The multi-ligament ankle fracture: Epidemiology, key anatomical findings and fixation strategies in unstable open injuries.

Background: Ankle fracture surgery has traditionally focussed on restoration of bony anatomy, with fixation of the malleoli and syndesmotic stabilisation where applicable. However, high energy open fracture-dislocations can also result in periosteal stripping of the stabilising capsuloligamentous attachments. As such, restoration of osseous anatomy alone may not result in sufficient articular stability. Objectives: In this series from a level 1 trauma centre, we report a subset of highly unstable open ankle fractures with combined capsuloligamentous injuries, in which restoration of osseous anatomy did not result in a stable joint. Supplementary soft tissue reconstruction and other stabilisation techniques were required. Methods: Retrospective case series of eligible patients from a level 1 trauma centre. Inclusion criteria were open ankle fractures with tibial extrusion (AO 44) and persistent instability post-bony fixation, age over 18 years and non-diabetic. Analysis of injury pattern, mechanism, pathological anatomy, soft tissue and orthopaedic reconstruction methods was performed. Results: 16 patients were identified during the study period who met the eligibility criteria, out of 95 open ankle fractures treated between January 2017-December 2020. Most patients were under 65 (n = 13; 81.3%) and sustained combined or isolated injuries of the deltoid ligament, anterior capsule, lateral ligament complex (ATFL±CFL) and tibialis posterior retinaculum. The commonest injury pattern was tibial extrusion via a medial soft tissue defect with deltoid ligament and anteromedial capsule rupture. Associated syndesmotic instability and fixation was common (n = 10; 62.5%). Supplementary stabilisation methods to standard bony fixation included capsuloligamentous reconstruction or repair, "ORIF+" external fixation, or conversion to primary fusion or hindfoot nail. Six patients required either local or free flap soft tissue coverage. Conclusions: A subset of up to 20% of open ankle fractures require supplementary fixation beyond anatomical restoration of the bony anatomy due to persistent ligamentous instability. They are associated with capsuloligamentous and syndesmotic disruption, more commonly affecting the medial structures. These rare injuries can be defined as multi-ligament ankle fractures. Surgeons should be aware of this subset and be able to recognise where supplementary stabilisation strategies are required.

Assessing and managing open fractures: a systematic approach.

Open fractures are complex injuries strongly associated with high-energy trauma. Assessment should include the mechanism and place of injury, timing, associated injuries and comorbidities. The initial management of these fractures, whether in the prehospital setting or emergency department, must include the following in a prompt manner: administration of antibiotics and tetanus prophylaxis, photography, reduction or re-alignment, wound coverage and splintage. Imaging includes plain X-rays and a computed tomography trauma scan, as well as an angiogram if vessel damage is suspected. Collectively, the energy of the mechanism of injury, with the level of contamination, potential for compartment syndrome and vascular damage, determines the operative urgency. Operative management can be a one- or two-stage procedure, because definitive internal skeletal fixation should only be attempted if soft tissue coverage can occur during the same operation. Ideally, all open fractures should be closed within 72 hours. This article explores the evidence for current best practice.

The effect of COVID-19 lockdown on psychiatric admissions: role of gender.

BACKGROUND: The UK went into nationwide lockdown on 24 March 2020, in response to COVID-19. The direct psychiatric effects of this are relatively unknown. AIMS: We examined whether the first UK lockdown changed the demographics of patients admitted to psychiatric hospitals (to include gender, legality, route of admission and diagnoses), independent of seasonal variation.. METHOD: We conducted an anonymous review of psychiatric admissions aged ≥18 years in the 6-month period after the announcement of the first UK lockdown (March to August 2020), and in the previous year (March to August 2019), in Kent and Medway NHS and Social Care Partnership Trust in-patient facilities. The number of admissions were compared, along with factors that may help to explain the psychological effects of national lockdown. RESULTS: There was no significant increase in total number of admissions or the gender percentage. However, there was a 11.8% increase in formal sectioning under the Mental Health Act 1983. This increase was sustained and statistically significant across all 6 months. A sustained decrease in admissions via the crisis team was also observed as being statistically significant. Separate diagnoses saw changes in percentage of admissions between March and May. The most statistically significant was schizophrenia admissions for men in April (18.7%), and women in March (18.4%). CONCLUSIONS: Our findings highlight the effect of COVID-19 on the legal status of psychiatric admissions, and emphasise the importance of having a robust, adaptable and open psychiatric service that caters to the ongoing needs of patients, regardless of government restrictions.

Investigating Perceptual Biases, Data Reliability, and Data Discovery in a Methodology for Collecting Speech Errors From Audio Recordings.

This work describes a methodology of collecting speech errors from audio recordings and investigates how some of its assumptions affect data quality and composition. Speech errors of all types (sound, lexical, syntactic, etc.) were collected by eight data collectors from audio recordings of unscripted English speech. Analysis of these errors showed that: (i) different listeners find different errors in the same audio recordings, but (ii) the frequencies of error patterns are similar across listeners; (iii) errors collected "online" using on the spot observational techniques are more likely to be affected by perceptual biases than "offline" errors collected from audio recordings; and (iv) datasets built from audio recordings can be explored and extended in a number of ways that traditional corpus studies cannot be.