Natural experiments in thoracic and upper extremity trauma research

Abstract

The overall aim of this thesis is to explore the value of natural experiments in orthopaedic trauma surgery. This is focused on thoracic and upper extremity injuries where, due to a lack of high quality evidence, there is a lot of practice variation, between national hospitals, and between countries such as the Netherlands and Switzerland. This thesis extends three parts. In the first part we will dive into thoracic trauma and affiliated fractures. We start with a clinical lesson in the assessment of rib fractures (Chapter 2). Then we investigate what the current evidence is on optimal treatment of rib fractures in elderly patients (Chapter 3). Chapter 4 is the primary study of this part as it is the first prospective natural experiment of this thesis which compares operative treatment to nonoperative treatment in patients with multiple rib fractures. We conclude part 1 with complementary studies which focuses solely on nonoperative treatment and outcomes (Chapter 5), the quality of life after rib fixation (Chapter 6) and then what the effect of rib fixation is on patients with affiliated clavicle fractures (Chapter 7) and scapula fractures (Chapter 8). In the second part we add an extra layer to the methodology and introduce the expert panel process to further reduce confounding. In Chapter 9 we discuss the research proposal of the natural experiment and in Chapter 10 we present the results of the second prospective natural experiment study of this thesis which compares operative treatment to nonoperative treatment in patients with proximal humerus fractures Part 3 solely consist of Chapter 11 where we discuss the Dutch trauma registry, which could be a potential basis for more data driven natural experiment trauma studies.