Diagnostic Accuracy and Confidence in Management of Forearm and Hand Fractures Among Foundation Doctors in the Accident and Emergency Department: Survey Study.

BACKGROUND: Accurate interpretation of radiographs is crucial for junior doctors in the accident and emergency (A&E) department (the emergency medicine department). However, it remains a significant challenge and a leading cause of diagnostic errors. OBJECTIVE: This study aimed to evaluate the accuracy and confidence of foundation doctors (doctors within their first 2 years of qualifying) in correctly interpreting and managing forearm and hand fractures on plain radiographs. METHODS: A total of 42 foundation doctors with less than 2 years of experience and no prior emergency medicine training who worked in a large district general hospital participated in a web-based questionnaire. The questionnaire consisted of 3 case studies: distal radius fracture, scaphoid fracture, and a normal radiograph. Respondents were required to identify the presence or absence of a fracture, determine the fracture location, suggest appropriate management, and rate their confidence on a Likert scale. RESULTS: Overall, 48% (61/126) of respondents accurately identified the presence and location of fractures. The correct management option was chosen by 64% (81/126) of respondents. The median diagnostic confidence score was 4 of 10, with a mean diagnostic certainty of 4.4 of 10. Notably, respondents exhibited a significantly lower confidence score for the normal radiograph compared to the distal radius fracture radiograph (P=.01). CONCLUSIONS: This study reveals diagnostic uncertainty among foundation doctors in interpreting plain radiographs, with a notable inclination toward overdiagnosing fractures. The findings emphasize the need for close supervision and senior support to mitigate diagnostic errors. Further training and educational interventions are warranted to improve the accuracy and confidence of junior doctors in radiographic interpretation. This study has several limitations, including a small sample size and reliance on self-reported data. The findings may not be generalizable to other health care settings or specialties. Future research should aim for larger, more diverse samples and explore the impact of specific educational interventions on diagnostic accuracy and confidence.

Prevention of Perioperative Hypothermia: A Prospective, Randomized, Controlled Trial of Bair Hugger Versus Inditherm in Patients Undergoing Elective Arthroscopic Shoulder Surgery.

PURPOSE: To determine if a clinically significant difference in the core body temperature (CBT) exists between the Bair Hugger (BH) and Inditherm (IT) warming devices in patients undergoing arthroscopic shoulder surgery. METHODS: This was a parallel, 2-treatment, prospective, randomized, controlled trial conducted in patients undergoing elective arthroscopic shoulder surgery in the beach-chair position using room-temperature irrigation fluid. The BH was used as the indicative forced-air warming device, whereas the IT served as the indicative resistive heating system. By use of a minimal clinically significant difference of 0.6°C and standard deviation of 0.6°C, a power analysis showed that a sample size of 90 patients (45 per group) would be required. Patients fulfilling the inclusion criteria were recruited from the clinics of the senior authors. Anesthetic and surgical protocols were standardized. The intraoperative CBT was recorded every 5 minutes using a nasopharyngeal thermistor probe. Demographic data as well as the volume of irrigation fluid used were also noted. RESULTS: A steady decline in the CBT was observed in both groups up to 30 minutes after induction of anesthesia. Beyond 30 minutes, the BH group showed a gradual increase in temperature whereas it continued to decline in the IT group. A statistically significant difference in the CBT was observed from 60 minutes onward (P = .025). This difference continued to increase up to 90 minutes (P < .001). At no time was a rise in the CBT observed in the IT group. At completion of the study and surgical procedure, 13 of 47 patients in the BH group and 32 of 44 patients in the IT group had hypothermia (P = .0002). CONCLUSIONS: The CBT was statistically significantly better with the use of the BH compared with the IT mattress. However, the differences in the CBT did not reach the level of clinical significance of 0.6°C. Far fewer patients in the BH group had hypothermia at the end of surgery. Therefore, this study supports the use of the BH in elective arthroscopic shoulder surgery for the prevention of hypothermia. LEVEL OF EVIDENCE: Level I.

Extraction of Fractured Femoral Stem in Primary Cemented Hip Replacements: Surgical Technique using a Mole Wrench.

Extracting a fractured stem poses a technical challenge in revision surgery. A number of techniques have been described based on method of fixation (cemented or uncemented); location of the fracture; and composition of the stem alloy. These include the drilling and cortical window techniques. We describe our surgical removal of a proximally fractured cemented stem using a Mole wrench.

The effect of obesity on theatre utilisation time during primary hip and knee replacements.

