McMaster University

McMaster University

A traffic collision involving 2 white cars with x-ray images of broken limbs superimposed.

Road Traffic Accidents and Associated High-Energy Trauma

Principal Investigators

A photo link to the bio of Dr. Mohit Bhandari

Dr. Mohit Bhandari

A photo link to the bio of Dr. Brad Petrisor

Dr. Brad Petrisor

A photo link to the bio of Dr. Bill Ristevski

Dr. Bill Ristevski

A photo link to the bio of Dr. Gerard Slobogean

Dr. Gerard Slobogean

Current Research Initiatives



The INORMUS study is a large multi-centre, international, prospective cohort study that will include 40,000 patients with musculoskeletal trauma (fractures and/or dislocations) from Africa, Asia, and Latin America. The objective of the INORMUS study is to determine the incidence of major complications (mortality, re-operation and infection) and the factors associated with these major complications.


FLOW logo

Using a 2×3 factorial randomized trial design in 2,500 patients who were treated operatively for open fractures, this study will investigate the effect of different irrigation solutions (soap versus saline) and irrigation pressure (high pressure versus low pressure versus gravity flow) on patient important outcomes.


FAITH-2 logo

The FAITH-2 trial seeks to identify a surgical and nutritional strategy to minimize fracture fixation complications and to optimize bone health in order to improve patient outcomes in non-geriatric patients with hip fractures (femoral neck fractures). FAITH-2 will utilize a 2x2 factorial randomized design, we will compare two surgical implants (sliding hip screws versus cancellous screws) AND nutritional supplementation (vitamin D3 4,000 international units per day for six months versus placebo) on patient important complications and quality of life in 807 non-geriatric (ages 18 to 60 years) femoral neck fracture patients


Distractions on the Road: Injury eValuation in Surgery And FracturE clinics (DRIVSAFE): Our proposed cross-sectional study aims to assess the burden of distracted driving on patients who present to orthopaedic fracture clinics.  Specifically, the primary aims of the study are to determine: (1) what proportion of patients present with a musculoskeletal injury that was the direct or indirect result of distracted driving; and (2) what types and severity of injuries can distracted driving lead to. Our secondary aims include evaluating (1) the types and frequency of distracted driving in fracture patients and (2) the types and frequency of distracted driving witnessed by fracture patients in other drivers. 



Trauma is the leading cause of death in the first four decades of life, surpassed only by cancer and atherosclerosis as the major cause of death in all age groups. For every person killed as a result of an injury, threefold more survive and are left permanently disabled. Musculoskeletal injuries, such as fractures and dislocations, are very common manifestations of trauma. The Canadian Institute for Health Information reports 119,301 musculoskeletal injury-related hospitalizations annually in Canada. Globally, trauma-related care costs are over 100 billion dollars per year. Our research in road traffic and associated high energy trauma encompasses three research programs, each of which are described in more detail below.

Global Trauma

January 1st, 2011 marked the beginning of the United Nations and World Health Organization’s collaboration for improving education, reducing mortality, and developing primary preventative strategies for road traffic injuries worldwide. The World Health Organization’s Global Road Traffic Safety Report recommended a major focus on research and interventions in developing nations, as over 90 percent of the world’s fatalities on the roads occur in low-income and middle-income countries (LMIC). In contrast to the declining rates of injury seen in Western countries, LMICs are experiencing an increase in injury rates, largely due to increased motorization in these countries. Furthermore, the quality of fracture care is widely variable among LMICs. Previous attempts to characterize the fracture burden in many of these countries have proven inadequate because most LIMCs lack prospective registries to document the volume of injuries, the treatments chosen, and the outcomes achieved. Of the studies that have been performed, most have been limited by insufficient sample size, scope, and generalizability. As a result, the true burden of orthopaedic injuries in many countries remains to be explored. Identification of common trends in diagnosis, management, complications, and outcomes of orthopaedic trauma is the first step toward resolving disparities in global fracture burden.

