A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds.

BACKGROUND: The management of open fractures requires wound irrigation and débridement to remove contaminants, but the effectiveness of various pressures and solutions for irrigation remains controversial. We investigated the effects of castile soap versus normal saline irrigation delivered by means of high, low, or very low irrigation pressure. METHODS: In this study with a 2-by-3 factorial design, conducted at 41 clinical centers, we randomly assigned patients who had an open fracture of an extremity to undergo irrigation with one of three irrigation pressures (high pressure [>20 psi], low pressure [5 to 10 psi], or very low pressure [1 to 2 psi]) and one of two irrigation solutions (castile soap or normal saline). The primary end point was reoperation within 12 months after the index surgery for promotion of wound or bone healing or treatment of a wound infection. RESULTS: A total of 2551 patients underwent randomization, of whom 2447 were deemed eligible and included in the final analyses. Reoperation occurred in 109 of 826 patients (13.2%) in the high-pressure group, 103 of 809 (12.7%) in the low-pressure group, and 111 of 812 (13.7%) in the very-low-pressure group. Hazard ratios for the three pairwise comparisons were as follows: for low versus high pressure, 0.92 (95% confidence interval [CI], 0.70 to 1.20; P=0.53), for high versus very low pressure, 1.02 (95% CI, 0.78 to 1.33; P=0.89), and for low versus very low pressure, 0.93 (95% CI, 0.71 to 1.23; P=0.62). Reoperation occurred in 182 of 1229 patients (14.8%) in the soap group and in 141 of 1218 (11.6%) in the saline group (hazard ratio, 1.32, 95% CI, 1.06 to 1.66; P=0.01). CONCLUSIONS: The rates of reoperation were similar regardless of irrigation pressure, a finding that indicates that very low pressure is an acceptable, low-cost alternative for the irrigation of open fractures. The reoperation rate was higher in the soap group than in the saline group. (Funded by the Canadian Institutes of Health Research and others; FLOW ClinicalTrials.gov number, NCT00788398.).

Orthopaedic Trainees Retain Knowledge After a Partner Abuse Course: An Education Study.

INTRODUCTION: Intimate partner violence (IPV) is a serious global issue that results in a large number of injuries and deaths among women. Educating clinicians about IPV can help providers identify, prevent, and treat victims, and, ultimately, improve care for victims of abuse. We sought to determine the effect of a half-day educational course on IPV for orthopaedic surgical trainees on knowledge and attitudes. QUESTIONS/PURPOSES: We asked (1) whether a half-day educational course on IPV can improve orthopaedic surgical trainees' knowledge and (2) attitudes regarding IPV; and (3) whether a course on IPV can be accepted and viewed as valuable by trainees? METHODS: Using published research on IPV in patients with musculoskeletal injuries, we developed a half-day educational course. The curriculum included lectures and discussion regarding the basics of IPV, the current state of IPV research, what to do when a patient is a victim or perpetrator, and the orthopaedic surgeon's role in recognizing, preventing, and assisting with IPV. All 33 course participants (30 men and three women), all orthopaedic surgical trainees, completed a questionnaire that included general true or false or agree or disagree statements regarding their knowledge, attitudes, and practices of IPV in the musculoskeletal setting; the questionnaire also included a knowledge test of 25 true or false statements. The questionnaire was administered immediately before, immediately after, and 3 months after the course; 76% (25 of 33) took the test immediately after the course and 82% (27 of 33) completed the test at 3 months. Participant knowledge scores were compared across the three different times to determine the effect of the course. RESULTS: Participants increased their knowledge after the course, and the increased knowledge was retained at retesting at 3 months; the mean percentage of correct answers before the course was 57%, which increased to 73% after the course, and was 68% 3 months later (F = 9.505; p = 0.001). Before the course, most of the course participants (30 of 32; 94%) agreed that IPV is an important issue; agreement increased to 100% immediately after the course. The largest change in attitude was in response to the statement: "I am skeptical that the health care system has the resources to screen for IPV." Before the course, 53% (17 of 32) of trainees endorsed this statement, but the percent decreased to 36% (nine of 25) after the course and remained low at 33% (nine of 27), at the 3-month test. CONCLUSIONS: Our findings show that a short course on IPV in patients with musculoskeletal injuries led to an improvement and retention of knowledge 3 months after the course. Based on our findings, we recommend that IPV education be integrated in training programs for orthopaedic surgeons. Future projects should focus on developing and implementing a sustainable education program that can affect practice for healthcare professionals and trainees in multiple clinical settings.

