Academic literature on the topic 'Compensation, injury, trauma, outcome'

Identifying who might develop disabling pain or poor mental health after injury is a high priority so that healthcare providers can provide targeted preventive interventions. This retrospective cohort study aimed to identify predictors of disabling pain or probable mental health conditions at 12 months post-injury. Participants were recruited 12-months after admission to a major trauma service for a compensable transport or workplace injury (n = 157). Injury, compensation claim, health services and medication information were obtained from the Victorian Orthopaedic Trauma Outcome Registry, Victorian State Trauma Registry and Compensation Research Database. Participants completed questionnaires about pain, and mental health (anxiety, depression, posttraumatic stress disorder) at 12 months post-injury. One third had disabling pain, one third had at least one probable mental health condition and more than one in five had both disabling pain and a mental health condition at 12 months post-injury. Multivariable logistic regression found mental health treatment 3–6 months post-injury, persistent work disability and opioid use at 6–12 months predicted disabling pain at 12 months post-injury. The presence of opioid use at 3–6 months, work disability and psychotropic medications at 6–12 months predicted a mental health condition at 12 months post-injury. These factors could be used to identify at risk of developing disabling pain who could benefit from timely interventions to better manage both pain and mental health post-injury. Implications for healthcare and compensation system are discussed.

ObjectivesCompensable injury increases the likelihood of having persistent pain after injury. Three-quarters of patients report chronic pain after traumatic injury, which is disabling for about one-third of patients. It is important to understand why these patients report disabling pain, in order to develop targeted preventative interventions. This study examined the experience of pain and disability, and investigated their sequential interrelationships with, catastrophising, kinesiophobia and self-efficacy 1 year after compensable and non-compensable injury.DesignObservational registry-based cohort study.SettingMetropolitan Trauma Service in Melbourne, Victoria, Australia.ParticipantsParticipants were recruited from the Victorian State Trauma Registry and Victorian Orthopaedic Trauma Outcomes Registry. 732 patients were referred to the study, 82 could not be contacted or were ineligible, 217 declined and 433 participated (66.6% response rate).Outcome measuresThe Brief Pain Inventory, Glasgow Outcome Scale, EuroQol Five Dimensions questionnaire, Pain Catastrophising Scale, Pain Self-Efficacy Questionnaire, Injustice Experience Questionnaire and the Tampa Scale of Kinesiophobia.MethodsDirect and indirect relationships (via psychological appraisals of pain/injury) between baseline characteristics (compensation, fault and injury characteristics) and pain severity, pain interference, health status and disability were examined with ordinal, linear and logistic regression, and mediation analyses.ResultsInjury severity, compensable injury and external fault attribution were consistently associated with moderate-to-severe pain, higher pain interference, poorer health status and moderate-to-severe disability. The association between compensable injury, or external fault attribution, and disability and health outcomes was mediated via pain self-efficacy and perceived injustice.ConclusionsGiven that the associations between compensable injury, pain and disability was attributable to lower self-efficacy and higher perceptions of injustice, interventions targeting the psychological impacts of pain and injury may be especially necessary to improve long-term injury outcomes.

Road trauma remains a significant public health problem. We aimed to identify sub-groups of motor vehicle collisions in Victoria, Australia, and the association between collision characteristics and outcomes up to 24 months post-injury. Data were extracted from the Victorian State Trauma Registry for injured drivers aged ≥16 years, from 2010 to 2016, with a compensation claim who survived ≥12 months post-injury. People with intentional or severe head injury were excluded, resulting in 2735 cases. Latent class analysis was used to identify collision classes for driver fault and blood alcohol concentration (BAC), day and time of collision, weather conditions, single vs. multi-vehicle and regional vs. metropolitan injury location. Five classes were identified: (1) daytime multi-vehicle collisions, no other at fault; (2) daytime single-vehicle predominantly weekday collisions; (3) evening single-vehicle collisions, no other at fault, 36% with BAC ≥ 0.05; (4) sunrise or sunset weekday collisions; and (5) dusk and evening multi-vehicle in metropolitan areas with BAC < 0.05. Mixed linear and logistic regression analyses examined associations between collision class and return to work, health (EQ-5D-3L summary score) and independent function Glasgow Outcome Scale - Extended at 6, 12 and 24 months. After adjusting for demographic, health and injury characteristics, collision class was not associated with outcomes. Rather, risk of poor outcomes was associated with age, sex and socioeconomic disadvantage, education, pre-injury health and injury severity. People at risk of poor recovery may be identified from factors available during the hospital admission and may benefit from clinical assessment and targeted referrals and treatments.

The purpose of this review article is to assess the current literature on the outcomes of simple orthopaedic trauma. Simple trauma is defined as the fracture or injury of one limb due to an acute event. Fractures are the most common cause of hospitalized trauma in Australia and associated with multiple social, psychological and physical consequences for patients. The literature to date suggests that there are multiple factors leading to relatively poor outcomes following simple trauma, modifiable and non-modifiable. The most oft cited are older age, lower educational status, being injured at work, injury severity score, pre-existing disease, workers compensation, litigation and pain at initial assessment. Additional psychological risk factors quoted attribute to the injury to an external source and the use of passive coping strategies. This review aims to summarise the relevant literature relating to these risk factors and give direction to improving outcomes and future research into this important area.

Objective: To evaluate the visual outcome of ocular trauma and its medicolegal interpretation in a tertiary care hospital, Karachi.Methods: This was a prospective, cross-sectional observational study conducted at Abbasi Shaheed Hospital, Karachi. Data was collected through nonprobability consecutive sampling technique. The study duration was 12 months, from 14 September 2014 to 15 September 2015. Inclusion criteria were patients of both genders aged between 18 - 60 years, presenting with ocular trauma in the outpatient department or admitted through an emergency in the department of Ophthalmology. The exclusion criterion was patients suffering from all extraocular injuries. Patients were followed up for a period of 6 months. Statistical analysis was done through SPSS version 20.0Results: There were 99 patients, with a mean age of 31.6 ± 18.5 SD years. Males were 74.7% and 82 (82.2 %) were unskilled. Closed globe injury was seen in 54 (54.5%) and the open globe in 45 (45.5%). Nine percent of the patients were assault cases and 90.9% cases were accidental. The corneal injury was seen in 43 (71.6%) and scleral injury in 5 (8.3%) of the patients. At the time of trauma 39.4% of patients presented with 6/60 visual acuity, in the early post-op period 50.5% were 6/6, whereas at six-month follow-up 90.9% patients were with 6/6 visual acuity. Wilcoxon Signed Ranks Test showed P-value less than 0.01.Conclusion: It was concluded that the major outcome of ocular trauma was impaired visual acuity, which improved significantly on regular follow-ups. Medicolegal interpretation of ocular trauma is imperative and should be accounted for properly. It should be exercised by the medicolegal officer, to not give the final report before at least 6 months of follow-up in case of poor visual outcome. Moreover, educate the person to demand compensation during this period.

BackgroundEmployment is an important marker of functional recovery from injury. There are few population-based studies of long-term employment outcomes, and limited data on the patterns of return to work post injury.ObjectivesThis study sought to characterise patterns of engagement in work over the four-year period following major traumatic injury, and to identify factors associated with those patterns.MethodWe conducted a population-based, prospective cohort study using the Victorian State Trauma Registry. A total of 1086 working age individuals, in paid employment or full-time education before injury, were followed-up through telephone interview at 6, 12, 24, 36, and 48 months post-injury. Responses to return to work (RTW) questions were used to define four discrete patterns: early and sustained; delayed; failed; no RTW. Predictors of RTW patterns were assessed using multivariate multinomial logistic regression.ResultsSlightly more than half of respondents (51.6%) recorded early sustained RTW. A further 15.5% had delayed and 13.3% failed RTW. One in five (19.7%) did not RTW. Compared with early sustained RTW, predictors of delayed and no RTW included being in a manual occupation and injury in a motor vehicle accident. Older age and receiving compensation predicted both failed and no RTW patterns. Pre-injury disability was an additional predictor of failed RTW. Presence of co-morbidity was an additional predictor of no RTW.ConclusionsA range of personal, occupational, injury, health and compensation system factors influence RTW patterns after serious injury. Early identification of people at risk for delayed, failed or no RTW is needed so that targeted interventions can be delivered.

Mental illness is pervasive among trauma populations and is linked to worse outcomes and recidivism. The Victims of Crime Advocacy and Recovery Program (VOCARP) prospectively provides patient services such as educational materials, compensation, advocacy and mental health care to patients with physical injuries. The purpose was to assess for relationship between resource use and development of mental illness after injury. Two control groups: a random selection of patients who did not use VOCARP (n=212) and 201 patients with non-violent trauma were obtained. Over 22 months 1,019 patients utilized VOCARP. Of all 1,432 patients, 43% had preexisting mental illness, and 17% had a new or worsening mental illness after injury. Patients with VOCARP use had more preexisting mental illness (47% vs. 35%, p<0.01), particularly depression and stress disorders. Conversely, VOCARP use was associated with lower rates of mental illness post-injury (15% vs. 22%). Following injury, VOCARP users had more stress disorders (57% vs. 37%), but less depression (25% vs. 41%) and suicidal ideation (7% vs. 24%), all p<0.05. 113 patients (11% of 1,019) used mental health services, which was associated with lower recidivism for new violent injury (4.4% vs. 11.7%, p=0.016). On regression analysis, unemployment (OR: 0.61, p=0.012) and use of VOCARP services (OR: 0.54, p=0.008) were predictive of decreased risk for new mental illness. Mental illness is pervasive among patients with injuries resulting from violence. VOCARP programming appears beneficial for limiting risk of new mental illness after injury.

Abstract Repetitive illness sometimes is wrongly called repetitive injury or cumulative trauma, but the latter are misnomers because the employee cannot identify a specific injury as a cause of the symptoms. In workers’ compensation, such gradual illness claims may be compensable if the condition arises during the course of employment, which requires that it be caused by occupational duties, exposures, or equipment used on the employer's premises. Expert impairment evaluators face three requirements: they must know the best scientific evidence currently available regarding causation of the condition(s) in question, ie, generic causation; the facts of the individual case, ie, specific causation; and the legal threshold in the applicable jurisdiction for acceptance of a condition as work related. The AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition, is an excellent resource and provides the physician a blueprint for the assessment of causation in occupational injury and illness claims. The book adopts the methodology developed by the National Institute for Occupational Safety and Health and the American College of Occupational and Environmental Medicine. When asked to render opinions regarding causation, a physician is wise to consider this methodology in determining the work relatedness of the condition. Medical opinions based on an accepted methodology and the best scientific evidence will result in better patient outcomes.

