Single-leg versus double-leg hip spica casts in the management of paediatric femoral shaft fractures? A systematic review and meta-analysis.

Background: Paediatric femoral shaft fractures can be managed with single- or double-leg hip spica casting between ages six-months and six-years. The aim of this review was to determine if single-leg hip spicas reduce the impact on family life without compromising fracture stability. Methods: The study was registered on PROSPERO (CRD42023454309). MEDLINE, Embase, Web of Science, Cochrane Library, and clinical trial registers were searched to May 2023 for level I-III evidence. Primary outcomes were impact on family life and fracture stability. Where appropriate, Meta-analysis was completed using RevMan v5.4. Risk of bias was assessed using RoB 2.0 (RCTs) and ROBINS-I (non-RCTs). Certainty of evidence was measured with GRADE. Results: From 234 identified papers, four met the inclusion criteria (two RCTs; two non-RCTs). A total of 339 children were included (single-leg spica: 176; double-leg spica: 163). Three studies were 'high risk' and one study 'moderate risk' of bias. Impact on family life parameters were too heterogenous for pooled meta-analysis. Non-pooled data identified significantly more missed work days in the double-leg spica group and the 'Impact on Family' Scale significantly favoured single-leg spicas. For fracture stability, meta-analysis identified that (i) mal-union rates were significantly lower in single-leg spica: OR 0.08 (95 % CI 0.01 to 0.69; p = 0.02); (ii) MUA in theatre was not significantly different: OR 0.97 (95 % CI 0.19 to 4.86; p = 0.97); and (iii) wedge adjustment was not significantly different: OR 3.46 (95 % CI 0.48 to 24.92; p = 0.22). Certainty of evidence was assessed as 'very low'. Conclusion: Single-leg hip spicas may be associated with reduced impact on family life without compromising fracture stability compared with double-leg hip spicas. However, the evidence is weak. Therefore, a propensity score matched observational study is required to understand if subgroups of patients (age, fracture pattern, mechanism of injury) would benefit from a single- or double-leg hip spica.

Open lower limb fractures in the UK trauma system: A multicentre prospective audit of current practice.

INTRODUCTION: Open fractures represent limb-threatening and life-changing injuries. Clear standards define how patients with these injuries should be managed in the UK. The study of open fractures is, therefore, a key measurable example of major trauma management as a whole. This study was conducted to characterise the demographic, assessment and treatment of patients sustaining lower limb open fractures across UK Regional Trauma Networks. METHODS: A prospective, multicentre, audit was conducted according to a prespecified protocol against the relevant British Orthopaedic Association (BOA) & British Association of Plastic, Reconstructive & Aesthetic Surgeons (BAPRAS) standards for Trauma. All UK hospitals treating adults with open fractures were eligible to take part in the study. Patients included were injured during a six month collection period at each site. RESULTS: 3 Major Trauma Centres (MTCs) and 5 Trauma Units (TUs) were enrolled, with data collected by 24 collaborators. 239 patients were included, 11 had bilateral open fractures. There were 38 patient datasets collected from TUs and 201 from MTCs. Patients were predominantly male with high energy injuries. 31.3% of patients from MTCs were transferred in from another facility. Antibiotics were given to 41.7% of patients within 1 hour. 74.4% of limbs with open fractures had a splint applied in the emergency department. 85.8% of patients had a documented orthoplastics plan. 41.7% of patients with a high energy injury had their wound debrided within 12 hours. DISCUSSION: 42.3% of patients with open fractures in our cohort were managed at some point in a TU, indicating triage was required within the trauma network. Due to sampling, we may be under-estimating the number of patients passing through TUs, however, we have demonstrated that this cohort exists. These patients are under-represented in many other studies and registries such as the Trauma Audit Research Network (TARN) due to the funding model for data collection that privileges data collection in MTCs. CONCLUSION: This study gives extensive new insight into the demographics and management of patients with open lower limb fractures in the UK, demonstrating a widespread involvement of TUs and consistent deviation from national standards.

Helicopter and ground emergency medical services transportation to hospital after major trauma in England: a comparative cohort study.

