Rib fracture fixation in a patient on veno-venous ECMO for severe blunt thoracic trauma.

Thoracic chest wall trauma is a common injury in patients admitted to hospital following injury and is associated with high mortality. British Orthopaedic Association Standards for Trauma and Orthopaedics guidelines recommend consideration of rib fracture fixation in patients with flail chest wall injuries with respiratory compromise or uncontrollable pain. Veno-venous extracorporeal membrane oxygenation (ECMO) can be utilised in patients with severe respiratory dysfunction and we present the case of a patient who underwent rib fracture fixation while receiving ECMO. A 32-year-old male was admitted to our department following a 4.5m fall. He sustained significant thoracic injuries with multiple ribs fractures and a flail segment from the right fourth to ninth ribs. Treatment consisted of bilateral chest drains, ECMO support, tracheostomy and rib fracture fixation to the eighth and ninth ribs. The patient made a rapid recovery following surgery and ECMO support was ceased 2.5 days postoperatively. The case shows that a well-prepared, combined specialty surgical team can safely perform rib fixation for a patient on ECMO.

Orthopaedic assessment unit: a service model for the delivery of orthopaedic trauma care in a major trauma centre during the global pandemic (COVID-19).

INTRODUCTION: We describe a new service model, the Orthopaedic Assessment Unit (OAU), designed to provide care for trauma patients during the COVID-19 pandemic. Patients without COVID-19 symptoms and isolated musculoskeletal injuries were redirected to the OAU. METHODS: We prospectively reviewed patients throughput during the peak of the global pandemic (7 May 2020 to 7 June 2020) and compared with our historic service provision (7 May 2019 to 7 June 2019). The Mann-Whitney and Fisher Exact tests were used to test the statistical significance of data. RESULTS: A total of 1,147 patients were seen, with peak attendances between 11am and 2pm; 96% of all referrals were seen within 4h. The majority of patients were seen by orthopaedic registrars (52%) and nurse practitioners (44%). The majority of patients suffered from sprains and strains (39%), followed by fractures (22%) and wounds (20%); 73% of patients were discharged on the same day, 15% given follow up, 8% underwent surgery and 3% were admitted but did not undergo surgery. Our volume of trauma admissions and theatre cases decreased by 22% and 17%, respectively (p=0.058; 0.139). There was a significant reduction of virtual fracture clinic referrals after reconfiguration of services (p<0.001). CONCLUSIONS: Rapid implementation of a specialist OAU during a pandemic can provide early definitive trauma care while exceeding national waiting time standards. The fall in trauma attendances was lower than anticipated. The retention of orthopaedic staff in the department to staff the unit and maintain a high standard of care is imperative.

Broken guidewire intramedullary: what to do now?

Instrument breakage during orthopaedic procedures is relatively uncommon, but it remains a challenging problem to orthopaedic surgeons. We report a case of a broken guidewire during intramedullary nail fixation of a proximal femur fracture with subtrochanteric extension. We also report a simple yet effective technique for removal of a broken guidewire from the medulla of the proximal femur without causing much iatrogenic trauma.

Necrotising fasciitis in the North East of Scotland: a 10-year retrospective review.