Introduction. In MRI, the difference in sensitivity between tissues is used to obtain images weighted by the inhomogeneity of the magnetic field termed susceptibility-weighted imaging (SWI) and a high-resolution 3D radiofrequency gradient echo scan with full speed compensation is applied. The aim was to determine the features of lesions caused by traumatic brain injury in children using the SWI sequence. Materials and methods. 535 TBI children aged two months up to 18 years old (average age 9.58 ± 1.5) were studied. There were 325 boys (60.7%), 210 girls (39.3%). MRI was performed without and with intravenous contrast on a Phillips Achieva 3 T scanner with T1- and T2WI, 2D and 3D images, FLAIR, magnetic resonance angiography (TOF MRA), SWI, and DW/DTI, MRS and fMRI, SWI were used for visualization of DAI. Results. Patients included children with severe TBI - 178 (33.3%), moderate TBI - 172 (32.1%) and mild TBI - 185 (34.6%). Of the 535 injured children, 129 (24.1%) had MRI performed within the first 24 hours from the moment of injury, up to 48 hours - at 91 (17.0%), up to 72 hours - in 78 (14.6%) and up to 13 days - in 237 (44.3%). DAI foci at all degrees of TBI were detected in 422 (78.9%) children out of 535 children. Conclusion. SWI is a sensitive method for diagnosing brain lesions in TBI and significantly contributes to predicting outcomes in the early stages after trauma. The amount of brain lesions diagnosed by SWI correlates with the degree of injury according to the Glasgo Coma Scale. The study of the brain functional connections can inform about possible relationships between the localization of the SWI lesion and cognitive deficits, potentially providing an opportunity to use SWI in the hyperacute phase.

Background: Despite the reliance on administrative data in epidemiological studies, there is little information on the completeness of co-morbidities in administrative data coded from medical records. Objective: The aim of this study was to quantify the agreement between the International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) administrative coding of mental health, drug and alcohol co-morbidities and medical records in a severely injured patient population. Method: A random sample of patients ( n = 500) captured by the Victorian State Trauma Registry and definitively managed at the state’s adult major trauma services was selected for the study. Retrospective medical record review was conducted to collect data about documented co-morbidities. The agreement between ICD-10-AM data generated from routine hospital coding and medical record–based co-morbidities was determined using Cohen’s κ and prevalence-adjusted bias-adjusted kappa (PABAK) statistics. Results: The percentage of agreement between the medical record and ICD-10-AM coding for mental health, drug and alcohol co-morbidities was 72.8%, and the PABAK showed moderate agreement (PABAK = 0.46; 95% confidence interval (CI): 0.37, 0.54). There was no difference in agreement between unintentional injury patients (PABAK = 0.52; 95% CI: 0.42, 0.62) compared with intentional injury patients (PABAK = 0.36, 95% CI: 0.23, 0.49), and no change in agreement for patients admitted before (PABAK = 0.40; 95% CI: 0.30, 0.50) and after the introduction of mandatory co-morbidity coding (PABAK = 0.46; 95% CI: 0.37, 0.54). Conclusion: Despite documentation in the medical record, a large proportion of mental health, drug and alcohol conditions were not coded in ICD-10-AM. Acknowledgement of these limitations is needed when using ICD-10-AM coded co-morbidities in research studies and health policy development. Implications: This work has implications for researchers of drug and alcohol abuse; mental health; accidents and injuries; workers' compensation; health workforce; health services; and policy decisions for healthcare, emergency services, insurance industry, national productivity and welfare costings reliant on those research outcomes.

Doctor of Philosophy
Work-related injuries and road traffic injuries are common causes of morbidity and are major contributors to the burden of disease worldwide. In developed countries, these injuries are often covered under compensation schemes, and the costs of administering these schemes is high. The compensation systems have been put in place to improve the health outcomes, both physical and mental, of those injured under such systems; yet there is a widespread belief, and some evidence, that patients treated under these schemes may have worse outcomes than if they were treated outside the compensation system. Chapter One of this thesis explores the literature pertaining to any effect that compensation may have on patient outcomes. It is noted that the concept of “compensation neurosis” dates from the nineteenth century, with such injuries as “railway spine”, in which passengers involved in even minor train accidents at the time, would often have chronic and widespread symptoms, usually with little physical pathology. Other illnesses have been similarly labelled over time, and similarities are also seen in currently diagnosed conditions such as repetition strain injury, back pain and whiplash. There are also similarities in a condition that has been labelled “shell shock”, “battle fatigue”, and “post-traumatic stress disorder”; the latter diagnosis originating in veterans of the Vietnam War. While there is evidence of compensation status contributing to the diagnosis of some of these conditions, and to poor outcomes in patients diagnosed with these conditions, there is little understanding of the mechanism of this association. In contrast to popular stereotypes, the literature review shows that malingering does not contribute significantly to the effect of compensation on health outcomes. Secondary gain is likely to play an important role, but secondary gain is not simply confined to financial gain, it also includes gains made from avoidance of workplace stress and home and family duties. Other psychosocial factors, such as who is blamed for an injury (which may lead to retribution as a secondary gain) or the injured person’s educational and occupational status, may also influence this compensation effect. The literature review concludes that while the association between compensation and health after injury has been widely reported, the effect is inconsistent. These inconsistencies are due, at least in part, to differences in definitions of compensation (for example, claiming compensation versus using a lawyer), the use of different and poorly defined diagnoses (for example, back pain), a lack of control groups (many studies did not include uncompensated patients), and the lack of accounting for the many possible confounding factors (such as measures of injury severity or disease severity, and socio-economic and psychological factors). The literature review also highlighted the variety of different outcomes that had been used in previous studies, and the paucity of literature regarding the effect of compensation on general health outcomes. This thesis aims to explore the association between compensation status and health outcome after injury. It addresses many of the methodological issues of the previously published literature by, i selecting study populations of patients with measurable injuries, ii clearly defining and separating aspects of compensation status, iii including control groups of non-compensated patients with similar injuries iv allowing for a wide variety of possible confounders, and v using clearly defined outcome measures, concentrating on general health outcomes. Before commencing the clinical studies reported in Chapters Three and Four, a systematic review and meta-analysis was performed to quantify and analyse the effect of compensation on outcome after surgery. This allowed a clearly defined population of studies to be included, and was relevant to the thesis as the surgeries were performed as treatment of patients who had sustained injuries. The study, which is reported in Chapter Two, hypothesised that outcomes after surgery would be significantly worse for patients treated under compensation schemes. The study used the following data sources: Medline (1966 to 2003), Embase (1980 to 2003), CINAHL, Cochrane Controlled Trials Register, reference lists of retrieved articles and textbooks, and contact with experts in the field. The review included any trial of surgical intervention where compensation status was reported and results were compared according to that status, and no restrictions were placed on study design, language or publication date. Data extracted were study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type. Studies were selected by two unblinded independent reviewers, and data were extracted by two reviewers independently. Data were analysed using Cochrane Review Manager (version 4.2). Two hundred and eleven papers satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (worker's compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and one paper described a benefit associated with compensation. A meta-analysis of 129 papers with available data (20,498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval 3.28 to 4.37, random effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all sub-groups. This study concludes that compensation status is associated with poor outcome after surgery, and that this effect is significant, clinically important and consistent. Therefore, the study hypothesis is accepted. However, as data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Determination of the mechanism for the association between compensation status and poor outcome, shown in the literature review (Chapter One) and the systematic review (Chapter Two) required further study. Two studies were designed to further explore this association and these are reported in Chapters Three and Four. The retrospective study reported in Chapter Three, the Major Trauma Outcome Study (MTOS), aimed to explore the association between physical, psychosocial, and compensation-related factors and general health after major physical trauma. The primary hypothesis predicted significantly poorer health outcomes in patients involved in pursuing compensation, allowing for possible confounders and interactions. The study also examined other health outcomes that are commonly associated with compensation, and examined patient satisfaction. Consecutive patients presenting to a regional trauma centre with major trauma (defined as an Injury Severity Score greater than 15) were surveyed between one and six years after their injury. The possible predictive factors measured were: general patient factors (age, gender, the presence of chronic illnesses, and the time since the injury), injury severity factors (injury severity score, admission to intensive care, and presence of a significant head injury), socio-economic factors (education level, household income, and employment status at the time of injury and at follow-up), and claim-related factors (whether a claim was pursued, the type of claim, whether the claim had settled, the time to settlement, the time since settlement, whether a lawyer was used, and who the patient blamed for the injury). Multiple linear regression was used to develop a model with general health (as measured by the physical and mental component summaries of the SF-36 General Health Survey) as the primary outcome. The secondary outcomes analysed were: neck pain, back pain, post-traumatic stress disorder, and patient satisfaction. On multivariate analysis, better physical health was significantly associated with increasing time since the injury, and with lower Injury Severity Scores. Regarding psychosocial factors, the education level and household income at the time of injury were not significantly associated with physical health, but pursuit of compensation, having an unsettled claim, and the use of a lawyer were strongly associated with poor physical health. Measures of injury severity or socio-economic status were not associated with mental health. However, the presence of chronic illnesses and having an unsettled compensation claim were strongly associated with poor mental health. Regarding the secondary outcomes, increasing neck pain and back pain were both significantly associated with lower education levels and the use of a lawyer, but not significantly associated with claiming compensation. The severity of symptoms related to post-traumatic stress disorder was not associated with measures of injury severity, but was significantly and independently associated with the use of a lawyer, having an unsettled compensation claim, and blaming others (not themselves) for the injury. The strongest predictor of patients’ dissatisfaction with their progress since the injury was having an unsettled compensation claim, and as with the other secondary outcomes, patient satisfaction was not significantly associated with injury severity factors. Factors relating to the compensation process were among the strongest predictors of poor health after major trauma, and were stronger predictors than measures of injury severity. The hypothesis that general physical and mental health would be poorer in patients involved in seeking compensation for their injury was accepted. This study concludes that the processes involved with claiming compensation after major trauma may contribute to poor health outcomes. The prospective study reported in Chapter Four, the Motor Vehicle Accident Outcome Study (MVAOS), aimed to explore the effect of compensation related factors on general health in patients suffering major fractures after motor vehicle accidents (MVAs). The study hypothesized that general health would be poorer in patients claiming compensation for their injuries. Patients presenting to 15 hospitals with one or more major fractures (any long bone fracture, or fracture of the pelvis, patella, calcaneus or talus) after a motor vehicle accident were invited to participate in this prospective study. Initial data was obtained from the patient and the treating doctors. Both the patients and treating surgeons were followed up with a final questionnaire at six months post injury. General factors (age, gender, treating hospital, country of birth, presence of chronic illnesses and job satisfaction), injury factors (mechanism of injury, number of fractures, and the presence of any non-orthopaedic injuries), socioeconomic factors (education level, income, and employment status), and compensation-related factors (whether a claim was made, the type of claim, whether a lawyer was used, and who was blamed for the injury) were used as explanatory variables. The primary outcome was general health as measured by the physical and mental component summaries of the SF-36 General Health Survey. The secondary outcomes were neck pain, back pain, and patients’ ratings of satisfaction with progress and of recovery. Multiple linear regression was used to develop predictive models for each outcome. Completed questionnaires were received from 232 (77.1%) of the 301 patients included in the study. Poor physical health at six months was strongly associated with increasing age, having more than one fracture, and using a lawyer, but not with pursuit of a compensation claim. Poor mental health was associated with using a lawyer and decreasing household income. Increasing neck pain and back pain were both associated with the use of a lawyer and with lower education levels. Higher patient satisfaction and patient-rated recovery were both strongly associated with blaming oneself for the injury, and neither were associated with pursuit of compensation. Although the use of a lawyer was a strong predictor of the primary outcomes, the pursuit of a compensation claim was not remotely associated with these outcomes, and therefore the study hypothesis was rejected. The studies reported in this thesis are compared in the final chapter, which concludes that poor health outcomes after injury are consistently and strongly associated with aspects of the compensation process, particularly the pursuit of a compensation claim, involvement of a lawyer, and having an unsettled claim. Compensation systems may be harmful to the patients that these systems were designed to benefit. Identification of the harmful features present in compensation systems my allow modification of these systems to improve patient outcomes.

