The Impact of Multiple Extremity Injuries (MEI) on the
Severity of Trauma: Injury Severity Score in Patients Died from Head Injury
Amer Eitwati,* Kamal Salih
Mohamed,** Mohamed H Abed El-Latef,***
Abstract:
Objective: Orthopaedic
injuries do have a significant effect on the severity of head trauma. Trauma
systems based on breakdown of anatomic structure of organs and tissues, could
be used for objectification, comparison and establishing of severity of
injuries. The Injury Severity Score (ISS) and its new version (NISS) are
important tools for grading the severity of injury to trauma patients.
Purpose: The purpose of
this paper is to study the effect of fractures of extremities on trauma
severity in persons fatally injured in traffic accidents, and according to this
finding to point out the ISS and NISS values of critical injuries.
Materials
And Methods:
A retrospective study of all cases of road traffic accident (RTA) admitted to 2nd
March Hospital during a 12 month period (2003-2004) were analyzed. The
abbreviated injury score (AIS) of the most severe injury in each of the six
body regions was recorded under AIS score in the scoring table. The ISS and
NISS were then obtained.
Results: The present
study showed that the mean age is 30.7 ±20.2 years and the male to female ratio
is about 4:1. The most susceptible age group is between 21-30 years of age and
comprising 26.9% of total 160 cases. Children below 10 years constitutes 18% of
total cases. The mean ISS in our patients was 36.5 (SD ±8.97) and the mean NISS
is 44.97(SD±10.8). The ISS of patients without MEI (33.8±9.03) is lower than
the values in patients with MEI (37.9±8.49). However, the NISS is nearly the
same in patients with (44.3±10.1) and without (45.6±11.45) MEI. Children with
MEI have a higher ISS (40 versus 31) and NISS (47 versus 40) among the three
age groups. The ISS of adults and elderly patients with MEI is higher than
those who have no MEI (37.4 versus 34.8 and 37.8 versus 33.3). On the other
hand adults and elderly patients without MEI have NISS higher than those with
MEI ( 46 versus 43.1 and 47 versus 45.1). Critical (n= 195) and severe but not
life threatening (n=138) head and neck injuries are present in 40.2 % of the
total injuries. Multiple injuries of the extremities represents 21.1 %, of the
total injuries. Fifty percent of the patient have MEIs. These includes
fractures of upper (n=53) and lower limbs and pelvis (n=128).
Conclusion: The NISS is a
more accurate predictor of in-hospital death than the ISS and should be chosen
over the ISS for case-mix control in trauma research, especially in certain
subpopulations such as head/neck-injured patients.
Introduction:
The excessive costs of RTA, $100
billion and more than 150,000 deaths annually represents a major public health
dilemma to any nation either developed or developing. Indirect costs, include
rehabilitation costs, as well as direct costs, are incurred during the
post-trauma hospitalization.1
Trauma patients with multiple extremity injuries (MEI) make heavy
demands on hospital resources and face long-term difficulties in
rehabilitation.2 Accordingly, attention must focus on prevention of
injuries in the young and the elderly to reduce morbidity, mortality, and the
costs of trauma.3
It is now accepted that deaths
in the trauma setting can be prevented by an organized approach to care.
Multiple injury patients need fast and adequate help because of the high
mortality, especially in the first 24 hours.4 For example, Copeland
et al (1998)5 found a significant correlation between bilateral
femoral fractures and death.
Multiple extremity injuries (MEI
) have a significant effect on trauma outcomes such as length of hospital stay
(LOS), ICU admission and mortality rate.6
Although A1S and ISS
appropriately reflect the impact of extraskcletal injuries in patients with
certain fracture, e.g. femur fractures, they do nol adequately reflect the
increased morbidity associated with multiple lower extremity fractures.
Furthermore, the recognition of this high-risk group is not possible using the
traditional ISS alone from retrospective or prospective databases.2
*) Department of Surgery, Faculty
of Medicine, Sebha University, Sebha – Libya.
**) Dept. of Neurosurgery,
Faculty of Medicine, Sebha University, Sebha – Libya.
***) Department of Anatomy,
Faculty of Medicine, Sebha University, Sebha – Libya.