Radial head and neck fractures: functional results and predictors of outcome.

BACKGROUND: The purpose of this study was to determine the functional outcomes and predictive factors of radial head and neck fractures. METHODS: Over an 18-month period, we performed a prospective study of 237 consecutive patients with a radiographically confirmed proximal radial fracture (156 radial head and 81 radial neck). Follow-up was carried out over a 1-year period using clinical and radiologic assessment, including the Mayo Elbow Score (MES). Multivariate regression analysis was used to determine significant predictors of outcome according to the MES. RESULTS: Of the 237 patients enrolled in the study, 201 (84.8%) attended for review, with a mean age of 44 years (range, 16-83 years; standard deviation, 17.3). One hundred eighty-seven (93%) patients achieved excellent or good MESs. The mean MES for Mason type-I (n = 103) and type-II (n = 82) fractures was excellent, with only two patients undergoing surgical intervention. For Mason type-III (n = 11) and type-IV (n = 5) fractures, the flexion arc, forearm rotation arc, and MES in the nonoperatively treated patients were not significantly different (all p ≥ 0.05) from those managed operatively. Regression analysis revealed that increasing age, increasing fracture complexity according to the AO-OTA classification, increasing radiographic comminution, and operative treatment choice were independently significant predictors of a poorer outcome (all p < 0.05). CONCLUSIONS: A majority of radial head and neck fractures can be treated nonoperatively, achieving excellent or good results. Age, fracture classification, radiographic comminution, and treatment choice are important factors that determine recovery.

Radial shortening following a fracture of the proximal radius.

BACKGROUND AND PURPOSE: The Essex-Lopresti lesion is thought to be rare, with a varying degree of disruption to forearm stability probable. We describe the range of radial shortening that occurs following a fracture of the proximal radius, as well as the short-term outcome in these patients. PATIENTS AND METHODS: Over an 18-month period, we prospectively assessed all patients with a radiographically confirmed proximal radial fracture. Patients noted to have ipsilateral wrist pain at initial presentation underwent bilateral radiography to determine whether there was disruption of the distal radio-ulnar joint suggestive of an Essex-Lopresti lesion. Outcome was assessed after a mean of 6 (1.5-12) months using clinical and radiographic results, including the Mayo elbow score (MES) and the short musculoskeletal function assessment (SMFA) questionnaire. One patient with a Mason type-I fracture was lost to follow-up after initial presentation. RESULTS: 60 patients had ipsilateral wrist pain at the initial assessment of 237 proximal radial fractures. Radial shortening of ≥ 2mm (range: 2-4mm) was seen in 22 patients (mean age 48 (19-79) years, 16 females). The most frequent mechanism of injury was a fall from standing height (10/22). 21 fractures were classified as being Mason type-I or type-II, all of which were managed nonoperatively. One Mason type-III fracture underwent acute radial head replacement. Functional outcome was assessed in 21 patients. We found an excellent or good MES in 18 of the 20 patients with a Mason type-I or type-II injury. INTERPRETATION: The incidence of the Essex-Lopresti lesion type is possibly under-reported as there is a spectrum of injuries, and subtle disruptions often go unidentified. A full assessment of all patients with a proximal radial fracture is required in order to identify these injuries, and the index of suspicion is raised as the complexity of the fracture increases.

Effect of Tourniquet Use During Surgical Treatment of Open Fractures.