Distracted Driving

According to statistics from the National Highway Traffic Safety Administration and from the Canadian provincial governments, distracted driving is a factor in approximately 4 million motor vehicle crashes in North America each year, where distracted drivers are three times more likely to be in a crash with a high risk of fatality. Traffic collision-related health care costs and lost productivity are causing economic losses of at least $10 billion annually. Furthermore, the use of mobile devices while driving is increasing substantially across North America, augmenting the risk of injury due to collision and road fatalities. While there is a growing body of research linking collision with mobile use, there is a lack of evidence describing the burden of distracted driving outcomes, including musculoskeletal injuries and their sequelae.

To enhance this body of research, the Centre for Evidence-Based Orthopaedics is developing a program of research concerning distracted driving in the orthopaedic field. In our research program, we are planning to first conduct a systematic review evaluating the available literature followed by a cross-sectional study in orthopaedic fracture clinics . The cross-sectional study will evaluate the prevalence of distracted driving, its contributing factors and subsequent outcomes (associated burden). Next steps will involve a video study using randomly selected road intersection footage to assess distracted driving across Canada and a focus group study to inform knowledge translation interventions for injury prevention.

Open Fractures

High energy fractures are often a result of road traffic accidents and these fractures are often severely displaced; a state in which the fracture ends are widely separated from each other. The displacement necessitates internal fixation surgery where the fracture ends are put together and a metal implant is inserted into the bone to secure the fracture. Unfortunately, complications following internal fixation are common and include implant failure, infection, and nonunion of the fracture. The best methods of treating these challenging fractures remain unknown.

High energy open fractures (fractures that break through the skin) are common manifestations of trauma. Open fractures account for an estimated 250,000 fractures in North America annually. These open fractures are often complicated by infections, wound healing problems, and failure of fracture healing. Infection is estimated to occur in up to 50% of open fractures that are severe or become grossly contaminated due to the mechanism of their injury. The additional treatment required to treat infections, as well as wound and bone healing complications represents a significant increase to health care cost, and a significant impact on the patients’ quality of life. The optimal method of treating open fracture wounds remains unknown.

High Energy Hip Fractures

Hip fractures predominately affect elderly people; however, it is estimated that over 300,000 hip fractures occur worldwide in patients under the age of 50 annually. Research has also shown that fracture patients are vitamin D insufficient and may therefore be at risk for fracture healing complications. These fractures are particularly devastating for younger aged (non-geriatric) patients, causing profound impairments of quality of life and function. The optimal method of fixing hip fractures (femoral neck fractures) in non-geriatric patients remains highly controversial in the surgical community.

Based upon the rationale above, the specific objectives of our research program in road traffic and associated high energy trauma are:

  • To explore the factors associated with major outcomes following fracture treatment in low-middle income countries.
  • To compare optimal wound irrigation strategies for the initial treatment of severe open fracture wounds.
  • To determine the optimal treatment methods for high energy fractures.

Recent Publications

  • Can J Surg. 2013 Oct;56(5):E114-20.

    Development and preliminary validation of a Function IndeX for Trauma (FIX-IT).

  • BMC Musculoskelet Disord. 2013 Mar 22;14(1):103.

    Predictors of nonunion and reoperation in patients with fractures of the tibia: an observational study.

  • J Orthop Trauma. 2013 Mar;27(3):177-81.

    Loss of follow-up in orthopaedic trauma: is 80% follow-up still acceptable?

  • J Orthop Trauma. 2013 Sep:27(9):e213-9.

    Assessment Group for Radiographic Evaluation and Evidence (AGREE) Study Group. Assessment of radiographic fracture healing in patients with operatively treated femoral neck fractures.

  • J Orthop Trauma. 2013 Apr;27(4):183-8.

    (Sample) size matters! An examination of sample size from the SPRINT Trial.

  • J Bone Joint Surg Am. 2012 Oct 3;94(19):1786-93.

    Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) Investigators. Prognostic factors for predicting outcomes after intramedullary nailing of the tibia.

  • J Knee Surg. 2012 Nov;25(5):397-402.

    Suture repair versus arrow repair for symptomatic meniscus tears of the knee: a systematic review.

  • Lancet. 2012 Sep 22;380(9847):1109-19.

    Advances and future directions for management of trauma patients with musculoskeletal injuries. Lancet.

