Journal of Trauma and Injury

Volume 38(2); June 2025

Review Articles

Surgical site infections: a comprehensive review: Ahmad Reza Rezaei, Damian Zienkiewicz, Amir Reza Rezaei; J Trauma Inj. 2025;38(2):71-81. Published online June 27, 2025; DOI: https://doi.org/10.20408/jti.2025.0019

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Abstract PDF: Surgical site infections (SSIs) represent a major public health challenge, contributing to increased morbidity, mortality, and healthcare costs worldwide. This paper presents a comprehensive review of the epidemiology, classification, risk factors, microbiological aspects, treatment modalities, and prevention strategies for SSIs, based on contemporary research and evidence-based practice protocols. An extensive literature review was conducted, synthesizing existing studies on SSIs. A comprehensive search was performed in PubMed, Embase, Cochrane Library, and guidelines from leading organizations such as the American College of Surgeons, the US Centers for Disease Control and Prevention, the World Health Organization, and the Infectious Diseases Society of America. Inclusion criteria encompassed peer-reviewed articles as well as American and European medical guidelines focusing on the epidemiology, risk factors, microbiology, treatment, and prevention of SSIs. The review adhered to the PECO (population, exposure, comparator, outcome) framework. Some of the most significant global concerns related to SSIs include antibiotic resistance and the contamination of surgical instruments, particularly in resource-poor settings. Trauma patients, especially those undergoing emergency procedures or sustaining open fractures, are at increased risk for SSIs due to the severity of their injuries and higher contamination risks. These findings underscore the importance of preventive measures, such as appropriate preoperative interventions, strict aseptic techniques, and proper antibiotic prophylaxis, in reducing SSI incidence and improving patient outcomes.; Summary

Deciphering the effectiveness of computed tomography scoring systems in improving mortality prediction for traumatic brain injury: a systematic review and bibliometric analysis: Astrid Ekklesia Saputri, Eunike Priscila, Rian Ka Praja, Ysrafil Ysrafil; J Trauma Inj. 2025;38(2):82-90. Published online June 25, 2025; DOI: https://doi.org/10.20408/jti.2025.0009

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Abstract PDF: Purpose
Traumatic brain injury is associated with adverse prognoses and significant neurological impairments that negatively affect patients' quality of life and physiological well-being. The aim of this study was to compare various computed tomography (CT) scoring systems in order to evaluate their effectiveness in predicting mortality and in risk stratification.
Methods
The evolution and trends in the use of CT scoring systems were analyzed through a bibliometric analysis of 72 Scopus-indexed documents using VOSviewer ver. 1.6.19. A systematic review was conducted following the 2020 PRISMA guidelines, with data obtained from PubMed Advance, Scopus, and Google Scholar for the period 2003–2024. A total of 198 journals were identified and subsequently filtered down to 6 that met the inclusion criteria.
Results
The bibliometric analysis revealed a progressive shift toward the use of CT scoring systems for novel diagnostic purposes and mortality prediction. The Rotterdam CT score demonstrated the highest total link strength and was most frequently published in 2017. In contrast, the Marshall CT score was more widely referenced in studies published after 2020. Despite being recognized for its sensitivity, the Helsinki CT score has not garnered equivalent research attention. Furthermore, the review suggested that the Rotterdam CT score is superior in predicting mortality among traumatic brain injury patients, with the Marshall CT score also demonstrating potential.
Conclusions
A review of the extant literature indicates that the Helsinki CT score exhibits the highest predictive accuracy, effectively estimating both mortality probability and long-term prognosis. Since 2015, research on the Helsinki CT score has steadily increased.; Summary

Original Articles

Vulnerability of the border area: analysis of the Traffic Accident Analysis System in Korea: Doo-Hun Kim, Hangjoo Cho, Sung Yub Jeong, Maru Kim; J Trauma Inj. 2025;38(2):91-96. Published online June 19, 2025; DOI: https://doi.org/10.20408/jti.2024.0100

