Management of open elbow fractures: experiences and outcomes from a UK major trauma center.

HYPOTHESIS AND BACKGROUND: Open fractures about the elbow are an infrequent but complex injury with limited existing literature. The aims of the study were to review the treatment strategies of open elbows fractures, functional outcome and complication rates associated with the injury, and correlate the outcome with the topography of the fracture. METHODS: Patients (n = 21) with open elbow fractures injuries over a 2-year period were analyzed. They were assessed regarding the orthoplastic characteristics of their injury as well any other associated injuries. Outcomes were assessed objectively (achievement of bony union, range of movement, infection status, need for further procedures) and subjectively (Oxford Elbow Score, EQ-5D, EQ-VAS). RESULTS: The commonest grade of open injury was grade 3 (43%). Associated orthopedic injuries were present in 62% and associated system injuries in 57%. Almost half of the patients were noted to have had a significantly increased presenting mortality risk as per Injury Severity Score assessment. Mean time to first wound débridement was 31 hours. There were no cases of deep or chronic infection. Complete bony union was noted in 85% of patients, and 48% of patients required removal of metalwork. Subgroup analysis of the cohort by fracture topography (single unipolar elbow bone injury vs. multiple elbow bony injuries) demonstrated no significant difference (P > .05) regarding rate of complication or final Oxford Elbow Score, EQ-5D or EQ-VAS. Patients with injuries that involved the distal humerus had the highest rate for further procedures (P < .05). The average Oxford Elbow Score, EQ-5D, and EQ-VAS scores for the whole cohort at final follow-up were 37.4, 0.54, and 62.18, respectively. DISCUSSION: Open elbow injuries are usually from high-energy trauma and often combined with other significant injuries. As a result, the timelines to elbow surgery were often delayed. However, this did not impact the local infection rates nor did it necessitate further surgery, but made achieving all British Orthopaedic Association Standards for Trauma targets difficult. Chronic infection was not an issue in this cohort. Subgroup analysis indicates open distal humerus fractures carry the highest risk for further procedures. This is most commonly in the form of removal of metalwork and fibrinolysis. End outcomes for patients with open elbow fractures can be positive, despite the notable presenting Injury Severity Score. A subspecialist elbow and orthoplastic approach whenever possible is advocated.

Improving the efficiency of ankle fracture care through home care and day-surgery units: Delivering safe surgery on a value-based healthcare model.

OBJECTIVES: Preoperative home care for suitable patients with ankle fractures is becoming an increasingly common practice. It allows adequate time for reduction of ankle swelling following a decision to undertake operative fixation has been made. We aim to assess the safety, efficiency, cost-effectiveness and differences in clinical & patient outcomes of day surgery unit (DSU) care for ankle fracture treatment in selected patients. Our study combined home therapy treatment with DSU care for suitable ankle fractures. DESIGN: Prospective cohort study. SETTING: Trauma Centre. PATIENTS: Fifty-three patients requiring operative fixation for an ankle fracture were divided into 2 groups. Patients in group 1 entered the home care combined with DSU treatment pathway whilst in group 2 were treated as in patient in the main trauma theatre in our standard pathway. INTERVENTION: Comparison of Home Care & Day Case Surgery vs. in patient admission for patients requiring operative ankle fractures fixation. MAIN OUTCOME MEASURES: Prospective data collection was undertaken over a 2-year period, on fracture type, logistical outcomes including time to surgery and total length of stay in the hospital and clinical outcomes including the rate of post-operative complications, incidence of unplanned surgical revisions and objective patient satisfaction. Economic analysis was performed to compare the marginal cost saving per case for group 1 vs. group 2. RESULTS: There were 21 patients in group 1. They waited for on average 5.8 days at home for their operation and none were admitted pre or post operatively. There were no associated complications and the majority of patients were discharged from follow-up at 6 weeks post-surgery. In-group 2, there were 32 patients. They waited on average 2.4 days for their operation in the hospital and had an average length of stay of 4.9 days. One patient in group 2 suffered from a deep vein thrombosis. The benefit from our chargeable tariff for group 1 patients was £2295 per case while the margin for group 2 patients was £277 per case. The financial benefit to the health care provider was £2018 in favour of home care and DSU treatment, with high service satisfaction and low complication rates. DISCUSSION: This study provides focused evidence supporting the use of home care for the management of ankle fractures. The DSU pathway improves the value in healthcare delivery with high patient satisfaction scores when compared to the traditional pathway. Our model demonstrates predictably good clinical outcomes with a financial cost benefit over in-patient admission care model for selected patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intratendinous supraspinatus cyst as a cause of shoulder impingement.

We report the case of a 29-year-old gentleman with shoulder impingement. An articular-sided intratendinous supraspinatus cyst was identified as the cause of his symptoms. Arthroscopic cyst debridement resulted in a good outcome at 1-year follow-up. Cysts around the shoulder are a well described pathological entity. They consist of different categories, including intraosseus cysts of the humeral head and glenoid, paralabral cysts and cysts associated with the acromioclavicular joint. Although paralabral cysts that lie intramuscularly or between the muscle bellies have frequently been reported, this is the first report of an intratendinous supraspinatus cyst with an intact rotator cuff. We describe the case, its management and the postsurgical outcome.