible when classifying a fracture–the more precise the description the better the data recorded. Attention should be paid to upper-case versus lower-case letters and ( ) versus [ ] as this will aid in accurate fracture pattern retrieval from databases. Fracture localization–bones and segments The bone is identified (Fig 1).Fig 1: Designation of bone location.Next, it is necessary to determine where in the bone the fracture is located. This requires precise definitions of the parts of a bone. The proximal and distal end segments of the long bones are defined by a square whose sides are the same length as the widest part of the epiphysis/metaphysis in question (Heim's system of squares).23 Each bone has a proximal and distal end segment, between which the diaphysis or shaft is located. These definitions apply to any bone with articulations at both ends and a segment of cortical bone between the articulations, for example, a femur, or a metacarpal, or a phalanx. With the two bone systems now having separate codes, it was decided to maintain the standard definition of the end segments with bones not separated (Fig 2).Fig 2: Determine the location of the end segment.Two exceptions are the proximal femur, defined as being above a line that passes transversely through the inferior edge of the lesser trochanter and the malleolar segment of the distal tibia. The bone segments are numbered as: Proximal end segment = 1 Diaphyseal segment = 2 Distal end segment = 3 The location of the fracture is determined by finding its center. This is defined as follows: In a simple fracture, the center of the fracture is obvious (Fig 3). In a wedge fracture, the center is at the level of the broadest part of the wedge (Fig 4). In a fragmentary wedge and a multifragmentary fracture, the center can be determined only after reduction (Fig 4). Any diaphyseal fracture associated with a displaced articular component is considered an articular fracture. If a fracture is associated with an undisplaced fissure that reaches the joint, it is classified as a metaphyseal or diaphyseal fracture depending on its center. If one bone has two completely separate fractures, one in the diaphysis and one in the proximal or distal end segments (eg, a femoral diaphysis and a femoral neck fracture), each fracture must be classified separately. Fig 3: Simple fractures. The dot represents the center of the fracture.Fig 4: Wedge fractures. The dot represents the center of the fracture.Fracture morphology: types, groups, subgroups, qualifications, and universal modifiers The type (upper-case letter) is a general description of fracture patterns while the group (numerals) is a more specific description based on the individual bone or specific fracture pattern. The morphology of the diaphyseal fracture is defined as: Simple–Type A fractures have a single circumferential disruption of the diaphysis. An oblique fracture forms an angle ≥30° to a line perpendicular to the long axis of the bone. (Fig 3). Wedge–Type B fractures are characterized by contact between the main fragments after reduction usually restoring the length of the bone. The wedge may be or in multiple fragments fragmentary The between and wedge is and not easily determined so these terms were to the universal modifiers (Fig 4). C fractures of many fracture and fracture fragments. These fractures were as wedge or complex fractures in the Müller classification. is a term that confusion it is and is in the 2018 by the term many fracture and not a wedge fracture. In the diaphyseal segment, the segment is or in many fragments so that after reduction if the were there would be no contact between the proximal and distal fragments. is used to describe fragmentation of a wedge or segment (Fig Multifragmentary morphology for end segment fractures is based on they are extraarticular into the articular or intraarticular an into the articular The fracture line may be metaphyseal or but it the articular it may be The fracture part of the articular while the of the joint and is to the and diaphysis. There is a disruption of the articular and the articular is completely separated from the diaphysis. description of fracture morphology at the articular or use the previously defined terms of simple disruption of the joint and multifragmentary of the joint fractures are classified as extraarticular simple fractures (Fig segments fractures are divided into three The proximal end segment of the humerus and femur are Simple proximal humeral fractures one or the or Neer and proximal femoral fractures the are type A The articular type does not in the humerus or Proximal humeral fracture one and the or Neer and the proximal femoral fracture the femoral neck are type Proximal humeral articular fractures the anatomical neck of the humerus and fractures the femoral are type C. The definitions or description of groups and are fracture Universal modifiers The universal modifiers are descriptive terms of fracture associated or location that are to fractures. that are for Universal modifiers may be added to the end of the fracture code within square universal modifiers may be within the same of and separated by a A proximal humerus with and = proximal end segment, articular or fracture, with multifragmentary metaphyseal fracture and articular fracture with an dislocation = Dislocation is also is also Diaphyseal 1 and and 2 to of 3 with of to to bone but not included through bone bone associated with a fracture with a type fracture type fracture system is used with the of the International The fracture qualifications are descriptive terms of fracture morphology or location that are specific to each fracture. All fracture classification qualifications are lower-case letters to from the fracture which is an upper-case All fracture qualifications are in of the in the fracture code as a lower-case within a appropriate in the classification the qualification that to an the is proximal end segment, articular or fracture, with multifragmentary metaphyseal fracture and simple articular fracture with an dislocation process of classification and coding a diaphyseal process of classification and coding an of the AO/OTA classification Since the original of the AO/OTA Fracture Classification in the 1996 Journal of Orthopaedic Trauma there has been important in fracture classification the of a accepted fracture The years of use of the AO/OTA compendium has its and Although the process of classification validation has been and expensive and generally not practical in a retrospective for accepted classifications. With the use of validated a standardized classification of injury is The AOTIB and OTA Classification Committee through the International Comprehensive Classification of Fractures and Dislocations Committee the need to make the compendium as and standardized as This compendium addresses many of the prior criticisms as well as the prior editions and adding new published classifications. These changes in and presentation should make the compendium more universal and to These standardized classification systems should make injury description more standardized and so improve research and fracture The collaboration of the AOTIB and the OTA through their classification committees has in the of the compendium copyright to both organizations so it is available for any clinician to use This collaboration has its in both and The organizations are committed to to the compendium and as

