Bumping to a rollator walker: How pretibial hematomas create more costs than pretibial lacerations.

Pretibial lacerations (PL) and pretibial hematomas (PH) are debilitating traumas among the elderly and infirm. The injuries are frequently grouped together despite differences in treatment and symptoms. Patients are known to have multiple contacts in health care, perhaps because of inadequate treatment. Despite the burden, financial costs have not been assessed. Calculate and compare the treatment costs of PLs and PHs for differences and provide economic incentives to treat and diagnose patients optimally. From linkage to ICD10 diagnoses, we analysed NordDRG product invoices generated by the treatment of the patients. We calculated and compared the costs of treatment in both cohorts from the invoices. This method has not been previously used for analysing wound care costs. Mean treatment costs were 1800€ (PL) and 3300€ (PH). The total costs, emergency room, surgical treatment, and inpatient care of PHs were higher than PLs (P = .0486, P = .0002, P = .0058, P = .6526). PLs generate more costs from the outpatient clinic but were not statistically significant (P = .6533). PHs cause a higher economic burden than PLs. Costs arise from repeat ER visits and the need for surgeries because of delayed treatment. PLs have multiple contacts in the wound clinic. Improvement in the diagnosis and treatment of both injuries is needed.

Therapeutic Exercises and Modalities in Athletes With Acute Hamstring Injuries: A Systematic Review and Meta-analysis.

CONTEXT: Hamstring strain is a common injury to the lower limbs. Early intervention in the acute phase aids with restoring hamstring function and prevents secondary related injury. OBJECTIVE: To systematically review and summarize the effectiveness of exercise-based interventions combined with physical modalities currently used in athletes with acute hamstring injuries. DATA SOURCES: Five databases (EMBASE, Medline, Cochrane Library, SPORTDiscus, and Web of Science) were searched from inception to July 2021. STUDY SELECTION: A total of 4569 studies were screened. Nine randomized controlled trials (RCTs) on the effect of therapeutic exercise programs with and without physical agents in athletes with acute hamstring injuries were identified for meta-analysis. STUDY DESIGN: Systematic review and meta-analysis. LEVEL OF EVIDENCE: Level 1. DATA EXTRACTION: The studies were screened, and the evidence was rated using the PEDro scale. Nine RCTs with PEDro scores ranging between 3 and 9 were included and extracted pain intensity, time to return to play (TTRTP), and reinjury rate in the study. RESULTS: Loading exercises during extensive lengthening were shown to facilitate TTRTP at P < 0.0001 but did not prevent recurrence (P = 0.17), whereas strengthening with trunk stabilization and agility exercise did not reduce the duration of injury recurrence (P = 0.16), but significantly reduced the reinjury rate (P < 0.007) at a 12-month follow-up. The results of the stretching programs and solely physical modalities could not be pooled in the statistical analysis. CONCLUSION: The meta-analysis indicated that a loading program helps athletes to return to sports on a timely basis. Although strengthening with trunk stabilization and agility exercise cannot significantly reduce recovery time, the program can prevent reinjury. The clinical effects of stretching programs and pure physical modality interventions could not be concluded in this study due to limited evidence. PROSPERO REGISTRATION: CRD42020183035.

An assessment of the diagnosis, treatment, and outcomes of lower extremity stress fractures in pediatric and adolescent populations.

OBJECTIVES: To present one of the first descriptive case series of pediatric and adolescent lower extremity stress injuries, their management, and outcomes in athletes and non-athletes. METHODS: The IRB-approved retrospective study included patients under 18 years at a tertiary children's hospital who were diagnosed with a lower extremity stress fracture/reaction. Demographic data, mechanism of injury, physical exam, radiographic findings, treatment, & outcomes were collected. Descriptive statistical analysis was conducted. RESULTS: Ninety-seven patients with stress injuries on clinical exams and on radiographs or MRI were included. The average age when diagnosed was 11.7 years (range 1.1-18 years) and the most common injuries were to the tibia (n = 33, 28.4%) and the least common involved were the cuneiforms (n = 4, 3.4%). Patients under the age of 14 were more likely to experience cuboid and calcaneal stress injuries (mean age 5.5 and 8.3 years respectively). Nineteen patients (19.6%) had high-risk stress fractures, with the average age of 14.9 years versus 11.6 for those with low risk (p-value = 0.01) and return to activity time being 15 weeks compared to 10.5 (p-value = 0.027). The most common forms of treatment were controlled ankle motion (CAM), walker boots (58.6%), and physical therapy (PT) (38.1%). The mean Lower Extremity Function Score of the patient population was 73.8, indicating no clinically important difference from full functionality. CONCLUSION: Lower extremity stress injuries in this cohort were most seen in the tibia, although patients younger than 14 had a high number of cuboid and calcaneal stress injuries. Those with high-risk stress fractures were older and took longer to recover from when compared to low-risk injuries. Treatment is commonly conservative, with CAM boots and PT being the most frequently utilized interventions and serving as a successful approach to treatment, with patients returning to activity at an average of 11.4 weeks, which is comparable to similar studies.