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Abstract PDF: Purpose
This study assessed patient vulnerability following traffic accidents (TAs) in Korea’s border area (BA).
Methods
The BA includes cities and counties directly adjacent to the demilitarized zone with North Korea. The rear area (RA) is defined as the area immediately adjacent to the BA. TA data from 2017 to 2021 were obtained from the Traffic Accident Analysis System in Korea. Information on road length, population, number of TAs, injured patients, and fatalities was collected. The number of TAs and fatalities per 1 km of road length and per 100,000 people was calculated. Severity (number of fatalities per 100 TA cases) and lethality (number of fatalities divided by the sum of fatalities and injured patients) were used to assess the vulnerability of each area.
Results
A total of 55,463 TAs were analyzed. Although the RA exhibited higher numbers of TAs and deceased patients per 1 km of road length and per 100,000 people, the BA showed significantly higher fatalities per 100,000 people as well as increased severity and lethality.
Conclusions
The BA is more likely to be associated with death following TAs, despite a lower overall TA incidence compared to the RA. Further analysis is needed to address and mitigate this vulnerability.; Summary

Correlation between bispectral index values and the Glasgow Coma Scale in traumatic brain injury patients: a prospective observational study: Anjum H. Mujawar, Pradnya M. Bhalerao, Sujit J. Kshirsagar; J Trauma Inj. 2025;38(2):97-102. Published online June 30, 2025; DOI: https://doi.org/10.20408/jti.2025.0026

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Abstract PDF: Purpose
Traumatic brain injury (TBI) severity is typically assessed using the Glasgow Coma Scale (GCS). In contrast, the bispectral index (BIS) objectively evaluates a patient’s level of consciousness in an intensive care unit. The primary objective of this study was to evaluate the correlation between GCS and BIS values in TBI patients. Secondary objectives included determining the range of BIS scores corresponding to different levels of consciousness and assessing the correlation among mild, moderate, and severe TBI.
Methods
Sixty patients participated in a prospective observational study conducted at a government tertiary care facility. After obtaining a detailed history and performing a physical examination, each patient’s age, sex, intubation status, computed tomography brain findings, and vital signs were recorded. Subsequently, the patients’ GCS and BIS values were measured at 0, 6, 12, 18, and 24 hours. Quantitative data are presented as mean±standard deviation, while qualitative data are illustrated using frequency and percentage tables. Spearman correlation analysis was employed to evaluate the association.
Results
Spearman correlation analysis demonstrated a strong positive relationship between BIS and GCS at 0 hours (r=0.655, P<0.05), 6 hours (r=0.647, P<0.05), 12 hours (r=0.652, P<0.05), 18 hours (r=0.659, P<0.05), and 24 hours (r=0.648, P<0.05). Moreover, the mean BIS value decreased significantly with increasing severity of head injury.
Conclusions
Similar to the GCS, the BIS correlates with head injury severity and may serve as a complementary tool for predicting outcomes in TBI patients.; Summary

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ijawdij: J Trauma Inj. 2025;38(2):101-109. Published online July 11, 2025; DOI: https://doi.org/123 [Accepted]

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Abstract PDF: dawijjd; Summary

Original Articles

Lessons from foreign military surgeons in the Korean War: advancing trauma surgery and preparing for future conflicts: Kun Hwang, Chan Yong Park; J Trauma Inj. 2025;38(2):103-110. Published online June 16, 2025; DOI: https://doi.org/10.20408/jti.2025.0041

