Vertical Fracture of the Medial Malleolus With Concurrent Ipsilateral Achilles Tendon Rupture in a Patient With Progressive Collapsing Foot Deformity: A Rehabilitation Dilemma.

A male in his 40s presented with a vertical shear type medial malleolar fracture with an ipsilateral Achilles tendon rupture with a pes planovalgus deformity. Both injuries were diagnosed concurrently on presentation. This is a rare injury pattern with no consensus on optimum management. This is the first case report where pes planus is also described alongside the injuries. The medial malleolar fracture was successfully treated surgically with an open reduction and internal fixation (ORIF) with antiglide plating. Following ORIF, the patient underwent functional rehabilitation for the Achilles tendon rupture. The purpose of this case report is to highlight this infrequent injury pattern, which poses a great therapeutic dilemma. The therapeutic considerations regarding surgical and non-surgical approaches to management are thoroughly presented and discussed.

Preparation/administration of push-dose versus continuous infusion epinephrine and phenylephrine: A simulation.

BACKGROUND: Hypotension is a common problem in the emergency department (ED) and intensive care unit (ICU) and can increase risk for poor outcomes. Many EDs/ICUs utilize epinephrine and phenylephrine to treat hypotension and these medications are most often administered as a continuous infusion (CI). Push-dose (PD) is the administration of small medication doses as intermittent intravenous pushes (IVPs). There is limited information comparing the time required to prepare and administer PD versus CI and errors have been reported when preparing and administering these medications at bedside. This simulation study sought to estimate preparation and administration times and preparation and errors with PD and CI epinephrine and phenylephrine when prepared by an ED/ICU pharmacist. METHODS: This crossover simulation study took place in a simulation center at an academic medical center and utilized a multi-venous intravenous training arm kit equip with an 18-gauge intravenous line, an extension tubing set, and a luer-lock adapter. The primary outcome was total preparation and administration time in seconds. The secondary outcome was major preparation and administration errors, defined as errors causing a five-fold or greater overdose. RESULTS: In total, 16 pharmacists participated, including nine ED and seven ICU pharmacists. PD had faster total preparation and administration time and administration time, but not preparation time; PD showed an approximate 70 s decrease in total preparation and administration time versus CI. PD had more major preparation and administration errors and six PD preparations (18.8%, 6/32) had at least one major preparation and administration error. CI, on the other hand, had no major preparation and administration errors. DISCUSSION: This simulation found faster total preparation and administration time with PD versus CI epinephrine and phenylephrine, but also found that PD had more major preparation and administration errors. Dilutional errors during medication preparation were the cause of 83.3% (5/6) of our overdoses. CONCLUSION: This simulation study showed that ED/ICU pharmacists had faster median total preparation and administration times for PD epinephrine and phenylephrine versus CI, but PD also had more preparation and administration errors.

Femur fracture in a paediatric patient with hereditary hyaline fibromatosis syndrome.

An 18-month-old girl with hereditary hyaline fibromatosis syndrome (HHFS) and fixed flexion contractures presented with an oblique femur fracture, following a fall out of her mother's arms. The fracture was abutting intramedullary hyaline lesions. Due to her condition, balanced traction was impossible to apply. The authors report effective treatment of her injury using a non-operative approach in an early hip spica, over a 4-week period. There was no evidence of delayed osseous healing. Early spica application could be used as a definitive management option in children with femur fractures and fixed flexion contractures in future. This case emphasises the need for preventative measures to support bone health in patients with HHFS.

The impact of digitisation of a virtual fracture clinic on referral quality, outcomes and assessment times.

BACKGROUND: Virtual fracture clinics (VFCs) have become widely adopted, aiming to improve efficiency, standardise patient care and reduce clinic appointments for injuries that can be managed conservatively. A variety of means exist to manage VFC referrals and assessment, including paper-based and digital methods. This study assesses VFC referral quality and outcomes before and after implementation of a digital VFC referral and management system. METHODS: A retrospective analysis was conducted of all VFC referrals and assessments from July 2017-March 2020 in a large UK district general hospital. All referrals and assessments were analysed for quality and completeness of referral information, grade of assessor, outcome of assessment, referral-to-assessment time, and assessment-to-surgery time (for those requiring operative management). RESULTS: 3038 paper and 9,228 digital referrals were analysed by 2 separate reviewers. Quality and completeness of referral information showed significant improvement in 11 predetermined key data points with the digital referral system (p < 0.001). Date and mechanism of injury were the most commonly missing data criteria (67.5% and 68.2%, respectively) with paper referrals. Significant improvements were noted in the proportion of Consultant delivered VFC assessments (84.2% vs 71.0%; p < 0.001), VFC discharge rate (20.8% vs 13.1%; p < 0.001) and patients recalled for urgent review (6.2% vs 0.8%; p < 0.001) with digital referrals. Mean referral-to-assessment (31.2 vs 49.9 h; p < 0.001) and assessment-to-surgery (9.2 vs 13.0 days; p = 0.01) times also reduced significantly with referral digitisation. CONCLUSION: Improvements in virtual referral quality and completeness directly lead to facilitation of more thorough, detailed and appropriate virtual assessments; improving timely decision-making, reducing unnecessary appointments, and permitting better prioritisation of workload and earlier surgery for patients requiring operative treatment. Purpose-built digital solutions are an excellent means of achieving these aims.

