Achilles tendon rupture: what you need to know.

Heel pain and a history of a 'pop' or feeling 'something go' are the buzz phrases classically associated with Achilles tendon rupture. However, the diagnosis is often missed in clinical practice because of the assumption that this is a sporting injury suffered only by the young or middle-aged. In a sedentary older patient, the injury may be dismissed as an ankle sprain. If swelling is present but no injury is recalled then deep vein thrombosis is suspected, but Achilles rupture is not. The diagnosis of Achilles tendon rupture is clinical, based on history and examination. Radiological imaging (ultrasound scan) is useful to plan orthopaedic management and exclude concomitant deep vein thrombosis. In most cases, non-operative management with the ankle held plantar flexed in a boot is the current best practice.

Realistic scenarios of environmental disturbance lead to functionally important changes in benthic species-environment interactions.

Changes in community structure concurrent with environmental forcing often form a precursor to changes in species diversity, and can have substantive consequences for ecosystem functioning. Here, we assess the effects of altered levels of evenness that are representative of different levels of eutrophication and changes in salinity associated with altered precipitation patterns, on the mediation of nutrient release by sediment-dwelling invertebrate communities. We find that an adjustment towards a more even distribution of species corresponds with an increase in sediment particle reworking that, in general, translates to increased levels of nutrient release. This response, however, is dependent on the functional role of each species in the community and is influenced by concomitant changes in salinity, especially when salinity extends beyond the range typically experienced by the community. Overall, our findings highlight the dynamic nature of species contributions to functioning and reinforce the importance of understanding when, and how, the mechanistic basis of species-environment interactions are modified as the influence of abiotic and biotic factors flex under periods of directional forcing.

Posterior malleolus fractures: worth fixing.

The posterior malleolus component of a fracture of the ankle is important, yet often overlooked. Pre-operative CT scans to identify and classify the pattern of the fracture are not used enough. Posterior malleolus fractures are not difficult to fix. After reduction and fixation of the posterior malleolus, the articular surface of the tibia is restored; the fibula is out to length; the syndesmosis is more stable and the patient can rehabilitate faster. There is therefore considerable merit in fixing most posterior malleolus fractures. An early post-operative CT scan to ensure that accurate reduction has been achieved should also be considered. Cite this article: Bone Joint J 2017;99-B:1413-19.

Hip fracture surgery in mixed-use emergency theatres: is the infection risk increased? A retrospective matched cohort study.

Introduction The National Institute of Health and Care Excellence recommends that people with hip fracture should have surgery on the day of, or the day after, admission. However, there remains unacceptable variation in performance around the country, with a range of 13-91% of patients meeting this target. Dedicated trauma lists have insufficient capacity in many hospitals. We occasionally employ a mixed-use emergency theatre to facilitate early surgery. Increased risk of infection has been raised as a concern owing to microbial surface contamination from a preceding unclean case and lack of laminar flow in these theatres. The objective of this study was to investigate whether there is an increased risk of surgical site infections in patients who had hip fracture surgery in a mixed-use emergency theatre. Methods Between August 2010 and July 2014, 74 patients had hip fracture surgery in a mixed-use emergency theatre without laminar flow. This group was compared with a control group of patients who had hip fracture surgery in dedicated orthopaedic theatres with laminar flow. Infection was the primary outcome measured. Results There was no statistically significant difference in the rate of infection, length of stay or 30-day mortality, readmission or reoperation rates between the two groups. Conclusions Operating on hip fractures in mixed-use theatre did not lead to an increase in infection or other complications in our series. We feel that the risk of infection can be balanced against advantages of timely operation and it may therefore be justified to use these theatres when faced with lack of time on the trauma list. A much larger series would be required to investigate the effects of confounders.

An approach for the identification of exemplar sites for scaling up targeted field observations of benthic biogeochemistry in heterogeneous environments.

Continental shelf sediments are globally important for biogeochemical activity. Quantification of shelf-scale stocks and fluxes of carbon and nutrients requires the extrapolation of observations made at limited points in space and time. The procedure for selecting exemplar sites to form the basis of this up-scaling is discussed in relation to a UK-funded research programme investigating biogeochemistry in shelf seas. A three-step selection process is proposed in which (1) a target area representative of UK shelf sediment heterogeneity is selected, (2) the target area is assessed for spatial heterogeneity in sediment and habitat type, bed and water column structure and hydrodynamic forcing, and (3) study sites are selected within this target area encompassing the range of spatial heterogeneity required to address key scientific questions regarding shelf scale biogeochemistry, and minimise confounding variables. This led to the selection of four sites within the Celtic Sea that are significantly different in terms of their sediment, bed structure, and macrofaunal, meiofaunal and microbial community structures and diversity, but have minimal variations in water depth, tidal and wave magnitudes and directions, temperature and salinity. They form the basis of a research cruise programme of observation, sampling and experimentation encompassing the spring bloom cycle. Typical variation in key biogeochemical, sediment, biological and hydrodynamic parameters over a pre to post bloom period are presented, with a discussion of anthropogenic influences in the region. This methodology ensures the best likelihood of site-specific work being useful for up-scaling activities, increasing our understanding of benthic biogeochemistry at the UK-shelf scale.