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Abstract PDF: Purpose
The Korean War (1950–1953) significantly advanced military medicine, with foreign military surgeons playing a pivotal role in transforming trauma care under extreme conditions.
Methods
Resources such as PubMed, JSTOR, and reports from participating nations formed the basis of this study. A thorough comparative analysis was performed to examine the similarities and differences in medical practices between the United Nations Command and North Korean forces.
Results
The United States introduced Mobile Army Surgical Hospitals, revolutionizing trauma care by enabling rapid intervention near combat zones. Innovations such as helicopter evacuation, whole blood transfusions, and antibiotic treatments reduced mortality rates among treated soldiers to as low as 3%. British surgeons excelled in managing abdominal wounds and performing orthopedic surgery, often undertaking limb-saving procedures. Field hospitals provided comprehensive care for combat injuries and infectious diseases—a major concern given the inadequate sanitation. The Indian 60th Parachute Field Ambulance treated over 20,000 casualties, demonstrating adaptability in harsh environments. The Indian Field Hospital not only treated military casualties but also provided care to Korean civilians, offering life-saving medical interventions under challenging conditions. Denmark deployed the hospital ship MS Jutlandia, equipped with advanced surgical facilities, enabling a level of medical care that was not practical on land. The Swedish Red Cross Field Hospital in Busan delivered crucial medical aid to both military personnel and civilians; its staff focused on civilian outreach and controlling epidemics, with treatments targeting diseases such as typhoid and tuberculosis. Norwegian mobile surgical teams specialized in rapid interventions near combat zones, performing life-saving operations within hours of injury and thus minimizing complications and increasing survival rates.
Conclusions
The lessons learned from these contributions continue to influence modern military and civilian healthcare systems, highlighting the importance of innovation, collaboration, and resilience in conflict settings.; Summary

Management and outcomes of open and endovascular aortic repair with blunt traumatic aortic injuries in Western Australia: Amyna Jiwani, Warren D. Raymond, Fernando Picazo-Pineda, Sudhakar Rao, Kishore Sieunarine; J Trauma Inj. 2025;38(2):111-124. Published online June 30, 2025; DOI: https://doi.org/10.20408/jti.2024.0101

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Abstract PDF Supplementary Material: Purpose
Blunt traumatic aortic injuries (TAIs) require timely surgical intervention to prevent death. We described the management and outcomes of polytrauma patients with TAI after open and endovascular repair in Western Australia.
Methods
We performed a retrospective cohort study of patients with TAI admitted to the State Trauma Unit, Royal Perth Hospital from 2008 to 2018. Patient data were obtained from the Trauma Database and supplemented with chart review.
Results
Among 57 patients with TAI, 45 (78.9%) were male, with a mean age of 41 years, and were mainly involved in motor vehicle crashes (89.5%). They had a median Injury Severity Score of 34 (interquartile range [IQR], 21–45) and a median length of stay of 18 days. Concurrent injuries occurred in nearly all patients, including musculoskeletal (56 patients, 98.2%; mainly fractures, 91.2%), central nervous system (33 patients, 57.9%; mostly hemorrhage), injury to the chest cavity (46 patients, 80.7%), and abdominal organs (32 patients, 56.1%). The most common TAI grade was III (56.1%), followed by grade I (22.8%) and grade II (21.1%); all grade IV patients died before vascular consultation. TAI was managed with endovascular surgery (thoracic endovascular aortic repair, TEVAR) in 37 (64.9%, of which early TEVAR was performed in 29 [78.4%]), open surgery in 4 (7.0%), and conservative management in 16 (28.1%). Vascular procedures had a median duration of 81 minutes (IQR, 60–97 minutes). Acute vascular surgery–related complications were infrequent (5.3%), and all occurred post-TEVAR, mainly involving upper limb ischemia that required bypass or stenting within 72 hours of the index procedure. After discharge (52 patients), 3 patients were lost to follow-up regarding surgical survival, and late complications occurred in 6 of 48 vascular surgery patients (12.5%), who all underwent TEVAR.
Conclusions
TAI patients who received a vascular surgery review and were managed either conservatively or surgically showed favorable postdischarge survival rates and surgical results.. Patients with grade II or III TAI who underwent endovascular repair had favorable short- and long-term outcomes.; Summary

Dual plating in the management of nonunion complex distal femur fractures following lateral locked plate fixation: radiological and functional outcomes of a prospective study: Nilesh Barwar, Gypsy Gargi, Ankit Rai, Abhay Elhence, Sumit Banerjee, Nitesh Gahlot; J Trauma Inj. 2025;38(2):125-136. Published online June 27, 2025; DOI: https://doi.org/10.20408/jti.2024.0054

