A Quality Improvement Project to Measure and Improve the Quality of Below-Knee Ankle Cast Application in Emergency Departments.

Background Ankle fractures are very common injuries seen in an emergency setting. Initial management involves the application of below-knee plaster casts. At our local trauma meetings, we have observed that below-knee casts are often applied incorrectly which can result in suboptimal outcomes for patients and increase the burden on plaster room services if re-application is required. This quality improvement project aimed to assess the quality of below-knee cast applications for ankle fractures in two local district general hospitals (DGHs). Methodology We performed a closed-loop audit utilising a retrospective analysis of patients who underwent casting for unstable ankle fractures. Two audit cycles were completed over a 90-day period across two DGHs. Working within our local orthopaedic unit, we created a targeted, multi-disciplinary educational programme led by experienced plaster technicians. Between audit cycles, we organised a single interactive session with specialist nurses in the urgent treatment centre (UTC) of our DGH while a second DGH did the same with junior doctors working in the emergency department. Both sessions demonstrated correct casting techniques and discussed the importance of a neutral ankle position for optimal patient recovery. Our audit criteria were based on AO Foundation guidance, which states that the ankle should be immobilised in a neutral plantigrade position. All patients with an unstable ankle fracture requiring immobilisation in a below-knee cast were included in the audit. We measured the angle of plantarflexion from neutral, with 90° representing a neutral angle. The angle between the axis of the tibia and the sole of the foot was measured and judged to be within an acceptable range if it was between 80° and 100°, representing a stable ankle position. The audit findings were presented in our local audit meeting. Results In our first audit cycle, we collected data from 65 patients across both sites (N = 32 for DGH 1 and N = 33 for DGH 2). The mean angle was 108.5° and 18 of the 65 (27.7%) patients had angles of ankle plantarflexion that were in the acceptable range (80°-100°). Following the intervention, we again collected data from 61 patients across both sites (N = 28 for DGH 1 and N = 33 for DGH 2). The mean angle was 106.2° and 23 of the 61 (37.7%) patients had an acceptable angle of ankle plantarflexion (80°-100°). Both of our outcome measures showed an improvement but were not statistically significant. The hospital that provided an educational session for the doctors showed an improvement in acceptable ankle casts of 3% while the hospital which provided an educational session for the UTC team improved by 22%. Conclusions We demonstrated a quantifiable approach to assess and improve the quality of below-knee cast application for ankle fractures via a single intervention that would be easily reproducible in other hospitals. We suggest further studies to investigate below-knee cast application quality and its association with patient outcomes as our data and other preliminary sources suggest that current standards are unsatisfactory.

Periprosthetic Femoral Fractures and Their Surgical Outcomes Between 2011 and 2021: A Single-Centre Observational Study.

Introduction Periprosthetic femoral fractures (PFFs) present a significant burden on the health service. The incidence continues to rise globally as a result of an ageing population and an increase in the number of primary hip and knee arthroplasties being performed. This is a 10-year, retrospective, observational study that aims to better understand the outcomes of PFF in our district general hospital. Materials and methods We identified the demographic information of patients who had a PFF and looked at how the American Society of Anesthesiologists (ASA) score, time to operation, length of stay, complications, and mortality data vary depending on where the fracture is sited and the operative management employed. Results During the period between January 2011 and March 2021, we identified 214 cases of PFF. The mean age was 82.5 years with a female preponderance of 76%. Between 2011-2016 and 2017-2021, the number of cases of PFF increased and patients with an ASA score of 3 or more increased from 43% to 73%. Length of stay was longer in the proximal PFF revision group than in the proximal PFF fixation group. Overall PFF mortality rates at 30 days, 90 days, and one year were 6%, 10%, and 15%, respectively. Conclusion Over the 10-year period, there was a significant increase in the incidence of patients presenting with PFF with multiple comorbidities. Mortality rates were lower in proximal PFF patients who underwent revision procedures rather than fixation. The patient demographics, complication rates, and mortality rates were comparable to similar studies across different countries.

Acute compartment syndrome of the thigh in a body builder following open reduction and internal fixation for proximal femur fracture.

Acute compartment syndrome (ACS) of the thigh following femoral fracture has been rarely reported in previous literature. This condition must be diagnosed quickly to prevent the affected limb becoming ischaemic. We document the management of ACS of the thigh in a healthy male patient who suffered a proximal femur fracture following a high-speed road traffic accident. Early identification of characteristic clinical signs allowed for a diagnosis of ACS to be made and then managed with an emergency fasciotomy. The patient is a bodybuilder with an exceptionally large muscle mass. This made ACS more difficult to identify and wound closure a complex process over a period of 13 days. We aimed to highlight the importance of maintaining a high index of suspicion for ACS following traumatic injuries, recognising that ACS in larger patients can be mistaken for an increased analgesia requirement and closing fasciotomies slowly using mass tension sutures.

Vitamin D in the Foot and Ankle: A Review of the Literature.

BACKGROUND: Vitamin D is an essential vitamin that targets several tissues and organs and plays an important role in calcium homeostasis. Vitamin D deficiency is common, particularly at higher latitudes, where there is reduced exposure to ultraviolet B radiation. We reviewed the role of vitamin D and its deficiency in foot and ankle pathology. METHODS: The effects of vitamin D deficiency have been extensively studied, but only a small portion of the literature has focused on the foot and ankle. Most evidence regarding the foot and ankle consists of retrospective studies, which cannot determine whether vitamin D deficiency is, in fact, the cause of the pathologies being investigated. RESULTS: The available evidence suggests that insufficient vitamin D levels may result in an increased incidence of foot and ankle fractures. The effects of vitamin D deficiency on fracture healing, bone marrow edema syndrome, osteochondral lesions of the talus, strength around the foot and ankle, tendon disorders, elective foot and ankle surgery, and other foot and ankle conditions are less clear. CONCLUSIONS: Based on the available evidence, we cannot recommend routine testing or supplementation of vitamin D in patients with foot and ankle pathology. However, supplementation is cheap, safe, and may be of benefit in patients at high risk for deficiency. When vitamin D is supplemented, the evidence suggests that calcium should be co-supplemented. Further high-quality research is needed into the effect of vitamin D in the foot and ankle. Cost-benefit analyses of routine testing and supplementation of vitamin D for foot and ankle pathology are also required.

A rare case of gallbladder fistulation with a 60-year-old appendicectomy scar.

We present an extremely unusual case of an external biliary fistula in an 87-year-old woman who presented with a 1-day history of spontaneous green discharge from a 60-year-old appendicectomy scar. Examination revealed a sinus in the right iliac fossa overlying her appendicectomy scar, with a raised white cell count and C reactive protein. A CT scan revealed a complex fistula connecting the gallbladder to the subcutaneous tissue in the right flank, which further connected inferiorly with a fistula to the previous appendicectomy scar and a small iliopsoas collection. Endoscopic retrograde cholangiopancreatography revealed several stones in the common bile duct, which were removed using a balloon catheter. The patient was further managed with a long course of antibiotics and discharged with a long-term drainage bag. A literature search revealed no previously reported cases of an external biliary fistula communicating with an appendicectomy scar.