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Acute Care for Traumatic Injuries and Surgical Outcomes

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Emergency Medicine".

Deadline for manuscript submissions: closed (31 March 2025) | Viewed by 11782

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Dr. Matthias Fröhlich

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Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, 51109 Cologne, Germany
Interests: orthopedics; trauma surgery; sports traumatology; polytrauma care; hip and knee; preclinical trauma care

Dr. Michael Caspers

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Guest Editor

1. Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, 51109 Cologne, Germany
2. Institute for Research in Operative Medicine (IFOM), Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke, Ostmerheimer Str., 200, 51109 Cologne, Germany
Interests: trauma surgery; polytrauma care; coagulation

Special Issue Information

Dear Colleagues,

This Special Issue focuses on the immediate management and treatment of traumatic injuries, as well as the subsequent surgical outcomes, resulting from accidents, falls, violence, or other forms of physical trauma. The field of acute care for traumatic injuries involves providing timely and specialized medical interventions to stabilize patients, prevent further damage, and optimize outcomes, which may include emergency resuscitation, diagnostic imaging, surgical interventions, pain management, and rehabilitation. Since the average life expectancy of global populations has been increasing in recent decades, doctors now often have to provide care for patients who suffer from several comorbidities, which may require specialized treatment algorithms for older patients.

By continually improving acute care protocols and surgical techniques, healthcare professionals aim to enhance patient outcomes, minimize complications, and improve the overall quality of life of individuals who have experienced traumatic injuries. With this purpose in mind, we cordially invite all authors to submit original or review articles to the Special Issue.

Dr. Matthias Fröhlich
Dr. Michael Caspers
Guest Editors

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

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Keywords

trauma injuries
orthopedics
polytrauma
emergency care
coagulation disorders
fractures
surgical outcomes
acute care
diagnostic imaging

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Published Papers (9 papers)

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Research

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12 pages, 1104 KiB

Open AccessArticle

Impact of Surgical Stabilization of Flail Chest Injuries on Postoperative Computed Tomography Lung Volumes

by Moses K. D. El Kayali, Georg Böning, Moritz Günther Mewes, Karl F. Braun, Karin Steinecke, Konrad Neumann, Ulrich Stöckle, Vera Jaecker and Marcel Niemann

J. Clin. Med. 2025, 14(11), 3644; https://doi.org/10.3390/jcm14113644 - 22 May 2025

Viewed by 139

Abstract

Background: Flail chest (FC) injuries are multiple adjacent segmental rib fractures, commonly associated with a high complication and mortality risk. Recent evidence suggests that the early surgical stabilization of FC injuries is beneficial for restoring breathing mechanics. However, little is known about the effects on lung volumes when invasive ventilation is performed after surgery. Methods: This retrospective study included multiple trauma (MT) patients operatively treated for an FC injury between 2011 and 2024. The indication for surgery was based on a computed tomography (CT) proof of an FC, objectifiable paradoxical breathing, and prolonged weaning. All patients treated used a single osteosynthesis system. Lung volumes were manually measured in preoperative and postoperative CT scans of the thorax in the thinnest CT reconstructions available. The primary outcomes of interest were the changes in the lung volumes following surgical stabilization of the FC. Results: During this study, 21 patients (90.48% male) were operatively treated for their FC injury. All patients had been affected by high-energy trauma. The corresponding median Injury Severity Score (ISS) was 26 (IQR 17.5, 33). Patients suffered 7 (IQR 6, 10) and 6 (IQR 2, 9) fractured ribs of the left and right hemithorax, respectively. Three (IQR 0, 3) and two (IQR 0, 3) ribs of the left and right hemithorax, respectively, were stabilized at 7 (IQR 2, 18) days post admission. There were no significant changes in the lung volumes comparing preoperative and postoperative CT scans. Conclusions: As this study did not detect CT volume changes comparing preoperative and postoperative scans, CT scans following surgery may not qualify for an objective measurement of the surgical effectiveness regarding lung volume restoration in the short-term follow-up. Long-term changes in CT-measured lung volume changes need to be evaluated to prove an objective surrogate parameter for surgical effectiveness regarding the restoration of the thorax integrity. Full article