Work-related injuries and road traffic injuries are common causes of morbidity and are major contributors to the burden of disease worldwide. In developed countries, these injuries are often covered under compensation schemes, and the costs of administering these schemes is high. The compensation systems have been put in place to improve the health outcomes, both physical and mental, of those injured under such systems; yet there is a widespread belief, and some evidence, that patients treated under these schemes may have worse outcomes than if they were treated outside the compensation system. Chapter One of this thesis explores the literature pertaining to any effect that compensation may have on patient outcomes. It is noted that the concept of “compensation neurosis” dates from the nineteenth century, with such injuries as “railway spine”, in which passengers involved in even minor train accidents at the time, would often have chronic and widespread symptoms, usually with little physical pathology. Other illnesses have been similarly labelled over time, and similarities are also seen in currently diagnosed conditions such as repetition strain injury, back pain and whiplash. There are also similarities in a condition that has been labelled “shell shock”, “battle fatigue”, and “post-traumatic stress disorder”; the latter diagnosis originating in veterans of the Vietnam War. While there is evidence of compensation status contributing to the diagnosis of some of these conditions, and to poor outcomes in patients diagnosed with these conditions, there is little understanding of the mechanism of this association. In contrast to popular stereotypes, the literature review shows that malingering does not contribute significantly to the effect of compensation on health outcomes. Secondary gain is likely to play an important role, but secondary gain is not simply confined to financial gain, it also includes gains made from avoidance of workplace stress and home and family duties. Other psychosocial factors, such as who is blamed for an injury (which may lead to retribution as a secondary gain) or the injured person’s educational and occupational status, may also influence this compensation effect. The literature review concludes that while the association between compensation and health after injury has been widely reported, the effect is inconsistent. These inconsistencies are due, at least in part, to differences in definitions of compensation (for example, claiming compensation versus using a lawyer), the use of different and poorly defined diagnoses (for example, back pain), a lack of control groups (many studies did not include uncompensated patients), and the lack of accounting for the many possible confounding factors (such as measures of injury severity or disease severity, and socio-economic and psychological factors). The literature review also highlighted the variety of different outcomes that had been used in previous studies, and the paucity of literature regarding the effect of compensation on general health outcomes. This thesis aims to explore the association between compensation status and health outcome after injury. It addresses many of the methodological issues of the previously published literature by, i selecting study populations of patients with measurable injuries, ii clearly defining and separating aspects of compensation status, iii including control groups of non-compensated patients with similar injuries iv allowing for a wide variety of possible confounders, and v using clearly defined outcome measures, concentrating on general health outcomes. Before commencing the clinical studies reported in Chapters Three and Four, a systematic review and meta-analysis was performed to quantify and analyse the effect of compensation on outcome after surgery. This allowed a clearly defined population of studies to be included, and was relevant to the thesis as the surgeries were performed as treatment of patients who had sustained injuries. The study, which is reported in Chapter Two, hypothesised that outcomes after surgery would be significantly worse for patients treated under compensation schemes. The study used the following data sources: Medline (1966 to 2003), Embase (1980 to 2003), CINAHL, Cochrane Controlled Trials Register, reference lists of retrieved articles and textbooks, and contact with experts in the field. The review included any trial of surgical intervention where compensation status was reported and results were compared according to that status, and no restrictions were placed on study design, language or publication date. Data extracted were study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type. Studies were selected by two unblinded independent reviewers, and data were extracted by two reviewers independently. Data were analysed using Cochrane Review Manager (version 4.2). Two hundred and eleven papers satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (worker's compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and one paper described a benefit associated with compensation. A meta-analysis of 129 papers with available data (20,498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval 3.28 to 4.37, random effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all sub-groups. This study concludes that compensation status is associated with poor outcome after surgery, and that this effect is significant, clinically important and consistent. Therefore, the study hypothesis is accepted. However, as data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Determination of the mechanism for the association between compensation status and poor outcome, shown in the literature review (Chapter One) and the systematic review (Chapter Two) required further study. Two studies were designed to further explore this association and these are reported in Chapters Three and Four. The retrospective study reported in Chapter Three, the Major Trauma Outcome Study (MTOS), aimed to explore the association between physical, psychosocial, and compensation-related factors and general health after major physical trauma. The primary hypothesis predicted significantly poorer health outcomes in patients involved in pursuing compensation, allowing for possible confounders and interactions. The study also examined other health outcomes that are commonly associated with compensation, and examined patient satisfaction. Consecutive patients presenting to a regional trauma centre with major trauma (defined as an Injury Severity Score greater than 15) were surveyed between one and six years after their injury. The possible predictive factors measured were: general patient factors (age, gender, the presence of chronic illnesses, and the time since the injury), injury severity factors (injury severity score, admission to intensive care, and presence of a significant head injury), socio-economic factors (education level, household income, and employment status at the time of injury and at follow-up), and claim-related factors (whether a claim was pursued, the type of claim, whether the claim had settled, the time to settlement, the time since settlement, whether a lawyer was used, and who the patient blamed for the injury). Multiple linear regression was used to develop a model with general health (as measured by the physical and mental component summaries of the SF-36 General Health Survey) as the primary outcome. The secondary outcomes analysed were: neck pain, back pain, post-traumatic stress disorder, and patient satisfaction. On multivariate analysis, better physical health was significantly associated with increasing time since the injury, and with lower Injury Severity Scores. Regarding psychosocial factors, the education level and household income at the time of injury were not significantly associated with physical health, but pursuit of compensation, having an unsettled claim, and the use of a lawyer were strongly associated with poor physical health. Measures of injury severity or socio-economic status were not associated with mental health. However, the presence of chronic illnesses and having an unsettled compensation claim were strongly associated with poor mental health. Regarding the secondary outcomes, increasing neck pain and back pain were both significantly associated with lower education levels and the use of a lawyer, but not significantly associated with claiming compensation. The severity of symptoms related to post-traumatic stress disorder was not associated with measures of injury severity, but was significantly and independently associated with the use of a lawyer, having an unsettled compensation claim, and blaming others (not themselves) for the injury. The strongest predictor of patients’ dissatisfaction with their progress since the injury was having an unsettled compensation claim, and as with the other secondary outcomes, patient satisfaction was not significantly associated with injury severity factors. Factors relating to the compensation process were among the strongest predictors of poor health after major trauma, and were stronger predictors than measures of injury severity. The hypothesis that general physical and mental health would be poorer in patients involved in seeking compensation for their injury was accepted. This study concludes that the processes involved with claiming compensation after major trauma may contribute to poor health outcomes. The prospective study reported in Chapter Four, the Motor Vehicle Accident Outcome Study (MVAOS), aimed to explore the effect of compensation related factors on general health in patients suffering major fractures after motor vehicle accidents (MVAs). The study hypothesized that general health would be poorer in patients claiming compensation for their injuries. Patients presenting to 15 hospitals with one or more major fractures (any long bone fracture, or fracture of the pelvis, patella, calcaneus or talus) after a motor vehicle accident were invited to participate in this prospective study. Initial data was obtained from the patient and the treating doctors. Both the patients and treating surgeons were followed up with a final questionnaire at six months post injury. General factors (age, gender, treating hospital, country of birth, presence of chronic illnesses and job satisfaction), injury factors (mechanism of injury, number of fractures, and the presence of any non-orthopaedic injuries), socioeconomic factors (education level, income, and employment status), and compensation-related factors (whether a claim was made, the type of claim, whether a lawyer was used, and who was blamed for the injury) were used as explanatory variables. The primary outcome was general health as measured by the physical and mental component summaries of the SF-36 General Health Survey. The secondary outcomes were neck pain, back pain, and patients’ ratings of satisfaction with progress and of recovery. Multiple linear regression was used to develop predictive models for each outcome. Completed questionnaires were received from 232 (77.1%) of the 301 patients included in the study. Poor physical health at six months was strongly associated with increasing age, having more than one fracture, and using a lawyer, but not with pursuit of a compensation claim. Poor mental health was associated with using a lawyer and decreasing household income. Increasing neck pain and back pain were both associated with the use of a lawyer and with lower education levels. Higher patient satisfaction and patient-rated recovery were both strongly associated with blaming oneself for the injury, and neither were associated with pursuit of compensation. Although the use of a lawyer was a strong predictor of the primary outcomes, the pursuit of a compensation claim was not remotely associated with these outcomes, and therefore the study hypothesis was rejected. The studies reported in this thesis are compared in the final chapter, which concludes that poor health outcomes after injury are consistently and strongly associated with aspects of the compensation process, particularly the pursuit of a compensation claim, involvement of a lawyer, and having an unsettled claim. Compensation systems may be harmful to the patients that these systems were designed to benefit. Identification of the harmful features present in compensation systems my allow modification of these systems to improve patient outcomes.