INTRODUCTION: The aim of this study is to assess the effect of body mass index (BMI) and body weight on theatre utilisation time during primary total hip (THR) and knee replacements (TKR). METHODS: A total of 1859 cases were included (820 THR and 1039 TKR). Patients were divided into groups based on BMI and body weight. The time interval from 'starting anaesthesia' to 'transfer back to recovery' was used as total theatre time. Hierarchal regression analysis was then used to study the effect of BMI and body weight while controlling the effect of any confounding variables. RESULTS: In THR cases, the median theatre time was significantly different between BMI and body weight subgroups (p=0.001). In TKR cases, the median theatre time was more significantly different between weight subgroups (p<0.001) than BMI subgroups (p=0.021). Regression analysis showed that only weight remained a significant predictor (p=0.018) of theatre time in THR cases after controlling for other variables. In TKR cases, body weight and BMI were not predictors of theatre time after controlling for other variables. CONCLUSION: Body weight is a significant predictor of theatre time during THR. Neither weight nor BMI predicted theatre time during TKR.

Anterior knee pain: an unusual presentation of renal cell carcinoma.

Metastasis of any kind to the patella is rare. Metastasis to the patella causing symptoms representing the first presentation of underlying malignancy is rarer still. We report the case of a previously fit and well 74-year-old male presenting with left anterior knee pain. The initial diagnosis was osteoarthritis but after continued symptoms a diagnosis of solitary patella metastasis from a primary renal cell carcinoma was confirmed.

An evaluation of retrospective outcome scores in elective foot and ankle surgery.

BACKGROUND: Patient reported outcome measures are becoming more popular in their use. Retrospective scoring is not yet a validated method of data collection but one that could greatly decrease the complexity of research projects. We aim to compare preoperative and retrospective scores in order to assess their correlation and accuracy. METHODS: 36 patients underwent elective foot and ankle surgery. All patients were scored preoperatively using the SF-12 (including both the physical and mental subsets) and FFI. Patients then recorded both PROMs at the 3-month follow up (av. 139 days). Results were then analyzed for statistical significance. RESULTS: 36 patients (av. age 54.6): completed both sets of questionnaires. There were 15 hindfoot and 21 forefoot procedures. No retrospective scores were identical. The mean percentage difference between the preoperative scores was -7.9% (-17.3 to 1.6%, 95% CI) for Physical Component of SF12, -3.2% (-10.3 to 3.9%, 95% CI) for mental component of SF12 and 40.7% (25.3 to 56.1%, 95% CI) for FFI. This retrospective accuracy was statistically significant (p<0.001). When the scores were plotted against each other, the outcome measurements showed positive correlations (Physical SF 12 p=0.48, Mental SF 12 p=0.80 and FFI p=0.81). With both PROMs mean percentage differences combined, patients undergoing hindfoot procedures (3.5%; -5.0 to 12.1%, 95% CI) were more accurate with retrospective scoring than their forefoot counterparts (17.5%; 5.0 to 30.0%, 95% CI). This was not statistically significant (p=0.07). Using regression analysis, we found no significant statistical difference in the retrospective accuracy when compared against both time to retrospective scoring and the outcome measure at 3 months post operatively. CONCLUSION: Retrospective scoring appears to lack accuracy when compared to prospective methods. However, our data shows the SF12 is recalled more accurately than the FFI (p<0.001) and both the mental and physical components are recalled to within 10% of the pre-operative score. These results show patients tend to recall their symptoms at a worse level preoperatively than originally described, especially those with forefoot problems.

Fractures of the clavicle: an overview.

Fractures of the clavicle are a common injury and most often occur in younger individuals. For the most part, they have been historically treated conservatively with acceptable results. However, over recent years, more and more research is showing that operative treatment may decrease the rates of fracture complications and increase functional outcomes. This article first describes the classification of clavicle fractures and then reviews the literature over the past decades to form a conclusion regarding the appropriate management. A thorough literature review was performed on assessment of fractures of the clavicle, their classification and the outcomes following conservative treatment. Further literature was gathered regarding the surgical treatment of these fractures, including the methods of fixation and the surgical approaches used. Both conservative and surgical treatments were then compared and contrasted. The majority of recent data suggests that operative treatment may be more appropriate as it improves functional outcome and reduces the risk of complications such as non-union. This is particularly evident in mid shaft fractures, although more high grade evidence is needed to fully recommend this, especially regarding certain fractures of the medial and lateral clavicle.

Total wrist arthroplasty using the Universal 2 prosthesis.