(This article belongs to the Special Issue Acute Care for Traumatic Injuries and Surgical Outcomes)

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13 pages, 1707 KiB

Open AccessArticle

Determining the Optimal Cutoff Value for the Reverse Shock Index Multiplied by the Glasgow Coma Scale for the Prediction of In-Hospital Mortality in Pediatric Trauma Patients: A Retrospective Cohort Study

by Sol Ji Choi, Min Joung Kim, Ha Yan Kim, Shin Young Park, Yoo Seok Park, Moon Kyu Kim, Ji Hwan Lee and Seo Hee Yoon

J. Clin. Med. 2025, 14(9), 2994; https://doi.org/10.3390/jcm14092994 - 26 Apr 2025

Viewed by 238

Abstract

Background/Objectives: Despite the growing burden caused by pediatric trauma, the accuracy of prehospital triage remains suboptimal due to the lack of reliable pediatric-specific tools. In this study, we aimed to evaluate the predictive validity of the reverse shock index multiplied by the Glasgow Coma Scale (rSIG) for in-hospital mortality in pediatric trauma patients and to determine appropriate age-specific rSIG cutoff values for triage use. Methods: We conducted a multicenter retrospective observational study using data from the Korean Emergency Department-Based Injury In-Depth Surveillance registry; these data covered trauma patients aged ≤18 years, spanning the period from 2011 to 2022. The rSIG was calculated using the initial vital signs and Glasgow Coma Scale scores upon arrival at the emergency department. Age groups with shared rSIG cutoffs were identified using the area under the receiver operating characteristic curve (AUC) and Akaike information criterion. Cutoff values were derived using the Youden index or further optimized to align with triage goals (<5% under-triage, <35% over-triage). Results: Among 333,995 pediatric trauma patients, the in-hospital mortality rate was 0.07%. The rSIG cutoff values derived using the Youden index showed strong predictive performance, with an AUC of 0.920 (95% CI: 0.897–0.943). The cutoff values adjusted to meet triage goals—13.3 for those aged 0–9 years, 18.4 for 10–14 years, and 20.9 for 15–18 years—achieved the best balance, with 30.94% over-triage and 9.17% under-triage. Conclusions: The rSIG is a reliable predictor of in-hospital mortality in pediatric trauma cases. We recommend using cutoff values that are optimized to meet triage goals. Further research is warranted to develop standardized methods to derive triage-appropriate cutoff values. Full article

(This article belongs to the Special Issue Acute Care for Traumatic Injuries and Surgical Outcomes)

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18 pages, 1296 KiB

Open AccessArticle

Challenges in Saving Trauma Patients in Seoul Based on the 2016–2020 Community-Based Severe Trauma Survey

