Management and outcomes of isolated paediatric tibial spine fractures.

Paediatric fractures of the tibial spine are relatively rare and controversy remains around how these injuries are best managed (Gans et al., 2014; Hargrove et al., 2004). Consequently most non-specialised paediatric units have limited experience of managing these injuries. This study aims to review the management and outcomes of isolated paediatric tibial spine fractures in a tertiary paediatric orthopaedic centre between 2008 and 2016. Data were collected on patient demographics, mechanism of injury, imaging, Meyers and McKeever grade of injury (Meyers and McKeever), management and outcomes, including Cincinnati and Lysholm-Tegner knee scores at a mean of 36 months post-operatively. 40 patients were included, 21 were male and the mean age was 11.8 years. 3 cases were Meyers and McKeever type I, 13 were type II and 24 were type III. 30 underwent operative management comprising of open reduction and single screw fixation, with or without a washer. 9 patients underwent subsequent metalwork removal at a mean of 10 months post-operatively. 10 underwent non-operative management, consisting of cast immobilisation and bracing. 33 patients (83%) were available for follow up. No statistically significant differences were seen in either outcome score between those treated operatively or non-operatively, or between different grades of injury, or if metalwork were removed or not. Our study shows good functional outcomes following paediatric tibial spine fracture. We advocate the use of CT to assess fracture displacement to help guide management. We have shown type I and reducible type II injuries can successfully be managed conservatively and non-reducible type II and type III injuries can be successfully treated with open reduction and single screw fixation. In our experience post-operative knee stiffness can persist for up to 6 months but generally improves. Metalwork removal was only indicated if the patient had on going stiffness after this time or if they had on going pain.

A review of the management of blunt splenic trauma in England and Wales: have regional trauma networks influenced management strategies and outcomes?

INTRODUCTION The spleen remains one of the most frequently injured organs following blunt abdominal trauma. In 2012, regional trauma networks were launched across England and Wales with the aim of improving outcomes following trauma. This retrospective cohort study investigated the management and outcomes of blunt splenic injuries before and after the establishment of regional trauma networks. METHODS A dataset was drawn from the Trauma Audit Research Network database of all splenic injuries admitted to English and Welsh hospitals from 1 April 2010 to 31 March 2014. Demographic data, injury severity, treatment modalities and outcomes were collected. Management and outcomes were compared before and after the launch of regional trauma networks. RESULTS There were 1457 blunt splenic injuries: 575 between 2010 and 2012 and 882 in 2012-14. Following the introduction of the regional trauma networks, use of splenic artery embolotherapy increased from 3.5% to 7.6% (P = 0.001) and splenectomy rates decreased from 20% to 14.85% (P = 0.012). Significantly more patients with polytrauma and blunt splenic injury were treated with splenic embolotherapy following 2012 (61.2% vs. 30%, P < 0.0001). Increasing age, injury severity score, polytrauma and Charlson Comorbidity Index above 10 were predictors of increased mortality (P < 0.001). Increasing systolic blood pressure (odds ratio, OR, 0.757, 95% confidence interval, CI, 0.716-0.8) and Glasgow Coma Scale (OR 0.988, 95% CI 0.982-0.995) were protective. CONCLUSIONS This study demonstrates a reduction in splenectomy rate and an increased use of splenic artery embolotherapy since the introduction of the regional trauma networks. This may have resulted from improved access to specialist services and reduced practice variation since the establishment of these networks.