Five-year outcomes for patients sustaining severe fractures of the lower limb : mid-term results from the Wound management for Open Lower Limb Fracture (WOLLF) trial.

AIMS: The aim of this study was to report the outcomes of patients with severe open fractures of the lower limb in the five years after they took part in the Wound management for Open Lower Limb Fracture (WOLLF) trial. METHODS: The WOLLF trial compared standard dressings to negative pressure wound therapy (NPWT) applied at the end of the first surgical wound debridement, and patients were followed-up for 12 months. At 12 months, 170 of the original 460 participants agreed to take part in this medium-term follow-up study. Patients reported their Disability Rating Index (DRI) (0 to 100, where 100 is total disability) and health-related quality of life (HRQoL) using the EuroQol five-dimension three-level health questionnaire (EQ-5D-3L) annually by self-reported questionnaire. Further surgical interventions related to the open fracture were also recorded. RESULTS: There was no evidence of a difference in patient-reported disability, HRQoL, or the need for further surgery between patients treated with NPWT versus standard dressings at five years. Considering the combined results for all participants, there was a small but statistically significant change in DRI scores over time (1.6 units per year; p = 0.005), but no evidence that EQ-5D-3L scores changed significantly during years two to five (p = 0.551). CONCLUSION: This study shows that the high levels of disability and reduced HRQoL reported by patients 12 months after severe open fractures of the lower limb persist in the medium term, with little evidence of improvement between years two and five. Cite this article: Bone Joint J 2022;104-B(5):633-639.

Hamstring Strain Injury in Athletes: A Summary of Clinical Practice Guideline Recommendations: Using the Evidence to Guide Physical Therapist Practice.

Hamstring strain injuries (HSIs) are common in sports that involve high-speed running, jumping, kicking, explosive lower extremity movements, or lifting objects from the ground. HSIs may result in considerable impairment, activity limitation, and participation restriction, including time lost from competitive sports. The high reinjury rate is also a challenge. Improving reinjury risk assessment and decision making for safe return to play is a high priority for all stakeholders. J Orthop Sports Phys Ther 2022;52(3):127-128. doi:10.2519/jospt.2022.0501.

Pretibial lacerations.

Patients with pretibial lacerations are commonly referred to plastic surgery services for operative intervention. However, the vast majority of cases can be managed conservatively. Through understanding the epidemiology and pathophysiology underlying these injuries to appropriately assessing and managing these patients, this review demonstrates how best to facilitate wound healing and undertake conservative management. A multidisciplinary approach to managing patients with pretibial lacerations is discussed so that clinicians can provide a better quality of life for patients through optimisation and preventing further decline.

Comparison of Clinical Outcomes of Lower Extremity Burns in Diabetic and Nondiabetic Patients: A Retrospective Analysis.

Diabetes mellitus is an increasingly prevalent chronic disease that leads to long-term health consequences. Some long-term clinical sequelae of diabetes include coronary artery disease, peripheral vascular disease, peripheral neuropathy, and impaired wound healing. These can increase hospital stay and complications such as wound infections and amputations among patients with lower extremity burns. A retrospective analysis was performed of all isolated lower extremity burns from a single tertiary burn care center from 2006 to 2017. Patients were stratified by diabetic status and the incidence of lower extremity amputations was the primary outcome. Multivariable regression was used to model the association between diabetes and amputations, adjusting for patient and injury characteristics. A total of 198 patients were identified as meeting inclusion criteria, 160 were nondiabetic and 38 were diabetic. Age was significantly different between nondiabetic and diabetic patients; mean age was 46 ± 18 vs 62 ± 17 years (P < .0001). Length of stay was also significantly different, median length of stay was 11 (interquartile range 7-15) vs 18 (interquartile range 12-24; P < .001), with diabetic patients staying longer. There was a significantly greater proportion of diabetic patients that had an amputation (control 4% vs diabetic 29%; P < .0001). After adjustment for patient and injury characteristics, there was a significant association between diabetes and amputation (P = .002). Among patients with isolated lower extremity burns, those with a preexisting condition of diabetes had a longer hospitalization and increased amputations, despite similar size of burn. Diabetes is an important risk factor to acknowledge in patients with these injuries to optimize care.

