Does a delay in surgery for distal radial fractures affect patient outcome?

Current guidelines from the British Orthopaedic Association state that if fractures of the distal radius are operated on then this should take place within 3 days of injury for intra-articular fractures, 7 days for extra-articular fractures and 3 days when a trial of conservative management has failed. This retrospective cohort study aimed to assess whether there was any difference in outcome between patients receiving timely or delayed surgery, using the Patient-Rated Wrist Evaluation score at >12 months after injury as the primary outcome measure. Data from 380 patients treated at two district general hospitals over a 5-year period were obtained using electronic databases to capture the demographics and treatment details and postal questionnaires to assess current function. The study showed no statistical or clinical differences in outcome measures between the timely or delayed cohorts in any of the three treatment groups.Level of evidence: III.

Flexible nails have a significantly increased risk of complications compared with plating techniques when treating diaphyseal femoral fractures in children aged 5-12: A systematic review.

BACKGROUND: One third of paediatric femoral fractures occur between the ages of 5 and 12. The American Academy of Orthopaedic Surgeons (AAOS) provide evidence-based guidance for treating such fractures that occur in children under 5 and over 12 but not for this age cohort. We aimed to synthesise the available evidence comparing flexible nailing versus plating techniques for diaphyseal femoral fractures in children between the ages of 5 and 12. METHODOLOGY: A systematic review of interventional and observational studies was performed using MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, WHO Global Index Medicus and LILACS. The search strategy combined keywords for: children, diaphyseal femoral fractures, plates and nails. Two independent reviewers screened, selected, assessed quality and extracted data from identified studies. The primary outcome was overall complication rates. Secondary outcomes assessed rates of individual complications, and operative variables (e.g. operative time, blood loss). RESULTS: Five studies fulfilled the eligibility criteria. No RCTs were identified. The studies included 308 femoral fractures in 306 patients: 174 fractures were treated with flexible nailing and 134 with plating. The post-operative complication rate was 27.0% (n = 47) after flexible nails and 12.7% (n = 17) after plating, relative risk 2.13 (95% CI 1.28, 3.53; p = 0.0035). The relative risk of malunion was 3.59 (95% CI 1.05, 12.25; p = 0.0409) with flexible nails and of prominent metalwork was 5.39 (95% CI 1.25, 23.31; p = 0.0241) with flexible nails. CONCLUSIONS: Data on this topic for this age group is limited despite accounting for one third of paediatric femoral fractures. This review identified a significantly increased relative risk of all complications, and in particular with respect to malunion and prominent metalwork when fractures in this cohort are treated with flexible nails compared to plates. A multi-centre randomised trial to determine if either treatment is superior would be justified.

Managing polytrauma patients.

Embedding physiological markers into treatment algorithms has helped trauma teams rationalise interventions safely and signifies a departure from the dichotomy of damage control orthopaedics (DCO) and early total care (ETC) to early appropriate care (EAC). This has been shown to reduce length of stay and cost to treating centres. This article seeks to provide a clear summary of current concepts for managing orthopaedic injuries in the multiply injured patient.

Attitudes to Palliative Care in Patients With Neck-of-Femur Fracture-A Multicenter Survey.

INTRODUCTION: The mortality of patients with neck-of-femur (NOF) fractures remains high, with increasing recognition of a subgroup of patients with predictable mortality. The role of palliative care in this group is poorly understood and underdeveloped. This research aims to investigate current clinician attitudes toward palliative care for patients with NOF fracture, and explore processes in place for early identification for patients nearing the end of life. MATERIALS AND METHODS: An online survey was constructed with reference to National Institute for Health and Clinical Excellence end-of-life guidelines (CG13) and distributed to multidisciplinary teams involved in the care of NOF fracture patients in 4 hospitals of contrasting size and location in the United Kingdom. RESULTS: Forty health-care professionals with a broad range of seniority and roles responded. The palliative care team was felt to have several potential roles in the care of NOF fracture patients, but there was difference of opinion between specialties about what these were. A number of barriers to palliative referral were identified, including stigma and active surgical management. The majority (75%) felt that all NOF fracture patients should have a discussion about ceiling of care, with difference of opinion about who should do so, and when. DISCUSSION: As the elderly population has grown, so too has the volume of NOF fracture patients. It is increasingly important to identify and escalate patients who have poor prognosis following hip fracture and ensure they benefit from palliative care where appropriate. This survey demonstrates a barrier to addressing the care of these patients and a lack of consensus on identification and referral to appropriate palliative care planning. CONCLUSIONS: There should be close communication between specialties with regard to requirements for palliative care in NOF fracture patients, with ongoing education and clear local and national guidance to ensure they receive the right care at the right time.