INTRODUCTION: Necrotising fasciitis is a life-threatening rapidly progressing bacterial infection of the skin requiring prompt diagnosis and treatment. Optimum care warrants a combination of surgical debridement, antibiotics and intensive care support. All cases of necrotising fasciitis in 10 years in the North East of Scotland were reviewed to investigate and improve patient care. METHODS: Cases between August 2006 and February 2016 were reviewed using case notes and electronic hospital records. Data including mode of admission, clinical observations, investigations, operative interventions, microbiological and clinical outcomes was collected and reviewed. Analysis required multidisciplinary input including microbiology, infectious disease, trauma and orthopaedics, plastic surgery and intensive care teams. RESULTS: A total of 36 cases were identified. The mean laboratory risk indicator for necrotising fasciitis (LRINEC) score was 7 and 86% of patients fulfilled the criteria for necrotising fasciitis. Patients were commonly haemodynamically stable upon admission but deteriorated rapidly; 36% of patients had a temperature of over 37.5 degrees C on initial observations; 29/36 patients were discharged, 6 patients died acutely (acute mortality rate of 17%); 18/31 of cases were polymicrobial with Streptococcus pyogenes, the common organism. Six amputations or disarticulations were performed from a total of 82 operations in this group, with radical debridement the usual primary operation. The mean time to theatre was 3.54 hours. Highly elevated admission respiratory rate (50 breaths/minute) was associated with increased mortality. CONCLUSIONS: Necrotising fasciitis presents subtly and carries significant morbidity and mortality. A high index of suspicion allows early diagnosis and intervention. We believe that a pan-specialty approach is the cornerstone for good outcomes.

Magnetic resonance imaging investigation of radio-lunate relations: use in assessing distal radial fracture reduction.

Reformatted magnetic resonance imaging scans of 27 normal wrists were examined in incremental degrees of rotation around the central axis of the radial shaft to 30° in both directions from true lateral. A line was superimposed on the outer border of the radial dorsal cortex and continued distally to the carpal region. Measurements were made from the superior pole of the lunate to this line. This distance did not change significantly with rotation. This allows a quick and accurate way of assessing distal radial fracture reduction from poorly taken lateral radiographs. In addition, the relevant landmarks are not obscured by implants or casts. LEVEL OF EVIDENCE: III, diagnostic study.

The d 3Π state of LiRb.

We report our spectroscopic studies of the d 3Π state of ultra-cold 7Li85Rb using resonantly enhanced multi-photon ionization and depletion spectroscopy with bound-to-bound transitions originating from the metastable a 3Σ+ state. We evaluate the potential of this state for use as the intermediate state in a stimulated-Raman-adiabatic-passage transfer scheme from triplet Feshbach LiRb molecules to the X 1Σ+ ground state and find that the lowest several vibrational levels possess the requisite overlap with initial and final states, as well as convenient energies. Using depletion measurements, we measured the well depth and spin-orbit splitting. We suggest possible pathways for short-range photoassociation using deeply bound vibrational levels of this electronic state.

Investigation of radiolunate relations in normal and fractured wrists.

As the distal radius fracture is one of the most commonly encountered upper limb injuries, the aim of this study was to provide a quick and easy method to aid in the assessment of fractured wrists, both pre- and post-fixation, by utilising the relationship of the radial shaft and the lunate. A retrospective analysis on 100 consecutive patients with normal wrist radiographs was performed. The results demonstrated that the variations of radiolunate anatomy followed a normal distribution. The normal anatomical relationship was then described. A second part to the study consisted of reviewing our method of radiocarpal analysis on a cohort of patients who had sustained a distal radius fracture. Carpal alignment pre- and post-fixation was measured, with the results demonstrating that by using this assessment method, it was possible with a quick glance of the radiograph, to determine whether satisfactory correction of the fracture had been achieved.

Male mate choice influences female promiscuity in Soay sheep.

In most animal species, males are predicted to compete for reproductive opportunities, while females are expected to choose between potential mates. However, when males' rate of reproduction is constrained, or females vary widely in 'quality', male mate choice is also predicted to occur. Such conditions exist in the promiscuous mating system of feral Soay sheep on St Kilda, Scotland, where a highly synchronized mating season, intense sperm competition and limitations on sperm production constrain males' potential reproductive rate, and females vary substantially in their ability to produce successful offspring. We show that, consistent with predictions, competitive rams focus their mating activity and siring success towards heavier females with higher inclusive fitness. To our knowledge, this is the first time that male mate choice has been identified and shown to lead to assortative patterns of parentage in a natural mammalian system, and occurs despite fierce male-male competition for mates. An additional consequence of assortative mating in this population is that lighter females experience a series of unstable consorts with less adept rams, and hence are mated by a greater number of males during their oestrus. We have thus also identified a novel male-driven mechanism that generates variation in female promiscuity, which suggests that the high levels of female promiscuity in this system are not part of an adaptive female tactic to intensify post-copulatory competition between males.

