Paediatric supracondylar fractures: assessment and management.

Supracondylar fractures of the distal humerus are the most common fracture around the elbow in children. A thorough initial assessment must be conducted to identify any associated neurovascular injury and carefully documented. The assessment should include a vascular examination of the radial pulse, temperature, colour and capillary refill time. A neurological examination must comment on the motor and sensory function of the radial, median and ulnar nerves. X-rays allow an evaluation of the fracture location and type, and the degree of displacement. Immobilisation in plaster is the gold standard treatment for paediatric supracondylar fracture of the humerus where the degree of displacement is within acceptable parameters. Casting should be followed by orthogonal radiographs and a repeat neurovascular assessment of the limb. Oral analgesia and safety netting information should be provided on discharge, and the child reviewed in a fracture clinic within 1 week of the injury. The British Orthopaedic Association Standards for Trauma and Orthopaedics for supracondylar fractures of the humerus in children are useful for junior orthopaedic and emergency medicine clinicians to refer to when dealing with these injuries.

Fracture-related infections.

Fracture-related infection is a serious complication which can occur following musculoskeletal injury and is associated with significant morbidity. These complications can be challenging to recognise, and experts have provided a clearer definition of fracture-related infection to help with the diagnosis and detection of these infections. This system includes clinical, radiological and laboratory-based diagnostic features which are either confirmatory or suggestive of fracture-related infection. Treatment requires a multifaceted approach with multidisciplinary involvement, and generally a combination of surgical techniques and prolonged antibiotics, the timing and choice of which should be optimised. This article provides an evidence-based review of the British Orthopaedic Association Standards for Trauma for the diagnosis and management of fracture-related infections.

Acute musculoskeletal infection in children: assessment and management.

Musculoskeletal infection in children is challenging to treat, and includes septic arthritis, deep tissue infection, osteomyelitis, discitis and pyomyositis. Delays to diagnosis and management, and under-treatment can be life-threatening and result in chronic disability. The British Orthopaedic Association Standards for Trauma include critical steps in the timely diagnosis and management of acute musculoskeletal infection in children, the principles of acute clinical care and the service delivery requirements to appropriately manage this cohort of patients. Orthopaedic and paediatric services are likely to encounter cases of acute musculoskeletal infection in children and thus an awareness and thorough understanding of the British Orthopaedic Association Standards for Trauma guidelines is essential. This article reviews these guidelines and associated published evidence for the management of children with acute musculoskeletal infection.

Paediatric forearm fractures: assessment and initial management.

The forearm is the most common site of fracture in children. At the time of initial assessment, a thorough examination and neurovascular assessment of the limb is necessary. X-rays allow evaluation of the fracture location and type, in addition to the degree of displacement. With the help of intranasal opiates, manipulation of fracture fragments can be performed in the emergency department. Immobilisation in plaster is the gold standard treatment for paediatric forearm fractures where the degree of displacement is within acceptable parameters. Manipulation and casting should be followed by orthogonal radiographs and a repeated neurovascular assessment of the limb. Oral analgesia and safety netting information should be provided on discharge and the child should be reviewed in fracture clinic within a week of the injury. This article reviews the British Orthopaedic Association Standards for Trauma and Orthopaedics for the early management of paediatric forearm fractures that do not require operative management.

Assessment and management of adult ankle fractures: understanding the evidence.

Ankle fractures are a common injury. Assessment should include looking at the mechanism of injury, comorbidities, associated injuries, soft tissue status and neurovascular status. Emergent reduction is required for clinically deformed ankles. Investigations should include plain radiographs and a computed tomography scan for more complex injuries or those with posterior malleolus involvement. An assessment of ankle stability determines treatment, taking into account comorbidities and preoperative mobility which need special consideration. Non-operative management includes splint or cast, allowing for early weightbearing when the ankle is stable. Operative management includes open reduction and internal fixation, intramedullary nailing (of the fibula and hindfoot) and external fixation. Syndemosis stabilisation includes suture button or screw fixation. The aim of treatment is to restore ankle stability and this article explores the current evidence in best practice.

