Quality assurance in segmental neck of femur fractures.

Purpose The purpose of this paper is to report a rare case of segmental neck of femur fracture (SNoFF) and highlight its quality assurance and governance implications with respect to national guidelines, care pathways and best practice tariff. Design/methodology/approach Case report of an SNoFF in a 67-year-old woman treated at a district general hospital (DGH) was used in this study. Findings SNoFF required additional implants that delayed the surgery by five days. The authors were unable to adhere to the British Orthopaedic Association standards for trauma and Scottish Inter-Collegiate Guidelines Network recommendations which indicate that all neck of femur fractures (NoFFs) be fixed within 48 h. Though the patient was discharged without any untoward event and had an uneventful recovery, this case led us to introspect and learn how best to avoid such an incident from repeating again. Research limitations/implications This case led to an overhaul of NoFF and trauma services. The local logistics was restructured to procure "Trochanteric grip plates" within 24 h to provide mandated quality of care in an effort towards improving patient experience/outcomes. Originality/value SNoFF are rare injuries and its diagnosis is either delayed or missed in at least 20 per cent of the cases on initial evaluation. The non-availability of additional implants readily on the shelf coupled with lack of a trauma bed at the tertiary centre resulted in an unacceptable delay from admission to definitive surgery. The authors recommend that all DGHs have a mechanism/emergency procurement procedure system in place to obtain the required instrumentation kits rapidly through a sharing scheme with regional hospitals or through implant vendor to avoid unacceptable delays to surgery.

Total Humeral Endoprosthesis Replacement to Salvage Periprosthetic Fractures in Rheumatoid Arthritis.

The authors report their experience in the management of a 53-year-old woman with rheumatoid arthritis who presented with bilateral asynchronous traumatic periprosthetic fractures of the humerus after bilateral elbow replacements. One side was treated with a long-stem revision and internal fixation with bone graft, while the other side was treated with a long-stem distal humeral replacement. She sustained pathological periprosthetic fractures on top of the long-stemmed implants. Total humeral endoprosthesis replacements were performed bilaterally as salvage procedures to provide a stable platform for her elbow and hand function. At manuscript submission, the patient was 24 months and 36 months postoperatively on the left and right sides, respectively. Her Oxford Shoulder Scores were 21 (left side) and 24 (right side). There is little information about the management of periprosthetic fractures of the humerus after long-stem revisions with severe bone loss. To the best of the authors' knowledge, this is the first case report describing the use of bilateral total humeral endoprosthesis replacements in the management of complex unstable periprosthetic fractures. This is a valuable treatment option for patients with poor bone quality, bone loss, and loose components. [Orthopedics. 2017; 40(2):e363-e366.].

Percutaneous Reduction and Fixation Using Two K-wires In Paediatric Angulated Radial Neck Fractures.

BACKGROUND: Fractures of the radial neck in children are usually seen at about the age of five years, after the appearance of the proximal radial epiphysis. They are usually caused by a fall on the outstretched hand which produces a valgus strain [1]. Minor degrees of angulation can be accepted and treated conservatively, but advice on the maximum acceptable angulation varies widely, up to as much as 45°0 [2] More severely angulated and displaced fractures have been variously treated by closed or open reduction, but the precise indications for each are not clear [3]. In a retrospective study Steele et al. found that open reduction generally had a poor result and that open reduction with internal fixation was even worse, as has been reported by others [4, 5]. METHODS: We describe a modified percutaneous technique using two (1.6 mm) K-wires for reduction (one wire for leverage and one wire for translation) and two K-wires for rotationally stable fixation. RESULTS: Nine patients were included in the study. The median age of the patients was 9.6 years. There were six males and three females. The average follow up period was 23 months. The final results of the study included six patients with excellent results and one with a good result. Unfortunately, two patients were visitors and failed to attend for review. CONCLUSION: We have found this technique effective and easily reproducible. Level of evidence IV - Case series.

A Simple Dressing Technique Following Dermofasciectomy and Full Thickness Skin Grafting of the Fingers in the Treatment of Severe Dupuytren's Contracture.

Dupuytren's disease with severe finger contractures and recurrent contractures following previous surgery often have extensive skin involvement. In these severe cases, excision of the diseased chord along with the involved skin is a good option to reduce the risk of recurrance. The resulting skin defect can be covered with a full thickness skin graft (FTSG) or a cross finger flap. Cross finger flaps have donor finger morbidity and hence a full thickness graft is usually preferred. The FTSG extending to the midlateral margins on both sides of the finger reduces the risk of joint contracture due to graft shrinkage. Once the FTSG is sutured in place, the standard practice is to compress and secure the graft to its recipient bed with a tie-over dressing and this can be time consuming. We present a simple dressing technique to secure the FTSG without the need for a tie-over dressing.