Work-related injuries and road traffic injuries are common causes of morbidity and are major contributors to the burden of disease worldwide. In developed countries, these injuries are often covered under compensation schemes, and the costs of administering these schemes is high. The compensation systems have been put in place to improve the health outcomes, both physical and mental, of those injured under such systems; yet there is a widespread belief, and some evidence, that patients treated under these schemes may have worse outcomes than if they were treated outside the compensation system. Chapter One of this thesis explores the literature pertaining to any effect that compensation may have on patient outcomes. It is noted that the concept of “compensation neurosis” dates from the nineteenth century, with such injuries as “railway spine”, in which passengers involved in even minor train accidents at the time, would often have chronic and widespread symptoms, usually with little physical pathology. Other illnesses have been similarly labelled over time, and similarities are also seen in currently diagnosed conditions such as repetition strain injury, back pain and whiplash. There are also similarities in a condition that has been labelled “shell shock”, “battle fatigue”, and “post-traumatic stress disorder”; the latter diagnosis originating in veterans of the Vietnam War. While there is evidence of compensation status contributing to the diagnosis of some of these conditions, and to poor outcomes in patients diagnosed with these conditions, there is little understanding of the mechanism of this association. In contrast to popular stereotypes, the literature review shows that malingering does not contribute significantly to the effect of compensation on health outcomes. Secondary gain is likely to play an important role, but secondary gain is not simply confined to financial gain, it also includes gains made from avoidance of workplace stress and home and family duties. Other psychosocial factors, such as who is blamed for an injury (which may lead to retribution as a secondary gain) or the injured person’s educational and occupational status, may also influence this compensation effect. The literature review concludes that while the association between compensation and health after injury has been widely reported, the effect is inconsistent. These inconsistencies are due, at least in part, to differences in definitions of compensation (for example, claiming compensation versus using a lawyer), the use of different and poorly defined diagnoses (for example, back pain), a lack of control groups (many studies did not include uncompensated patients), and the lack of accounting for the many possible confounding factors (such as measures of injury severity or disease severity, and socio-economic and psychological factors). The literature review also highlighted the variety of different outcomes that had been used in previous studies, and the paucity of literature regarding the effect of compensation on general health outcomes. This thesis aims to explore the association between compensation status and health outcome after injury. It addresses many of the methodological issues of the previously published literature by, i selecting study populations of patients with measurable injuries, ii clearly defining and separating aspects of compensation status, iii including control groups of non-compensated patients with similar injuries iv allowing for a wide variety of possible confounders, and v using clearly defined outcome measures, concentrating on general health outcomes. Before commencing the clinical studies reported in Chapters Three and Four, a systematic review and meta-analysis was performed to quantify and analyse the effect of compensation on outcome after surgery. This allowed a clearly defined population of studies to be included, and was relevant to the thesis as the surgeries were performed as treatment of patients who had sustained injuries. The study, which is reported in Chapter Two, hypothesised that outcomes after surgery would be significantly worse for patients treated under compensation schemes. The study used the following data sources: Medline (1966 to 2003), Embase (1980 to 2003), CINAHL, Cochrane Controlled Trials Register, reference lists of retrieved articles and textbooks, and contact with experts in the field. The review included any trial of surgical intervention where compensation status was reported and results were compared according to that status, and no restrictions were placed on study design, language or publication date. Data extracted were study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type. Studies were selected by two unblinded independent reviewers, and data were extracted by two reviewers independently. Data were analysed using Cochrane Review Manager (version 4.2). Two hundred and eleven papers satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (worker's compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and one paper described a benefit associated with compensation. A meta-analysis of 129 papers with available data (20,498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval 3.28 to 4.37, random effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all sub-groups. This study concludes that compensation status is associated with poor outcome after surgery, and that this effect is significant, clinically important and consistent. Therefore, the study hypothesis is accepted. However, as data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Determination of the mechanism for the association between compensation status and poor outcome, shown in the literature review (Chapter One) and the systematic review (Chapter Two) required further study. Two studies were designed to further explore this association and these are reported in Chapters Three and Four. The retrospective study reported in Chapter Three, the Major Trauma Outcome Study (MTOS), aimed to explore the association between physical, psychosocial, and compensation-related factors and general health after major physical trauma. The primary hypothesis predicted significantly poorer health outcomes in patients involved in pursuing compensation, allowing for possible confounders and interactions. The study also examined other health outcomes that are commonly associated with compensation, and examined patient satisfaction. Consecutive patients presenting to a regional trauma centre with major trauma (defined as an Injury Severity Score greater than 15) were surveyed between one and six years after their injury. The possible predictive factors measured were: general patient factors (age, gender, the presence of chronic illnesses, and the time since the injury), injury severity factors (injury severity score, admission to intensive care, and presence of a significant head injury), socio-economic factors (education level, household income, and employment status at the time of injury and at follow-up), and claim-related factors (whether a claim was pursued, the type of claim, whether the claim had settled, the time to settlement, the time since settlement, whether a lawyer was used, and who the patient blamed for the injury). Multiple linear regression was used to develop a model with general health (as measured by the physical and mental component summaries of the SF-36 General Health Survey) as the primary outcome. The secondary outcomes analysed were: neck pain, back pain, post-traumatic stress disorder, and patient satisfaction. On multivariate analysis, better physical health was significantly associated with increasing time since the injury, and with lower Injury Severity Scores. Regarding psychosocial factors, the education level and household income at the time of injury were not significantly associated with physical health, but pursuit of compensation, having an unsettled claim, and the use of a lawyer were strongly associated with poor physical health. Measures of injury severity or socio-economic status were not associated with mental health. However, the presence of chronic illnesses and having an unsettled compensation claim were strongly associated with poor mental health. Regarding the secondary outcomes, increasing neck pain and back pain were both significantly associated with lower education levels and the use of a lawyer, but not significantly associated with claiming compensation. The severity of symptoms related to post-traumatic stress disorder was not associated with measures of injury severity, but was significantly and independently associated with the use of a lawyer, having an unsettled compensation claim, and blaming others (not themselves) for the injury. The strongest predictor of patients’ dissatisfaction with their progress since the injury was having an unsettled compensation claim, and as with the other secondary outcomes, patient satisfaction was not significantly associated with injury severity factors. Factors relating to the compensation process were among the strongest predictors of poor health after major trauma, and were stronger predictors than measures of injury severity. The hypothesis that general physical and mental health would be poorer in patients involved in seeking compensation for their injury was accepted. This study concludes that the processes involved with claiming compensation after major trauma may contribute to poor health outcomes. The prospective study reported in Chapter Four, the Motor Vehicle Accident Outcome Study (MVAOS), aimed to explore the effect of compensation related factors on general health in patients suffering major fractures after motor vehicle accidents (MVAs). The study hypothesized that general health would be poorer in patients claiming compensation for their injuries. Patients presenting to 15 hospitals with one or more major fractures (any long bone fracture, or fracture of the pelvis, patella, calcaneus or talus) after a motor vehicle accident were invited to participate in this prospective study. Initial data was obtained from the patient and the treating doctors. Both the patients and treating surgeons were followed up with a final questionnaire at six months post injury. General factors (age, gender, treating hospital, country of birth, presence of chronic illnesses and job satisfaction), injury factors (mechanism of injury, number of fractures, and the presence of any non-orthopaedic injuries), socioeconomic factors (education level, income, and employment status), and compensation-related factors (whether a claim was made, the type of claim, whether a lawyer was used, and who was blamed for the injury) were used as explanatory variables. The primary outcome was general health as measured by the physical and mental component summaries of the SF-36 General Health Survey. The secondary outcomes were neck pain, back pain, and patients’ ratings of satisfaction with progress and of recovery. Multiple linear regression was used to develop predictive models for each outcome. Completed questionnaires were received from 232 (77.1%) of the 301 patients included in the study. Poor physical health at six months was strongly associated with increasing age, having more than one fracture, and using a lawyer, but not with pursuit of a compensation claim. Poor mental health was associated with using a lawyer and decreasing household income. Increasing neck pain and back pain were both associated with the use of a lawyer and with lower education levels. Higher patient satisfaction and patient-rated recovery were both strongly associated with blaming oneself for the injury, and neither were associated with pursuit of compensation. Although the use of a lawyer was a strong predictor of the primary outcomes, the pursuit of a compensation claim was not remotely associated with these outcomes, and therefore the study hypothesis was rejected. The studies reported in this thesis are compared in the final chapter, which concludes that poor health outcomes after injury are consistently and strongly associated with aspects of the compensation process, particularly the pursuit of a compensation claim, involvement of a lawyer, and having an unsettled claim. Compensation systems may be harmful to the patients that these systems were designed to benefit. Identification of the harmful features present in compensation systems my allow modification of these systems to improve patient outcomes.

Doctor of Philosophy
Work-related injuries and road traffic injuries are common causes of morbidity and are major contributors to the burden of disease worldwide. In developed countries, these injuries are often covered under compensation schemes, and the costs of administering these schemes is high. The compensation systems have been put in place to improve the health outcomes, both physical and mental, of those injured under such systems; yet there is a widespread belief, and some evidence, that patients treated under these schemes may have worse outcomes than if they were treated outside the compensation system. Chapter One of this thesis explores the literature pertaining to any effect that compensation may have on patient outcomes. It is noted that the concept of “compensation neurosis” dates from the nineteenth century, with such injuries as “railway spine”, in which passengers involved in even minor train accidents at the time, would often have chronic and widespread symptoms, usually with little physical pathology. Other illnesses have been similarly labelled over time, and similarities are also seen in currently diagnosed conditions such as repetition strain injury, back pain and whiplash. There are also similarities in a condition that has been labelled “shell shock”, “battle fatigue”, and “post-traumatic stress disorder”; the latter diagnosis originating in veterans of the Vietnam War. While there is evidence of compensation status contributing to the diagnosis of some of these conditions, and to poor outcomes in patients diagnosed with these conditions, there is little understanding of the mechanism of this association. In contrast to popular stereotypes, the literature review shows that malingering does not contribute significantly to the effect of compensation on health outcomes. Secondary gain is likely to play an important role, but secondary gain is not simply confined to financial gain, it also includes gains made from avoidance of workplace stress and home and family duties. Other psychosocial factors, such as who is blamed for an injury (which may lead to retribution as a secondary gain) or the injured person’s educational and occupational status, may also influence this compensation effect. The literature review concludes that while the association between compensation and health after injury has been widely reported, the effect is inconsistent. These inconsistencies are due, at least in part, to differences in definitions of compensation (for example, claiming compensation versus using a lawyer), the use of different and poorly defined diagnoses (for example, back pain), a lack of control groups (many studies did not include uncompensated patients), and the lack of accounting for the many possible confounding factors (such as measures of injury severity or disease severity, and socio-economic and psychological factors). The literature review also highlighted the variety of different outcomes that had been used in previous studies, and the paucity of literature regarding the effect of compensation on general health outcomes. This thesis aims to explore the association between compensation status and health outcome after injury. It addresses many of the methodological issues of the previously published literature by, i selecting study populations of patients with measurable injuries, ii clearly defining and separating aspects of compensation status, iii including control groups of non-compensated patients with similar injuries iv allowing for a wide variety of possible confounders, and v using clearly defined outcome measures, concentrating on general health outcomes. Before commencing the clinical studies reported in Chapters Three and Four, a systematic review and meta-analysis was performed to quantify and analyse the effect of compensation on outcome after surgery. This allowed a clearly defined population of studies to be included, and was relevant to the thesis as the surgeries were performed as treatment of patients who had sustained injuries. The study, which is reported in Chapter Two, hypothesised that outcomes after surgery would be significantly worse for patients treated under compensation schemes. The study used the following data sources: Medline (1966 to 2003), Embase (1980 to 2003), CINAHL, Cochrane Controlled Trials Register, reference lists of retrieved articles and textbooks, and contact with experts in the field. The review included any trial of surgical intervention where compensation status was reported and results were compared according to that status, and no restrictions were placed on study design, language or publication date. Data extracted were study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type. Studies were selected by two unblinded independent reviewers, and data were extracted by two reviewers independently. Data were analysed using Cochrane Review Manager (version 4.2). Two hundred and eleven papers satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (worker's compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and one paper described a benefit associated with compensation. A meta-analysis of 129 papers with available data (20,498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval 3.28 to 4.37, random effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all sub-groups. This study concludes that compensation status is associated with poor outcome after surgery, and that this effect is significant, clinically important and consistent. Therefore, the study hypothesis is accepted. However, as data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Determination of the mechanism for the association between compensation status and poor outcome, shown in the literature review (Chapter One) and the systematic review (Chapter Two) required further study. Two studies were designed to further explore this association and these are reported in Chapters Three and Four. The retrospective study reported in Chapter Three, the Major Trauma Outcome Study (MTOS), aimed to explore the association between physical, psychosocial, and compensation-related factors and general health after major physical trauma. The primary hypothesis predicted significantly poorer health outcomes in patients involved in pursuing compensation, allowing for possible confounders and interactions. The study also examined other health outcomes that are commonly associated with compensation, and examined patient satisfaction. Consecutive patients presenting to a regional trauma centre with major trauma (defined as an Injury Severity Score greater than 15) were surveyed between one and six years after their injury. The possible predictive factors measured were: general patient factors (age, gender, the presence of chronic illnesses, and the time since the injury), injury severity factors (injury severity score, admission to intensive care, and presence of a significant head injury), socio-economic factors (education level, household income, and employment status at the time of injury and at follow-up), and claim-related factors (whether a claim was pursued, the type of claim, whether the claim had settled, the time to settlement, the time since settlement, whether a lawyer was used, and who the patient blamed for the injury). Multiple linear regression was used to develop a model with general health (as measured by the physical and mental component summaries of the SF-36 General Health Survey) as the primary outcome. The secondary outcomes analysed were: neck pain, back pain, post-traumatic stress disorder, and patient satisfaction. On multivariate analysis, better physical health was significantly associated with increasing time since the injury, and with lower Injury Severity Scores. Regarding psychosocial factors, the education level and household income at the time of injury were not significantly associated with physical health, but pursuit of compensation, having an unsettled claim, and the use of a lawyer were strongly associated with poor physical health. Measures of injury severity or socio-economic status were not associated with mental health. However, the presence of chronic illnesses and having an unsettled compensation claim were strongly associated with poor mental health. Regarding the secondary outcomes, increasing neck pain and back pain were both significantly associated with lower education levels and the use of a lawyer, but not significantly associated with claiming compensation. The severity of symptoms related to post-traumatic stress disorder was not associated with measures of injury severity, but was significantly and independently associated with the use of a lawyer, having an unsettled compensation claim, and blaming others (not themselves) for the injury. The strongest predictor of patients’ dissatisfaction with their progress since the injury was having an unsettled compensation claim, and as with the other secondary outcomes, patient satisfaction was not significantly associated with injury severity factors. Factors relating to the compensation process were among the strongest predictors of poor health after major trauma, and were stronger predictors than measures of injury severity. The hypothesis that general physical and mental health would be poorer in patients involved in seeking compensation for their injury was accepted. This study concludes that the processes involved with claiming compensation after major trauma may contribute to poor health outcomes. The prospective study reported in Chapter Four, the Motor Vehicle Accident Outcome Study (MVAOS), aimed to explore the effect of compensation related factors on general health in patients suffering major fractures after motor vehicle accidents (MVAs). The study hypothesized that general health would be poorer in patients claiming compensation for their injuries. Patients presenting to 15 hospitals with one or more major fractures (any long bone fracture, or fracture of the pelvis, patella, calcaneus or talus) after a motor vehicle accident were invited to participate in this prospective study. Initial data was obtained from the patient and the treating doctors. Both the patients and treating surgeons were followed up with a final questionnaire at six months post injury. General factors (age, gender, treating hospital, country of birth, presence of chronic illnesses and job satisfaction), injury factors (mechanism of injury, number of fractures, and the presence of any non-orthopaedic injuries), socioeconomic factors (education level, income, and employment status), and compensation-related factors (whether a claim was made, the type of claim, whether a lawyer was used, and who was blamed for the injury) were used as explanatory variables. The primary outcome was general health as measured by the physical and mental component summaries of the SF-36 General Health Survey. The secondary outcomes were neck pain, back pain, and patients’ ratings of satisfaction with progress and of recovery. Multiple linear regression was used to develop predictive models for each outcome. Completed questionnaires were received from 232 (77.1%) of the 301 patients included in the study. Poor physical health at six months was strongly associated with increasing age, having more than one fracture, and using a lawyer, but not with pursuit of a compensation claim. Poor mental health was associated with using a lawyer and decreasing household income. Increasing neck pain and back pain were both associated with the use of a lawyer and with lower education levels. Higher patient satisfaction and patient-rated recovery were both strongly associated with blaming oneself for the injury, and neither were associated with pursuit of compensation. Although the use of a lawyer was a strong predictor of the primary outcomes, the pursuit of a compensation claim was not remotely associated with these outcomes, and therefore the study hypothesis was rejected. The studies reported in this thesis are compared in the final chapter, which concludes that poor health outcomes after injury are consistently and strongly associated with aspects of the compensation process, particularly the pursuit of a compensation claim, involvement of a lawyer, and having an unsettled claim. Compensation systems may be harmful to the patients that these systems were designed to benefit. Identification of the harmful features present in compensation systems my allow modification of these systems to improve patient outcomes.