Surgical management of obesity: what you need to know.

Obesity is a worldwide epidemic and official figures demonstrate a rising prevalence, both in the UK and globally. Increasingly, there is a recognised place for surgical intervention in carefully selected patients, but there is limited understanding of the pathway and process among non-specialist clinicians. This article summarises the available guidelines and literature on the surgical management of obesity for hospital physicians, surgeons and GPs. The focus is on appropriate referral criteria, key bariatric procedures, postoperative management and, most importantly, the complications of surgery and how to recognise them.

Management of urological trauma associated with pelvic fractures.

Urological trauma is frequently encountered in patients with high energy pelvic fractures and can have debilitating long-term sequelae for patients without appropriate multidisciplinary management. Anterior pelvic ring disruption causes a high incidence of bladder rupture and urethral injuries, and initial assessment requires urological tract imaging and emergent bladder drainage before subsequent surgical repair. Pelvic ring disruption requires urgent fixation and should be managed as an open fracture in the context of significant bladder and urethral injury with urinary leakage. Long-term outcomes are variable and genitourinary dysfunction is commonly reported among patients with pelvic fractures. Optimisation of patient outcomes relies heavily on collaborative management between orthopaedic and urological specialists and requires an appreciation of the anatomical intricacies of the pelvis. This article provides an overview of the British Orthopaedic Association Standards for Trauma and Orthopaedics management of urological trauma in the context of pelvic fractures.

Spinal clearance and management of spinal cord injury in the trauma patient.

The British Orthopaedic Association's Standards for Trauma and Orthopaedics outline the essential clinical standards for spinal clearance and management of spinal cord injury in the acute trauma patient. From initial presentation in the hospital setting to long-term rehabilitation, the recommendations for clinical assessment, imaging, treatment priorities and the role of trauma networks are summarised.

The BOAST recommendations for care of the older or frail orthopaedic trauma patient.

Safe and effective care for the elderly or physiologically frail patient in cases of trauma requires a multidisciplinary perioperative approach. This article expands upon the British Orthopaedic Association Standards for Trauma and Orthopaedics guidelines for the management of the older or frail orthopaedic trauma patient. Optimisation of the patient is key to a successful surgical outcome, because these patients often have significant comorbidities involving bone health, nutrition, cognitive function and cardiovascular stability. This article discusses the evidence base for tailoring the management of these patients and the importance of doing so in an ageing population. It considers the requisite preoperative procedures and investigations, guidelines for specific cases such as comatose patients or those with complex fractures, and ceiling of care discussions, and then focuses on the postoperative period, including physiotherapy, rehabilitation goals and medical management.

Distal radius fractures: an evidence-based approach to assessment and management.

Distal radius fractures account for one in five bony injuries in both primary and secondary care. These are commonly the result of a fall on outstretched hands or high-energy trauma. On assessment, clinicians should determine the mechanism of injury, associated bony or soft tissue injuries, and neurovascular symptoms. Investigations should always include radiographs to evaluate for intra-articular involvement and fracture displacement. Owing to the heterogeneous injury patterns and patient profiles, the preferred management should consider the severity of the fracture, desired functional outcome and patient comorbidities. Non-operative management in select patients can give good results, especially in older adults. Immobilisation with or without reduction forms the mainstay of non-operative treatment. Surgical management options include closed reduction and application of a cast, percutaneous K-wires, open reduction and internal fixation with plates, or external fixation. Patients should be encouraged to mobilise as soon as it is safe to do so, to prevent stiffness. Median nerve compression is the most common complication followed by tendon rupture, arthrosis and malunion. This article outlines the British Orthopaedic Association Standards for Trauma and Orthopaedics for the management of distal radius fractures.

Acute compartment syndrome in the limb.

Compartment syndrome of the limb is a true orthopaedic emergency that warrants prompt evaluation and treatment. Acute compartment syndrome of the limb is not uncommon and has the potential to cause devastating morbidity and mortality. Failure to provide urgent surgical intervention once established can lead to irreversible tissue damage within hours of onset. Compartment syndrome can occur across all limbs, the buttocks and even the abdomen, but this article focuses solely on the diagnosis of acute compartment syndrome of the limb. Acute compartment syndrome can have a wide range of causes, with trauma representing approximately 70% of cases.

