Management of displaced supracondylar fractures in children and adherence to the BOAST guideline- experience in a District General Hospital, UK.

Background: Supracondylar fracture is the most common elbow fracture in children. These fractures can be associated with significant complications, including nerve injury, vascular compromise, compartment syndrome and clinical deformity. The British Orthopaedic Association Standards for Trauma (BOAST) provide clear and comprehensive guidance for managing the supracondylar fracture. Aims: We reviewed the management of displaced (Gartland type 2 and 3) supracondylar fractures and adherence to BOAST guidelines between 1st audit and re-audit following the introduction of supracondylar assessment proforma. Methods: We retrospectively analysed the adherence to BOAST guidelines for 103 patients operated between 2014 and 2020. Documentation of vascular status and individual nerve functions were assessed during presentation to the emergency department, immediately before surgery, and postoperatively before discharge from the hospital. We also reviewed the documentation of the K-wire's size utilised for fixation, the medial wire fixation technique, and post-fixation stability during the operation. A new supracondylar fracture assessment proforma was designed and implemented after the 1st audit as part of the quality improvement measure. During the second stage of the audit cycle, we reviewed 22 patients and used the same methodology as the first audit to analyse the data. Results: Results: We found significant improvements in the documentation of capillary refill time from 65 % to 95.5 % (p = 0.0038), radial pulse from 59.2 % to 95.5 % (p = 0.0009), and documentation of individual nerve function from 37.9 % to 72.7 % (p = 0.0040) in the emergency department during 2nd stage of the audit cycle. Individual nerve function documentation by the operating team immediately before surgery changed from 42.7 % to 50 %. The use of 2 mm K-wires improved from 53.3 % to 89.5 % (p = 0.0037) Documentation of medial wire fixation technique and post-fixation stability increased to 100 % from 82.9 % to 89.5 % from 42.7 % (p = 0.0002), respectively. Postoperatively, we noted improvement in both radial pulse and capillary refill time documentation from 27.2 % to 54.2 % (p = 0.0216) and the individual nerve function from 9.7 % to 50 % (p = 0.00005). Conclusion: Poor adherence in stage 1 of the audit cycle to BOAST standards was significantly improved in stage 2 (Re-audit) after introducing a simple supracondylar fracture assessment proforma and focussed educational sessions.

Lessons of the month: Giant cell arteritis with Horner's syndrome and vertebral dissection.

We present a case of an 82-year-old woman presenting with left-sided Horner's syndrome and stroke. She also had a 6-week history of intermittent dizziness, reduced appetite, lethargy, muscle stiffness and weight loss. Examination revealed left temporal artery and left posterior auricular artery tenderness. Her ESR showed 62 mm/hr and imaging showed left vertebral artery dissection. Temporal artery biopsy was positive.The case highlights a rare presentation of giant cell arteritis with Horner's syndrome and left vertebral artery dissection. High clinical suspicion is required to prevent delay in diagnosis and treatment.

Lesson of the month: Severe granulomatosis with polyangiitis (GPA): a diagnostic challenge during the COVID-19 pandemic.

We present the case of a 71-year-old woman with bilateral pneumonia who continued to deteriorate despite multiple courses of antibiotics. When dexamethasone was added to cover the possibility of COVID-19 pneumonia, she rapidly improved. Subsequently, she was found to have a strongly positive PR3 anti-nuclear cytoplasmic antibody (ANCA) and clinical features consistent with granulomatosis with polyangiitis (GPA) with upper respiratory tract and renal involvement. The case highlights how the COVID-19 pandemic can create new challenges in the diagnosis of GPA.

Lessons of the month 4: Giant cell arteritis with normal inflammatory markers and isolated oculomotor nerve palsy.

Giant cell arteritis (GCA) is an important condition to suspect and treat early, as failure to do so can result in anterior ischaemic optic neuropathy and subsequent permanent visual loss.A 71-year-old woman presented to her local emergency department with a 1-week history of constant, moderate-severe global headache associated with intermittent periorbital pain. Two weeks later she developed sudden horizontal diplopia. Examination demonstrated right oculomotor nerve palsy. Her erythrocyte sedimentation rate (ESR) was 9 mm/hr. Repeat blood tests 1 month later showed an ESR of 67 mm/hr. Temporal artery biopsy was positive.A review from a cohort of 764 patients with suspected GCA who underwent biopsy found the sensitivity of an elevated ESR and c-reactive protein was 84% and 86%, respectively, but the specificity was only 30%. Therefore, inflammatory markers should only act as a guide, and caution should be taken in their interpretation especially with respect to the time of sampling in the disease evolution.Isolated oculomotor nerve palsy in association with GCA is rare. The first case series was described by miller fisher in 1959 who observed two patients presenting with diplopia, ptosis and ocular palsies. In anyone over the age of 50 who develops a new, refractory headache and cranial neuropathy, GCA should be the first consideration.