Introduction There is substantial evidence of an association between seeking financial compensation and poor injury recovery and Return to Work (RTW). The causal nature of this relationship remains complex and imprecise. Many compensation related measures are generic and do not encompass the complexity of scheme design or the socio-political environment in which they operate. This is particularly relevant in Australia where all states and territories provide access to financial compensation following motor vehicle related trauma. In addition, motor vehicle related trauma is a significant contributor to the burden of injury and work disability. Early identification of predictors (including compensation related factors) is essential for developing efficacious interventions and purposeful scheme policy and design to facilitate injury recovery and RTW. Accordingly, the overarching aim of this thesis is to explore the impact of seeking financial compensation on injury recovery following motor vehicle related orthopaedic trauma. Initially, Chapter 1 provides the background and historical context of how compensation schemes were thought to influence physical and psychological health. It includes an overview of the current burden of injury, and relevant scheme design. Given the background to this relatively new field of research, mixed methods were employed across three areas: a systematic review (Chapter 2); qualitative studies (Chapters 3 and 4); and an inception cohort study (Chapters 5-7). Methods and results In Chapter 2, the aim of the systematic review is to identify associations between specific compensation related factorsand health outcomes following musculoskeletal injury from prognostic and/or intervention studies. Searches were conducted using electronic medical journal databases. Selection criteria included: prognostic factors associated with validated health outcomes; six or more months follow up; and multivariate statistical analysis. Twenty nine articles were assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to determine evidence levels. The results are mixed. There is strong evidence of an association between compensation status and poorer psychological function; and legal representation and poorer physical function. There is moderate evidence of an association between compensation status and poorer physical function; and legal representation and poorer psychological function. There is limited evidence of an association between compensation status and increased pain. No studies reported positive associations between compensation status and a health or functional outcome. In Chapters 3 and 4, qualitative methods are used to examine the impact of seeking financial compensation with greater granularity. The aims are: firstly, to explore the factors that influence recovery from serious injuries, particularly differences between people with compensable and non-compensable injuries; and secondly, to understand people’s perceptions and experiences of the claims process after sustaining mild-moderate compensable injuries, and to explore ways to assist and improve those experiences. The first eight focus groups (34 attendees, 21 compensable) were conducted two to seven years post injury within the trauma service of a University Teaching Hospital. The second five focus groups (32 attendees) were conducted one year post injury within a single Compulsory Third Party (CTP) personal injury scheme. All were audio-recorded and transcribed. The methodology was based on a grounded theory approach using thematic analysis and constant comparison to generate coding categories for themes. Data saturation was reached. Analyst triangulation was used to ensure credibility of results. Key themes for the first series are: astrong sense of entitlement and injustice; a difficult claims and settlement process; an inability to move on with life during the claims process, an extreme dislike of medico-legal assessments; the necessity of legal representation to assist with the claims process; and a perceived lack of trust about having to prove an injury or disability (Chapter 3). Key themes for the second series are: complexity of the claims process; requirement of legal representation; injury recovery expectations; importance of timely healthcare decision making; and improvements for injury recovery. To assist with injury recovery, access to objective information about the claims process using online technology and social media was considered paramount (Chapter 4). In Chapters 5-7, an inception cohort study was conducted following moderate-severe injuries. The aims are: firstly, to investigate the predictors of seeking financial compensation, namely making a claim and seeking legal representation at six months (Chapter 5); secondly, to determine the predictors (including compensation related factors) of time to RTW (Chapter 6); and thirdly, to investigate the influence of seeking financial compensation (i.e. making a claim) on injury recovery. Admitted patients were recruited prospectively from two trauma hospitals with upper and/or lower extremity fractures following a motor vehicle crash. Baseline data were collected within two weeks of injury, follow up data at six, 12 and 24 months (by written questionnaire). Additional demographic and injury-related information was retrieved from hospital databases. Main outcomes were: time to RTW (number of days); Short Form-36 Version 2.0 (SF36v2), Physical/Mental Component Scores (PCS/MCS); Post Traumatic Stress Disorder (PTSD) Checklist Civilian Version (PCL-C); and Global Rating of Change (GRC) scale. Analysis involved: descriptive statistics for baseline characteristics; comparison of compensable and non-compensable participants with Analysis of Variance (ANOVA) and chi-squared tests; for predictors, logistic regression, Cox proportional hazards regression models, and linear mixed models were used. There were 452 participants. Baseline characteristics showed: mean age 40 years; 75% male; 74% working pre-injury; 30% in excellent pre-injury health; 56% sustained serious injuries (Injury Severity Score [ISS] 9-15); 61% had a low-middle range household income; 35% self-reported at-fault in the crash; and 61% made a claim at six months. Participant follow up data was available at six, 12 and 24 months for 301(67%), 271(60%), and 230(51%) respectively. Results showed that there are no significant differences in pre-injury or baseline health status between those who made a claim and those who did not, but these measures largely related to physical health. As an outcome, seeking financial compensation at six months is associated with a higher pre-injury Body Mass Index (BMI) rather than injury-related factors, and seeking legal representation at six months is solely related to socio-economic factors (Chapter 5). For those working pre-injury (n=334, 74%), a longer time to RTW is associated with greater injury severity and lower occupational skill levels; while a shorter time to RTW is associated with recovery expectations for usual activities within 90 days, full-time pre-injury work hours, and very good self-assessed pre-injury health status. Legal representation (analysed at six months only) is not associated with time to RTW (Chapter 6). As a predictor, seeking financial compensation is associated with poor injury recovery, mainly for mental health status (MCS) and PTSD (PCL-C). However, the differences are of marginal clinical significance. Irrespective of compensation status, the majority have poor injury recovery on all measures over time, especially for mental health (Chapter 7). Conclusions In summary, these results contribute to existing evidence that seeking financial compensation is associated with poor injury recovery, particularly mental health status. The causal nature of the relationship remains complex but it is posited that part of the explanation lies in scheme policy and design including legislative framework. Background pre-injury factors, namely pre-existing physical and mental health status, psychosocial and socioeconomic factors also play a role. There are opportunities to trial interventions that could improve injury recovery and/or decrease work disability. Collectively, these include screening for risk factors of poor recovery and/or RTW, access to early appropriate treatment and rehabilitation, and vocational rehabilitation for those most vulnerable. None of these are novel but they can be problematic to implement in a compensable environment.Reducing the adversarial aspects of the claims process is important and could possibly alleviate the need to seek legal representation. Some initiatives are likely to require legislative change but others could be implemented with moderate resources. Ongoing mixed methods and interdisciplinary research with an emphasis on modifiable factors is recommended.

