Comparison of side effects and patient perceptions towards Rapid Rhino and Merocel packs in epistaxis.

OBJECTIVE: Non-dissolvable nasal packs (Rapid Rhino and Merocel) are widely used in secondary healthcare centres for the control of epistaxis, with some side effects. METHODS: A prospective, observational cohort study was conducted of adults who required Rapid Rhino or Merocel packing for acute epistaxis management in a large healthcare centre between March 2020 and 2021. A validated modified version of the 22-item Sino-Nasal Outcome Test was used. RESULTS: A total of 80 adults requiring non-dissolvable packs were recruited. Seventy per cent of patients had Rapid Rhino packs inserted. Embarrassment was greater in patients who used Rapid Rhino than Merocel. Merocel packs had a significantly higher mean pain score on removal compared to Rapid Rhino. There was no correlation between rebleed rate and type of nasal pack used. CONCLUSION: Non-dissolvable Rapid Rhino and Merocel nasal packs have similar efficacy in controlling epistaxis. Rapid Rhino packs are more embarrassing for patients in comparison to Merocel packs, but are less painful to remove.

The Ability of Patients to Provide Standardized, Patient-Taken Photographs for the Remote Assessment of Dupuytren Disease.

BACKGROUND: Clinical goniometry for the assessment of contracture in Dupuytren disease is time-consuming and costly, and there is no universal method for evaluating the severity of the disease. This study aims to evaluate the feasibility of patient-taken photography for the remote assessment of Dupuytren disease. METHODS: Patients at our unit were provided with instructions on how to take standardized photographs of their diseased hand(s), which were subsequently analyzed by computer software to obtain formal measurements of the severity of disease. Compliance with photography instructions and ability to provide a photo of sufficient quality for analysis were measured. RESULTS: In all, 222 patients supplied photos for analysis; 158 patients (71.2%) were able to take the photographs as instructed. The remaining 28.8% took 1 or more of the images incorrectly or of insufficient quality. There were no statistically significant differences between those able to take the photos as directly versus those who took the photos incorrectly when compared by sex, age, or severity of disease. CONCLUSIONS: Patient-taken photography used to estimate disease severity in Dupuytren disease is an achievable, efficient, and reliable method of remotely assessing and monitoring patients and may be increasingly useful given the current health care climate and preference for remote consultations.

The Impact of COVID-19 on the Choice of Treatment for Hand Fractures: A Single-Centre Concordance Study.

Background: Management of hand trauma has evolved to incorporate assessment, treatment and rehabilitation of patients in a 'one-stop' clinic on initial presentation. Our aim was to evaluate the effect of coronavirus disease 2019 (COVID-19) on the choice of treatment for hand fractures using inter-rater agreement between surgeons. Methods: All patients with hand fractures during the COVID-19 lockdown from March to May 2020 were included in the study. Two experienced hand surgeons blinded to management and outcomes independently reviewed radiographic images and relevant clinical history to provide their opinion on optimal treatment. Weighted kappa analysis was performed to determine concordance and inter-rater agreement between the two surgeons and actual management. Results: The study included 82 patients (62 men and 20 women) with a mean age of 40.3 (SD 19.7). The injuries occurred most often at home following an accident (34%) or a fall (28%). Fractures involved the metacarpals in 29 patients and the distal phalanx in 22 patients. Thirty-five patients underwent surgery, whereas 47 were managed conservatively. Overall agreement between actual management and consultant A and consultant B was moderate (κ = 0.55, p < 0.0001 and κ = 0.63, p < 0.0001, respectively). Subgroup analysis showed a weak agreement between actual management of metacarpal fractures and consultant A and consultant B (κ = 0.22, p = 0.29 and κ = 0.47, p = 0.02, respectively). Inter-rater agreement was substantial for management of metacarpal fractures (κ = 0.73, p < 0.0001), but weak for distal phalanx fractures (κ = 0.29, p = 0.03). Conclusion: Our study has shown that overall management of hand fractures remained optimised throughout the pandemic. However, a lack of concordance was observed in the management of metacarpals. Level of Evidence: Level IV (Therapeutic).

