Bumping to a rollator walker: How pretibial hematomas create more costs than pretibial lacerations.

Pretibial lacerations (PL) and pretibial hematomas (PH) are debilitating traumas among the elderly and infirm. The injuries are frequently grouped together despite differences in treatment and symptoms. Patients are known to have multiple contacts in health care, perhaps because of inadequate treatment. Despite the burden, financial costs have not been assessed. Calculate and compare the treatment costs of PLs and PHs for differences and provide economic incentives to treat and diagnose patients optimally. From linkage to ICD10 diagnoses, we analysed NordDRG product invoices generated by the treatment of the patients. We calculated and compared the costs of treatment in both cohorts from the invoices. This method has not been previously used for analysing wound care costs. Mean treatment costs were 1800€ (PL) and 3300€ (PH). The total costs, emergency room, surgical treatment, and inpatient care of PHs were higher than PLs (P = .0486, P = .0002, P = .0058, P = .6526). PLs generate more costs from the outpatient clinic but were not statistically significant (P = .6533). PHs cause a higher economic burden than PLs. Costs arise from repeat ER visits and the need for surgeries because of delayed treatment. PLs have multiple contacts in the wound clinic. Improvement in the diagnosis and treatment of both injuries is needed.

An assessment of the diagnosis, treatment, and outcomes of lower extremity stress fractures in pediatric and adolescent populations.

OBJECTIVES: To present one of the first descriptive case series of pediatric and adolescent lower extremity stress injuries, their management, and outcomes in athletes and non-athletes. METHODS: The IRB-approved retrospective study included patients under 18 years at a tertiary children's hospital who were diagnosed with a lower extremity stress fracture/reaction. Demographic data, mechanism of injury, physical exam, radiographic findings, treatment, & outcomes were collected. Descriptive statistical analysis was conducted. RESULTS: Ninety-seven patients with stress injuries on clinical exams and on radiographs or MRI were included. The average age when diagnosed was 11.7 years (range 1.1-18 years) and the most common injuries were to the tibia (n = 33, 28.4%) and the least common involved were the cuneiforms (n = 4, 3.4%). Patients under the age of 14 were more likely to experience cuboid and calcaneal stress injuries (mean age 5.5 and 8.3 years respectively). Nineteen patients (19.6%) had high-risk stress fractures, with the average age of 14.9 years versus 11.6 for those with low risk (p-value = 0.01) and return to activity time being 15 weeks compared to 10.5 (p-value = 0.027). The most common forms of treatment were controlled ankle motion (CAM), walker boots (58.6%), and physical therapy (PT) (38.1%). The mean Lower Extremity Function Score of the patient population was 73.8, indicating no clinically important difference from full functionality. CONCLUSION: Lower extremity stress injuries in this cohort were most seen in the tibia, although patients younger than 14 had a high number of cuboid and calcaneal stress injuries. Those with high-risk stress fractures were older and took longer to recover from when compared to low-risk injuries. Treatment is commonly conservative, with CAM boots and PT being the most frequently utilized interventions and serving as a successful approach to treatment, with patients returning to activity at an average of 11.4 weeks, which is comparable to similar studies.

The nationwide epidemiological and health insurance disease burden of knee and lower leg injuries in Hungary / A térd- és lábszársérülések okozta országos epidemiológiai és egészségbiztosítási betegségteher Magyarországon.