Osier,
Baker and Long (1997)7 found that a modification of the ISS called the New
Injury Severity Score (NISS) is more sensitive for mortality. Considering its
easier calculation and better predictive power, it is suggested that the NISS
should replace the traditional ISS in trauma outcome research.8
Furthermore, it has been confirmed that NISS performed the mortality prediction
in trauma patients better than ISS.9
Materials
and Methods:
160 (125 males and 35 females)
patients of road traffic accidents admitted and died in the 2nd
March Hospital. The accessible clinical medical data were analyzed for persons
fatally injured in road traffic accidents who survived trauma less than 15
days. The first step in the scoring was to grade all injuries for a given case
using the trauma chart.10 The AIS code of the most severe injury in
each of the six body regions was recorded under AIS score in the scoring table.
The ISS was then obtained by summing the squares of the highest AIS code in
each of the three most severely injured regions. NISS is obtained by the sum of
the squares of the AIS scores of each of a patient's three most severe AIS
injuries regardless of the body region in which they occur.7 The
values were expressed in means and slandered deviation and the results were
analyzed statistically using Chi -square test and T test.11
Results:
Most of the patients in this
series are males (n=125),with a male to female ratio of about 4:1. The age range
in this series is 1.5 to 80 years and the mean is 30.7+20.2 years. The most
susceptible age group involved is between 21-30 years of age comprising 26.9%
of total 160 patients. This group has a NISS (44) higher than their ISS( 37)
with a difference value of+7. Children below 10 years constitutes 18% of the
total and have NISS (48) higher than ISS (36) with a difference value of +12.
Patients above 70 years (71-80 years age group) constitute only sex patients,
i.e., 3.8% of total cases, and have ISS and NISS of 37 and 45 respectively with
a difference value +8 However, the difference between ISS and NISS in the whole
series range between +12 and +7. (Table 1,2).
The maximum ISS and NISS score
is 65 and 75 respectively. The ISS for all patients (n=160) is 36.5 (SD ±8.97)
with a range between 10 to 65 and the NISS is 44.97 (SD ±10.8) with a range
between 17 to 75 (Table I).
Table
3 showed that 50.6% (n=Sl) of the patients have an ISS of 31-40 and 45.6%
(n=73) of the patients have a NISS of 41-50. Twenty percent of the patients
(n=32) have NISS of 51 to 60, and only 4.4% have ISS of the same category.
Those who have NISS of more than 60 are 3.1% (n=5), while only one patient
(0.6%) has ISS more than 60. There is a
highly significant difference between ISS and NISS (X2= 20.31, P≤0.01). There
is 53 patients with identical NISS and ISS values (33.1%),(Table l).
The ISS of patients without MEI
(33.8±9.03) is lower than the values in patients with MEI (37.9±8.49). However,
the NISS is almost the same in patients with (44.3±10.1) and without
(45.6±11.45) MEI, (Table 4).
Children with MEI have a higher
ISS (40 versus 31) and NISS (47 versus 40) among the three age groups. The ISS
of adults and elderly patients with MEI is higher than those who have no MEI
(37.4 versus 34.8 and 37.8 versus 33.3). On the other hand adults and elderly
patients without MEI have NISS higher than those with MEI (46 versus 43 and 47
versus 45), (Table 5).
Table
1: Age, Sex, ISS and NISS
of
160 patient
|
Age (Years)
|
|
|
Range
|
1.5-80
|
|
Mean (SD)
|
30.7(SD ± 20.2)
|
|
Sex
|
|
|
Male
|
125
|
|
Female
|
35
|
|
Ratio
|
4:1
|
|
ISS
|
|
|
Range
|
10-65
|
|
Mean (SD)
|
36.5(SD ± 8.97)
|
|
NISS
|
|
|
Range
|
17-75
|
|
Mean (SD)
|
44.97(SD±10.8)
|
|
No. of identical ISS and NISS
|
53. (33.1%)
|
|
No. of discrepancies between
ISS and NISS
|
107 (66.9%)
|
According to the AIS score
287/933 of the injuries are severe but not life threatening while 211/933 were
critical. Head and neck injuries are present in 41.2 % of the total injuries,
the critical cases represent 50.8% (n= 195) and severe but not life threatening
is 35.9% (n=138). More than fifty percent of injuries of extremities are
moderate and 46.7% are severe not life threatening. Multiple injuries of the
extremities represents 21.1 %, of the total injuries. Fifty percent of the
patients have multiple extremity injuries. These includes lower limbs and
pelvic fractures (n=128) and fractures of upper (n=53). The most common
fractures in the lower limb are: fracture of fibula, tibia ,femur and pelvis
(n= 34, 29, 29, 17 respectively). The
most common fractures of the upper limb are: fracture of humerus, clavicle and
both bones of forearm (n=15.11,9 respectively), (Table 4, 6,7).