Time to intravenous antibiotic administration (TIbiA) in severe open tibial fractures: Impact of change to national guidance.

INTRODUCTION: Severe open tibial fractures are limb-threatening injuries. Outcomes depend on a complex interplay of patient, injury and treatment factors. 2009 guidelines from the British Orthopaedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) recommend prophylactic intravenous antibiotic administration within three hours of injury. More recent National Institute for Health and Care Excellence (NICE) 2016 guidelines recommend pre-hospital antibiotic administration where possible. This study aimed to analyse the impact of time to antibiotics on development of deep infection. METHODS: Adult acute Gustilo-Anderson 3B open tibial fractures managed at a single UK Major Trauma Centre were reviewed retrospectively over a three-year period, including a period before and after the regional ambulance service introduced a policy of administering pre-hospital intravenous antibiotics to open fractures in 2016. Development of deep infection was recorded as the primary outcome measure. Complete case regression analysis was performed. Time was assessed as a continuous variable and as thresholds with antibiotics received within one or three hours of injury. RESULTS: 156 patients with 159 fractures were included. Following introduction of new guidance in 2016, median time to antibiotics decreased from 180 to 160 min and more patients received pre-hospital antibiotics (2% vs. 33%). Overall, 7.5% developed deep infection (n = 12) within a median follow-up of 26 months. Logistic regression found no relationship between any independent variable, including time to antibiotic administration, and development of deep infection. CONCLUSIONS: There are a variety of factors identified in the literature and in national policies and treatment guidelines as potentially modifiable to reduce the risk of deep infection following open fractures. In this study, time to antibiotic administration was not associated with the risk of developing deep infection. The results of this study demonstrate a low infection rate, which may be due to expedient expert care delivered by a dedicated orthoplastic service in line with national guidance where achievable.

Testing and refining a loudness model for time-varying sounds incorporating binaural inhibition.

This paper describes some experimental tests and modifications to a model of loudness for time-varying sounds incorporating the concept of binaural inhibition. Experiment 1 examined the loudness of a 100% sinusoidally amplitude-modulated 1000-Hz sinusoidal carrier as a function of the interaural modulation phase difference (IMPD). The IMPD of the test sound was 90° or 180° and that of the comparison sound was 0°. The level difference between the test and the comparison sounds at the point of equal loudness (the LDEL) was estimated for baseline levels of 30 and 70 dB sound pressure level and modulation rates of 1, 2, 4, 8, 16, and 32 Hz. The LDELs were negative (mean = -1.1 and -1.5 dB for IMPDs of 90° and 180°), indicating that non-zero IMPDs led to increased loudness. The original version of the model predicted the general form of the results, but there were some systematic errors. Modifications to the time constants of the model gave a better fit to the data. Experiment 2 assessed the loudness of unintelligible speech-like signals, generated using a noise vocoder, whose spectra and time pattern differed at the two ears. Both the original and modified models gave good fits to the data.

A randomised controlled trial to test the effectiveness of decision training on assessors' ability to determine optimal fitness-to-drive recommendations for older or disabled drivers.

BACKGROUND: Driving licensing jurisdictions require detailed assessments of fitness-to-drive from occupational therapy driver assessors (OTDAs). We developed decision training based on the recommendations of expert OTDAs, to enhance novices' capacity to make optimal fitness-to-drive decisions. The aim of this research was to determine effectiveness of training on novice occupational therapists' ability to make fitness-to-drive decisions. METHODS: A double blind, parallel, randomised controlled trial was conducted to test the effectiveness of decision training on novices' fitness-to-drive recommendations. Both groups made recommendations on a series of 64 case scenarios with the intervention group receiving training after reviewing two thirds of the cases; the control group, at this same point, just received a message of encouragement to continue. Participants were occupational therapy students on UK and Australian pre-registration programmes who individually took part online, following the website instructions. The main outcome of training was the reduction in mean difference between novice and expert recommendations on the cases. RESULTS: Two hundred eighty-nine novices were randomised into intervention; 166 completed the trial (70 in intervention; 96 in control). No statistical differences in scores were found pre-training. Post training, the control group showed no significant change in recommendations compared to the experts (t(96) = -.69; p = .5), whereas the intervention group exhibited a significant change (t(69) = 6.89; p < 0.001). For the intervention group, the mean difference compared with the experts' recommendations reduced with 95% CI from -.13 to .09. Effect size calculated at the post-training demonstrated a moderate effect (d = .69, r = .32). CONCLUSIONS: Novices who received the decision training were able to change their recommendations whereas those who did not receive training did not. Those receiving training became more able to identify drivers who were not fit-to-drive, as measured against experts' decisions on the same cases. This research demonstrated that novice occupational therapists can be trained to make decisions more aligned to those of expert OTDAs. The decision training and cases have been launched as a free training resource at www.fitnesstodrive.com . This can be used by novice driver assessors to increase their skill to identify drivers who are, and are not fit-to-drive, potentially increasing international workforce capacity in this growing field of practice.