Injuries to the Teeth" is an update of the issues presented in the previous 2007 edition; the book aims to present the dental traumatology from the perspective of an interdisciplinary treatment. The book comprises 44 chapters, accompanied by several appendices and an index. This book presents the nature of traumatic injuries, and then wound healing subsequent to injury, response of oral tissues to trauma, response of traumatized dental tissues to various treatment procedures and prediction and timing of healing complications. The book tackles the characteristics of oral stem cells, the development of a bio-root and bone-resorbing osteoclasts with their role in dental tissue regeneration. The psychological aspects of traumatic dental injuries and the different types of orofacial injuries in child physical abuse are presented, and then their classification, epidemiology and etiology are described. Following the examination and diagnosis of dental injuries, we are informed about the different forms of traumatic injuries to the teeth, from coronary fractures, radicular fractures, dislocations, concussion and subluxation, extrusive and intrusive luxation, avulsion, injuries to the supporting bone and soft tissue, primary dentition and developing teeth. The management of traumatic injuries to the teeth is exhaustively presented from regenerative endodontics, reinforcing endodontically, orthodontic treatment, restoration with resin composites, porcelain laminate veneers, conventional bridges, autotransplantation and implant therapy. The restoration of the traumatized tooth is approached from several perspectives: biological, preventive and predicting the economic aspect. Based on the experience of the Oral and Maxillofacial Surgery Department at the University Hospital in Copenhagen, Denmark, which has had over 4000 patients in more than 50 years, the Dental Trauma Guide has been complemented since 2006. To promote best practices in dental traumatology, Scandinavian researchers have established the International Association of Dental Traumatology (IADT) and the journal Dental Traumatology. The appendices provide us with a number of useful observation sheets, starting with an emergency record for acute dental trauma, a clinical examination form, a summary of treatment and a comparison between costs / effectiveness of different treatment solutions. It is a comprehensive textbook, useful and necessary to undergraduate BDS, postgraduates in pediatric dentistry, oral surgery, endodontics, and general dentists that address dental trauma in a common effort to find the best treatment solutions for victims of dental trauma.