by Hoonsung Park, Seung Min Baik, Hangjoo Cho, Maru Kim and Jae-Myeong Lee

J. Clin. Med. 2025, 14(5), 1471; https://doi.org/10.3390/jcm14051471 - 22 Feb 2025

Viewed by 584

Abstract

Background/Objectives: The preventable trauma death rate (PTDR) reflects the quality of trauma management systems. In the Republic of Korea, the PTDR in Seoul, the capital city, decreased from 30.8% in 2015 to 20.4% in 2019. However, it remains the highest in the country. In contrast, Gyeonggi-Incheon, which includes Gyeonggi Province and Incheon Metropolitan City surrounding Seoul, had the lowest nationwide PTDR (27.4% in 2015 to 13.1% in 2019). This study aimed to investigate the characteristics and in-hospital mortality risk factors for patients with trauma in Seoul and Gyeonggi-Incheon. Methods: This retrospective cohort study used data from a 2016 to 2020 Community-Based Severe Trauma Survey. Among 237,616 patients, 24,448 were included in the study after applying the inclusion and exclusion criteria. Results: The proportions of the population with motor vehicle and workers’ compensation insurance increased with increasing injury severity in both regions. The injury severity score (ISS) was significantly higher in Gyeonggi-Incheon in the ISS < 9 and ISS 9–15 groups. Across all hospital levels, the proportion of patients who visited regional trauma centers in Seoul was low across all three ISS groups (0.2%[n = 26], 0.6%[n = 23], and 1.9%[n = 56] for ISS < 9, ISS 9–15, and ISS > 15, respectively). Conversely, in Gyeonggi-Incheon, the proportion of patients who visited regional trauma centers increased as injury severity increased across all three ISS groups (37.3%[n = 1404], 50.6%[n = 732], and 64.4%[n = 856] for ISS < 9, ISS 9–15, and ISS > 15, respectively). In Seoul, the identified in-hospital mortality risk factors included age, National Health Insurance (NHI) loss, other insurance, ISS, regional and local emergency centers or institutes, and the number of angioembolizations. In Gyeonggi-Incheon, the in-hospital mortality risk factors included age, ISS, falls and slippage, and the number of angioembolizations. Conclusions: The unique in-hospital mortality risk factors in Seoul compared with those in Gyeonggi-Incheon include transfers to regional emergency centers (ISS > 15), local emergency centers or institutes (ISS > 15), NHI loss (ISS 9–15 and ISS > 15), and the use of other insurance (ISS > 15). Full article

(This article belongs to the Special Issue Acute Care for Traumatic Injuries and Surgical Outcomes)

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12 pages, 429 KiB

Open AccessArticle

Optimizing Outcomes in Mangled Lower Extremity Reconstruction: Insights from a Retrospective Study of 93 Patients and Their Functional Scores

by Serdar Düzgün, Mehmet Taner Özdemir, Nurettin Manti, Nuri Koray Ülgen and Mehmet Orçun Akkurt

J. Clin. Med. 2025, 14(5), 1436; https://doi.org/10.3390/jcm14051436 - 21 Feb 2025

Cited by 1 | Viewed by 521

Abstract

Background/Objectives: Over the past 25 years, reconstructive techniques and patient management advancements have significantly improved outcomes in mangled lower extremity injuries. Functional results of limb salvage have been demonstrated to surpass those of primary amputations. Developments such as local fasciocutaneous flaps, vacuum-assisted closure, and hyperbaric oxygen therapy have enhanced the reconstructive ladder. Despite progress, the utility of the Mangled Extremity Severity Score (MESS) and Gustilo–Anderson classification remains debated, particularly in their prognostic value for limb salvage decisions. In the study, we aimed to evaluate the outcomes of optimizing mangled lower extremity reconstruction in 93 patients, focusing on their functional scores retrospectively. Methods: This retrospective study analyzed 93 patients treated for mangled lower extremities between January 2015 and October 2022. Patients were assessed for age, gender, injury location, MESSs, Gustilo–Anderson classifications, surgical methods, and functional outcomes using the Lower Extremity Functional Scale (LEFS). Surgical interventions included internal and external fixation, skin grafts, local flaps, muscle flaps, and free tissue transfer. LEFS scores were categorized into disability levels for functional evaluation. Correlations were drawn between LEFS and variables such as MESS, Gustilo–Anderson types, and nerve injuries. Results: Among the 93 patients, 16 had MESSs ≥ 7, and 77 had MESSs < 7. Reconstruction methods included local fasciocutaneous and muscle flaps (37 patients), free tissue transfer (29 patients), and skin grafting with vacuum-assisted closure (27 patients). Smoking was associated with delayed union and increased infection rates. LEFS scores were significantly lower in patients with MESSs ≥ 7, Gustilo grade 3C fractures, and tibial nerve injuries. Flap failures and a higher number of surgeries (>3) also correlated with poorer functional outcomes. The average soft tissue healing time was 18 days, and bone union time was 17 weeks. Conclusions: Lower extremity reconstruction demands precise surgical planning and execution, prioritizing functional restoration. MESSs and Gustilo–Anderson classifications provide practical frameworks but have limitations in predicting long-term functionality. Factors such as joint involvement, nerve injuries, and flap selection significantly influence outcomes. Smoking and delayed healing remain critical challenges. While free flaps are essential for complex defects, more straightforward methods yield better outcomes in suitable cases. LEFS emerged as a reliable tool. Full article