Összefoglaló. Bevezetés: A térd és a lábszár sérülései jelentos terhet jelentenek az egyén és a társadalom számára. Célkituzés: Elemzésünk célja volt a térd- és lábszársérülés okozta éves epidemiológiai és egészségbiztosítási betegségteher vizsgálata Magyarországon. Adatok és módszerek: Az elemzésben felhasznált adatok a Nemzeti Egészségbiztosítási Alapkezelo (NEAK) finanszírozási adatbázisából származnak, és a 2018. évet fedik le. Vizsgáltuk az éves egészségbiztosítási kiadásokat, azok megoszlását, az éves betegszámot, valamint a 100 000 lakosra vetített prevalenciát korcsoportok és nemek szerinti bontásban. A térd és a lábszár sérülései kórképeket a Betegségek Nemzetközi Osztályozása (BNO, 10. revízió) szerinti S80-S89-es kóddal azonosítottuk. Eredmények: A legköltségesebb ellátási forma az aktívfekvobeteg-szakellátás volt, amelynek országos betegszáma összesen 18 398 fo (9868 fo férfi, 8530 fo no) volt. Az aktívfekvobeteg-szakellátás betegforgalmi adatai alapján a 100 000 fore eso prevalencia a férfiaknál 211,2 fo, a noknél 167,0 fo, együtt 188,1 fo volt. A NEAK 8,808 milliárd Ft-ot költött 2018-ban a térd- és lábszársérülések kezelésére, ami 32,59 millió USD-nak, illetve 27,62 millió EUR-nak felelt meg. Az aktívfekvobeteg-szakellátás a teljes egészségbiztosítási kiadás 61,4%-ával volt a legmeghatározóbb költségelem. A kiadások 52,0%-a férfiaknál, míg 48,0%-a noknél jelent meg. A 49. életévig a férfiak, míg az 50. életév feletti korosztályban a nok sérüléseibol származó ellátások betegszámai és költségei a magasabbak. Következtetés: Az aktívfekvobeteg-szakellátás bizonyult a fo költségtényezonek. A betegség elofordulási gyakorisága 26%-kal volt magasabb a férfiak esetében, mint a noknél. Orv Hetil. 2021; 162(Suppl 1): 54-60. INTRODUCTION: Injuries to the knee and lower leg pose a great burden for the individual and society. OBJECTIVE: The aim of our study was to determine the annual epidemiological disease burden and the health insurance treatment cost of knee and lower leg injuries in Hungary. DATA AND METHODS: Data were derived from the financial database of the National Health Insurance Fund Administration (NHIFA) of Hungary for the year 2018. The data analysed included annual health insurance costs and their distribution and annual patient numbers and prevalence per 100 000 population calculated for age groups and sex. Patients with knee and lower leg injuries were identified with the following code of the International Classification of Diseases, 10th revision: S80-S89. RESULTS: The most expensive insurance treatment category was acute inpatient care, presenting 18 398 patients in total (9868 men, 8530 women). Based on patient numbers in acute inpatient care, the prevalence in 100 000 population among men was 211.2 patients, among women 167.0 patients, in total 188.1 patients. In 2018, NHIFA spent 8.808 billion HUF on the treatment of patients with knee and lower leg injuries (32.59 million USD, 27.62 million EUR). Acute inpatient care with 61.4% of the total health insurance expenditure was the main cost driver. 52.0% of the costs was spent on the treatment of male, while 48.0% on female patients. Until the age of 49, the number of patients and their costs were higher for men, while those over the age of 50 were higher for women. CONCLUSION: Acute inpatient care was the major cost driver. The prevalence of the disease was by 26% higher in men compared to women. Orv Hetil. 2021; 162(Suppl 1): 54-60.

The effect of COVID-19 on a Major Trauma Network. An analysis of mechanism of injury pattern, referral load and operative case-mix.