The Organ Injury Scaling (OIS) Committee of the American Association for the Surgery of Trauma (AAST) was organized formally in 1987; the fundamental purpose was to devise injury severity scores for individual organs to facilitate clinical investigation and outcomes research. The OIS Committee members were selected on the basis of recognized clinical expertise as well as experience with injury scoring. The Committee was charged to develop a comprehensive set of OISs, monitor their application in the current literature, and recommend modifications when deemed appropriate. The following OISs for spleen and liver represent the first revisions in this long term project. Conceptually, the OIS is a classification scheme based on the anatomic disruption of an individual organ scaled 1 to 6, representing the least to most severe injury. Grades 1 to 5 represent increasingly complex injuries encountered in salvageable patients, while grade 6 is a destructive lesion incompatible with survival. Severity is based on potential threat to the patient's life, and the progressive scale derived from a comprehensive review of the current literature with consensus of the OIS Committee. Finally, the AAST Board of Managers approves all OISs prior to submission for publication. Despite this extensive preparation process, OISs are inherently limited by design as ordinal rather than interval scales. For example, the difference between a grade I versus II injury is generally less significant clinically than a grade IV versus V. The fundamental objective of the OIS, however, is not to assign prognostic value to a specific injury, but rather to provide a clearer description to facilitate comparison of an equivalent injury managed in one fashion versus another. To date, OISs have been developed and published in the Journal of Trauma for spleen, liver, kidney, [1] pancreas, duodenum, small bowel, colon, rectum, [2] chest wall, abdominal vascular, ureter, bladder, urethra, [3] and thoracic vascular, lung, cardiac, diaphragm. [4] While many of these OISs have been employed in clinical research, the individual scaling grades have not been studied independently for scientific accuracy. Nonetheless, with increased clinical testing and constructive review by other investigators, the need for revisions has become apparent. Spleen and liver OISs, first published in 1989, [1] have been applied frequently in the literature over the past five years, and describe two ongoing controversial areas in trauma care. Consequently, it is not surprising that revisions for these two OISs have become necessary. Some of these modifications were straightforward, while others required considerable deliberation of the OIS committee before a consensus could be reached. The significant revisions in the spleen and liver OIS include: 1) global downgrading of hematomas for both spleen and liver, acknowledging their relatively benign course with the advent of widespread CT scanning for blunt abdominal trauma, 2) addition of Couinard's segmental liver anatomy to facilitate quantification of lobar parenchymal disruption, employing internationally familiar terminology, 3) more rigorous criteria for grade IV and V hepatic injuries, recognizing the need to further delineate the operative challenges of these advanced lesions, and 4) restricting the advancement of one grade for multiple injuries within an OIS to grade III. The revised scale for spleen OIS is depicted in Table 1. The specific changes are increased threshold hematoma size to > 5cm for grade III, and elimination of ruptured intraparenchymal hematoma as a grade IV injury. The changes for the revised liver OIS (Table 2) are increased threshold hematoma size to > 10cm for grade III, increased amount of parenchyma involved to > 75% for grade V, and the addition of equivalent Counard segments for grade IV and grade V.Table 1: Spleen injury scale (1994 revision).Table 2: Liver injury scale (1994 revision).We hope these modifications will be helpful to those who employ OISs to improve care of the injured, and look forward to the evaluation of their scientific validity by experienced trauma surgeons.