Characterizations of how species mediate ecosystem properties require more comprehensive functional effect descriptors.

The importance of individual species in mediating ecosystem process and functioning is generally accepted, but categorical descriptors that summarize species-specific contributions to ecosystems tend to reference a limited number of biological traits and underestimate the importance of how organisms interact with their environment. Here, we show how three functionally contrasting sediment-dwelling marine invertebrates affect fluid and particle transport - important processes in mediating nutrient cycling - and use high-resolution reconstructions of burrow geometry to determine the extent and nature of biogenic modification. We find that individual functional effect descriptors fall short of being able to adequately characterize how species mediate the stocks and flows of important ecosystem properties and that, in contrary to common practice and understanding, they are not substitutable with one another because they emphasize different aspects of species activity and behavior. When information derived from these metrics is combined with knowledge of how species behave and modify their environment, however, detailed mechanistic information emerges that increases the likelihood that a species functional standing will be appropriately summarized. Our study provides evidence that more comprehensive functional effect descriptors are required if they are to be of value to those tasked with projecting how altered biodiversity will influence future ecosystems.

The saphenous nerve in foot and ankle surgery: its variable anatomy and relevance.

BACKGROUND: Several studies have raised doubt regarding the role of the saphenous nerve (SN) in the foot, and some authors omit the SN from ankle blocks. Our aim was to assess the SN anatomy with reference to foot and ankle surgery. METHODS: In 29 cadaveric feet the SN was traced to its termination. At the ankle, the distances from the SN to the tibialis anterior tendon (TAT) and the long saphenous vein (LSV) were recorded. RESULTS: In 24 specimens, a SN was present at the ankle, and in 19 specimens extended to the foot. The mean distances from the nerve to the TAT and LSV were 15 mm and 4mm respectively. The nerve reached the first metatarsal (MT) in 28% of specimens. CONCLUSION: Although the SN anatomy is less extensive than previously described, it often reaches the first MT and therefore should routinely be included in ankle blocks for forefoot surgery.

Determination of optimal screw positioning in flexor hallucis longus tendon transfer for chronic tendoachilles rupture.

BACKGROUND: Neglected ruptures of the tendoachilles pose a difficult surgical problem. There are no data to determine the optimal positioning of the FHL tendon to the calcaneus. METHODS: Two computer programmes (MSC.visualNastran Desktop 2002™ and Solid Edge(®) V19) were used to generate a human ankle joint model. Different attachment points of FHL tendon transfer to the calcaneus were investigated. RESULTS: The lowest muscle force to produce plantarflexion (single stance heel rise) was 1355 N. Plantarflexion increased for a more anterior attachment point. The maximum range of plantarflexion was 33.4° for anterior attachment and 24.4° for posterior attachment. There was no significant difference in range of movement when the attachment point was moved to either a medial or lateral position. CONCLUSIONS: A more posterior attachment point is advantageous in terms of power and the arc of motion (24.4°) is physiological. We recommend that FHL is transferred to the calcaneus in a posterior position.

Habitat structure mediates biodiversity effects on ecosystem properties.

Much of what we know about the role of biodiversity in mediating ecosystem processes and function stems from manipulative experiments, which have largely been performed in isolated, homogeneous environments that do not incorporate habitat structure or allow natural community dynamics to develop. Here, we use a range of habitat configurations in a model marine benthic system to investigate the effects of species composition, resource heterogeneity and patch connectivity on ecosystem properties at both the patch (bioturbation intensity) and multi-patch (nutrient concentration) scale. We show that allowing fauna to move and preferentially select patches alters local species composition and density distributions, which has negative effects on ecosystem processes (bioturbation intensity) at the patch scale, but overall positive effects on ecosystem functioning (nutrient concentration) at the multi-patch scale. Our findings provide important evidence that community dynamics alter in response to localized resource heterogeneity and that these small-scale variations in habitat structure influence species contributions to ecosystem properties at larger scales. We conclude that habitat complexity forms an important buffer against disturbance and that contemporary estimates of the level of biodiversity required for maintaining future multi-functional systems may need to be revised.