PURPOSE: The aim of this study was to evaluate changes in both mechanism and diagnoses of injuries presenting to the orthopaedic department during this lockdown period, as well as to observe any changes in operative case-mix during this time. METHODS: A study period of twelve weeks following the introduction of the nationwide "lockdown period", March 23rd - June 14th, 2020 was identified and compared to the same time period in 2019 as a "baseline period". A retrospective analysis of all emergency orthopaedic referrals and surgical procedures performed during these time frames was undertaken. All data was collected and screened using the 'eTrauma' management platform (Open Medical, UK). The study included data from a five NHS Foundation Trusts within North West London. A total of 6695 referrals were included for analysis. RESULTS: The total number of referrals received during the lockdown period fell by 35.3% (n=2631) compared to the same period in 2019 (n=4064). Falls remained proportionally the most common mechanism of injury across all age groups in both time periods. The proportion sports related injuries compared to the overall number of injuries fell significantly during the lockdown period (p<0.001), however, the proportion of pushbike related accidents increased significantly (p<0.001). The total number of operations performed during the lockdown period fell by 38.8% (n=1046) during lockdown (n=1732). The proportion of patients undergoing operative intervention for Neck of Femur (NOF) and ankle fractures remained similar during both study periods. A more non-operative approach was seen in the management of wrist fractures, with 41.4% of injuries undergoing an operation during the lockdown period compared to 58.6% at baseline (p<0.001). CONCLUSION: In conclusion, the nationwide lockdown has led to a decrease in emergency orthopaedic referrals and procedure numbers. There has been a change in mechanism of injuries, with fewer sporting injuries, conversely, there has been an increase in the number of pushbike or scooter related injuries during the lockdown period. NOF fractures remained at similar levels to the previous year. There was a change in strategy for managing distal radius fractures with more fractures being treated non-operatively.

Implementing a Locally Made Low-Cost Intervention for Wound and Lymphedema Care in Western Kenya.

In Western Kenya, the burden of chronic wounds and lymphedema has a significant impact on functionality and quality of life. Major barriers to provision of care include availability, affordability, and accessibility of bandages. At the Academic Model Providing Access to Healthcare, dermatologists and pharmacists collaborated to develop a 2-component compression bandage modeled after the Unna boot, using locally available materials, that is distributed through a revolving fund pharmacy network. In partnership with nursing, use of these bandages at a national referral hospital and a few county facilities has increased, but increasing utilization to an expanded catchment area is needed.

Medicine wastage in a thromboprophylaxis protocol for ambulatory trauma patients.

Thromboprophylactic medicine is provided routinely to patients who present to emergency departments (EDs) with lower leg fractures as a preventive measure against forming blood clots in an immobilised limb. A large amount of medicine is provided to these patients at discharge, but once they have recovered their mobility the remaining medicine is unusable and must be destroyed. There is a lack of data to quantify this waste. This article reports a service evaluation that was conducted in an ED to investigate the wastage and the cost implications of this treatment protocol. It shows that over half the medicine dispensed is subsequently wasted and makes recommendations for changing dispensing practice.

High-Risk Chief Complaints III: Abdomen and Extremities.

Abdominal and extremity complaints are common in the emergency department (ED) and, because of their frequency, clinical vigilance is vital in order not to miss the timely diagnosis of occult or delayed emergencies. Such emergencies, if not timely managed, are sources of significant patient morbidity and mortality and may expose ED physicians to possible litigation. Each patient complaint yields to a nuanced approach in diagnostics and therapeutics that can lead physicians toward the ruling in or out of the correct high-risk diagnosis. This article discusses the approach and risk management of this high-risk subset of abdominal and extremity diagnoses.

Thromboprophylaxis in lower limb immobilisation after injury (TiLLI).

Venous thromboembolic disease is a major global cause of morbidity and mortality. An estimated 10 million episodes are diagnosed yearly; over half of these episodes are provoked by hospital admission/procedures and result in significant loss of disability adjusted life years. Temporary lower limb immobilisation after injury is a significant contributor to the overall burden of venous thromboembolism (VTE). Existing evidence suggests that pharmacological prophylaxis could reduce overall VTE event rates in these patients, but the proportional reduction of symptomatic events remains unclear. Recent studies have used different pharmacological agents, dosing regimens and outcome measures. Consequently, there is wide variation in thromboprophylaxis strategies, and international guidelines continue to offer conflicting advice for clinicians. In this review, we provide a summary of recent evidence assessing both the clinical and cost effectiveness of thromboprophylaxis in patients with temporary immobilisation after injury. We also examine the evidence supporting stratified thromboprophylaxis and the validity of widely used risk assessment methods.

Ultrasonic debridement management of lower extremity wounds: retrospective analysis of clinical outcomes and cost.