Table 2: Age distribution of 160 RTA patients
|
Age (Years (
|
No. of patients
|
ISS
|
NISS
|
%of patients
|
Difference
|
|
1-10
|
29
|
36
|
48
|
18
|
12
|
|
11-20
|
25
|
35
|
43
|
15.6
|
7
|
|
21-30
|
43
|
37
|
44
|
26.9
|
7
|
|
31-40
|
18
|
36
|
44
|
11.3
|
8
|
|
41-50
|
17
|
37
|
44
|
10.6
|
7
|
|
51-60
|
12
|
36
|
44
|
7.5
|
8
|
|
61-70
|
10
|
36
|
45
|
6.3
|
9
|
|
71-80
|
6
|
37
|
45
|
3.8
|
8
|
Table
3: Distribution of ISS and NISS in 160 fatal road traffic accidents.
|
|
10-20
|
21-30
|
31-40
|
41-50
|
51-60
|
61-70
|
71-75*
|
X2
|
|
ISS
|
12
(7.5%)
|
31
(%)
|
81
(50.5%)
|
28
(17.5%)
|
7
(4.4%)
|
1
(0.6%)
|
--
|
20.31**
|
|
NISS
|
4
(2.5%)
|
8
(5%)
|
36
(22.5%)
|
73
(45.6%)
|
32
(20%)
|
5
(3.1%)
|
2
(1.3%)
|
|
** Highly significant at level
1% (P ≤0.01)
*
Excluded from the statistical analysis
Table
4: The average ISS and NISS of MEI patients and those presented without MEI
injuries.
|
|
No.
|
%
|
Mean
ISS
|
T
test
|
Mean
NISS
|
T
test
|
|
Patients with MEI
|
80
|
50
|
37.9±8.49
|
2.92**
|
44.3±10.1
|
0.75
NS
|
|
Patients without MEI
|
80
|
50
|
33.8±9.03
|
|
45.6±11.45
|
|
** Highly
significant at level (P ≤0.01).
NS: not significant.
Table 5: The ISS and NISS in children. Adults and Elderly patients with and
without MEI
|
|
Patients with
MEI
|
Patients
without MEI
|
||||
|
|
No.
|
Mean ISS
|
Mean NISS
|
No.
|
Mean ISS
|
Mean NISS
|
|
Children
|
21
|
40
|
47
|
20
|
31
|
45
|
|
Adults
|
47
|
37.4
|
43
|
56
|
34.8
|
46
|
|
Elderly
|
12
|
37.8
|
45
|
4
|
33.3
|
47
|
Table
6: AIS scores by body regions (number of total injuries=933)
|
AIS
|
1
|
2
|
3
|
4
|
5
|
No.
|
%
|
|
Head /Neck
|
9
|
20
|
138
|
22
|
195
|
384
|
41.2
|
|
Face
|
6
|
83
|
6
|
--
|
--
|
95
|
10.2
|
|
Thorax
|
—
|
8
|
34
|
21
|
5
|
68
|
7.3
|
|
Abdomen
|
—
|
10
|
17
|
10
|
11
|
48
|
5.1
|
|
Extremities
|
—
|
105
|
|
--
|
--
|
197
|
21.1
|
|
External
|
—
|
141
|
—
|
--
|
--
|
141
|
15.1
|
|
Total
|
15
|
367
|
287
|
53
|
211
|
933
|
100
|
Table
7: The pattern of fractures in 160 patients.
|
Head and neck Fractures (n=137)
|
No.
|
Upper Limb Fractures (n=53)
|
No.
|
Lower Limb and pelvic
Fractures (n=128)
|
No.