Abstract Traumatic brain injury can be a catastrophe for an individual and a huge economic burden for a society. Such injuries are common especially among young men and as many as half of the patients are under the influence of alcohol at the time of injury. Traumatic brain injuries can also frequently cause epileptic seizures. On the other hand, epileptic seizures are often caused by alcohol. A significant reduction in the tax on alcohol in Finland in 2004 led to a 10% increase in its consumption at the population level and a considerable increase in mortality rate among patients with alcoholic liver diseases. The risk of subsequent epileptic seizures and traumatic brain injuries among intoxicated head trauma subjects has not been evaluated before. The present cohort consists of all subjects who were admitted to the emergency room at Oulu University Hospital in 1999 on account of head trauma. These subjects were then followed-up for 10 years, which enabled the effect of the tax reduction on the long-term outcome to be observed. The effect of being under the influence of alcohol at the time of the index head trauma on the onset of a new epileptic seizure problem and further traumatic brain injuries was investigated. The mortality rate among head trauma subjects with harmful drinking increased significantly after the reduction in the alcohol tax, and the subjects with recorded alcohol-related seizure problems experienced an increased risk of death after the price reduction. Head trauma under the influence of alcohol predicted both new-onset seizure problems and traumatic brain injury during the follow-up. The results are in accordance with the previous observations of a rapid increase in mortality among heavy drinkers following a sharp reduction in alcohol prices. Inebriated head trauma subjects have an increased risk of subsequent traumatic brain injury and epileptic seizure
Tiivistelmä Traumaattinen aivovamma voi olla potilaalle katastrofi ja yhteiskunnalle valtava taloudellinen tappio. Aivovammat ovat yleisiä erityisesti nuorilla miehillä, ja jopa puolet niistä tapahtuu alkoholin vaikutuksen alaisena. Aivovammat aiheuttavat usein epileptisiä kohtauksia, jotka toisaalta usein johtuvat alkoholista. Vuonna 2004 Suomessa tapahtunut mittava alkoholiveron alennus lisäsi väestötasolla alkoholin kokonaiskulutusta 10 % vuoden aikana. Kuolleisuus erityisesti alkoholimaksasairauksiin lisääntyi voimakkaasti. Aiemmin ei ole tiedetty humalassa ilmaantuneen pään vamman vaikutuksesta potilaan riskiin saada uusi aivovamma tai uusi epileptinen kohtaus. Tutkimuskohortin muodostivat vuonna 1999 Oulun yliopistollisen sairaalan päivystyksessä hoidetut päähän vammautuneet potilaat. Heitä seurattiin rekisteritietojen avulla vuoden 2009 loppuun, minkä ansiosta voitiin tutkia veronalennuksen vaikutusta potilaiden pitkäaikaisennusteeseen. Tutkimuksessa havainnoitiin humalassa tapahtuneen pään vamman vaikutusta epileptisen kohtauksen ja uuden aivovamman ilmaantumiseen seuranta-aikana. Haitallisesti alkoholia käyttävien päähän vammautuneiden potilaiden kuolleisuus lisääntyi merkitsevästi alkoholiveron alennuksen jälkeen. Myös alkoholiin liittyvän epileptisen kouristuksen sairastaneilla kuolleisuus lisääntyi merkitsevästi. Alkoholin vaikutuksen alaisena tapahtunut pään vamma oli riskitekijä uudelle epileptiselle kohtaukselle sekä uudelle aivovammalle seuranta-aikana. Tulokset vahvistavat aiempia havaintoja siitä, että alkoholin hinnan voimakas lasku lisää nopeasti alkoholin suurkuluttajien kuolleisuutta. Humalassa päätään loukanneella on lisääntynyt riski saada uusi aivovamma sekä uusi epileptinen kohtaus

Introdução: O Trauma and Injury Severity Score (TRISS) é considerado padrão ouro na análise de probabilidade de sobrevida do doente traumatizado, apesar de suas limitações. Vários têm sido os esforços na tentativa de torná-lo mais acurado, tendo em vista seu importante papel nos Programas de Melhoria de Qualidade em Trauma. Objetivos: Propor três novos ajustes à equação do TRISS e comparar suas performances com o TRISS e o TRISS-like originais e com esses índices e o NTRISS com coeficientes ajustados à população do estudo; identificar se a técnica de imputação múltipla aumenta a acurácia das equações derivadas de bancos de dados com perdas e comparar o desempenho dos novos modelos quando derivados e aplicados em diferentes grupos de vítimas traumatizadas. Método: Trata-se de um estudo multicêntrico, retrospectivo, com vítimas de trauma internadas no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC FMUSP) e no Centro de Trauma da Universidade da Califórnia San Diego Medical Center (UCSD MC), no período de 1º de janeiro de 2006 a 31 de dezembro de 2010. As informações dos doentes foram agrupadas em Bancos de Dados Derivação e Teste, sendo o primeiro utilizado para derivar as equações e o segundo para validar as equações geradas. Os coeficientes dos modelos foram estabelecidos pela análise de regressão logística. A curva Receiver Operating Characteristics (ROC) foi utilizada para avaliar a performance dos modelos e o algoritmo de DeLonge et al. para comparar as áreas sob as curvas (AUC). Resultados: A casuística foi composta de 2.416 doentes do HC FMUSP (São Paulo, Brasil) e 8.172 participantes do UCSD MC (San Diego, EUA). Os novos modelos propostos foram o NTRISS-like, que incluiu as variáveis Melhor Resposta Motora (MRM), Pressão Artéria Sistólica (PAS), New Injury Severity Score (NISS) e idade; o TRISS SpO2, com as variáveis Escala de Coma de Glasgow, PAS, saturação periférica de oxigênio (SpO2), Injury Severity Score, além da idade e o NTRISSlike SpO2 (MRM + PAS + SpO2 + NISS + idade). Todas as equações tiveram coeficientes ajustados para trauma contuso e penetrante. A técnica de imputação múltipla aplicada à derivação das equações não melhorou a acurácia dos modelos. Os modelos TRISS original, TRISS, TRISS-like e NTRISS com coeficientes ajustados e as novas propostas não apresentaram diferença estatisticamente significativa em sua performance. As novas equações ajustadas aos dados de São Paulo e as geradas com informações de San Diego apresentaram diferentes AUC ao serem aplicadas nos dois grupos de doentes dessas localidades. A acurácia sempre foi maior quando as equações foram aplicadas na população de San Diego. Conclusões: Os novos modelos apresentaram boa acurácia (cerca de 89,5%) e desempenho similar a outros ajustes do índice TRISS anteriormente publicados; portanto, podem ser utilizados nas avaliações de qualidade da assistência ao traumatizado. Os ajustes dos índices de probabilidade de sobrevida à realidade local de sua aplicação não melhoraram seu desempenho, resultado que reforça a incerteza sobre a necessidade desses ajustes, conforme o local de aplicação do índice.
Introduction: Trauma and Injury Severity Score (TRISS) is considered the \"gold standard\" in the analysis of survival probability of trauma patients, despite its limitations. There have been several efforts to make it more accurate because of its important role in Trauma Quality Improvement Programmes. Objectives: To propose three new adjustments to the TRISS equation and compare their performances with the TRISS and TRISS-like originals and these indices and NTRISS with coefficients adjusted to the study population; identify if the multiple imputation technique increases the accuracy of the equations derived from databases with missing; and to compare the performance of the new models when derivatives and applied to different groups of trauma patients. Methods: This is a multicenter, retrospective study with trauma victims admitted to the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC FMUSP) and the Trauma Center at the University of California San Diego Medical Center (UCSD MC) for the period between January 1st, 2006 and December 31st, 2010. The information of patients were grouped into two different databases: derivation and testing; the first one served to derive the equations and the second was used to validate the equations generated. The model coefficients were established by logistic regression analysis. Receiver Operating Characteristic curve (ROC) was used to evaluate the performance of the models and De Long et al. algorithm to compare the areas under the curves (AUC). Results: The casuistic consisted of 2,416 patients from HC FMUSP (São Paulo, Brazil) and 8,172 participants from UCSD MC (San Diego, USA). The new models proposed were NTRISS-like which included the variables Best Motor Response (BMR), Systolic Blood Pressure (SBP), New Injury Severity Score (NISS) and age; TRISS SpO2 that included the variables Glasgow Coma Scale, SBP, saturation of peripheral oxygen (SpO2), Injury Severity Score and age; and NTRISS-like SpO2 (BMR + SBP + SpO2 + NISS + age). All equations had adjusted coefficients for blunt and penetrating trauma. The multiple imputation technique applied in the derivation of the equations did not improve the accuracy of the models. The original TRISS, and TRISS, TRISS-like and NTRISS with adjusted coefficients and the new proposals showed no statistically significant difference in performance. The new equations fitted to the São Paulo data and generated with information from San Diego showed different AUC when applied in the two patient groups in these localities. The accuracy was always higher when the equations were applied to the population of San Diego. Conclusions: The new models demonstrated good accuracy (about 89.5%) and similar performance to other TRISS adjustments previously published, and may be used in assessments of quality of care for traumatized. The survival probability scores adjustments to the local reality of its application did not improve its performance, a result that reinforces the uncertainty about the need for such adjustments, as the application site index.

Severe perineal trauma with injury to the anal sphincter at childbirth can have a profound effect on the physical and psychological wellbeing of women. This thesis describes literature examining resulting outcomes including effects on body image. It describes patient-based outcome measures used to capture this information, and evaluation of their psychometric properties. Body Image can be defined as an individual's perceptions and feelings about their own body. There is a growing interest in how this concept can influence quality of life and psychosocial dysfunction in medical disorders. This thesis aimed to examine relationships between severity of perineal trauma, general and genital specific body image and potentially influences such as symptoms of pelvic floor dysfunction. No patient-reported outcome measure validated for use in women after anal sphincter injury exists and this thesis also aimed to psychometrically evaluate an existing electronic questionnaire, ePAQ (electronic personal assessment questionnaire), for this application. In the thesis, a retrospective review of body image and physical outcomes attending a perineal clinic shows over half of women report perceived changes in body image after anal sphincter injury, with negative effects on self-esteem. A prospective observational cohort study explored genital and general body image in primiparous women grouped according to degree of perineal trauma or caesarean delivery. Women completed the Female Genital Self Image Score, the modified Body Image Score, ePAQ and the Edinburgh Postnatal Depression Scale a mean of 15.5 weeks (standard deviation 1.6) after delivery. There were significant differences in genital body image scores between the groups, but not in general body image, with regression analysis showing the greatest influence on genital body image to be the anatomical extent of the trauma. Embedded into this study was the evaluation of reliability (internal consistency and test-retest) and validity (face, content and construct) of ePAQ in the group of women with anal sphincter tears. This thesis presents the first research to quantify issues surrounding severe perineal trauma and body image and demonstrates that more severe trauma leads to a poorer genital body image. It also reports psychometric evaluation of ePAQ in women after anal sphincter injury providing the first single instrument with validity and reliability for use in this context.