PURPOSE: To report outcomes of 21 total wrist arthroplasties (TWA) using the Universal 2 prosthesis. METHODS: Five men and 14 women aged 44 to 82 (mean, 62) years underwent 21 total wrist arthroplasties for rheumatoid arthritis (n=19) and post-traumatic arthritis (n=2) by a single surgeon using the Universal 2 prosthesis. Pre- and post-operative pain and function were assessed by a single surgeon using the Disabilities of the Arm, Shoulder and Hand (DASH) score and the patient-rated wrist evaluation (PRWE) score. Range of motion, stability, dislocation rate, and neurovascular status were also assessed. Radiographs were evaluated for implant alignment and fit, screw positioning, and implant loosening. RESULTS: The mean time to assessment of the range of motion was 3.1 (range, 1.8-3.9) years, and the mean time to assessment of the PRWE score was 4.8 (range, 2.1-7.3) years. The range of motion in each direction and the mean DASH and PRWE scores improved significantly following TWA. Two patients had restricted range of motion, which was treated by manipulation under anaesthetic (after 6 months in one and 8 weeks in the other). One patient underwent excision of a palmar bony bridge. One patient endured extensor pollicis longus rupture and underwent tendon transfer after 5 months. Radiographs revealed no evidence of implant loosening, migration, or malalignment. There was no sign of osteonecrosis in the remaining carpals or metacarpals. CONCLUSION: The Universal 2 TWA achieved significant improvement in range of motion and functional outcome of the wrist, with reduced rates of early joint instability, dislocation, and implant loosening, compared to previous implants. The small implant size and cementless design reduce bone loss and osteonecrosis.

Intramedullary fixation of diaphyseal clavicle fractures using the rockwood clavicle pin: review of 86 cases.

AIM: This study reports the safety, efficacy and functional and patient centred outcomes of the largest published series of patients treated with the Rockwood clavicle pin (intramedullary device) to date. PATIENTS AND METHODS: A retrospective review of case notes, radiographs and follow-up by questionnaire was conducted. 86 patients were operated upon, 70 for acute fractures (group A) and 16 for non-union (group B). RESULTS: Rate of non-union was 2 (2.9%) in group A and 0 in group B. Mean Disability of the Arm, Shoulder and Hand (DASH) scores were 5.9 for group A and 8.7 for group B. Satisfaction was rated as good or excellent in 61 (96.8%) of responders and all patients would have the procedure again. Pin prominence was the predominant complication in both groups and all patients underwent a second procedure for metalwork removal. DISCUSSION: Rockwood clavicle pins are as effective as plates in achieving union and maintaining length, however the advantages of this less invasive technique should be weighed against the common complication of pin prominence and the inconvenience of removal of metalwork in all cases.

Distal radius volar locking plates: does a variable angle locking system confer a clinical advantage?

This retrospective study compared clinical, radiological and subjective outcomes between patients with a distal radius fracture fixed with a variable angle or fixed angle volar locking plate. Radiological parameters were assessed between initial and final post-operative films. Post-operative clinical range of motion as a proportion of that in the opposite wrist was assessed clinically, and satisfaction and subjective outcomes were assessed by questionnaire. One hundred and seven patients were included in the study; 65 underwent fixation with a variable angle and 42 with a fixed angle locking plate. There were five complications and secondary operations in each group. There was no significant difference between the groups in radiological parameters measured or the proportional range of motion. Visual analogue scale, Mayo Wrist and Quick DASH scores were not significantly different between the groups. Neither the subjective nor clinical outcomes of this study demonstrated clinical superiority of either plate system.

Non-union of Weber B distal fibula fractures: a case series.

Non-union of distal fractures of the fibula type Weber B is rare. Undisplaced and minimally displaced isolated lateral malleolar fractures (Weber B) usually unite without operative intervention. We present three cases of lateral malleolus non-union in healthy individuals. Two were treated with internal fixation plus bone grafting. The third patient remained asymptomatic and therefore did not undergo surgery for the fracture.

Haemostasis in Open Carpal Tunnel Release: Tourniquet vs Local Anaesthetic and Adrenaline.

Open carpal tunnel release is one of the commonest performed procedures in hand surgery. We performed a prospective randomised control trial to compare the efficacy and patient satisfaction of the traditional arm tourniquet versus infiltration of adrenaline and local anaesthetic solution to achieve haemostasis during the procedure. Using a combination of objective and subjective measures we concluded that infiltration of local anaesthetic and adrenaline not only provided adequate haemostasis but also provided a significantly more tolerable experience for the patient during the procedure.

Primary septic arthritis of the acromio-clavicular joint: case report and review of literature.

Primary septic arthritis of the Acromio clavicular joint is an uncommon disorder and is rarely seen even in an immunocompromised individual. We report a case of primary septic arthritis of the acromio-clavicular (A-C) joint caused by Staphylococcus aureus without any predisposing factors. The patient was admitted with left shoulder pain, restricted movements and fever. Laboratory parameters showed high C-reactive protein, raised erythrocyte sedimentation rate and leucocytosis. Blood cultures were positive for Staphylococcus-aureus. Magnetic resonance imaging (MRI) using Gadolinium enhancement revealed marked effusion in the A-C joint. Aspiration from the A-C joint revealed a heavy growth of Staphylococcus-aureus. The patient was successfully treated with 8 weeks of appropriate antibiotics with complete resolution of infection and return to full function.