|
|
Skull
|
110
|
Clavicle
|
11
|
Hip joint
|
5
|
|
Cervical spine
|
27
|
Humerus
|
15
|
Pelvis
|
17
|
|
|
|
Shoulder joint
|
1
|
Leg
|
4
|
|
|
|
Scapula
|
2
|
Tibia
|
29
|
|
|
|
Elbow
|
2
|
Knee
|
8
|
|
|
|
Forearm
|
9
|
Fibula
|
34
|
|
|
|
Radius
|
8
|
Foot
|
2
|
|
|
|
Ulna
|
4
|
Femur
|
29
|
|
|
|
Hand
|
1
|
|
|
Discussion:
Injury and deaths due to road
traffic crashes are a major public health problem in developing countries,
including sub-Saharan Africa.12 More than 80% of deaths in road
traffic accidents and more than 90% of those involving children occur in these
countries.13
The present study showed
that the mean age is 30.7 ±20.2 years and the male to female ratio is about
4:1. This dominance of males is readily explainable by the fact that males are
more exposed to hazards of roads as they constitute working and earning member
in majority of the families.14 However, Redmond et al (1990)15
found that, the male/female ratio was 2:1 and the mean age was 34 years. In
Nigeria, the mean age is 36.8 +/- 15.2 years for males and 45.5 +/- 23.0 years
for females.12
In this study, the most
susceptible age group is between 21-30 years of age and comprising 26.9% of
total 160 cases. Children below 10 years constitutes 18% of total cases.
Persons above 70 years (71-80 years age group) constitutes only six cases,
i.e., 3.8% of total patients. This is similar to the study ofAkash (2000),14
who found that the most vulnerable age group involved was between 21-30 years
of age comprising 38.52% of total 122 cases followed by the age group of 31-40
years comprising 19.67% of total cases. Children below 10 years constituted
only 2.45% of total cases. Persons above 80 years (81-90 years age group)
constituted only one case, i.e., 0.81% of total cases.
According to Collopy and his
group (1992),16 'Moderate' injury corresponded to ISS 8-13, 'severe'
to ISS 14-20 and 'critical' to ISS 21 and above. Also, Nikolic, Micic and
Mihailovic, (2001)17 found that the critical injury by ISS is 17.
Accordingly, most of our patients are belonging to the critical group, as the
mean ISS in our patients was 36.5 (SD ±8.97) and the mean NISS is 44.97(SD ±
10.8). In this series, 50.6% (n-8 !) of the patients have an ISS of 31-40 and
45.6% (n=73)of the patients have a NISS of 41-50. Twenty percent of the
patients (n=32) have NISS of 51 to 60, and only 4.4% have ISS of the same
category. Those who have NISS of more than 60 are 3.1% (n=5), while only one
patient (0.6%) has ISS more than 60. It has been found that the mean ISS score
for the 100 vehicular accident deaths was found to be 44 (range, 13-75).14
Furthermore, the median scores of the ISS and the NISS of non-survivors were 25
and 38 respectively.9
Akash (2000)14 showed
that victims with low ISS score had long survival period as compared to victims
with high ISS score who had short survival period. In this study, the mean
Injury Severity Score (ISS), is 36.5, with a range (10-65). This is in
agreement with the revised ISS based on autopsy review, in the series studied
by Marx et al (2004)18 where the ISS was 34.44. However.
Redmond et al (1990)15 who found that the mean ISS score was 9, with
a range 1-75 and there was a 33% mortality for patients with an ISS of 12 or
more.
The present study showed that
the ISS of patients without MEI (33.8±9.03) is lower than the values in
patients with MEI (37.9±8.49). However, the NISS is almost the same in patients
with (44.3±10.1) and without (45.6±11.45) MEI.19 found that, the
mean ISS was 25 +/- 13, and the mean NISS was 33 +/- 18. The discrepancy
between ISS and NISS is due to the presence of multiple orthopedic injuries.