CONTEXT: The Centers for Disease Control and Prevention estimates that approximately 1.4 million US individuals sustain traumatic brain injuries (TBIs) per year. Previous reports suggest an association between TBI and chronic pain syndromes (eg, headache) thought to be more common in patients with mild TBI and in those who have sustained brain injury from violent rather than unintentional trauma. Comorbid psychiatric disorders such as posttraumatic stress disorder (PTSD) may also mediate chronic pain symptoms. OBJECTIVES: To determine the prevalence of chronic pain as an underdiagnosed consequence of TBI and to review the interaction between chronic pain and severity of TBI as well as the characteristics of pain after TBI among civilians and combatants. EVIDENCE ACQUISITION: The Ovid/MEDLINE database was searched for articles published between 1951 and February 2008 using any combination of the terms brain injury, pain, headache, blast injury, and combat (combat disorders, war, military medicine, wounds and injuries, military personnel, veterans). The PubMed and MD Consult databases were searched in a similar fashion. The Cochrane Collaboration, National Institutes of Health Clinical Trials Database, Meta-Register of Current Controlled Trials, and CRISP databases were searched using the keyword brain injury. All articles in peer-reviewed journals reporting original data on pain syndromes in adult patients with TBI with regard to pain prevalence, pain category, risk factors, pathogenesis, and clinical course were selected, and manual searches were performed of their reference lists. The data were pooled and prevalence rates calculated. EVIDENCE SYNTHESIS: Twenty-three studies (15 cross-sectional, 5 prospective, and 3 retrospective) including 4206 patients were identified. Twelve studies assessed headache pain in 1670 patients. Of these, 966 complained of chronic headache, yielding a prevalence of 57.8% (95% confidence interval [CI], 55.5%-60.2%). Among civilians, the prevalence of chronic pain was greater in patients with mild TBI (75.3% [95% CI, 72.7%-77.9%]) compared with moderate or severe TBI (32.1% [95% CI, 29.3%-34.9%]). Twenty studies including 3289 civilian patients with TBI yielded a chronic pain prevalence of 51.5% (95% CI, 49.8%-53.2%). Three studies assessed TBI among 917 veterans and yielded a pain prevalence of 43.1% (95% CI, 39.9%-46.3%). PTSD may mediate chronic pain, but brain injury appears to have an independent correlation with chronic pain. CONCLUSIONS: Chronic pain is a common complication of TBI. It is independent of psychologic disorders such as PTSD and depression and is common even among patients with apparently minor injuries to the brain.

BACKGROUND: Of the many psychiatric symptoms that may result from brain injury, agitation and/or aggression are often the most troublesome. It is therefore important to evaluate the efficacy of psychotropic medication used in its management. OBJECTIVES: To evaluate the effects of drugs for agitation and/or aggression following acquired brain injury (ABI). SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other electronic databases. We also searched the reference lists of included studies and recent reviews. In addition we handsearched the journals Brain Injury and the Journal of Head Trauma Rehabilitation. There were no language restrictions. The searches were last updated in June 2006. SELECTION CRITERIA: Randomised controlled trials (RCTs) that evaluated the efficacy of drugs acting on the central nervous system for agitation and/or aggression, secondary to ABI, in participants over 10 years of age. DATA COLLECTION AND ANALYSIS: We independently extracted data and assessed trial quality. Studies of patients within six months after brain injury and/or in a confusional state, were distinguished from those of patients more than six months post-injury, or who were not confused. MAIN RESULTS: Six RCTs were identified and included in this review. Four of theses evaluated the beta-blockers, propranolol and pindolol, one evaluated the central nervous system stimulant, methylphenidate and one evaluated amantadine, a drug normally used in parkinsonism and related disorders. The best evidence of effectiveness in the management of agitation and/or aggression following ABI was for beta-blockers. Two RCTs found propranolol to be effective (one study early and one late after injury). However, these studies used relatively small numbers, have not been replicated, used large doses, and did not use a global outcome measure or long-term follow-up. Comparing early agitation to late aggression, there was no evidence for a differential drug response. Firm evidence that carbamazepine or valproate is effective in the management of agitation and/or aggression following ABI is lacking. AUTHORS' CONCLUSIONS: Numerous drugs have been tried in the management of aggression in ABI but without firm evidence of their efficacy. It is therefore important to choose drugs with few side effects and to monitor their effect. Beta-blockers have the best evidence for efficacy and deserve more attention. The lack of evidence highlights the need for better evaluations of drugs for this important problem.