BACKGROUND: The utilization of helicopter emergency medical services (HEMS) in modern trauma systems has been a source of debate for many years. This study set to establish the true impact of HEMS in England on survival for patients with major trauma. METHODS: A comparative cohort design using prospectively recorded data from the UK Trauma Audit and Research Network registry. 279 107 patients were identified between January 2012 and March 2017. The primary outcome measure was risk adjusted in-hospital mortality within propensity score matched cohorts using logistic regression analysis. Subset analyses were performed for subjects with prehospital Glasgow Coma Scale <8, respiratory rate <10 or >29 and systolic blood pressure <90. RESULTS: The analysis was based on 61 733 adult patients directly admitted to major trauma centers: 54 185 ground emergency medical services (GEMS) and 7548 HEMS. HEMS patients were more likely male, younger, more severely injured, more likely to be victims of road traffic collisions and intubated at scene. Crude mortality was higher for HEMS patients. Logistic regression demonstrated a 15% reduction in the risk adjusted odds of death (OR=0.846; 95% CI 0.684 to 1.046) in favor of HEMS. When analyzed for patients previously noted to benefit most from HEMS, the odds of death were reduced further but remained statistically consistent with no effect. Sensitivity analysis on 5685 patients attended by a doctor on scene but transported by GEMS demonstrated a protective effect on mortality versus the standard GEMS response (OR 0.77; 95% CI 0.62 to 0.95). DISCUSSION: This prospective, level 3 cohort analysis demonstrates a non-significant survival advantage for patients transported by HEMS versus GEMS. Despite the large size of the cohort, the intrinsic mismatch in patient demographics limits the ability to statistically assess HEMS true benefit. It does, however, demonstrate an improved survival for patients attended by doctors on scene in addition to the GEMS response. Improvements in prehospital data and increased trauma unit reporting are required to accurately assess HEMS clinical and cost-effectiveness.

Atypical presentation of appendicitis.

A woman aged 64 years presented as an emergency with a mass in the right iliac fossa, clinically within the abdominal wall, but an otherwise soft abdomen. Systemically, she was quite well with normal vital signs. Blood tests revealed raised inflammatory markers, and an abdominal CT scan demonstrated a perforated appendix with associated large subcutaneous abscess. This represents a rare presentation of a common condition, demonstrating how appendicitis can still be a challenging problem for the clinician. The patient underwent incision and drainage of the abscess, resulting in the formation of an enterocutaneous fistula (ECF). This was managed with enteral nutritional support, wound dressings and antibiotics. Following normal CT imaging, an ileocaecal resection was planned in the expectation that the ECF would persist. The operation was postponed due to intercurrent illness, during which time her symptoms and the ECF fully resolved.

Secretions from placenta, after hypoxia/reoxygenation, can damage developing neurones of brain under experimental conditions.

Some psychiatric diseases in children and young adults are thought to originate from adverse exposures during foetal life, including hypoxia and hypoxia/reoxygenation. The mechanism is not understood. Several authors have emphasised that the placenta is likely to play an important role as the key interface between mother and foetus. Here we have explored whether a first trimester human placenta or model barrier of primary human cytotrophoblasts might secrete factors, in response to hypoxia or hypoxia/reoxygenation, that could damage neurones. We find that the secretions in conditioned media caused an increase of [Ca(2+)]i and mitochondrial free radicals and a decrease of dendritic lengths, branching complexity, spine density and synaptic activity in dissociated neurones from embryonic rat cerebral cortex. There was altered staining of glutamate and GABA receptors. We identify glutamate as an active factor within the conditioned media and demonstrate a specific release of glutamate from the placenta/cytotrophoblast barriers invitro after hypoxia or hypoxia/reoxygenation. Injection of conditioned media into developing brains of P4 rats reduced the numerical density of parvalbumin-containing neurones in cortex, hippocampus and reticular nucleus, reduced immunostaining of glutamate receptors and altered cellular turnover. These results show that the placenta is able to release factors, in response to altered oxygen, that can damage developing neurones under experimental conditions.