Spontaneous Compartment Syndrome of the Hand in Systemic Sclerosis.

Compartment syndrome refers to a condition of compromised circulation within a limited space due to increased pressure within that space. The reduced tissue perfusion results in reduced venous drainage, leading to increased interstitial tissue pressure and subsequent compromised arterial flow. Although not as common as compartment syndrome of the leg and forearm, compartment syndrome of the hand is not rare and can lead to devastating sequelae as a result of tissue necrosis. Compartment syndrome of the hand has several etiologies, including trauma, arterial injury, thermal injury, and constrictive bandaging. The cardinal clinical sign is pain that is aggravated by passive stretching of the muscles within the involved compartments. Extremity function is usually restored with expeditious fasciotomy of the involved myofascial compartments, and complications, such as intrinsic muscular dysfunction and Volkmann's ischemic contracture, can usually be prevented. There are no reported cases of compartment syndrome of the hand in patients with systemic sclerosis or Raynaud's phenomenon. Systemic sclerosis is a form of scleroderma that affects the skin and internal organs. The limited cutaneous subset affects the skin of the extremities but is associated with a set of characteristic features that includes calcinosis, Raynaud's phenomenon, esophageal involvement, sclerodactyly, and telangiectasia. This report describes an unusual case of a patient who had spontaneous compartment syndrome of the hand. The patient's concomitant limited cutaneous systemic sclerosis may have played a role in this unusual occurrence. The diagnosis was based on the clinical picture, and the symptoms resolved after surgical decompression.

Atypical Osteomyelitis Caused by Mycobacterium chelonae in a Nonimmunocompromised Patient: A Case Report.

CASE: A previously healthy fifty-seven-year-old woman presented with an acute atypical mycobacterial infection of the first metatarsal bone of the left foot. Despite antimicrobial treatment, the infection was not controlled. First-ray amputation was performed, and antimicrobial treatment was continued for a total of six months. The patient was fitted with an orthotic (insole) and followed for eighteen months; there was no recurrence of infection. CONCLUSION: To the best of our knowledge, this is the first case report describing Mycobacterium chelonae osteomyelitis of the first metatarsal ray in an immunocompetent individual. This diagnosis should be considered in patients with osteomyelitis that persists despite the use of broad-spectrum antibiotics, even in healthy individuals.

Anterior interosseous nerve palsy as a complication of proximal humerus fracture.

Anterior interosseous nerve palsy subsequent to proximal humerus fracture is rare compared with an axillary nerve injury. This article presents a case of anterior interosseous nerve palsy secondary to such a fracture in an 87-year-old woman after a simple fall onto her outstretched hand. The patient had no sensory involvement but was unable to form an O with her thumb and index finger. She had a positive pointing index test on attempting to clasp her hand. The fracture and nerve palsy were treated conservatively. At 3-month follow-up, the patient had partial recovery; therefore, electromyography was not performed. By 6 months, she had complete recovery of anterior interosseous nerve palsy. This case highlights the possibility of sustaining anterior interosseous nerve palsy with proximal humerus fracture with a classical clinical presentation. Because most nerve lesions after proximal humerus fracture are neurapraxia, symptoms usually resolve either partially or completely after a few months. It is recommended that cases with proximal humerus fracture be evaluated carefully for median nerve and axillary nerve injury. In addition, it is recommended to perform electromyography if no signs of recovery are evident at 3-month follow-up.

Temporary external fixation facilitates open reduction and internal fixation of intra-articular calcaneal fractures.

Management of intra-articular calcaneal fractures during the past years has ranged from the nihilistic approach of no active treatment to open reduction and internal fixation or even to early subtalar arthrodesis. Operative treatment presents the surgeon with many challenges. Good results require atraumatic exposure, anatomic reduction, rigid fixation and early mobilization. We describe the use of a temporary external fixator as an intraoperative aid in the open reduction and internal fixation of intra-articular calcaneal fractures. We propose this operative strategy as an option for the treatment of calcaneal fractures. The controlled distractive force provides numerous benefits. These include improved exposure of the subtalar joint, correction of angulation and maintenance of temporary stability prior to definitive fixation. We have found this technique applicable and easily reproducible.