BACKGROUND: We sought to evaluate whether tourniquet use, with the resultant ischemia and reperfusion, during surgical treatment of an open lower-extremity fracture was associated with an increased risk of complications. METHODS: This is a retrospective cohort study of 1,351 patients who had an open lower-extremity fracture at or distal to the proximal aspect of the tibia and who participated in the FLOW (Fluid Lavage of Open Wounds) trial. The independent variable was intraoperative tourniquet use, and the primary outcome measures were adjudicated unplanned reoperation within 1 year of the injury and adjudicated nonoperative wound complications. RESULTS: Unplanned reoperation and nonoperative wound complications were roughly even between the no-tourniquet (18.7% and 19.1%, respectively) and tourniquet groups (17.8% and 20.8%) (p = 0.78 and p = 0.52). Following matching, as determined by model interactions, tourniquet use was a significant predictor of unplanned reoperation in Gustilo Type-IIIA (odds ratio, 3.60; 95% confidence interval, 1.16 to 11.78) and IIIB fractures (odds ratio, 16.61; 95% confidence interval, 2.15 to 355.40). CONCLUSIONS: The present study showed that tourniquet use did not influence the likelihood of complications following surgical treatment of an open lower-extremity fracture. However, in cases of severe open fractures, tourniquet use was associated with increased odds of unplanned reoperation; surgeons should be cautious with regard to tourniquet use in this setting. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of different outcome instruments following foot and ankle trauma.

BACKGROUND: Identifying optimal treatment strategies in patients with traumatic foot and ankle injuries has been hampered by the use of multiple available outcome measures with unproven reliability and validity. This prospective observational study aimed to measure the correlation between six functional outcome measures in patients with traumatic foot and ankle injuries. MATERIALS AND METHODS: Patients 18 years of age or older with a traumatic foot or ankle injury completed the Short Form-12 (SF-12), Short Musculoskeletal Functional Assessment (SMFA), Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM), American Academy of Orthopedic Surgeons (AAOS), Foot and Ankle Questionnaire and American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale at a single followup visit. Raw scores for each of the outcome measures were calculated. Fifty-two patients were enrolled in our study. Pearson correlation coefficients provided measures of correlation. RESULTS: Moderate to strong correlations were found for most pairwise comparisons of raw scores and functional categorical rankings (ρ=|0.5243 to 0.92|, p < 0.002). The strongest correlations were found between the SMFA, FFI, FAAM and AAOS Foot and Ankle Questionnaire. CONCLUSION: High correlations between scores on six commonly used functional outcome instruments suggest it is likely unnecessary to use more than one instrument when examining functional outcome in patients with traumatic foot and ankle injuries. However, inconsistencies between measures in the same patient population suggest a need for further validation and scrutiny.

Design issues in a non-regulatory trial.

Randomized, controlled trials (RCTs) represent the highest level of evidence attainable. Although up to 60% of clinical questions cannot be answered by an RCT, it is still the ideal method of comparing orthopedic implants. The strength of the findings of RCTs is a result of the investigator’s ability to limit bias through careful attention to study design. Bias may be limited through randomization, allocation concealment, and blinding. Unfortunately, RCTs involving different surgical techniques or implants present many challenges that may introduce bias and threaten the validity of study results. The purpose of this review is to outline these issues and present possible solutions to these challenges, with the ultimate goal of improving surgeons’ understanding of how to design and critically appraise RCTs involving orthopedic implants.

Injury in Brazilian Jiu-Jitsu Training.