Non-chewing diets and cerumen impaction in the external ear canal in a residential aged care population.

OBJECTIVE: To examine whether diets involving reduced chewing affect the degree of cerumen impaction in older people in residential care. METHODS: A total of 51 people (53% male) over 65 years (80.5 ± 9.3) were recruited from two residential aged care facilities in Perth, Australia. Participants were classified as "chewers" (on unrestricted or soft food diets), or "non-chewers" (on pureed or nil by mouth diets), and completed a survey about predisposing factors for cerumen impaction. Otoscopy and tympanometry were used to assess cerumen impaction and ear canal occlusion. Participants with excess cerumen were referred for wax removal. RESULTS: No significant difference in cerumen accumulation was found between groups. However, 57% of participants showed excess cerumen requiring removal. CONCLUSION: Diets involving reduced chewing are not associated with increased cerumen in older people in residential care. The prevalence of cerumen impaction is high in this population, and improved cerumen screening and management is needed in residential aged care.

Iatrogenic adrenal suppression following caudal epidural and facet joint injection.

Caudal epidural injections and facet joint injections using steroids and local anaesthetic are widely used methods of pain control in patients suffering from radicular leg pain. In the vast majority of cases this is low risk. We present an interesting case of a patient who suffered from symptomatic adrenal suppression following a caudal epidural injection, and thus wish to draw this rare but significant complication to the attention of orthopaedic practitioners.

Patella incarceration with associated patella fracture: a rare case of a paediatric patient with no associated femoral fracture.

We describe the case of a 15-year-old girl who presented to the Accident and Emergency Department with right knee pain and a tense effusion following a twist and fall directly onto her right knee. An MRI scan demonstrated that she had an incarcerated dislocated patella with an associated patella avulsion fracture. This required open reduction. Open reduction and fixation was performed using suture anchors. We feel that this case is particularly pertinent since nearly all previous case reports describe an incarcerated patella with an associated femur fracture. Furthermore, no previous case reports have been published in a child.

Characteristics of children who do not attend their hospital appointments, and GPs' response: a mixed methods study in primary and secondary care.

BACKGROUND: Children who do not attend (DNA) their hospital outpatient appointments are a concern because this potentially compromises the child's health and incurs financial cost. Little is known about children who DNA or the views of GPs to non-attendance. AIM: To describe the characteristics of children who DNA hospital paediatric outpatient appointments, and explore how GPs view and respond to DNAs. DESIGN AND SETTING: A mixed methods study of data from all new referrals to a children's hospital in the South West of England between 1 September and 31 October 2012. METHOD: Data were extracted from patients' hospital and GP records, and Stata was used to analyse the data quantitatively. Analysis focused on describing the characteristics of children who DNA, and the process of care that followed. Practices that had either the highest or lowest number of DNAs were purposefully sampled for GPs who had referred children to secondary care at the study hospital within the previous year. Interviews were held between May 2014 and July 2015, and were analysed thematically. RESULTS: Children who DNA are more likely to be from an area of greater deprivation (adjusted odds ratio [AOR] 1.02, 95% confidence interval [CI] = 1.00 to 1.02, P = 0.04), and with a child protection alert in their hospital notes (AOR 2.72, 95% CI = 1.26 to 5.88, P = 0.01). Non-attendance is communicated poorly to GPs, rarely coded in patients' GP records, and few GP practices have a formal policy regarding paediatric DNAs. CONCLUSION: Non-attendance at hospital outpatient appointments may indicate a child's welfare is at risk. Communication between primary and secondary care needs to be improved, and guidelines developed to encourage GPs to monitor children who DNA.