Ultrasound Directed Reduction of Colles' type distal radial fractures in ED (UDiReCT): a feasibility randomised controlled trial.

BACKGROUND: There is a high rate of surgical fixation of displaced Colles' type distal radial wrist fractures despite fracture manipulation in the ED. Point-of-care ultrasound has been used to guide ED manipulations but its effect on the quality of fracture reduction or subsequent need for surgical fixation is unknown. This study aims to assess the feasibility of conducting a definitive randomised controlled trial to assess the use of ultrasound to guide these fracture manipulations. METHODS: We conducted a pragmatic randomised controlled feasibility trial in two EDs in England over a 6-month period (7 October 2019 to 6 April 2020). Adult patients with wrist fractures undergoing manipulation in the ED were randomised 1:1 to ultrasound-guided distal radial fracture manipulation or manipulation with sham ultrasound. The primary outcome for this study was trial recruitment rate. Other measures were recorded to assess potential future definitive trial outcomes and feasibility. RESULTS: Of 120 patients meeting inclusion criteria, 48 (40%) were recruited and randomised in the two centres, giving overall recruitment rates of 0.3 and 1.8 participants per week at each site, respectively, and 1 participant per week overall. The most common reason that patients were not included was research staff availability. After 6 weeks, six patients in each group (26% intervention, 24% control) had undergone surgical fixation, with 98% data completeness for this potential definitive trial primary outcome. Randomisation, blinding and data collection processes were effective but there were data limitations in the X-ray assessment of fracture positions. CONCLUSION: A definitive study of a similar design would be feasible within UK ED practice but organisational factors and research staff availability should be considered when estimating the predicted recruitment rate and required sites. 6-week surgical fixation rate was the most reliable outcome measure. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03868696).

Can we reduce morphine use in elderly, proximal femoral fracture patients using a fascia iliac block?

Proximal femoral fractures are becoming increasingly common with an ageing population. Many patients have multiple comorbidities increasing their risk of opiate complications. 40 consecutive patients presenting with a proximal femoral fracture to a trauma centre in the UK were given either a Fascia Iliaca Block (FIB) with oral analgesia or just oral analgesia to control their pre-operative pain. Numeric pain scores and morphine consumption were used as outcome measures. Patients receiving a FIB had significant reduction in their pain scores compared to patients only receiving oral pain relief. There was also a significant reduction in both the actual oral morphine taken and the renal calculated level of morphine products in the group receiving the FIB. Patients undergoing a FIB required almost 50 mg less oral morphine pre-operatively. Nerve blocks should be used routinely to help pre-operative pain in proximal femoral fracture patients and to reduce the amount of morphine products prescribed. This prevents potential opiate complications in a highly susceptible cohort of patients often suffering with impaired renal function as a co-morbidity.

The Latarjet Procedure For Anterior Shoulder Instability : A Consecutive Prospective Series Of 50 Cases.

The Latarjet is a successful primary and revision option for anterior shoulder instability. However, recent reports have highlighted varying complication rates. Our study prospectively collected clinical, functional and radiological outcomes of patients undergoing the procedure. Forty-eight consecutive patients (fifty shoulders) underwent the Latarjet procedure in a single UK centre. Clinical, radiological and functional follow-up was performed. Mean clinical follow-up was 32 months and radiological follow-up 20 months. 95% shoulders were subjectively graded "excellent" or "good" and 5% "fair". Mean Rowe, Oxford Shoulder Instability Score, American Shoulder and Elbow selfassessment Score and Subjective Shoulder Value Score all improved post-operatively (p<0.001). No infections, dislocations, revisions or metalworkrelated complications occurred. There was one intra-operative coracoid fracture and five transient neurological injuries, resolving within three months. The long-term complication rate was 2%. The Latarjet procedure is safe and reliable for treating anterior shoulder instability with a very low long-term complication rate providing excellent clinical and functional outcomes.

Tracking a painful episode after a joint replacement using patient-reported outcome measures (PROMs).

Patient-reported outcome measures (PROMs) are an important tool in measuring the benefit of a surgery for patients and for clinicians. The results of such assessment tools can be used to monitor patient progress or initiate intervention. The scores also provide a reproducible evaluation of functional recovery and well-being after surgery. We report the case of a 68-year-old woman who underwent left unicondylar knee replacement in November 2011 followed by right unicondylar knee replacement in April 2012. Prospective, web-based electronic PROMs were used preoperatively and every 6-12 months postoperatively to monitor the improvement in pain and function symptoms. These outcome measures were beneficial in helping to monitor an episode of new pain in her left knee, without requiring invasive or extensive investigation.

Non-operative management, supported by self-monitoring using web-based patient reported outcome measures (PROMs), in knee osteoarthritis.

Despite being straightforward to collect and key to providing patient-centred, individualised care, the routine use of patient reported outcome measures (PROMs) remains limited in the National Health Service. Herein is described the case of a 69-year-old woman who presented to secondary care with osteoarthritis. Web-based PROMs were used to track the patient's symptoms and function. Lifestyle changes were recommended to manage the osteoarthritis. Monitoring enabled the patient to take control of her disease management. Two years later, she continues to manage her knee symptoms conservatively, recording progress by using a web-based system. This case illustrates how web-based PROMs can be used to support conservative management of knee osteoarthritis by both empowering patients and minimising the burden on secondary care outpatient services.

Patient-reported outcome measures (PROMs): enhancing decision making and follow-up.

A case presentation of patient undergoing elective total knee replacement. Patient-reported outcome measures prospectively collected electronically pre and postoperatively allowed real-time review, aiding follow-up and reducing the need for clinical, face-to-face follow-up.