We reviewed research on the relationship between (a) exposure to psychological trauma and (b) nonsuicidal self-injury (NSSI) and suicidality (suicidal ideation [SI] and suicide attempts [SA]) in individuals with dissociative disorders and posttraumatic stress disorder (PTSD). The review provides a context for the special issue of the Journal of Trauma & Dissociation on these topics. Exposure to childhood sexual abuse is the most consistent traumatic antecedent of self-harm, although traumatic violence in childhood (particularly physical abuse) and adulthood (particularly domestic violence) and exposure to multiple types of traumatic stressors also are associated with NSSI and SI/SA. Dissociative disorders and PTSD are consistently associated with increased NSSI and SA/SI. There is preliminary cross-sectional evidence that dissociation and posttraumatic stress disorders may mediate the relationship between psychological trauma and NSSI and SI/SA. Research on emotion dysregulation as a potential cross-cutting mechanism linking dissociation, PTSD, and self-harm is also reviewed. We conclude with a discussion of implications for clinical practice and future directions for scientific research.

A special interest group of the American Congress of Rehabilitation Medicine [ACRM; Mild Traumatic Brain Injury Committee. (1993). Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 8 (3), 86-87.] was the first organized interdisciplinary group to advocate four specific criteria for the diagnosis of a mild traumatic brain injury (TBI). More recently, the World Health Organization (WHO) Collaborative Center Task Force on Mild Traumatic Brain Injury [Carroll, L. J., Cassidy, J. D., Holm, L., Kraus, J., & Coronado, V. G. (2004). Methodological issues and research recommendations for mild traumatic brain injury: the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. Journal of Rehabilitation Medicine, (Suppl. 43), 113-125.] conducted a comprehensive review of the definitions utilized in evidence-based studies with mild TBI patients. Based on this review, the WHO task force maintained the same four criteria but offered two modifications. The similarities and differences between these two definitions are discussed. The authors of the ACRM and the WHO definitions do not provide guidelines or specific recommendations for diagnosing the four criteria. Thus, we provide recommendations for assessing loss of consciousness, retrograde and post-traumatic amnesia, disorientation and confusion as well as clarification of the neurologic signs that can be indicative of a diagnosis of mild TBI. Finally, confounding factors mentioned in both definitions that should exclude a mild TBI diagnosis are summarized.

OBJECTIVE: To review the history of the innovation of damage control (DC) for management of trauma patients. BACKGROUND: DC is an important development in trauma care that provides a valuable case study in surgical innovation. METHODS: We searched bibliographic databases (1950-2015), conference abstracts (2009-2013), Web sites, textbooks, and bibliographies for articles relating to trauma DC. The innovation of DC was then classified according to the Innovation, Development, Exploration, Assessment, and Long-term study model of surgical innovation. RESULTS: The "innovation" of DC originated from the use of therapeutic liver packing, a practice that had previously been abandoned after World War II because of adverse events. It then "developed" into abbreviated laparotomy using "rapid conservative operative techniques." Subsequent "exploration" resulted in the application of DC to increasingly complex abdominal injuries and thoracic, peripheral vascular, and orthopedic injuries. Increasing use of DC laparotomy was followed by growing reports of postinjury abdominal compartment syndrome and prophylactic use of the open abdomen to prevent intra-abdominal hypertension after DC laparotomy. By the year 2000, DC surgery had been widely adopted and was recommended for use in surgical journals, textbooks, and teaching courses ("assessment" stage of innovation). "Long-term study" of DC is raising questions about whether the procedure should be used more selectively in the context of improving resuscitation practices. CONCLUSIONS: The history of the innovation of DC illustrates how a previously abandoned surgical technique was adapted and readopted in response to an increased understanding of trauma patient physiology and changing injury patterns and trauma resuscitation practices.