OBJECTIVE: The aim of this study was to assess wound healing outcomes following direct, low-frequency, high-intensity, ultrasonic debridement as a surgical adjunct for non-healing lower extremity wounds. METHODS: A retrospective review was conducted for patients undergoing lower extremity wound treatment with direct, low-frequency (22.5 kHz), high-intensity (~60 W/cm2) ultrasonic debridement between January 2010 and January 2016. Clinical outcomes were assessed up to 180-days post-ultrasonic debridement. Descriptive statistics, cost and univariate analysis were performed. RESULTS: Overall, 82 wounds in 51 patients were included. Mean age was 57.0 years (range: 32-69), and average body mass index (BMI) was 30.8 kg/m². Patient comorbidities consisted of smoking (47%; n=24), hypertension (75%; n=38), diabetes (45%; n=23), and peripheral vascular disease (51%, n=26). Average wound age at initial presentation was 1013 days (range: 2-5475 days) with an average wound size of 9.0cm x 7.4cm. At 180-days post-debridement, 60% (n=49) of wounds had completely healed. Readmission (47%; n=24) and reoperation (45%; n=23) rates were characterised by the reason for readmission and reoperation respectively. Readmission for wound healing (70%, n=39) was primarily for further debridements (41%; n=16). Wound infection (30%; n=7) was the most common readmission for wound complications (30%; n=17). Reoperations primarily consisted of treatments for further wound healing 96% (n=51). Cost analysis showed a lower total treatment cost for patients with improved healing ($78,698), compared with non-improved wounds ($137,707). CONCLUSION: In a complex, heterogeneous cohort of chronic extremity wounds, the use of direct, low-frequency, high-intensity, ultrasonic debridement is a safe and reliable adjunctive therapy for the management of these wounds.

The Economic Burden of Non-fatal Musculoskeletal Injuries in Northeastern Tanzania.

BACKGROUND: Although musculoskeletal injuries have increased in sub-Saharan Africa, data on the economic burden of non-fatal musculoskeletal injuries in this region are scarce. OBJECTIVE: Socioeconomic costs of orthopedic injuries were estimated by examining both the direct hospital cost of orthopedic care as well as indirect costs of orthopedic trauma using disability days and loss of work as proxies. METHODS: This study surveyed 200 patients seen in the outpatient orthopedic ward of the Kilimanjaro Christian Medical Center, a tertiary hospital in Northeastern Tanzania, during the month of July 2016. FINDINGS: Of the patients surveyed, 88.8% earn a monthly income of less than $250 and the majority of patients (73.7%) reported that the healthcare costs of their musculoskeletal injuries were a catastrophic burden to them and their family with 75.0% of patients reporting their medical costs exceeded their monthly income. The majority (75.3%) of patients lost more than 30 days of activities of daily living due to their injury, with a median (IQR) functional day loss of 90 (30). Post-injury disability led to 40.6% of patients losing their job and 86.7% of disabled patients reported a wage decrease post-injury. There were significant associations between disability and post-injury unemployment (p < .0001) as well as lower post-injury wages (p = .022). CONCLUSION: This exploratory study demonstrates that in this region of the world, access to definitive treatment post-musculoskeletal injury is limited and patients often suffer prolonged disabilities resulting in decreased employment and income.

Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies.