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Abstract PDF: Purpose
Managing complex distal femur fractures presents technical challenges. Although the lateral locked plate has become standard for these fractures, failures are not uncommon when this device is used alone. Patients with nonunion of distal femur fractures following treatment with a single lateral locked plate were examined. Revision surgery was performed by applying dual plates, and their efficiency was evaluated.
Methods
This study investigated 24 aseptic and 3 septic nonunions of distal femur fractures, classified as AO/OTA type C, that were previously managed with open reduction and internal fixation using only a lateral locked plate. Revision surgery involved replacing the broken 5.0-mm lateral locked plate, supplementing the medial side with a 4.5-mm T-plate, and applying bone grafting at the fracture site. Septic cases were managed using a staged approach with dual implant application.
Results
Following revision surgery, bony union was achieved in 83.3% of aseptic nonunions, with a mean bone healing time of 22.5 weeks (range, 15–27 weeks). Additional surgery was required for the remaining 16.6%. Using staged management, the septic nonunions were united in a mean of 30.25 weeks (range, 27–32 weeks). Significant improvements were noted in the Tegner Lysholm Knee Scoring Scale, with median preoperative and postoperative scores of 30 (range, 12–67) and 80 (range, 66–90), respectively (P<0.001). Limb pain, as measured by the visual analog scale for knee pain, improved significantly from a preoperative median of 6 (range, 4–8) to 3 (range, 1–6) postoperatively (P<0.001). All patients were ambulatory without supportive devices. However, the mean knee range of motion was 80° (range, 40°–120°). Limb shortening was observed in six cases (22.2%; average shortening, 2.3±1.0 cm).
Conclusions
Dual plating appears to be an effective approach for managing failed complex distal femur fractures following initial treatment with a single lateral locked plate.; Summary

Case Reports

Similarities and differences between lightning and electrical injuries: two case reports: Yi Liu, Zosimo Ken L. Jimeno, Wan Azman Wan Sulaiman; J Trauma Inj. 2025;38(2):137-141. Published online March 25, 2025; DOI: https://doi.org/10.20408/jti.2024.0067

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Abstract PDF: Exposure to electrical current, whether through accidental contact in residential or industrial settings or via lightning strikes, represents a serious global health concern. Although numerous studies have been published on the differences between electrical and lightning injuries, they are often discussed together due to the similarities in their clinical presentations, management approaches, and outcomes. The question of whether electrical and lightning injuries should be studied together remains a matter of debate. Here, we present two cases: one of a lightning injury and another of an electrical injury. Our discussion aims to improve the understanding of lightning and electrical injuries as distinct entities. Vigorous resuscitative measures are recommended and given the complexity of electrical and lightning injuries and their long-term sequelae, patients should be managed in a multidisciplinary burn center. Furthermore, the knowledge and awareness of the general population must be improved to reduce the incidence of such injuries.; Summary

Successful laparotomy for intra-abdominal hypertension following veno-venous extracorporeal membrane oxygenation after severe thoracoabdominal trauma: a case report: Yo Huh, Jonghwan Moon, Kyoungwon Jung, Hye-Min Sohn; J Trauma Inj. 2025;38(2):142-146. Published online March 25, 2025; DOI: https://doi.org/10.20408/jti.2024.0060

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Abstract PDF: Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is often used as a life-saving therapy for lung injuries; however, it presents challenges, including bleeding risks and potential reductions in ECMO flow. This case report details the intricate management of a 16-year-old boy who suffered severe thoracoabdominal trauma following a nine-floor fall. The patient sustained severe lung injury and damage to multiple solid organs, including liver lacerations, and was placed on VV-ECMO. When initiating ECMO, it is crucial to carefully consider anticoagulation to avoid potential bleeding complications. Therefore, despite the usual risks associated with ECMO, such as bleeding and reduced flow rates, anticoagulation was withheld due to the risk of hemorrhage from the liver injury. While on ECMO support, the patient experienced a sudden decrease in flow and blood pressure, suggesting an increase in intra-abdominal pressure. An immediate decompressive laparotomy revealed a significant hemoperitoneum, primarily caused by oozing from the liver laceration. The prompt recognition of abdominal distension and the timely decision to proceed with surgery without further imaging were key to the successful treatment. Postoperatively, the patient showed good recovery, with gradual weaning from ECMO, extubation, and eventual discharge. In conclusion, this case highlights the importance of ongoing monitoring for patients with complex trauma who are on ECMO. External factors, including elevated intra-abdominal pressure, can impair ECMO performance. Meticulous management and a multidisciplinary approach are essential in these intricate cases, which involve the nonsurgical treatment of solid organ damage accompanied by severe lung injury.; Summary