Wound photography for evaluation of surgical site infection and wound healing after lower limb trauma.

AIMS: Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery. METHODS: Data from two large, UK-based multicentre randomized controlled major trauma trials investigating SSI and wound healing after surgical repair of open lower limb fractures that could not be primarily closed (UK WOLLF), and surgical incisions for fractures that were primarily closed (UK WHiST), were examined. Trial interventions were standard wound care management and negative pressure wound therapy after initial surgical debridement. Wound outcomes were collected from 30 days to six weeks. We compared the level of agreement between wound photography and clinical assessment of CDC-defined SSI. We are also assessed the level of agreement between blinded independent assessors of the photographs. RESULTS: Rates of CDC-defined deep SSI were 7.6% (35/460) after open fracture and 6.3% (95/1519) after closed incisional repair. Photographs were obtained for 77% and 73% of WOLLF and WHiST cohorts respectively (all participants n = 1,478). Agreement between photographic-SSI and CDC-SSI was fair for open fracture wounds (83%; k = 0.27 (95% confidence interval (CI) 0.14 to 0.42)) and for closed incisional wounds (88%; k = 0.29 (95% CI 0.20 to 0.37)) although the rate of photographically detected deep SSIs was twice as high as CDC-SSI (12% vs 6%). Agreement between different assessors for photographic-SSI (WOLLF 88%, k = 0.63 (95% CI 0.52 to 0.72); WHiST 89%; k = 0.61 (95% CI 0.54 to 0.69)); and wound healing was good (WOLLF 90%; k = 0.80 (95% CI 0.73 to 0.86); WHiST 87%; k = 0.57 (95% CI 0.50 to 0.64)). CONCLUSION: Although wound photography was feasible within the research context and inter-rater assessor agreement substantial, digital photographs used in isolation overestimated deep SSI rates, when compared to CDC criteria. Wound photography should not replace clinical assessment in pragmatic trials but may be useful for screening purposes where surgical infection outcomes are paramount. Cite this article: Bone Joint J 2021;103-B(12):1802-1808.

A comparison of efficacy, efficiency, and durability in novel tourniquet designs.

BACKGROUND: Exsanguination due to extremity hemorrhage is a major cause of preventable traumatic deaths. Extremity tourniquet use has been shown to be safe and improve survival. The purpose of this study was to compare the efficacy, efficiency, and durability of the Generation 7 Combat Application Tourniquet (CAT; North American Rescue, Greer, SC), the Tactical Mechanical Tourniquet (TMT; Combat Medical Systems, Harrisburg, NC), and the SOF Tactical Tourniquet-Wide (SOFTT-W; Tactical Medical Solutions, Anderson, SC). METHODS: This study was a three-phase randomized, cross-over trial. In successive trials, subjects were timed during the application of each tourniquet to the upper and lower extremity. Following successful lower extremity application, subjects low crawled 25 ft and then were dragged 25 ft, after which effectiveness was reassessed, as defined by the cessation of distal pulses by Doppler ultrasound. RESULTS: In arm application, both the CAT and TMT had significantly less failure rates than the SOFTT-W (5.56%, 19.44%, 58.33%), with the CAT being the fastest tourniquet when compared with TMT and SOFTT-W (37.8 seconds, 65.01 seconds, 63.07 seconds). In leg application, the CAT had significantly less rates of failure when compared with the SOFTT-W, but there was no other significant difference between the tourniquets (27.78%, 44.44%, 61.11%). In addition, the CAT was significantly faster than both the TMT and SOFTT-W when applied to the leg (8.33 seconds, 40.96 seconds, 34.5 seconds). There was no significant difference in tourniquet failure rates between the three tourniquets after subject maneuvers in phase 3 (34.29%, 42.86%, 45.45%). DISCUSSION: The CAT is as effective as the TMT and significantly more effective than the SOFTT-W. In addition, the CAT demonstrated shorter application times than either the TMT or SOFTT-W. However, there was no significant difference between the three tourniquets in their ability to maintain pulselessness after subject maneuvers. LEVEL OF EVIDENCE: Care management, level II.