The purpose of this review is to describe and critically evaluate current knowledge regarding diagnosis, assessment, and management of chronic overload leg injuries which are often non-specific and misleadingly referred to as 'shin splints'. We aimed to review clinical entities that come under the umbrella term 'Exercise-induced leg pain' (EILP) based on current literature and systematically searched the literature. Specifically, systematic reviews were included. Our analyses demonstrated that current knowledge on EILP is based on a low level of evidence. EILP has to be subdivided into those with pain from bone stress injuries, pain of osteo-fascial origin, pain of muscular origin, pain due to nerve compression and pain due to a temporary vascular compromise. The history is most important. Questions include the onset of symptoms, whether worse with activity, at rest or at night? What exacerbates it and what relieves it? Is the sleep disturbed? Investigations merely confirm the clinical diagnosis and/or differential diagnosis; they should not be solely relied upon. The mainstay of diagnosing bone stress injury is MRI scan. Treatment is based on unloading strategies. A standard for confirming chronic exertional compartment syndrome (CECS) is the dynamic intra-compartmental pressure study performed with specific exercises that provoke the symptoms. Surgery provides the best outcome. Medial tibial stress syndrome (MTSS) presents a challenge in both diagnosis and treatment especially where there is a substantial overlap of symptoms with deep posterior CECS. Conservative therapy should initially aim to correct functional, gait, and biomechanical overload factors. Surgery should be considered in recalcitrant cases. MRI and MR angiography are the primary investigative tools for functional popliteal artery entrapment syndrome and when confirmed, surgery provides the most satisfactory outcome. Nerve compression is induced by various factors, e.g., localized fascial entrapment, unstable proximal tibiofibular joint (intrinsic) or secondary by external compromise of the nerve, e.g., tight hosiery (extrinsic). Conservative is the treatment of choice. The localized fasciotomy is reserved for recalcitrant cases.

Standard wound management versus negative-pressure wound therapy in the treatment of adult patients having surgical incisions for major trauma to the lower limb-a two-arm parallel group superiority randomised controlled trial: protocol for Wound Healing in Surgery for Trauma (WHIST).

INTRODUCTION: Patients with closed high-energy injuries associated with major trauma have surprisingly high rates of surgical site infection in incisions created during fracture fixation. One factor that may reduce the risk of surgical site infection is the type of dressing applied over the closed surgical incision. In this multicentre randomised clinical trial, negative-pressure wound therapy will be compared with standard dressings with outcomes of deep infection, quality of life, pain and disability. METHODS AND ANALYSIS: Adult patients presenting to hospital within 72 hours of sustaining major trauma, requiring a surgical incision to treat a fractured lower limb, are eligible for inclusion. Randomisation, stratified by trial centre, open/closed fracture at presentation and Injury Severity Score (ISS) ≤15 versus ISS ≥16 will be administered via a secure web-based service using minimisation. The random allocation will be to either standard wound management or negative-pressure wound therapy.Trial participants will usually have clinical follow-up at the local fracture clinic for a minimum of 6 months, as per standard National Health Service practice. Diagnosis of deep infection will be recorded at 30 days. Functional, pain and quality of life outcome data will be collected using the Disability Rating Index, Douleur Neuropathique Questionnaire and Euroqol - 5 Dimension - 5 level (EQ-5D-5L) questionnaires at 3 months and 6 months postinjury. Further data will be captured on resource use and any late postoperative complications.Longer term outcomes will be assessed annually for 5 years and reported separately. ETHICS AND DISSEMINATION: National Research Ethics Committee approved this study on 16 February 2016 16/WM/0006.The National Institute for Health Research Health Technology Assessment monograph and a manuscript to a peer-reviewed journal will be submitted on completion of this trial. The results of this trial will inform clinical practice on the clinical and cost-effectiveness of the treatment of this injury. TRIAL REGISTRATION NUMBER: ISRCTN12702354; Pre-results.

Access to post-discharge inpatient care after lower limb trauma.

BACKGROUND: Most hospitals in the United States are required to provide emergency care to all patients, regardless of insurance status. However, uninsured patients might be unable to access non-acute services, such as post-discharge inpatient care (PDIC). This could result in prolonged acute hospitalization. We tested the hypothesis that insurance status would be independently associated with both PDIC and length of stay (LOS). METHODS: An observational study was undertaken using the California State Inpatient Database (2007-2011), which captures 98% of patients admitted to hospital in California. All patients with a diagnosis of orthopedic lower limb trauma were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes 820-828. Multivariable logistic and generalized linear regression models were used to adjust odds of PDIC and LOS for patient and hospital characteristics. RESULTS: There were 278,573 patients with orthopedic lower limb injuries, 160,828 (57.7%) of which received PDIC. Uninsured patients had lower odds of PDIC (adjusted odds ratio 0.20, 95% confidence interval 0.17-0.24) and significantly longer hospital LOS (predicted mean difference 1.06 [95% confidence interval 0.78-1.34] d) than those with private insurance. CONCLUSIONS: Lack of health insurance is associated with reduced access to PDIC and prolonged hospital LOS. This potential barrier to hospital discharge could reduce the number of trauma beds available for acutely injured patients.