(This article belongs to the Special Issue Acute Care for Traumatic Injuries and Surgical Outcomes)

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8 pages, 502 KiB

Open AccessArticle

Epidemiology and Mortality of Surgical Amputations in Severely Injured Patients with Extremity Injuries—A Retrospective Analysis of 32,572 Patients from the TraumaRegister DGU^®

by Julian Scherer, Jakob Hax, Michel Paul Johan Teuben, Hans-Christoph Pape, Rolf Lefering and Kai Sprengel

J. Clin. Med. 2024, 13(22), 7000; https://doi.org/10.3390/jcm13227000 - 20 Nov 2024

Viewed by 1034

Abstract

Background: Extremity fractures are common injuries in polytraumatized patients. Concomitant injuries to the soft tissue, vessels and nerves in these fractures are defined as mangled extremities. The decision for or against limb salvage is dependent on the patient’s physiology and the limb status. In severely injured patients with critical physiological status, limb salvage may be contraindicated. International data on the epidemiology and management of mangled limbs in severely injured patients are lacking. Thus, the aim of this study was to assess the incidence of polytraumatized patients with severe injuries to either upper (UL) or lower limb (LL) as well as their management. Methods: A retrospective cohort analysis was conducted of patients aged 16 years and above with an Injury Severity Score (ISS) ≥ 16 who sustained fractures to the limbs and were admitted to a certified trauma center of the TraumaRegister DGU^® (TR-DGU) between 2009 and 2019. Results: In total, we assessed 32,572 patients (UL: 14,567, mean age 48.3 years, 70% male and LL: 18,005, mean age 47.0 years, 70.5% male) The mean ISS in UL was 28.8 (LL 29.3). Fractures to the humerus (n = 4969) and radius (n = 7008) were predominantly assessed in UL, and fractures to the femur (n = 9502) and tibia (n = 8076) were most common in LL. In both groups, the most frequent injury mechanism was motor vehicle accidents, and more than half (UL: 9416 and LL: 11,689) of the patients had additional severe Abbreviated Injury Scale (AIS) ≥ 3 chest trauma. 915 patients in UL and 1481 in LL died within 24 h of the index admission. Surgical amputation occurred in 242 (UL) and 422 (LL) cases with a peak ratio in patients with an ISS above 50 in both groups. In both groups, patients with severe concomitant chest trauma were more often surgically amputated. In both groups, fewer patients with surgical amputations died within 24 h of admission (3.3% vs. 6.3% UL; 6.4% vs. 8.3% LL) compared to patients without amputation, but more patients with surgical amputations died within the overall hospital admissions (15.7% vs. 11.9% UL; 19.2% vs. 14.2%). In both groups, hemodynamical shock as well as the administration of Packed Red Blood Cells (PRBCs) were associated with a higher amputation rate. Conclusions: Surgical amputations after major trauma seem to be rare. Hemodynamical instability seems to play a key role in the management of mangled limbs. Patients with life-saving surgical amputation still have an increased overall in-hospital mortality. Full article

(This article belongs to the Special Issue Acute Care for Traumatic Injuries and Surgical Outcomes)

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9 pages, 414 KiB

Open AccessArticle

The Efficacy of Intraosseous Access for Initial Resuscitation in Patients with Severe Trauma: A Retrospective Multicenter Study in South Korea

by Youngmin Kim, Seung Hwan Lee, Sung Wook Chang, Yo Huh, Sunju Kim, Jeong Woo Choi, Hang Joo Cho and Gil Jae Lee