Thirty-seven percent of patients had NISS that was higher than their ISS. These
patients had a significantly higher mortality and suffered worse functional
outcomes.20
NISS is not only simple to
calculate but more predictive of survival as well. Moreover, NISS provides a
better fit throughout its entire range of prediction. It has been concluded
that NISS should replace ISS as the standard summary measure of human trauma.7
The NISS often increases the apparent severity of injury and provides a more
accurate prediction of short-term mortality.15 In our series there
is 53 patients with identical NISS and ISS values (33.1%). According to
Brenneman and his colleagues (1998)15 patients with identical scores
had a lower mortality rate than patients with discrepant scores. In patients
with discrepant scores, the area under the receiver operating characteristic
curves was greater for the NISS than the ISS, and greater amounts of
discrepancy were associated with increasing rates of mortality.
The present study showed that
children with MEI have a higher ISS (40 versus 31) and NISS (47 versus 40)
among the three age groups. On the contrary, Moore et al. (1994)21
found that in 92% children injured in RTAs were of minor injuries and their ISS
were 9. The ISS of adults and elderly patients with MEI is higher than those
who have no MEI (37.4 versus 34.8 and 37.8 versus 33.3). On the other hand
adults and elderly patients without MEI have NISS higher than those with MEI.
(46 versus 43.1 and 47 versus 45.1).
According to the AIS score, the
present study showed that 287/933 of the injuries are severe but not life
threatening while 211/933 were critical. Head and neck injuries are present in
41.2 % of the total injuries, the critical cases represent 50.8% (n= 195) and
severe but not life threatening is 35.9% (n=138). Roberts et al (1991)22
found that the combination of head and lower limb injury was seen in 53%o of
patients admitted in a critical care department. Median injury severity score
(ISS) was 29, and 95%o of patients had an ISS of 16 or more. Life threatening
injuries were most commonly to the head, whilst less severe injuries, commonly
fractures, were to the limbs. Head and neck injuries were present in 80% of the
patients. Brain damage in multiple injury cases results in a high AIS. Since
the ISS is calculated by multiplication of AIS values, small differences in AIS
create considerable variations in ISS.4 The average NISS was also
significantly increased in the head injury group (6.54 vs 15,33).23
More than fifty percent of
injuries of extremities are moderate and 46.7% are severe not life threatening.
Multiple injuries of the extremities represents 21.1% of the total injuries.
Fifty percent of the patients have multiple extremity injuries. These includes
lower limbs and pelvic fractures (n=128) and fractures of upper (n=53). The
most common fractures in the lower limb are: fracture of fibula, tibia, femur
and pelvis (n=34, 29, 29, 17 respectively). The most common fractures of the
upper limb are: fracture of humerus, clavicle and both bones of forearm
(n=15.11,9 respectively.
Patients with bilateral femoral
fractures have a significantly higher risk of death, ARDS, and associated
injuries than patients with unilateral femoral fractures. This increase in
mortality is more closely related to associated injuries and physiologic
parameters than to the presence of bilateral femoral fractures. The presence of
bilateral femoral fractures should alert the clinician to the likelihood of
associated injuries, a higher Injury Severity Score, and the potential for a
more serious prognosis.5 However, the study of McKee et al (1997)24
revealed that fracture femur in a patient with a concomitant head injury does
not increase mortality or neurological disability.
Patients with orthopedic injury
have relatively worse functional recovery, and this worsens with time. As
trauma centers approach the limits of achievable survival, new advances in
trauma care can be directed more toward the quality of recovery for our
patients. This will be dependent on further development of screening, scoring,
and treatment systems designed to address issues of functional outcome across
injury boundaries for those who survive.25 Orthopedic injuries do
have a significant effect on trauma outcomes such as LOS and ICU
admission". Disregarding the anatomical regions makes calculation of the
NISS easier and gives extra accuracy to the new anatomic measure. The
traditional ISS should be replaced by the NISS in trauma-outcome research.8
Conclusion:
In the absence of facilities
such as emergency ultrasonography and CT scan, the correct value of ISS may not
always be calculated. ISS underestimates the severity of multiple
musculoskeletal injuries. The simple modification to NISS provides much more
useful predictive information on functional outcomes in survivors of trauma. It
has been concluded that the NISS performs as well as the ISS in pediatric
patients with lower injury severity and outperforms the ISS in those with higher
injury severity.
Furthermore, the NISS should be
chosen over the ISS for case-mix control in trauma research, especially in
certain subpopulations such as head/neck-injured patients.
Acknowledgments:
We would like to thank Dr. kamal
Marzook who did the statistical work in this paper.
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