Protocol for a randomised controlled trial of standard wound management versus negative pressure wound therapy in the treatment of adult patients with an open fracture of the lower limb: UK Wound management of Lower Limb Fractures (UK WOLLF).

INTRODUCTION: Patients who sustain open lower limb fractures have reported infection risks as high as 27%. The type of dressing applied after initial debridement could potentially affect this risk. In this trial, standard dressings will be compared with a new emerging treatment, negative pressure wound therapy, for patients with open lower limb fractures. METHODS AND ANALYSIS: All adult patients presenting with an open lower limb fracture, with a Gustilo and Anderson (G&A) grade 2/3, will be considered for inclusion. 460 consented patients will provide 90% power to detect a difference of eight points in the Disability Rating Index (DRI) score at 12 months, at the 5% level. A randomisation sequence, stratified by trial centre and G&A grade, will be produced and administered by a secure web-based service. A qualitative substudy will assess patients' experience of giving consent for the trial, and acceptability of trial procedures to patients and staff. Patients will have clinical follow-up in a fracture clinic up to a minimum of 12 months as per standard National Health Service (NHS) practice. Functional and quality of life outcome data will be collected using the DRI, SF12 and EQ-5D questionnaires at 3, 6, 9 and 12 months postoperatively. In addition, information will be requested with regards to resource use and any late complications or surgical interventions related to their injury. The main analysis will investigate differences in the DRI score at 1 year after injury, between the two treatment groups on an intention-to-treat basis. Tests will be two sided and considered to provide evidence for a significant difference if p values are less than 0.05. ETHICS AND DISSEMINATION: Ethical approval was given by NRES Committee West Midlands-Coventry & Warwickshire on 6/2/2012 (ref: 12/WM/0001). The results of the trial will be disseminated via peer-reviewed publications and presentations at relevant conferences. TRIAL REGISTRATION NUMBER: ISRCTN33756652.

Validation of the EQ-5D in Patients with Traumatic Limb Injury.

PURPOSE: The measurement properties of the EQ-5D have not been explored for patients with traumatic limb injuries. The purpose of this study was to examine the construct validity, predictive validity, and responsiveness of the EQ-5D in patients with traumatic limb injuries. METHODS: A consecutive cohort of 1,167 patients was assessed with the EQ-5D and the World Health Organization Quality of Life instrument (WHOQOL-BREF) at baseline while the patients were hospitalized because of the injury, and the patients were followed up at 3 months (1,003 patients), 6 months (1,010 patients), and 12 months (987 patients) after injury via telephone interview. RESULTS: The utility and visual analogue scale (VAS) scores of the EQ-5D had moderate to high association with the physical and psychological domains and the two general questions (overall QOL and overall health) of the WHOQOL-BREF at all time points except baseline (Pearson's correlation coefficient >0.3), but the EQ-5D profiles were weakly associated with the social and environment domains of the WHOQOL-BREF (absolute value of Spearman's correlation coefficient <0.3). These results indicate that the EQ-5D has satisfactory construct validity. The utility and VAS scores of the EQ-5D at 3 and 6 months after injury can predict (with moderate to large relationships) the four domains and two general questions of the WHOQOL-BREF administered at 12 months after injury. The responsiveness of the utility and VAS of the EQ-5D were high (effect sizes >0.9) at 0-3, 0-6, and 0-12 months after injury. CONCLUSIONS: The EQ-5D has sufficient construct validity, predictive validity, and responsiveness, and also provides evidence for using the utility of the EQ-5D for cost-utility analyses of patients with traumatic limb injuries in the future.

Extremity injuries as predictors of emergency care resource needs among blunt trauma patients in Japan.