Pain after ortho-plastic reconstruction of lower limb injuries: A snapshot study.

INTRODUCTION: The incidence of pain after flap reconstruction of complex lower limb injury is poorly reported in the literature, and yet represents a significant source of morbidity in these patients. In our centre (Southmead Hospital, Bristol, England) patients who have had flap reconstruction for complex lower limb injury are followed up at a joint ortho-plastics lower limb clinic run weekly. The aim of this study was to report the incidence of pain in such patients at follow-up in the specialist clinic. The impact of the experience of pain upon the quality of life, and the efficacy of analgesia was assessed these cases. PATIENTS AND METHODS: This was a cross sectional snapshot study of a cohort of complex lower limb patients attending our lower limb ortho-plastics outpatient clinic between the dates of: 17/5/16 and 28/6/16. Any patient attending clinic with previous flap reconstruction for lower limb injury was asked to complete the BPI (Brief Pain Index) questionnaire, and details regarding their injury and surgery were collected. RESULTS: There was a 100% response rate, with 33 patients completing the questionnaire. 28 out of the 33 patients (85%) reported ongoing pain. There was no significant relationship between time post operatively and average pain scores (Spearman's Rank R = 0.077), nor was there significant difference by age or gender. Over 25% of the patients with pain were not taking analgesia, however those using simple analgesia (paracetamol, NSAIDS) derived on average over 70% pain relief. CONCLUSIONS: Pain in a common complication following flap reconstruction for complex lower limb injury reported in 85% of our cohort. This pain does not seem to be correlated with time, gender or age, and responds well to simple analgesia in most cases. This emphasises the importance of asking about pain at follow up, and taking simple measures to improve pain outcomes.

Septic arthritis of unilateral lumbar facet joint with contiguous abscess, without prior intervention.

A 40-year-old female patient presented with persistent severe back pain radiating to the right leg, abdominal pain and constipation. Other clinical symptoms included nausea, vomiting and high-grade fever. Clinical examination showed generalised abdominal and lower back tenderness. There was no sensory loss or motor weakness in lower limbs, however investigations showed raised inflammatory markers. Radiographs of the lumbar spine and hip joint were normal. MRI revealed a septic arthritis of the right L3/4 facet joint, associated with a large abscess extending anteriorly to the right paraspinal muscles and posteriorly into the right posterolateral aspect of the epidural space in the central spinal canal, with moderate compression of the dural sac. Unlike any other reported similar case, this septic arthritis developed without prior medical intervention. The patient was treated successfully with ultrasound guided drainage of the facet joint/abscess and antibiotics.

Calcific tendonitis of the tibialis posterior tendon at the navicular attachment.

Calcific tendinosis (tendonosis/tendonitis) is a condition which results from the deposition of calcium hydroxyapatite crystals in any tendon of the body. Calcific tendonitis usually presents with pain, which can be exacerbated by prolonged use of the affected tendon. We report a case of calcific tendinosis in the posterior tibialis tendon at the navicular insertion. The pathology is rare in the foot, and extremely rare in the tibialis posterior tendon, indeed there are only 2 reported in the published literature. This case report highlights the need to consider calcific tendinosis in the foot despite its rarity. If this diagnosis is considered early, appropriate investigations can then be requested and unnecessary biopsies, use of antibiotics and surgery can be avoided. We also discuss possible causes of calcific tendinosis in the tibialis posterior tendon, the role of imaging modalities and review treatment methods.