J. Clin. Med. 2024, 13(13), 3702; https://doi.org/10.3390/jcm13133702 - 25 Jun 2024

Viewed by 1966

Abstract

Background/Objective: In patients with severe trauma, intraosseous (IO) access is an alternative when intravenous (IV) access proves challenging. However, detailed insights into its utilization patterns and effectiveness are lacking. This study aims to evaluate the use and efficacy of IO access in hemodynamically unstable patients with trauma at level-1 trauma centers in South Korea. Methods: Data from six centers over 12 months were analyzed, focusing on patients with traumatic cardiac arrest or shock. Overall, 206 patients were included in the study: 94 in the IO group and 112 in the IV group. Results: The first-attempt success rate was higher in the IO group than in the IV group (90.4% vs. 75.5%). The procedure time in the IO group was also shorter than that in the IV group. The fluid infusion rate was lower in the IO group than in the IV group; however, the use of a pressure bag with IO access significantly increased the rate, making it comparable to the IV infusion rate. Further, regarding IO access, a humeral site provided a higher infusion rate than a tibial site. Conclusions: IO access offers a viable alternative to IV access for the initial resuscitation in patients with trauma, providing advantages in terms of procedure time and first-attempt success rate. The use of a pressure bag and a humeral site for IO access afforded infusion rates comparable to those associated with IV access. Full article

(This article belongs to the Special Issue Acute Care for Traumatic Injuries and Surgical Outcomes)

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Review

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14 pages, 928 KiB

Open AccessReview

Conservative Treatment of Neonatal Brachial Plexus Palsy: A Narrative Review

by Valentina Boetto, Anna Markova, Federica Malgrati, Isabel Bongiovanni, Anna Bassetto, Chiara Pavese, Antonio Nardone, Giuseppe Massazza, Gabriele Colò and Paolo Titolo

J. Clin. Med. 2024, 13(24), 7826; https://doi.org/10.3390/jcm13247826 - 21 Dec 2024

Viewed by 1738

Abstract

Neonatal brachial plexus palsy (NBPP) is a flaccid paralysis of the upper limbs that occurs in about 0.4 percent of live births. This condition can produce permanent disabilities; to date, there is no consensus on protocols to be applied for the rehabilitation of children with this condition. The aim of this article is to provide a concise overview of conservative treatment beyond traditional physical therapy for the management of the child with NBPP and to offer a number of useful options for creating the most comprehensive and functional rehabilitation treatment possible. We conducted a narrative review after analyzing articles from the past 50 years on PubMed, Cochrane Library, Scopus, and Web of Science with the following search string [(“neonatal brachial plexus palsy” OR “obstetric brachial plexus palsy” OR “birth brachial plexus palsy”) AND (“rehabilitation” OR “physiotherapy” OR “conservative treatment”)]. We identified a potential of 1275 articles, but only 11 were exclusively about conservative approaches. The most represented rehabilitation approaches in the literature were botulinum toxin, constraint-induced movement therapy (CIMT), virtual reality, neuromuscular electrical stimulation, and kinesiotaping. In conclusion, the various rehabilitation approaches for NBPP are promising, but none can be considered the best option when used alone. In light of the current evidence, a multimodal approach is needed. Full article

(This article belongs to the Special Issue Acute Care for Traumatic Injuries and Surgical Outcomes)

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9 pages, 795 KiB

Open AccessReview

Heterotopic Ossifications Following Intramedullary Stabilization of Femoral Fractures in Polytraumatized Patients

by Gregor Wollner, Florian Hruska, Felix R. M. Koenig, Thomas Haider and Lukas L. Negrin