The nationwide epidemiological and health insurance disease burden of knee and lower leg injuries in Hungary / A térd- és lábszársérülések okozta országos epidemiológiai és egészségbiztosítási betegségteher Magyarországon.

Összefoglaló. Bevezetés: A térd és a lábszár sérülései jelentos terhet jelentenek az egyén és a társadalom számára. Célkituzés: Elemzésünk célja volt a térd- és lábszársérülés okozta éves epidemiológiai és egészségbiztosítási betegségteher vizsgálata Magyarországon. Adatok és módszerek: Az elemzésben felhasznált adatok a Nemzeti Egészségbiztosítási Alapkezelo (NEAK) finanszírozási adatbázisából származnak, és a 2018. évet fedik le. Vizsgáltuk az éves egészségbiztosítási kiadásokat, azok megoszlását, az éves betegszámot, valamint a 100 000 lakosra vetített prevalenciát korcsoportok és nemek szerinti bontásban. A térd és a lábszár sérülései kórképeket a Betegségek Nemzetközi Osztályozása (BNO, 10. revízió) szerinti S80-S89-es kóddal azonosítottuk. Eredmények: A legköltségesebb ellátási forma az aktívfekvobeteg-szakellátás volt, amelynek országos betegszáma összesen 18 398 fo (9868 fo férfi, 8530 fo no) volt. Az aktívfekvobeteg-szakellátás betegforgalmi adatai alapján a 100 000 fore eso prevalencia a férfiaknál 211,2 fo, a noknél 167,0 fo, együtt 188,1 fo volt. A NEAK 8,808 milliárd Ft-ot költött 2018-ban a térd- és lábszársérülések kezelésére, ami 32,59 millió USD-nak, illetve 27,62 millió EUR-nak felelt meg. Az aktívfekvobeteg-szakellátás a teljes egészségbiztosítási kiadás 61,4%-ával volt a legmeghatározóbb költségelem. A kiadások 52,0%-a férfiaknál, míg 48,0%-a noknél jelent meg. A 49. életévig a férfiak, míg az 50. életév feletti korosztályban a nok sérüléseibol származó ellátások betegszámai és költségei a magasabbak. Következtetés: Az aktívfekvobeteg-szakellátás bizonyult a fo költségtényezonek. A betegség elofordulási gyakorisága 26%-kal volt magasabb a férfiak esetében, mint a noknél. Orv Hetil. 2021; 162(Suppl 1): 54-60. INTRODUCTION: Injuries to the knee and lower leg pose a great burden for the individual and society. OBJECTIVE: The aim of our study was to determine the annual epidemiological disease burden and the health insurance treatment cost of knee and lower leg injuries in Hungary. DATA AND METHODS: Data were derived from the financial database of the National Health Insurance Fund Administration (NHIFA) of Hungary for the year 2018. The data analysed included annual health insurance costs and their distribution and annual patient numbers and prevalence per 100 000 population calculated for age groups and sex. Patients with knee and lower leg injuries were identified with the following code of the International Classification of Diseases, 10th revision: S80-S89. RESULTS: The most expensive insurance treatment category was acute inpatient care, presenting 18 398 patients in total (9868 men, 8530 women). Based on patient numbers in acute inpatient care, the prevalence in 100 000 population among men was 211.2 patients, among women 167.0 patients, in total 188.1 patients. In 2018, NHIFA spent 8.808 billion HUF on the treatment of patients with knee and lower leg injuries (32.59 million USD, 27.62 million EUR). Acute inpatient care with 61.4% of the total health insurance expenditure was the main cost driver. 52.0% of the costs was spent on the treatment of male, while 48.0% on female patients. Until the age of 49, the number of patients and their costs were higher for men, while those over the age of 50 were higher for women. CONCLUSION: Acute inpatient care was the major cost driver. The prevalence of the disease was by 26% higher in men compared to women. Orv Hetil. 2021; 162(Suppl 1): 54-60.

Quantification of immobilization-induced changes in human calf muscle using speed-of-sound ultrasound: An observational pilot study.