Surgical Exposure of the Distal Fibula to Protect the Peroneus Brevis Muscle Vascular Pedicle.

Ankle fractures are a common presentation to orthopaedic surgeons, with the lateral malleolus involved in 86% of cases. A soft tissue injury can be a concomitant feature of these injuries as a result of the primary injury or following secondary wound breakdown. The peroneus brevis muscle flap provides a reliable and robust option to cover the distal third of the lower limb. With an understanding of the anatomy and cautious dissection during periosteal elevation, the perforating vessels supplying the peroneus brevis can be preserved ensuring that a valuable reconstructive option is available. HOW TO CITE THIS ARTICLE: Irvine E, Cochrane E, Harwood P, et al. Surgical Exposure of the Distal Fibula to Protect the Peroneus Brevis Muscle Vascular Pedicle. Strategies Trauma Limb Reconstr 2021;16(3):176-178.

Delays in surgery for cholesteatoma due to COVID-19: is there an impact on rates of recidivism and major complications?

PURPOSE: To evaluate the relationship between the waiting time for surgery, and cholesteatoma recidivism rates and major complications. The secondary aims were to identify any other prognostic factors for cholesteatoma recidivism. METHODS: A retrospective single-centre study of 312 patients who underwent cholesteatoma surgery under the care of a single-surgeon, between 2004 and 2018, was performed. Waiting times for surgery were categorised into ≤ 90 days, 91-180 days, 181-270 days and > 271 days. The outcome measures were cholesteatoma recidivism and major complications (facial nerve palsy or intracranial complications). RESULTS: The mean age was 36.1 years ± 21.5 with 242 adults (77.6%) and 70 children (22.4%). The mean waiting time for surgery was 126.2 days (4.1 months) ± 96.0 days and the overall rate of recidivism was 11.2% (35/312 patients). No instances of facial nerve palsy or intracranial complications were identified. Rates of recidivism by waiting time for surgery were: 15.3% for 118 patients who waited ≤ 90 days, 9.7% for 134 patients who waited 91-180 days, 6.7% for 30 patients who waited 181-270 days and 4.3% for 23 patients who waited > 271 days. There was no significant difference amongst the different waiting time groups for rates of recidivism (p = 0.266). CONCLUSION: Increased waiting times for cholesteatoma surgery do not appear to be associated with increased rates of recidivism or major complications. Clinical judgement will always be required for complicated disease or patients with additional risk factors. The other prognostic factors for recidivism identified in this study were age (< 15 years) and congenital cholesteatoma.

When Marriage Hurts: A Literature Review of Embedded Jewellery Ring Injuries.

A ring is traditionally worn as a symbol of love and affection or as decorative ornamental jewellery. However, rings are not without risk. The spectrum of danger can range from debilitating avulsion injuries to simple contact dermatitis. Unknown to many, an unusual rarity exists; previous authors have termed this entity 'embedded ring syndrome'. We sought to review the literature and collate evidence on the common features of this syndrome. A literature review was performed on cases reported from 1947 to 2017 accessed through the healthcare database advanced search (HDAS). A total of 28 cases were analysed for demographics, symptomatology and operative techniques. Overall, 64.3% were females, and 50% had a psychiatric comorbidity. There was a causative event preceding the injury in 35.7% of cases; 71.4% had a reduced range of movement or reported a stiff finger and 32.1% had reduced sensation. The majority of patients underwent ring removal and primary closure, without documentation as to whether neurovascular bundles and tendons were visualised. Embedded ring injuries are rare. Consequently, information is sparsely available regarding its natural history and management. The hand surgeon's approach requires an understanding that the chronicity of these injuries can have a significant traumatic impact on the structures of the finger.

A case of acute confusion: Cushing's syndrome presenting with primary hyperparathyroidism.

Cushing's syndrome is a rare disease. Cushing's syndrome presenting as acute psychosis is an exceptional occurrence. We present the case of a 37-year-old woman who was admitted with acute confusion associated with mild hypercalcaemia and was subsequently diagnosed with parathyroid and adrenal adenomas. Our hospital sees approximately 6000 endocrine patients per year, with an incidence of around four Cushing's cases annually. This is the first such case to occur in our hospital and one of few described in the literature.