Traumatic dental injuries (TDIs) occur most frequently in children and young adults. Older adults also suffer TDIs but at significantly lower rates than individuals in the younger cohorts. Luxation injuries are the most common TDIs in the primary dentition, whereas crown fractures are more commonly reported for the permanent teeth. Proper diagnosis, treatment planning and follow up are very important to assure a favorable outcome. These updates of the International Association of Dental Traumatology's (IADT) Guidelines include a comprehensive review of the current dental literature using EMBASE, MEDLINE, PUBMED, Scopus, and Cochrane Databases for Systematic Reviews searches from 1996 to 2019 and a search of the journal Dental Traumatology from 2000 to 2019. The goal of these guidelines is to provide information for the immediate or urgent care of TDIs. It is understood that some follow-up treatment may require secondary and tertiary interventions involving dental and medical specialists with experience in dental trauma. As with previous guidelines, the current working group included experienced investigators and clinicians from various dental specialties and general practice. The current revision represents the best evidence based on the available literature and expert opinions. In cases where the published data were not conclusive, recommendations were based on the consensus opinions of the working group. They were then reviewed and approved by the members of the IADT Board of Directors. It is understood that guidelines are to be applied using careful evaluation of the specific clinical circumstances, the clinician's judgment, and the patient's characteristics, including the probability of compliance, finances and a clear understanding of the immediate and long-term outcomes of the various treatment options vs non-treatment. The IADT does not, and cannot, guarantee favorable outcomes from adherence to the Guidelines. However, the IADT believes that their application can maximize the probability of favorable outcomes.

OBJECTIVE: The purpose of this study was to review the literature relating to the psychosocial costs associated with traumatic brain injury (TBI). METHODS: Nine online journal databases, including MEDLINE, CINAHL, PsychINFO, and PUBMED, were queried for studies between July 2010 and May 2012 pertaining to the economic burden of head injuries. Additional studies were identified through searching bibliographies of related publications and using Google internet search engine. RESULTS: One hundred and eight potentially relevant abstracts were identified from the journal databases. Ten papers were chosen for discussion in this review. All but two of the chosen papers were US studies. The studies included a cost-benefit analysis of the implementation of treatment guidelines from the US brain trauma foundation and a cost-effectiveness analysis of post-acute traumatic brain injury rehabilitation. CONCLUSION: Very little research has been published on the economic burden that mild and moderate traumatic brain injury patients pose to their families, careers, and society as a whole. Further research is needed to estimate the economic burden of these patients on healthcare providers and social services and how this can impact current health policies and practices.

The purpose of a scaling system for specific injuries is to provide a common language to facilitate the clinical decisions and the investigative basis for this decision making. This brief overview describes the evolution of the Organ Injury Scaling (OIS) system developed by the American Association for the Surgery of Trauma. The OIS system is based on the magnitude of anatomic disruption and is graded as 1 (minimal), 2 (mild), 3 (moderate), 4 (severe), 5 (massive), and 6 (lethal). To date, the American Association for the Surgery of Trauma OIS system has been developed for visceral and vascular injuries of the neck, chest, abdomen, and extremities. The fundamental objective of OIS is to provide a common language to describe specific organ injuries. The primary purpose of OIS is to facilitate clinical decision making and the necessary research endeavors to improve this process. A good example of this concept is the tumor, node, metastasis classification for solid organ malignancies: a system used worldwide to guide patient care and clinical investigation.