Thesis (M.S.)--Boston University
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In this pilot study, 28 subjects ages 0 to 6 years who had sustained head injuries were assessed as to their functional status at one and six months post hospital discharge. The functional assessments used were the Rand Child Health Scale, the Battelle Developmental Inventory Screening Test, the Battelle Developmental Inventory Motor Domain, and the Pediatric Evaluation of Disability Inventory. Correlations between these functional measures and trauma scores reported through the National Pediatric Trauma Registry (Glasgow Coma Scale; Injury Severity Score, and Pediatric Trauma Score) were calculated to determine the predictive capacity of the trauma scores in determining functional outcome. The trauma scores were not found to be reliable predictors of functional outcome in these young children.
2031-01-01

Nonaccidental trauma from child abuse presents unique challenges to the anesthesiologist. Diagnosing abuse is difficult because children may present with nonspecific symptoms and vague clinical histories. Multiple organ systems may be involved, but the greatest risk of death stems from abusive head trauma. Anesthesiologists must know the pediatric traumatic brain injury treatment guidelines and be prepared to treat the complex disease processes of child abuse and abusive head trauma. This chapter discusses anesthesia for nonaccidental pediatric trauma, including abusive head trauma. Topics covered include cervical instability, intracranial hypertension, seizures, and anesthetic agents. Debriefing after a poor outcome is also covered.

♦ This chapter reinforces that children are not small adults and the management of these injuries must consider the effect on growth and development♦ Nail bed injuries require microsurgical repair if permanent deformity is to be avoided♦ Every attempt should be made to replace amputated digits, whatever the level of amputation♦ Good results are the common outcome in children’s fractures unless complicated by surgical intervention or infection. However, angulation, rotation, and intra-articular deformities should be corrected where possible♦ All children with deep lacerations of the upper limb should have a general anaesthetic for adequate exploration and repair of the wound♦ A high index of suspicion of nerve injury should exist when assessing hand lacerations, and the outcome of early surgical repair is good.

Traumatic brain injury (TBI) accounts for the majority of traumatic deaths and most disability due to trauma in people aged less than 40 years old. Current trends suggest this burden of disease will increase dramatically over the next 20 years. Successful management of patients after traumatic brain injury requires recognition of patients at risk of deterioration, appropriate investigation, including imaging, and prevention of systemic and intracranial secondary injury processes. Unlike trauma affecting other body systems, outcome from TBI has not improved in the last 10–15 years. Assessment of a patient with traumatic brain injury includes clinical examination and diagnostic imaging both of which can be quantified or graded using scores such as the Glasgow Coma Score (GCS) and the Marshall score for grading cranial computed tomographic (CT) scans. Clinical examination and diagnostic imaging can both aid in prognostication (http://www.crash.lshtm.ac.uk/Risk%20calculator/).

Although medical management of traumatic brain injury (TBI) may have improved in developed countries, TBI is still a major cause of mortality and morbidity. The demographics are skewed towards the younger patient population, and affects males more than females, but in general follow a bimodal distribution with peaks affecting young adults and the elderly. As a result, the loss of functional years is devastating. Pathology due to brain trauma is a complex two-hit phenomenon, frequently divided into ‘primary’ and ‘secondary’ injury. Hypoxia, ischaemia, and inflammation all play a role, and the importance of each component varies between patients and in an individual patient over time. The initial injury may increase intracranial pressure and reduce cerebral perfusion due to the presence of mass lesions or diffuse brain swelling. Further secondary insults, such as hypotension, reduced cerebral perfusion pressure, hypoxia, or fever may exacerbate swelling and inflammation, and further compromise cerebral perfusion. Although there are currently no specific effective treatments for TBI, an improved understanding of the pathophysiology may eventually lead to treatments that will reduce mortality and improve long-term functional outcome.

The term ‘polytrauma’ refers to blunt (or crush) trauma that involves multiple body regions or cavities, and compromises physiology to potentially cause dysfunction of uninjured organs. Polytrauma frequently affects muscles resulting in rhabdomyolysis. In daily life, it mostly occurs after motor vehicle accidents, influencing a limited number of patients; after mass disasters, however, thousands of polytrauma victims may present at once with only surgical features or with additional medical complications (crush syndrome). Among the medical complications, acute kidney injury (AKI) deserves special mention, since it is frequent and has a substantial impact on the ultimate outcome.Several factors play a role in the pathogenesis of polytrauma (or crush)-induced AKI: (1) hypoperfusion of the kidneys, (2) myoglobin-induced direct nephrotoxicity, and intratubular obstruction, and also (3) several other mechanisms (i.e. iron and free radical-induced damage, disseminated intravascular coagulation, and ischaemia reperfusion injury). Crush-related AKI is prerenal at the beginning; however, acute tubular necrosis may develop eventually. In patients with crush syndrome, apart from findings of trauma, clinical features may include (but are not limited to) hypotension, oliguria, brownish discoloration of urine, and other symptoms and findings, such as sepsis, acute respiratory distress syndrome, disseminated intravascular coagulation, bleeding, cardiac failure, arrhythmias, electrolyte disturbances, and also psychological trauma.In the biochemical evaluation, life-threatening hyperkalaemia, retention of uraemic toxins, high anion gap metabolic acidosis, elevated serum levels of myoglobin, and muscle enzymes are noted; creatine phosphokinase is very useful for diagnosing rhabdomyolysis.Early fluid administration is vital to prevent crush-related AKI; the rate of initial fluid volume should be 1000 mL/hour. Overall, 3–6 L are administered within a 6-hour period considering environmental, demographic and clinical features, and urinary response to fluids. In disaster circumstances, the preferred fluid formulation is isotonic saline because of its ready availability. Alkaline (bicarbonate-added) hypotonic saline may be more useful, especially in isolated cases not related to disaster, as it may prevent intratubular myoglobin, and uric acid plugs, metabolic acidosis, and also life-threatening hyperkalaemia.In the case of established acute tubular necrosis, dialysis support is life-saving. Although all types of dialysis techniques may be used, intermittent haemodialysis is the preferred modality because of medical and logistic advantages. Close follow-up and appropriate treatment improve mortality rates, which may be as low as 15–20% even in disaster circumstances. Polytrauma victims after mass disasters deserve special mention, because crush syndrome is the second most frequent cause of death after trauma. Chaos, overwhelming number of patients, and logistical drawbacks often result in delayed, and sometimes incorrect treatment. Medical and logistical disaster preparedness is useful to improve the ultimate outcome of disaster victims.

Ocular trauma in childhood is common and may cause transient or permanent visual impairment. The anesthetic management of children with penetrating eye injuries presents several unique challenges, including potential associated injuries that may take precedence over the treatment of the eye injury, the prevention of aspiration of gastric contents, the regulation of intraocular pressure (IOP), and the prevention of the oculocardiac reflex (OCR). An understanding of the mechanisms and management of these potential problems can favorably influence surgical outcome.

Pelvic ring injuries can be life and limb threatening. The mechanism of injury can often be a good indicator of the type of injury; the Young & Burgess classification deploys that concept to full effect. Early identification based on mechanism of injury and improved prehospital care can play a major role in the outcome following such injuries. Pelvic ring injuries can lead to significant haemorrhage. Mechanical measures to stabilize the pelvis, in addition to modern concepts of damage control resuscitation (DCR), have been shown to be effective in early management of potentially life-threatening haemorrhage. Emphasis is now entirely on protecting the primary clot following a pelvic ring injury. Mechanical disturbance by log rolling the patient or springing of the pelvis are strongly discouraged. Early radiological clearance of the pelvis is encouraged. The lethal triad of coagulopathy, acidosis, and hypothermia should be corrected simultaneously to improve outcome. A traffic light system for monitoring venous lactate as an indicator of the patients’ physiological state can help the intensive care practitioner and the surgeon identify optimum timing for surgery. Pelvic ring injuries are associated with significant concomitant injuries. Limb trauma can also be life or limb threatening. Early identification, splinting, and resuscitation follow the same guidelines as pelvic ring injuries. Open long bone fractures should be managed by senior orthopaedic and plastic surgeons.

♦ Major trauma results in a systemic stress response proportional to both the degree of initial injury (1st hit) and the subsequent surgical treatment (2nd hit).♦ The key physiological processes of hypoxia, hypovolaemia, metabolic acidosis, fat embolism, coagulation and inflammation operate in synergy during the days after injury/surgery and their effective management determines prognosis.♦ The optimal timing and method of long bone fracture fixation after major trauma remains controversial. Two divergent views exist between definitive early intramedullary fixation and initial external fixation with delayed conversion to an intramedullary nail once the patient’s condition has been better stabilised.♦ There is agreement that the initial skeletal stabilisation should not be delayed and that the degree of initial injury has a more direct correlation with outcome and the development of subsequent systemic complications rather than the method of long bone fracture stabilisation.♦ Trauma patients can be screened to identify those more ‘at risk’ of developing systemic complications such as respiratory insufficiency. Specific risk factors include: A high injury severity score; the presence of a femoral fracture; the combination of blunt abdominal or thoracic injury combined with an extremity fracture; physiological compromise on admission and uncorrected metabolic acidosis prior to surgery.♦ The serum concentration of pro-inflammatory cytokine interleukin (IL) 6 may offer an accurate method of quantifying the degree of initial injury and the response to surgery.♦ The effective management of the polytraumatised patient involves a team approach and effective communication with allied specialties and theatre staff. A proper hierarchy of the injuries sustained can then be compiled and an effective surgical strategy made.

Infusion fluids may be regarded as drugs in the perioperative setting. The therapeutic effects of crystalloid solutions are strongly related to the administered volume, while fluids of the colloid type may also improve microcirculation and have anti-inflammatory properties. The anaesthetist should be able to handle all available infusion fluids and be aware of their benefits, limitations, and risks. Fluid administration programmes for surgery are traditionally based on a balance method in which perceived and measured losses are continuously replaced. Two outcome-guided approaches—restrictive and goal-directed fluid therapy—have been added in recent years. The latter places all patients on the top of the Frank–Starling curve by titrating repeated bolus infusions of colloid fluid while observing the stroke volume response. Areas where special consideration should be given to fluid therapy include burn injury, children, day surgery, endoscopic surgery, neurosurgery, induction of spinal and epidural anaesthesia, and in septic and trauma-related shock. As volume is the key component of infusion fluids, kinetic analysis of their disposition is based on their dilution effect on components already present in the blood, usually haemoglobin.

AbstractTraumatic dental injuries account for majority of maxillofacial injuries affecting soft tissues as well as maxillofacial bones. History of immediate local measures employed to reduce the severity of injury helps in eliciting information regarding the original condition of the injured area. Time elapsed post trauma plays a major role in determining outcome of the intervention. Goal of the treatment is directed towards achieving the pre-traumatic occlusion and intra arch contour.

AbstractA maxillofacial surgeon plays a vital role in not only restoring the structural form of the maxillofacial unit but also aims to restore the pre-traumatic functional status of the patient. Diagnosis and Clinical evaluation with enhanced treatment planning and restoration of aesthetics and function is the key for any maxillofacial surgery. However, it is not always possible to achieve the most appropriate results in all cases. It is not uncommon to see failure or more mediocre outcomes following maxillofacial trauma surgery. The outcome of the primary treatment may depend on factors like the extent of the injury/defect, delay in diagnosis/management, improper treatment plan, lack of use in modern diagnostic/treatment planning utilities, poor execution of treatment plan, inexperience of the surgeon leading to not expecting the eventful deformities, not coordinating with other specialists to yield the most standard and deserving treatment for the patient with restoration of both form and function. Residual deformities are seen following primary treatment of trauma due to one more reason mentioned earlier. Correction of such residual deformities may be challenging to the surgeon but very often a life-changing experience for patients. It is the experience of the surgeon that helps to recognise the challenges ahead in restoring the form and function. Residual deformities are often evaluated by the extent of deformities following primary management. Apart from reasons that may pertain to the experience of the operating surgeon, pathobiology of the healing zone may also contribute to the residual deformities. This chapter discusses in detail about the traumatic residual deformities and its management, also in brief about post-oncosurgical residual deformities.