ABSTRACT: Short-term immobilization leads to fatty muscular degeneration, which is associated with various negative health effects. Based on literature showing very high correlations between MRI Dixon fat fraction and Speed-of-Sound (SoS), we hypothesized that we can detect short-term-immobilization-induced differences in SoS.Both calves of 10 patients with a calf cast on one side for a mean duration of 41 ±â€Š26 days were examined in relaxed position using a standard ultrasound machine. Calf perimeters were measured for both sides. A flat Plexiglas-reflector, placed vertically on the opposite side of the probe with the calf in-between, was used as a timing reference for SoS. SoS was both manually annotated by two readers and assessed by an automatic annotation algorithm. The thickness values of the subcutaneous fat and muscle layers were manually read from the B-mode images. Differences between the cast and non-cast calves were calculated with a paired t test. Correlation analysis of SoS and calf perimeter was performed using Pearson's correlation coefficient.Paired t test showed significant differences between the cast and non-cast side for both SoS (P < .01) and leg perimeter (P < .001). SoS was reduced with the number of days after cast installment (r = -0.553, P = .097). No significant differences were found for muscle layer thickness, subcutaneous fat layer thickness, mean fat echo intensity, or mean muscle echo intensity.Short-term-immobilization led to a significant reduction in SoS in the cast calf compared to the healthy calf, indicating a potential role of SoS as a biomarker in detecting immobilization-induced fatty muscular degeneration not visible on B-mode ultrasound.

The effect of COVID-19 on a Major Trauma Network. An analysis of mechanism of injury pattern, referral load and operative case-mix.

PURPOSE: The aim of this study was to evaluate changes in both mechanism and diagnoses of injuries presenting to the orthopaedic department during this lockdown period, as well as to observe any changes in operative case-mix during this time. METHODS: A study period of twelve weeks following the introduction of the nationwide "lockdown period", March 23rd - June 14th, 2020 was identified and compared to the same time period in 2019 as a "baseline period". A retrospective analysis of all emergency orthopaedic referrals and surgical procedures performed during these time frames was undertaken. All data was collected and screened using the 'eTrauma' management platform (Open Medical, UK). The study included data from a five NHS Foundation Trusts within North West London. A total of 6695 referrals were included for analysis. RESULTS: The total number of referrals received during the lockdown period fell by 35.3% (n=2631) compared to the same period in 2019 (n=4064). Falls remained proportionally the most common mechanism of injury across all age groups in both time periods. The proportion sports related injuries compared to the overall number of injuries fell significantly during the lockdown period (p<0.001), however, the proportion of pushbike related accidents increased significantly (p<0.001). The total number of operations performed during the lockdown period fell by 38.8% (n=1046) during lockdown (n=1732). The proportion of patients undergoing operative intervention for Neck of Femur (NOF) and ankle fractures remained similar during both study periods. A more non-operative approach was seen in the management of wrist fractures, with 41.4% of injuries undergoing an operation during the lockdown period compared to 58.6% at baseline (p<0.001). CONCLUSION: In conclusion, the nationwide lockdown has led to a decrease in emergency orthopaedic referrals and procedure numbers. There has been a change in mechanism of injuries, with fewer sporting injuries, conversely, there has been an increase in the number of pushbike or scooter related injuries during the lockdown period. NOF fractures remained at similar levels to the previous year. There was a change in strategy for managing distal radius fractures with more fractures being treated non-operatively.

Pretibial lacerations among elderly patients: A province-wide study from Kymenlaakso, Finland, 2015-2019.

In this retrospective cohort study, we analysed treatment and outcomes among ≥65-year-old patients who experienced a traumatic pretibial laceration in the province of Kymenlaakso, Finland, between 2015 and 2019. We reviewed computerised medical records for 116 patients with a pretibial laceration, 107 of whom we analysed in further detail. Patients were traced from injury to healing, including rehabilitation periods in health care centres. As expected, the majority of patients were elderly women (67%). Most lacerations were superficial and small, explaining why treatment was mostly conservative. Only 11 (9.48%) patients were treated operatively with surgical debridement or a split-thickness skin graft. The number of overall complications in wounds was high, with a complication rate of 30.2%. Most complications were local wound infections. We found that wound healing took more than 3 months in 32% of patients. Thorough patient tracing revealed numerous follow-up visits and long rehabilitative hospitalisation periods, indicating a significant decline in patient independence and the excessive use of resources. Successful wound healing was eventually observed in 89.66% patients. Furthermore, no terminology regarding pretibial lacerations was found in patient records. This study indicates that pretibial lacerations remain poorly recognised and understood in Finland.