  • Acta Orthop. 2012 Jun;83(3):317-8.

    Plate fixation or intramedullary fixation of humeral shaft fractures - an update

  • J Trauma. 2011 Sep;71(3):596-606.

    Fluid lavage of open wounds (FLOW): A multicenter, blinded, factorial pilot trial comparing alternative irrigating solutions and pressures in patients with open fractures.

  • Value Health. 2011 Jun;14:450-7.

    Economic Evaluation of Reamed versus Unreamed Intramedullary Nailing in Patients with Closed and Open Tibial Fractures: Results from the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT).

  • J Bone Joint Surg Am. 2008;90(12):2567-2578.

    Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures.

  • Journal of Hand Surgery

    Radiographic Arthrosis After Elbow Trauma: Interobserver Reliability.

  • JBJS

    Variability in the Definition and Perceived Causes of Delayed Unions and Nonunions: A Cross-Sectional, Multinational Survey of Orthopaedic Surgeons

  • Journal of Shoulder and Elbow Surgery

    The radiographic quantification of scapular malalignment after malunion of displaced clavicular shaft fractures

  • Journal of Orthopaedic Trauma

    Development and validation of an instrument to predict functional recovery in tibial fracture patients: The somatic pre-occupation and coping (SPOC) questionnaire

  • Journal of Orthopaedic Trauma

    The Pilon Map: Fracture Lines and Comminution Zones in OTA/AO Type 43C3 Pilon Fractures

  • Trials

    The impact of clinical data on the evaluation of tibial fracture healing.

  • Journal of Orthopaedic Trauma

    Nonoperative treatment for acute scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials.

  • Journal of Orthopaedic Trauma

    Radial head and neck fractures: Functional Results and predictors of outcome

  • BMC Musculoskeletal Disorders

    Comparison of published orthopaedic trauma trials following registration in

  • Journal of Orthopaedic Trauma

    The influence of large clinical trials in orthopedic trauma: do they change practice

  • Journal of Shoulder and Elbow Surgery

    The radiographic quantification of scapular malalignment after malunion of displaced clavicular shaft fractures

  • Journal of Epidemiology

    Outcomes assessment in the SPRINT multicenter tibial fracture trial: Adjudication committee size has trivial effect on trial results

  • Journal of Orthopaedic Trauma

    External fixation versus internal fixation for unstable distal radius fractures: a systematic review and meta-analysis of comparative clinical trials

  • Journal of Trauma and Acute Care Surgery

    A systematic review of early versus delayed wound closure in patients with open fractures requiring flap coverage

  • Sao Paulo Medical Journal

    Collaborative multicenter trials in Latin America: challenges and opportunities in orthopedic and trauma surgery

  • JBJS

    Efficacy and Safety of Recombinant Human Bone Morphogenetic Protein-2/Calcium Phosphate Matrix for Closed Tibial Diaphyseal Fracture: A Double-Blind, Randomized, Controlled Phase-II/III Trial


    A call to research: Documenting the non-fatal outcomes of injury

  • Clinical Orthopaedics and Related Research

    Cochrane in CORR ®: Surgical Versus Conservative Interventions for Treating Fractures of the Middle Third of the Clavicle


    Measuring foot and ankle injury outcomes: common scales and checklists

  • Canadian Journal of Surgery

    Low-intensity pulsed ultrasonography versus electrical stimulation for fracture healing: a systematic review and network meta-analysis

  • Journal Cover

    Young femoral neck fractures: are we measuring outcomes that matter?

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    Management of young femoral neck fractures: is there a consensus?

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    Complications following young femoral neck fractures

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    The orthopaedic trauma patient experience: a qualitative case study of orthopaedic trauma patients in Uganda.

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    Status of road safety and injury burden: China

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    Why a decade of road traffic safety?

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    Roads in India: safety and knowledge cross-sectional evaluation

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    Evidence gaps in the global decade of road traffic safety

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    Which Surgical Treatment for Open Tibial Shaft Fractures Results in the Fewest Reoperations? A Network Meta-analysis

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    A call to research: documenting the non-fatal outcomes of injury

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