This chapter discusses traumatic spinal cord and brain injuries. The first three studies review the background and key findings of the third National Acute Spinal Cord Injury Study (NASCIS) trial, examine the efficacy of the Canadian C-Spine Rule in the evaluation of cervical spine injuries in alert and stable trauma patients; and describe the development of the Thoracolumbar Injury Classification and Severity Score (TLICS) classification system. The next two studies assess the effect of early surgical decompression in patients with traumatic cervical spinal cord injury and delineate the role of secondary brain injury in determining patient outcome in severe traumatic brain injury. The following set of four studies evaluates the efficacy of phenytoin in preventing posttraumatic seizures, as well as the efficacy of intracranial pressure monitoring, induction of hypothermia, and decompressive craniectomy for severe traumatic brain injury. The last study, which is of historical value, identifies predictors of outcome in comatose patients with traumatic acute subdural hematoma.

Head trauma or traumatic brain injury (TBI) is one of the most serious, life-threatening conditions in trauma victims. Prompt and appropriate therapy is essential to obtain a favorable outcome. The aim of the acute care of patients with brain injury is to optimize cerebral perfusion and oxygenation and to avoid secondary brain injury. Secondary brain injury develops with times and cause further damage to nervous tissues. The common denominators of secondary injury are cerebral hypoxia and ischemia. A systemic approach such as the Advanced Trauma Life Support (ATLS) algorithm has been recommended for managing head injury patients. Quick initial assessment of the patient’s neurologic condition thoroughly is mandatory. There should be attention in evidence of intrathoracic or intraperitoneal hemorrhage in multiple traumatized patients. Optimizing the open airway and adequate ventilation depending on patient’s neurologic condition is first step in emergency therapy. Cerebral perfusion pressure should be maintained between 50 and 70 mmHg. Systemic hypotension is one of the major contributors to poor outcome after head trauma. Careful stabilization of the blood pressure with fluid resuscitation and a continuous infusion of an inotrope or vasopressor may be necessary. Standard monitoring with direct arterial blood pressure monitoring and periodical measurement of arterial blood gases, hematocrit, electrolytes, glucose, and serum osmolarity are important. Brain monitoring as with an electroencephalogram, evoked potentials, jugular venous bulb oxygen saturation (Sjo2), flow velocity measured by transcranial Doppler (TCD), brain tissue oxygenation (btPo2), and ICP monitoring may be used. The reduction of elevated ICP by means of giving barbituates, hyperventilation, diuretics and hyperosmolar fluid therapy, body posture and incremental CSF drainage are critical. Seizure prophylaxis, early enteral feeding, stress ulcer prophylaxis, prevention of hyperglycemic state, fever and prophylaxis against deep venous thrombosis in neurointensive care unit are also important after successful resuscitation of head trauma patients.

Traumatic brain injury (TBI) results from blunt trauma, acceleration–deceleration forces, rotational forces, or blast exposure to the head. The injury involves a heterogenous pattern of focal and/or diffuse axonal injury, leading to a wide range of symptoms. The severity of the injury covers the spectrum from mild to moderate to severe, with severe injury leading to possible coma and even death. The range of symptoms, the variability in treatment options, and the prognosis of TBI, as well as the psychosocial implications, make it a complex injury that often calls upon the services of neurosurgeons, neurologists, psychiatrists, psychologists, and rehabilitation specialists to help patients achieve the best possible outcome. This chapter aims to provide an overview of TBI that includes the classification, epidemiology, aetiology, pathophysiology, clinical symptoms, long-term outcome, diagnostic implications, and differential diagnosis, as well as possible treatment options and future directions for research.

Abstract Pancreatic and splenic trauma result from both blunt and penetrating injuries. The mechanism of injury is important in predicting the likelihood of trauma to these two organs. Because operative, non-operative, and interventional radiology play such an important role in the management of these injuries, diagnosis and classification of the injury based on anatomical and physiological factors are essential in planning surgery. The presence of injury to other organs is common and often determines the therapeutic approach and outcome. Non-operative management of isolated pancreas or spleen injuries is safe and effective when appropriate and done in the correct setting. The current body of evidence supporting the approaches to diagnosis and treatment described in this chapter lacks level 1 evidence but is based on multiple guidelines with lower levels of evidence.

This chapter focuses on brain trauma, which leads to a disruption of normal neurologic function. Before arrival in the hospital, a guideline-based treatment of traumatic brain injury (TBI) patients has to be initiated on-site. The patient then has to be transported to a specialized hospital equipped with a head computed tomography (CT), a neurosurgical department, and a neurointensive care unit. The chapter describes this process as well as the primary goals of maintaining an adequate perfusion and oxygenation of brain tissue. To achieve these goals, the intracranial pressure (ICP) and physiological variables should be kept within the normal range (homeostasis). This chapter also discusses complications like sepsis, pneumonia, and severe disturbances of coagulation, which should be prevented because they are independent predictors of adverse outcome.

The management of lower limb-threatening injuries is complex. Advances over the last few decades have provided the ability to salvage complex limb trauma but also have raised concerns that successful complex salvage surgery may not result in overall benefit for the patient. Surgical factors such as bony union, flap success, and a lack of complications are important but are not the sole factors upon which one can guide the patient toward their decision. The patient needs to know how the different treatments may affect their recovery, rehabilitation, return to work, and outcome. This chapter examines the indications and evidence for amputation and salvage by considering the importance of patient and injury-specific factors, biological and physiological variables, quality of life, patient satisfaction, and cost to the individual, hospital, and healthcare provider.

Head trauma is a traumatic injury to the skull and, when it reaches the brain, it can produce bleeding and clots. Depending on the severity of the trauma, it can generate physical sequelae and behavioral changes, which may appear soon after the trauma or in the medium term.PURPOSE: to verify the effects of electrical stimulation (NMES) and exercise in post-traumatic brain injury patients. A non-systematic review was performed based on randomized clinical trials in the PEDro and PubMed databases, published between 2009 and 2020. The articles with the highest score in the PEDro score were selected. The following keywords were used: traumatic brain injury. Six studies were selected. In one RCT, NMES induced reductions in chronaxis in the tibialis anterior, with a 1.5-day reduction in MV. An RCT, high-frequency or low-frequency NMES equally improved balance, dynamic gait and sleep quality, falls and headache frequency. In home patients, exercise increased functional reach testing and reduced Time Up and Go time. NMES improved post-void residual urine volume, void volume, maximum urinary flow rate, and Barthel Index scores after 8 weeks. Continuous cardiovascular reconditioning and moderate intensity improved cardiovascular fitness. There was no difference between groups in psychosocial functioning in either group. Rehabilitation of 4 h/day for 5 days/week improved functional independence. Intensive rehabilitation improves the early functional outcome of patients with TBI, but it must be continuous. Neurostimulation and exercise achieved significant improvements in strength, balance and gait, with different types of intervention in patients with head trauma. There is also an improvement in the cardiovascular response.

Personal body armor back-face dynamics are the driving force for behind armor blunt trauma. The potential timing for blunt force rib fracture was investigated using finite element analyses of soft and hard armor impacts against anterolateral ribs of a human body model. Armor back-face dynamics were acquired from experiments using soft and hard armor backed by gelatin and clay, respectively. Analysis of the simulations identified fracture-level maximum principal strain magnitudes for cortical rib tissue at times that were within the first tenth of the event and over 20 mm short of the peaks armor back-face displacement. These findings suggest early armor back-face dynamics play a role in blunt force injury outcome.

This study presents a novel approach for the quantification and classification of pulmonary contusion (PC). PC is a common thoracic injury, affecting up to 25% of patients sustaining blunt chest trauma. [1] Contusion volume at the time of hospitalization has been shown to be an independent predictor for the development of Acute Respiratory Distress Syndrome (ARDS), with the risk of ARDS increasing sharply with PC in excess of 20% by volume. [1] Despite the frequency of the injury and strong positive correlation between contusion volume and outcome, there are relatively few contusion quantification methods in the current literature. One such study utilized chest x-ray film to score PC according the amount of lung appearing to be damaged. [2] The study concluded that despite the limitations in using chest x-rays, a PC scoring system may be of value in determining the need for ventilator assistance and predicting outcome. A potentially more accurate approach to quantifying the severity of PC is through the use of computed tomography (CT) chest scans. CT is the preferred modality for obtaining volumetric pulmonary contusion data since the complete three-dimensional lung anatomy is captured. In this work a semi-automated approach is used to analyze PC in an isolated model of lung contusion in the rat. [3, 4] The CT-based approach enables the PC to be precisely quantified as the lesion progresses in time. The technique distinguishes the severity of the contusion by analyzing the composition of bands in the Hounsfield Unit (HU) range of lung image masks.

Blast induced neurotrauma (BINT), and posttraumatic stress disorder (PTSD) are identified as the “signature injuries” of recent conflicts in Iraq and Afghanistan. The occurrence of mild to moderate traumatic brain injury (TBI) in blasts is controversial in the medical and scientific communities because the manifesting symptoms occur without visible injuries. Whether the primary blast waves alone can cause TBI is still an open question, and this work is aimed to address this issue. We hypothesize that if a significant level of intracranial pressure (ICP) pulse occurs within the brain parenchyma when the head is subjected to pure primary blast, then blast induced TBI is likely to occur. In order to test this hypothesis, three post mortem human heads are subjected to simulated primary blast loading conditions of varying intensities (70 kPa, 140 kPa and 200 kPa) at the Trauma Mechanics Research Facility (TMRF), University of Nebraska-Lincoln. The specimens are placed inside the 711 mm × 711 mm square shock tube at a section where known profiles of incident primary blast (Friedlander waveform in this case) are obtained. These profiles correspond to specific field conditions (explosive strength and stand-off distance). The specimen is filled with a brain simulant prior to experiments. ICPs, surface pressures, and surface strains are measured at 11 different locations on each post mortem human head. A total of 27 experiments are included in the analysis. Experimental results show that significant levels of ICP occur throughout the brain simulant. The maximum peak ICP is measured at the coup site (nearest to the blast) and gradually decreases towards the countercoup site. When the incident blast intensity is increased, there is a statistically significant increase in the peak ICP and total impulse (p<0.05). Even after five decades of research, the brain injury threshold values for blunt impact cases are based on limited experiments and extensive numerical simulations; these are still evolving for sports-related concussion injuries. Ward in 1980 suggested that no brain injury will occur when the ICP<173 kPa, moderate to severe injury will occur when 173 kPa<ICP<235 kPa and severe injury will occur when ICP>235 kPa for blunt impacts. Based on these criteria, no injury will occur at incident blast overpressure level of 70 kPa, moderate to severe injuries will occur at 140 kPa and severe head injury will occur at the incident blast overpressure intensity of 200 kPa. However, more work is needed to confirm this finding since peak ICP alone may not be sufficient to predict the injury outcome.