Too Hot to Handle? Full-Thickness Burn Injury in a Child Caused by Cyanoacrylate Glue and Cotton-A Case Report and Experimental Study.

Domestic superglue (cyanoacrylate) in the hands of children can have devastating consequences, especially when cotton clothing is involved. When cotton comes into contact with cyanoacrylate, an intense exothermic reaction occurs, creating temperatures high enough to cause significant thermal injury. A literature review found 16 such cases of burns documented (2 adult and 14 pediatric). This article presents a case report of a 4-year-old child sustaining a full-thickness burn injury to her leg requiring skin grafting when superglue was spilt onto cotton pants. She was sitting near a fan heater at the time. An experiment was conducted to replicate the exothermic reaction between superglue and cotton and to determine if the addition of radiant heat would have any significant effect. The maximum temperature reached with one 3-g tube of superglue onto cotton pyjamas was 91°C (196°F) and occurred approximately 90 seconds postapplication. It took more than 3 minutes for the temperature to cool below 40°C (104°F). The addition of radiant heat from a fan heater placed 60 cm from the clothing found that the temperature peak was similarly reached and cooled, but the temperature did not reduce below 52°C (126°F) for over 20 minutes, proving that potential harm may be amplified if first aid is not appropriately sought. Product labeling and the knowledge of potential harm from such mechanism of injury remain inadequate. It is hoped that the reporting of this case contributes to an increase in public education and awareness of such dangers and may contribute to preventing avoidable future incidences.

Risk Factors for Wound Infection in Outpatients With Lower Extremity Burns.

BACKGROUND: We sought to evaluate risk factors for wound infection in patients with lower extremity (LE) burn. METHODS: Adults presenting with LE burn from January 2014 to July 2015 were included. Data regarding demographics, injury characteristics, and outcomes were obtained. The primary outcome was wound infection. Multivariate logistic regression analysis was performed to identify independent risk factors for wound infection. RESULTS: 317 patients were included with a mean age of 43 years and median total body surface area of .8%; 22 (7%) patients had a component of full-thickness (FT) burn; and 212 (67%) patients had below-the-knee (BTK) burn. The incidence of wound infection was 15%. The median time to infection was 5 days, and majority (61%) of the patients developed wound infection by day 5. Patients who developed wound infection were more likely to have an FT burn (22% vs. 5%, P < .001) and BTK burn (87% vs. 64%, P = .002), without a difference in other variables. Multivariate logistic regression analysis showed age (Odds ratio (OR) 1.02 and CI 1.00-1.04), presence of FT burn (OR 5.33 and CI 2.09-13.62), and BTK burn (OR 3.42 and CI 1.37-8.52) as independent risk factors for wound infection (area under the curve = .72). CONCLUSION: Age, presence of FT burn, and BTK burn are independent risk factors for wound infection in outpatients with LE burns.

Implementing a Locally Made Low-Cost Intervention for Wound and Lymphedema Care in Western Kenya.

In Western Kenya, the burden of chronic wounds and lymphedema has a significant impact on functionality and quality of life. Major barriers to provision of care include availability, affordability, and accessibility of bandages. At the Academic Model Providing Access to Healthcare, dermatologists and pharmacists collaborated to develop a 2-component compression bandage modeled after the Unna boot, using locally available materials, that is distributed through a revolving fund pharmacy network. In partnership with nursing, use of these bandages at a national referral hospital and a few county facilities has increased, but increasing utilization to an expanded catchment area is needed.

Evaluation of the efficacy of commercial and noncommercial tourniquets for extremity hemorrhage control in a perfused cadaver model.