J. Clin. Med. 2024, 13(18), 5557; https://doi.org/10.3390/jcm13185557 - 19 Sep 2024

Cited by 1 | Viewed by 975

Abstract

Introduction: Heterotopic ossifications (HOs) are a well-known complication following total hip arthroplasty. Yet only little is known about the development of HOs following a femoral fracture and intramedullary stabilization in polytraumatized patients. Thus, the present study aimed to investigate whether the development of HOs is being observed more frequently in patients suffering polytrauma compared to those with single-extremity trauma. Materials and Methods: The retrospective outcome study was conducted at our level I trauma center. All patients admitted from 2010 to 2020 were included if they (1) presented with multiple injuries (≥2 body regions), (2) had an Injury Severity Score ≥16, (3) suffered a femoral fracture, and (4) were treated with intramedullary stabilization. Furthermore, a control group was established to match the polytrauma group (sex, age), who were suffering from single-extremity trauma (femoral fracture) which was treated with intramedullary stabilization. Subsequently, X-rays of the hip were performed and evaluated for up to one-year post-trauma. Results: Our study group consisted of 36 patients in total (91.7% male; mean age 39.4 ± 17.4 years, range: 18–82 years). The polytrauma (PT) group included 12 patients (mean age 39.5 years, median ISS 28), whereas the control group (single-extremity-trauma) included 24 patients (mean age 39.3 years). We documented HOs in nine (75%) patients in the PT group vs. five (20.8%) patients in the single-extremity group (p = 0.03). Conclusion: In this study, we were able to demonstrate that heterotopic ossifications are being observed significantly more frequently in patients suffering from polytrauma in comparison to patients with single-extremity trauma following intramedullary stabilization after a femoral fracture. Full article

(This article belongs to the Special Issue Acute Care for Traumatic Injuries and Surgical Outcomes)

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14 pages, 1671 KiB

Open AccessCase Report

Positive Outcomes Following Cervical Acceleration-Deceleration (CAD) Injury Using Chiropractic BioPhysics^® Methods: A Pre-Auto Injury and Post-Auto Injury Case Series

by Tim C. Norton, Paul A. Oakley, Jason W. Haas and Deed E. Harrison

J. Clin. Med. 2023, 12(19), 6414; https://doi.org/10.3390/jcm12196414 - 9 Oct 2023

Cited by 4 | Viewed by 3831

Abstract

This series illustrates how rear-end impact motor vehicle collisions (MVCs) alter the cervical spine’s alignment and demonstrates therapeutic use of cervical extension traction to improve lordotic alignment and other outcomes. This is a retrospective reporting of 7 adult patients (4 males and 3 females, 28–42 years) treated for cervical hypolordosis. These subjects received Chiropractic BioPhysics^® (CBP^®) rehabilitation and then were involved in a rear-end MVC. All cases had radiographic assessment that quantified the buckling of the cervical spine, presumably resulting directly from the CAD trauma. After an average of 3 years and 9 months (range: 1–7.6 years) following their initial program of care, the 7 patients sought care for a second time after the MVC. At this time, compared with their previously recorded post-treatment spine radiographs, there was an average 18.7° (range: 7.6–35.4°) reduction in cervical lordosis, a 9.2 mm (range: 3.6–19.8 mm) increase in anterior head translation (AHT), an 11.3° (range: 0.2–19.9°) decrease in the atlas plane line (APL), as well as a 35.7% (range: 22–52%) average neck disability index score (NDI) measured after the MVC. After the crash, a second round of CBP rehabilitation was administered, resulting in an average 15.1° improvement in cervical lordosis, 10.9 mm reduction in AHT, 10.4° increase in APL, and a 23.7% drop in NDI after an average of 35 treatments over 9 weeks. Treatment was universally successful, as an average 80% re-establishment of the lordosis toward its pre-injury state was found. There were no adverse events reported. This case series demonstrates that motor vehicle collisions may alter the alignment of the cervical spine. Rehabilitation of the cervical curve using extension traction improved the patients’ initial pre-crash alignments toward their pre-injury alignments and was likely responsible for improvement in the patients’ conditions. Clinical trials are needed to confirm these findings. Full article

(This article belongs to the Special Issue Acute Care for Traumatic Injuries and Surgical Outcomes)

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