BACKGROUND: Major trauma presents major diagnostic and therapeutic problems. Any delay in providing the treatment necessary may lead to increased morbidity and mortality, prolonged length of hospital stay, and increased cost. This study was undertaken to determine the extent, contributing factors, and implication of missed injuries and relate them to the three surveys in a Danish Level I trauma center. METHODS: The records of all major traumatized patients admitted to the Odense University Hospital from January 1996 through December 1999 have been studied to determine the extent and type of missed injuries. The initial examination is carried out by the trauma team in the A&E department according to standard protocols. Resuscitation is carried out according to Advanced Trauma Life Support principles and details are documented in the patient journal and in a special trauma journal. RESULTS: Sixty-four of 786 patients (incidence, 8.1%) had 86 missed injuries. The missed injuries averaged 1.3 injuries per patient. There were 45 male and 19 female patients, with a median age of 33 years (range, 12-81 years). The median ISS was 17 (range, 4-50); 14%, 38%, and 48% of the injuries were missed in primary, secondary, and tertiary surveys, respectively. CONCLUSION: Our study demonstrates that missed injuries can occur at any stage of the management of patients with major trauma. Repeated assessments, both clinical and radiologic, are mandatory to diminish the problem. In initial assessment, one still has to treat the greatest threat to life before complete diagnosis of all injuries, but alertness to evolving injuries must remain throughout the patient's stay in hospital.

Rockwood gives you a complete print and multimedia package consisting of the established gold-standard three-volume reference on fractures, plus access to an integrated content Website. Rockwood, Green, and Wilkins' Fractures in its thoroughly revised, updated Sixth Edition is written by the world's foremost authorities. It provides comprehensive coverage of all bone and joint injuries, thorough discussion of alternative treatments for each injury, and coverage of the preferred methods. Volumes I and II cover fractures in adults, and Volume III covers fractures in children. The improved art program features 6,900 illustrations, all contained in your Solution image bank. Pearls and pitfalls have been added to the authors' preferred method presentations, and coverage of complications has been expanded. The Rockwood Solution Website will contain the fully searchable three-volume set in addition to feature articles from the Journal of Orthopaedic Trauma and a monthly update of relevant journal articles to keep you up to date. All images are downloadable so they can be used in your PowerPoint presentations. Features include: the newly updated Sixth Edition of the gold standard three-volume reference on fracturesuplus a Website that includes: Online Access: Website features fully searchable content from the three-volume set; Image Bank: a complete image bank searchable and downloadable to your Powerpoint presentations; Journal of Orthopaedic Trauma: featured articles will provide the latest techniques to help stay one step ahead in your practice. Featured articles: additional articles from Lippincott Williams amp Wilkins techniques journals to keep you up to date.

From the Department of Surgery (D.V.F.), Emory University School of Medicine, Surgeon-in-Chief, Grady Memorial Hospital, Atlanta, Georgia; Department of Surgery (S.R.S.), University of California, San Diego School of Medicine, Professor of Surgery Emeritus, University of Vermont College of Medicine; Graduate Medical Education and Quality Improvement, Trauma Services, Scripps Mercy Medical Center, San Diego, California. Submitted for publication February 17, 2010. Accepted for publication February 18, 2010. Address for reprints: David V. Feliciano, MD, Department of Surgery, 69 Jesse Hill Jr. Drive, SE, #304, Atlanta, GA 30303; email: [email protected].

SHOCK®: Injury, Inflammation, and Sepsis: Laboratory and Clinical Approaches includes studies of novel therapeutic approaches, such as immunomodulation, gene therapy, nutrition, and others. The mission of the Journal is to foster and promote multidisciplinary studies, both experimental and clinical in nature, that critically examine the etiology, mechanisms and novel therapeutics of shock-related pathophysiological conditions. Its purpose is to excel as a vehicle for timely publication in the areas of basic and clinical studies of shock, trauma, sepsis, inflammation, ischemia, and related pathobiological states, with particular emphasis on the biologic mechanisms that determine the response to such injury. Making such information available will ultimately facilitate improved care of the traumatized or septic individual. SHOCK® is also privileged to have fourteen distinguished Associate Editors, as well as a diverse group of editorial board members from various parts of the world, who enjoy the respect and admiration of their colleagues in their areas of investigation. The Official Journal of the Shock Society, the European Shock Society, the Indonesian Shock Society, the International Federation of Shock Societies, and the Official and International Journal of the Japan Shock Society