The impact of the novel coronavirus on trauma and orthopaedics in the UK.

At first glance, the novel coronavirus pandemic and orthopaedic surgery appear separate entities. Orthopaedic surgeons are not generally considered front-line staff in terms of the treatment of the disease that the novel coronavirus causes compared with anaesthetic and medical colleagues. However, the impact that the novel coronavirus is likely to have on the musculoskeletal injury burden and the morbidity associated with chronic musculoskeletal disease is significant. This article summarises the strategies currently being developed for the remodelling of orthopaedic services in the UK and the emergency British Orthopaedic Association Standards for Trauma and Orthopaedic guidelines released on 24 March 2020 in managing urgent orthopaedic patients during the novel coronavirus pandemic.

Urinary catheterization 2: technique and managing failure.

Urinary catheterization is an important procedure that is regularly performed in hospital. All clinicians should have a good working knowledge of urinary catheters and the competence to manage them effectively. This topic is discussed over two articles: the first article focused on indications, and this second discusses techniques and managing failure. Good technique is essential to prevent complications and if problems do occur, these must be managed efficiently to prevent long-term consequences. In some situations, this may require referral to the urology team for more specialized intervention. This article discusses this in more detail to help guide clinicians involved in urethral catheterization.

Urinary catheterization 1: indications.

Urinary catheterization is an important procedure that is regularly performed in hospital. All clinicians should have a good working knowledge of urinary catheters and the competence to manage them effectively. This topic will be discussed over two articles: this first article will focus on indications, and the second on techniques and managing failure. There are multiple indications for urethral catheter insertion and a range of catheter types and sizes. The choice of catheter is dependent on the patient and indication. This article discusses this in more detail to help guide clinicians involved in urethral catheterization.

Systematic Review of Stress Radiographic Modalities Stability Assessment in Supination External Rotation Ankle Fractures.

BACKGROUND: Isolated distal fibular fractures resulting from supination external rotation (SER) injuries without evidence of obvious talar shift on standard radiographs present a diagnostic dilemma for clinicians. The status of the deep deltoid ligament, the main stabilizer of the ankle joint, is assessed by an increase in medial clear space (MCS) on radiographs. Therefore, these injuries can be either stable or unstable. In recent years, considerable clinical and research efforts have been made to determine ankle stability following SER fracture. The purpose of this systematic review was to evaluate and compare the role of different stress radiograph modalities in assessing stability of the ankle with SER fractures with no obvious talar subluxation on standard radiographs. METHODS: The electronic databases MEDLINE, EMBASE, Ovid, Cochrane Central, CINAHL, and Google Scholar were searched from January 2000 to January 2018 to identify literature relating to radiologic assessment of stability of SER ankle fractures. RESULTS: Our literature search revealed 10 peer-reviewed articles that fulfilled inclusion criteria. This yielded a total of 698 patients. The systematic review found 3 broad categories of radiographic investigations in the assessment of ankle joint stability: external rotation (ER) stress radiographs, gravity stress views (GSV), and weightbearing (WB) radiographs. Proponents of WB radiographs have demonstrated how axial load can normalize ankle joint alignment in cases of proven instability. There was a consistently high grade of evidence for using a medial clear space (MCS) value of more than 4 to 5 mm to indicate an unstable ankle following SER fracture. CONCLUSION: In conclusion, the results of this systematic review support an MCS value of less than 4 to 5 mm as a good indicator of stability, regardless of choice of stress imaging modality. These patients can be allowed early weightbearing with expected good functional outcomes. Recent published literature favors WB stress radiographs as a reliable and safe technique for assessing stability in SER ankle fractures. However, it should be kept in mind that this is based on studies with relatively low grades of evidence. LEVEL OF EVIDENCE: Level II, systematic review of variable quality studies.