Soay rams target reproductive activity towards promiscuous females' optimal insemination period.

Female promiscuity is thought to have resulted in the evolution of male behaviours that confer advantages in the sperm competition that ensues. In mammalian species, males can gain a post-copulatory advantage in this sperm 'raffle' by inseminating females at the optimal time relative to ovulation, leading to the prediction that males should preferentially associate and copulate with females at these times. To the best of our knowledge, we provide the first high-resolution test of this prediction using feral Soay sheep, which have a mating system characterized by male competition for access to highly promiscuous females. We find that competitive males time their mate guarding (and hence copulations) to occur close to the optimal insemination period (OIP), when females are also increasingly likely to 'cooperate' with copulation attempts. Subordinate males practice an alternative mating tactic, where they break the integrity of the consort pair and force copulations on females. The timing of these forced copulations is also targeted towards the OIP. We thus provide quantitative evidence that female promiscuity has resulted in the evolution of reproductive strategies in which males 'load' the sperm raffle by targeting their mating activity towards female OIPs, when the probability of sperm-competition success is at its greatest.

Overt and covert competition in a promiscuous mammal: the importance of weaponry and testes size to male reproductive success.

Male contests for access to receptive females are thought to have selected for the larger male body size and conspicuous weaponry frequently observed in mammalian species. However, when females copulate with multiple males within an oestrus, male reproductive success is a function of both pre- and postcopulatory strategies. The relative importance of these overt and covert forms of sexual competition has rarely been assessed in wild populations. The Soay sheep mating system is characterized by male contests for mating opportunities and high female promiscuity. We find that greater horn length, body size and good condition each independently influence a male's ability to monopolize receptive females. For males with large horns at least, this behavioural success translates into greater siring success. Consistent with sperm-competition theory, we also find that larger testes are independently associated with both higher copulation rates and increased siring success. This advantage of larger testes emerges, and strengthens, as the number of oestrous females increases, as dominant males can no longer control access to them all. Our results thus provide direct quantitative evidence that male reproductive success in wild populations of mammals is dependent upon the relative magnitude of both overt contest competition and covert sperm competition.

Ropelike birthmarks on children who claim to remember past lives.

Description of birthmarks having the pattern of strands of a rope in a second known case includes some verification of the correspondence between the birthmarks and injuries from ropes on an identified decreased person.

Near-infrared transmittance spectroscopy for radiochemical ageing of EPDM.

The feasibility of using near-infrared spectroscopy as a sensitive technique to follow the influence of gamma-irradiation upon ageing of different EPDM (ethylene propylene diene monomer) elastomers has been evaluated. Although identification is difficult, differences can be observed between the non-irradiated and irradiated materials for total integrated doses from 50 to 450 kGy using a dose rate of 1 kGy h(-1) under an oxygen flow. The decrease in intensity of bands at 7040, 4610 and 4910 cm(-1) are linked to the disappearance of additives present in the elastomer such as excess of vulcanising or antioxidant agents and occur for the lowest irradiation dose. This disappearance is confirmed by TGA (thermogravimetric analysis). The increase in band intensities assigned to the formation of hydroxyl and carbonyl groups (5100, 4860 and 4670 cm(-1)) irradiation indicates an increase in oxidation with irradiation in the presence of oxygen. No bands linked to the presence of C=C from the diene have been detected, probably owing to the low concentration in the material and the weak intensity in near-infrared region. For strong irradiation doses (450 kGy), the three formulations studied show no difference in their NIR spectra, which is confirmed by the TGA of these irradiated materials. PCA performed at 5000-4600 cm(-1) or 7090-6980 cm(-1) shows efficient discrimination.