This study aimed to exhaustively examine associations between prehospital variables and emergency care resource needs among blunt trauma patients. The study included blunt trauma patients aged 15 years or older who were admitted to a tertiary care medical center in Osaka, Japan, from January 2005 to December 2009. The primary end point was a composite measure of overall emergency care resource needs. Predictive variables were easily detectable upper and lower extremity injuries. A multivariate logistic regression model was used to identify associations between the predictive variables and the end point; this model included other covariates known to be associated with emergency care resource needs (demographic characteristics, mechanism of injury, and physiological parameters). Of 982 blunt trauma patients, 81 died, and 573 required overall emergency care resources. Upper extremity injury (odds ratio [OR], 2.60) and lower extremity injury (OR, 4.50) were significantly associated with overall emergency care resource needs after controlling for other covariates. The results of this study suggest that easily detectable extremity injuries may be useful predictors of the emergency care resource needs of trauma patients. Further studies are needed to validate the predictive values of these injuries and to determine ways to use information about extremity injuries to improve triage decisions.

Costs and outcome for serious hand and arm injuries during the first year after trauma - a prospective study.

BACKGROUND: To study costs and outcome for serious hand and arm injuries during the first year after the trauma. METHODS: In patients with a Hand Injury Severity Score (HISS) > 50, DASH and EQ-5D scores as well as factors related to costs within the health care sector, costs due to lost production and total costs were evaluated. Cox-regression analysis stratifying for mechanism of injury was used to analyse return to work. RESULTS: The majority of the 45 included patients (median 42 years 16-64) were men with severe (n = 9) or major (n = 36) injuries with different type of injuries (amputations n = 13; complex injuries n = 18; major nerve injuries/full house n = 13; burn injury n = 1). DASH and EQ-5D decreased and increased, respectively, significantly over time during one year. Total costs (+34%) and costs of lost production were highest for persons injured at work. Factors associated with higher health care costs were age >50 years (+52%), injury at work (+40%) and partial labour market activity (+66%). Costs of lost production had a significant role in total costs of injury. Patients with major injuries had longer duration of sick leave. Patients with severe injuries were more likely to return to work [(RR 3.76 (95% CI 1.38-10.22) from Cox regression, controlling for age, gender and presence of nerve injury]. CONCLUSIONS: Despite the fact that work environments have constantly improved over the last decades, we found that hand injuries at work were most costly both in terms of health care and costs of lost production, although the severity, i.e. HISS, did not differ from injuries occurring at home or during leisure.

The cost of outpatient venous thromboembolism prophylaxis following lower limb injuries.

This paper reports the cost of outpatient venous thromboembolism (VTE) prophylaxis following 388 injuries of the lower limb requiring immobilisation in our institution, from a total of 7408 new patients presenting between May and November 2011. Prophylaxis was by either self-administered subcutaneous dalteparin (n = 128) or oral dabigatran (n = 260). The mean duration of prophylaxis per patient was 46 days (6 to 168). The total cost (pay and non-pay) for prophylaxis with dalteparin was £107.54 and with dabigatran was £143.99. However, five patients in the dalteparin group required nurse administration (£23 per home visit), increasing the cost of dalteparin to £1142.54 per patient. The annual cost of VTE prophylaxis in a busy trauma clinic treating 12 700 new patients (2010/11), would be £92 526.33 in the context of an income for trauma of £1.82 million, which represents 5.3% of the outpatient tariff. Outpatient prophylaxis in a busy trauma clinic is achievable and affordable in the context of the clinical and financial risks involved.

Reducing the cost of lower limb wound management through industry partnership and staff education.

Following an audit of practice in North East London Foundation Trust (NELFT), obstacles in the management of lower limb conditions were identified. An appraisal of needs in terms of skills and theory updates for staff led to a fixed-term 'honorary contract' between the trust and a wound-care company to facilitate a rolling programme of education, to upskill staff in terms of assessment and treatment, and develop standardised care pathways. After 3 months, a repeated practice audit revealed a reduction in nurse contact hours of 1156 hours. The partnership with industry proved to be beneficial and did not compromise care, and trust staff were not obligated to use their product.