Pain and paraesthesia produced by silicone ring and pneumatic tourniquets.

Twenty volunteers were recruited to compare a novel, silicone ring tourniquet (the Hemaclear® tourniquet) with a pneumatic tourniquet. After application of the tourniquets, the pain and paraesthesia experienced by the participants was scored at 1 minute, 5 minutes, and 10 minutes. This was repeated with the tourniquets on the forearm. On the upper arm, the silicone ring tourniquet was associated with a significantly lower pain score than the pneumatic tourniquet. The incidence of paraesthesia was also lower with the silicone ring tourniquet. When applied to the forearm, there was no statistically significant difference in pain scores between the two types of tourniquets. However the incidence of paraesthesia was again lower with the silicone ring tourniquet.

Munchausen's syndrome by Google.

A case is discussed of the use of medical images from the internet to support claims of injury. There were several inconsistencies in both history and examination even prior to the presentation of the specimen radiograph from the internet. Clinicians are advised to be vigilant, to question histories that do not match with examination findings, to ensure that all radiographs are adequately labelled with patient-specific information and to look for radiographic inconsistencies such as the presence or absence of accessory ossicles.

Liparid and macrourid fishes of the hadal zone: in situ observations of activity and feeding behaviour.

Using baited camera landers, the first images of living fishes were recorded in the hadal zone (6000-11000 m) in the Pacific Ocean. The widespread abyssal macrourid Coryphaenoides yaquinae was observed at a new depth record of approximately 7000 m in the Japan Trench. Two endemic species of liparid were observed at similar depths: Pseudoliparis amblystomopsis in the Japan Trench and Notoliparis kermadecensis in the Kermadec Trench. From these observations, we have documented swimming and feeding behaviour of these species and derived the first estimates of hadal fish abundance. The liparids intercepted bait within 100-200 min but were observed to preferentially feed on scavenging amphipods. Notoliparis kermadecensis act as top predators in the hadal food web, exhibiting up to nine suction-feeding events per minute. Both species showed distinctive swimming gaits: P. amblystomopsis (mean length 22.5 cm) displayed a mean tail-beat frequency of 0.47 Hz and mean caudal:pectoral frequency ratio of 0.76, whereas N. kermadecensis (mean length 31.5 cm) displayed respective values of 1.04 and 2.08 Hz. Despite living at extreme depths, these endemic liparids exhibit similar activity levels compared with shallow-water liparids.

Effects of copper and the sea lice treatment Slice on nutrient release from marine sediments.

Copper-based antifoulant paints and the sea lice treatment Slice are widely used, and often detectable in the sediments beneath farms where they are administered. Ten-day, whole sediment mesocosm experiments were conducted to examine how increasing sediment concentrations of copper or Slice influenced final water column concentrations of ammonium-nitrogen (NH(4)-N), nitrate+nitrite-nitrogen (NO(X)-N) and phosphate-phosphorus (PO(4)-P) in the presence of the non-target, benthic organisms Corophium volutator and Hediste diversicolor. Nominal sediment concentrations of copper and Slice had significant effects on the resulting concentrations of almost all nutrients examined. The overall trends in nutrient concentrations at the end of the 10-day incubations were highly similar between the trials with either copper or Slice, irrespective of the invertebrate species present. This suggests that nutrient exchange from the experimental sediments was primarily influenced by the direct effect of copper/Slice dose on the sediment microbial community, rather than the indirect effect of reduced bioturbation/irrigation due to increased macrofaunal mortality.

The "biro test" for autonomic dysfunction in carpal tunnel syndrome.

The aim of this study was to assess whether autonomic dysfunction associated with carpal tunnel syndrome (CTS) can be assessed quantitatively with a (modified) biro test of finger sweating. Twenty-six hands of 16 patients with CTS were compared with 30 hands of 15 normal subjects. A device was constructed to measure the angle from the horizontal at which a biro slips from the finger (the critical angle). In the control subjects, no significant difference was found in the critical angle between the little and index fingers in either hand. By comparison, in subjects with CTS, the critical angle was significantly lower in the index finger than in the little finger, the mean difference being 8.65 degrees , indicating a quantifiable and significant difference of sweating of the median nerve-innervated index finger.

Successful treatment of a chronically infected and necrotic tendo Achillis in a diabetic with excision, flexor hallucis longus transfer and split-skin grafting.