BACKGROUND: Tourniquets are a critical tool in the immediate response to life-threatening extremity hemorrhage; however, the optimal tourniquet type and effectiveness of noncommercial devices remain unclear. Our aim was to evaluate the efficacy of five tourniquets in a perfused-cadaver model. METHODS: This prospective study used a perfused-cadaver model with standardized superficial femoral artery injury bleeding at 700 mL/min. Five tourniquets were tested: combat application tourniquet; rapid application tourniquet system; Stretch, Wrap, And Tuck Tourniquet; an improvised triangle bandage windlass; and a leather belt. Forty-eight medical students underwent a practical hands-on demonstration of each tourniquet. Using a random number generator, they placed the tourniquets on the bleeding cadaver in random order. Time to hemostasis, time to secure devices, estimated blood loss, and difficulty rating were assessed. A one-way repeated measures analysis of variance was used to compare efficacy between the tourniquets in achieving the outcomes. RESULTS: The mean ± SD participant age was 25 ± 2.6 years, and 29 (60%) were male. All but one tourniquet was able to stop bleeding, but the rapid application tourniquet system had a 4% failure rate. Time to hemostasis and estimated blood loss did not differ significantly (p > 0.05). Stretch, Wrap, And Tuck Tourniquet required the longest time to be secured (47.8 ± 17.0 seconds), whereas the belt was the fastest (15.2 ± 6.5 seconds; p < 0.001). The improvised windlass was rated easiest to learn and apply, with 22 participants (46%) assigning a score of 1. CONCLUSION: Four of five tourniquets evaluated, including both noncommercial devices, effectively achieved hemostasis. A standard leather belt was the fastest to place and was able to stop the bleeding. However, it required continuous pressure to maintain hemostasis. The improvised windlass was as effective as the commercial devices and was the easiest to apply. In an emergency setting where commercial devices are not available, improvised tourniquets may be an effective bridge to definitive care.

Chronic Exertional Compartment Syndrome of the Leg Management Is Changing: Where Are We and Where Are We Going?

Chronic exertional compartment syndrome (CECS) is one of the wide range of causes of exercise-related leg pain in athletes. It is defined as a transient increase in compartment pressures during activity, which causes pain, because of the inability of the fascial compartments to accommodate and is usually relieved by cessation of exercise. Exercise-induced leg pain in the athletic population is a common complaint, with reports of up to 15% of all runners arriving to initial evaluation with this presentation. Often, this lower-extremity exertional pain is grouped into the common term of "shin splints" by athletes, which is a nondiagnostic term that implies no specific pathology. It may, however, encompass much of the differential for CECS, including medial tibial stress syndrome, muscle strain, and stress fracture. Improving diagnostic techniques, as well as treatments, will continue to help athletes and patients with leg pain in the future.

Management of hamstring injuries: current concepts review.

Injuries to the hamstring muscle complex are common in athletes, accounting for between 12% and 26% of all injuries sustained during sporting activities. Acute hamstring injuries often occur during sports that involve repetitive kicking or high-speed sprinting, such as American football, soccer, rugby, and athletics. They are also common in watersports, including waterskiing and surfing. Hamstring injuries can be career-threatening in elite athletes and are associated with an estimated risk of recurrence in between 14% and 63% of patients. The variability in prognosis and treatment of the different injury patterns highlights the importance of prompt diagnosis with magnetic resonance imaging (MRI) in order to classify injuries accurately and plan the appropriate management. Low-grade hamstring injuries may be treated with nonoperative measures including pain relief, eccentric lengthening exercises, and a graduated return to sport-specific activities. Nonoperative management is associated with highly variable times for convalescence and return to a pre-injury level of sporting function. Nonoperative management of high-grade hamstring injuries is associated with poor return to baseline function, residual muscle weakness and a high-risk of recurrence. Proximal hamstring avulsion injuries, high-grade musculotendinous tears, and chronic injuries with persistent weakness or functional compromise require surgical repair to enable return to a pre-injury level of sporting function and minimize the risk of recurrent injury. This article reviews the optimal diagnostic imaging methods and common classification systems used to guide the treatment of hamstring injuries. In addition, the indications and outcomes for both nonoperative and operative treatment are analyzed to provide an evidence-based management framework for these patients. Cite this article: Bone Joint J 2020;102-B(10):1281-1288.

Medicine wastage in a thromboprophylaxis protocol for ambulatory trauma patients.

Thromboprophylactic medicine is provided routinely to patients who present to emergency departments (EDs) with lower leg fractures as a preventive measure against forming blood clots in an immobilised limb. A large amount of medicine is provided to these patients at discharge, but once they have recovered their mobility the remaining medicine is unusable and must be destroyed. There is a lack of data to quantify this waste. This article reports a service evaluation that was conducted in an ED to investigate the wastage and the cost implications of this treatment protocol. It shows that over half the medicine dispensed is subsequently wasted and makes recommendations for changing dispensing practice.