Traumatic globe avulsion secondary to a penetrating orbital injury from a bicycle handlebar: a case report: Nishanth S. Iyengar, Edward Xie, Patricia Pahk, Nariman S. Boyle; J Trauma Inj. 2025;38(2):147-151. Published online April 1, 2025; DOI: https://doi.org/10.20408/jti.2024.0070

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Abstract PDF: A 60-year-old man presented with total avulsion of the right globe following a penetrating injury to the right orbit from a metal bicycle handlebar. There was no light perception in the right eye on presentation. External examination revealed a full-thickness, canalicular-involving, horizontal right upper eyelid laceration through which the luxated globe and other orbital contents extruded. The globe was intact. The patient underwent urgent surgical exploration. In the operating room the optic nerve and all extraocular muscles were found to be completely transected from the globe. The globe was enucleated, and the eyelid laceration was repaired with bicanalicular stent placement.; Summary

Cerebral fat emboli monitoring using transcranial Doppler ultrasound and confirmation of a successful treatment response: a case report: Morgan Jude, Ryan Martin, Ivy Nguyen, Christine Cocanour, Heather Nicoletto, Keyanna Raihani, Alicia Alley, Jeffrey R. Vitt; J Trauma Inj. 2025;38(2):152-158. Published online March 25, 2025; DOI: https://doi.org/10.20408/jti.2024.0075

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Abstract PDF: Fat emboli syndrome is a rare and potentially fatal condition that most commonly manifests after traumatic long-bone fractures. Cerebral fat emboli are one of the most feared complications leading to permanent neurologic injury, though methods for optimal monitoring in high-risk patients are lacking. We present a case of a 16-year-old female patient who presented to the emergency department following a motor vehicle collision with multiple injuries, including a comminuted femoral shaft and pelvic ring fracture, as well as an acute basilar artery occlusion due to fat embolism. Continuous transcranial Doppler ultrasound (TCD) of the bilateral middle cerebral arteries was utilized for emboli detection and evaluation of right-to-left shunt. The patient was found to have a high burden of microemboli on TCD in combination with a right-to-left shunt conferring increased risk of additional neurologic injury. Following surgical fixation of her orthopedic injuries, repeated TCD assessment demonstrated no further evidence of microemboli thus demonstrating efficacious response to definitive treatment. This report highlights the utility of TCD for early monitoring and detection of cerebral emboli in patients at risk for fat emboli syndrome as well as evaluating response to intervention.; Summary

Resolution is not the end: The Macklin effect after chest tube removal in a trauma patient with aging and comorbidities: a case report: Faye Abdulkareem, Fayez G. Aldarsouni, Sahar Alomar, Zisis Touloumis, Hussain M. AlHassan, Ghassan Z. Al Ramahi, Tareq Alsabahi, Khaled Twier, Mohammad Alsenani, Emad Alamoudi; J Trauma Inj. 2025;38(2):159-164. Published online March 25, 2025; DOI: https://doi.org/10.20408/jti.2024.0090

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Abstract PDF: Pneumomediastinum is an uncommon complication in cases of blunt chest trauma but can signal severe underlying issues. This report discusses a 69-year-old male patient with preexisting conditions of obesity, sleep apnea, and asthma, who experienced delayed pneumomediastinum and pneumopericardium following the removal of a chest tube. This tube had been placed to address a traumatic hemopneumothorax, which had resolved. The removal of the chest tube triggered a series of events, exacerbated by the patient's chronic health conditions. The patient was managed conservatively with close monitoring and physiotherapy, which successfully resolved the condition without the need for further invasive procedures. The multifactorial nature of the Macklin effect illustrates that even routine procedures such as chest tube removal can trigger a chain reaction in susceptible patients. The choice of conservative management, rather than immediate invasive interventions, underscores the delicate balance necessary in trauma care.; Summary

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