Chronic infections and ulceration around the tendo Achillis are difficult to manage. Split-skin grafts do not survive even on healthy exposed tendon. Refractory cases may require plastic surgical intervention with the use of free flaps. Patients with significant vascular disease are not suitable for such techniques. Flexor hallucis longus tendon transfer is an established treatment for chronic ruptures of the tendo Achillis. We report the successful treatment of an infected tendo Achillis with excision and reconstruction with flexor hallucis longus transfer. The muscle belly of this tendon allowed later skin grafting while the tendon transfer provided good functional recovery.

Photographic wound documentation of open fractures: an update for the digital generation.

OBJECTIVE: To examine the availability of working cameras in UK emergency departments and to discuss the merits of digital imaging over Polaroid. DESIGN: This study was conducted by means of a telephone questionnaire to 50 UK emergency departments. RESULTS: It was found that 80% were able to produce either a working Polaroid or digital camera, and that 63% of emergency departments had a digital camera available. CONCLUSIONS: We report a pronounced increase in the ability of emergency departments to photograph open fractures, due in part to the availability of digital cameras. We recommend the appropriate use of these tools in the management of open fractures.

Cost benefit with early operative fixation of unstable ankle fractures.

INTRODUCTION: Ankle fractures are common and many require surgical intervention. It has been well documented that a delay in fracture fixation results in increased length of hospital stay and increased complication rate. Initial delay can also allow swelling or blistering to develop which may necessitate a further delay in operative fixation for up to 1 week. The aim of the current study was to review the length of hospital in-patient stay for operative ankle fractures over the previous 12-month period at our hospital and compare this to the length of hospital stay following the introduction of a fast-track system for the fixation of these fractures (all fractures fixed within 48 h). PATIENTS AND METHODS: A retrospective review of all ankle fractures managed by open reduction and internal fixation over a 12-month period was undertaken. A protocol was then agreed to openly reduce and fix these fractures at the earliest possible opportunity over the next 6-month period. We then collected the data on all ankle fractures that needed open reduction and internal fixation over this 6-month period. The pre-protocol and post-protocol groups were then compared for total hospital length of stay and complication rate. RESULTS: In the 12-month retrospective review, there were 83 ankle fractures that required surgical intervention. Sixty-two of these had surgery within 48 h (mean length of stay, 5.4 days), and 21 had surgery after 48 h (mean length of stay, 9.5 days). There were 39 ankle fractures in the post-protocol group who all had surgery within 48 h (mean length of stay, 5 days). There was no increase in complication rate after implementation of the fast-track system. CONCLUSIONS: This study shows that early operative intervention for ankle fractures reduces the length of hospital stay. Intensive physiotherapy and co-ordinated discharge planning are also essential ingredients for early discharge. Early operative fixation for unstable ankle fractures has substantial cost-saving implications with no increase in complication rate.

E-mail and oncology: a survey of radiation oncology patients and their attitudes to a new generation of health communication.

Electronic mail (e-mail) is a powerful tool that can greatly enhance communication and has numerous potential applications within the medical profession. Physician-patient e-mail communication volume is increasing, but little research has addressed patient interests and concerns about this now commonplace technology. The goals of this study were to review the available literature regarding physician-patient e-mail practices, evaluate patient interest, assess patient perspectives about how e-mail communication might facilitate medical treatment and advice, and determine areas of patient concern regarding e-mail communication with their physicians. To this end, a population of cancer patients was sent a written survey designed to assess their access to e-mail and attitudes about physician-patient e-mail communication. We found that patients favored e-mail for increased convenience, efficiency, and timeliness about general health problems, while it was not favored for urgent matters.

Pelvic and acetabular fractures in the United Kingdom: a continued public health emergency.

In 1996 the quality of the early management of 100 consecutive patients referred to the SW Thames regional pelvic and acetabular unit between 1989 and 1992 was studied. The management of these patients was assessed in four specific areas, and guidelines were laid down. It was found that in 56% of patients the early management did not meet these suggested standards, with 34% having deficiencies in more than one area. These results were presented and published. Five years later, the early management of a further 100 consecutive referrals was assessed using these same guidelines, in order to close the audit loop. The treatment of 57% of patients still did not reach the guideline standards, but the number with problems in more than one area fell to 20%. There has been improvement in the early management of pelvic and acetabular injuries. The use of external fixation in cases of severe haemorrhage increased, but frames were often poorly applied. Early communication with the specialist centre was encouraged but unfortunately there was still an unacceptable delay in referral. The frequency of delayed referral actually increased during the 5 years between study groups.