BACKGROUND: Brazilian jiu-jitsu (BJJ) is a grappling-based martial art that can lead to injuries both in training and in competition. There is a paucity of data regarding injuries sustained while training in BJJ, in both competitive and noncompetitive jiu-jitsu athletes. HYPOTHESIS: We hypothesize that most BJJ practitioners sustain injuries to various body locations while in training and in competition. Our primary objective was to describe injuries sustained while training for BJJ, both in practice and in competition. Our secondary objectives were to classify injury type and to explore participant and injury characteristics associated with wanting to quit jiu-jitsu after injury. STUDY DESIGN: Descriptive epidemiology study. METHODS: We conducted a survey of all BJJ participants at a single club in Hamilton, Ontario, Canada. We developed a questionnaire including questions on demographics, injuries in competition and/or training, treatment received, and whether the participant considered discontinuing BJJ after injury. RESULTS: A total of 70 BJJ athletes participated in this study (response rate, 85%). Ninety-one percent of participants were injured in training and 60% of competitive athletes were injured in competitions. Significantly more injuries were sustained overall for each body region in training in comparison with competition (P < 0.001). Two-thirds of injured participants required medical attention, with 15% requiring surgery. Participants requiring surgical treatment were 6.5 times more likely to consider quitting compared with those requiring other treatments, including no treatment (odds ratio [OR], 6.50; 95% CI, 1.53-27.60). Participants required to take more than 4 months off training were 5.5 times more likely to consider quitting compared with those who took less time off (OR, 5.48; 95% CI, 2.25-13.38). CONCLUSION: The prevalence of injury is very high among BJJ practitioners, with 9 of 10 practitioners sustaining at least 1 injury, commonly during training. Injuries were primarily sprains and strains to fingers, the upper extremity, and neck. Potential participants in BJJ should be informed regarding significant risk of injury and instructed regarding appropriate precautions and safety protocols. CLINICAL RELEVANCE: Clinicians should be aware of the substantial risk of injury among BJJ practitioners and the epidemiology of the injuries as outlined in this article.

Femoral neck shortening after fracture fixation with multiple cancellous screws: incidence and effect on function.

BACKGROUND: Shortening of the femoral neck after fracture fixation with multiple parallel screws decreases the moment arm for the abductor muscles of the hip. This study aimed to assess the incidence of femoral neck shortening quantitatively and qualitatively in patients with femoral neck fractures treated with multiple cannulated screws, and to investigate its influence on functional outcome. METHODS: We conducted an observational study in a consecutive series of 56 patients with united fractures of the femoral neck treated with multiple cancellous screws. The latest anterior-posterior radiograph of the fractured hip was compared with that of the contralateral uninjured hip. After scanning and electronically overlapping those radiographs, femoral neck shortening was assessed. All identified patients were contacted and the Short Form-36 (SF-36) functional outcome questionnaire was administered. RESULTS: The shortening rate was 31% for undisplaced (14 of 45) and 27% for displaced fractures (3 of 11). The average abductor moment arm shortening was 10 +/- 4 mm. The average femur length decrease was 8 +/- 5 mm. In all other patients, abductor moment arm as well as femur length measurements were within 3 mm of the contralateral side and considered not to be shortened. Thirteen patients completed the SF-36 questionnaire (12 of 13 undisplaced fractures; all 13 with good fracture reduction). Patients with shortened fractures (8 of 13) had significantly lower Physical Functioning (p = 0.01) and Role Physical (p = 0.04) SF-36 subscores. CONCLUSIONS: Femoral neck shortening after femoral neck fracture fixation with multiple cancellous screws is common and it has a significant negative impact on physical functioning.

Outside the Bone: What Is Happening Systemically to Influence Fracture Healing?

This article summarizes presentations of a symposium on bone health-related hot topics of the 2016 Basic Science Focus Forum. Taken together, these topics emphasize the critical importance of bone health in fracture management, the systemic factors that influence fracture healing, and the need to focus on issues other than simply the technical aspects of fracture repair.

Factors Associated With Health-Related Quality of Life in Patients With Open Fractures.

OBJECTIVES: To analyze FLOW data to identify baseline patient, injury, fracture, and treatment factors associated with lower health-related quality of life (HRQoL) at 12-month postfracture. DESIGN: Prognostic study using data from a prospective randomized controlled trial. SETTING: Thirty-one clinical centers in the United States, Canada, Australia, and India. PATIENTS/PARTICIPANTS: One thousand four hundred twenty-seven patients with open fracture from the FLOW trial with complete 12-month Short Form-12 (SF-12) follow-up assessment and no missing data for selected baseline factors. INTERVENTION: Not applicable. MAIN OUTCOME MEASUREMENT: Physical Component Score (PCS) and the Mental Component Score (MCS) of the SF-12 at 12-month postfracture. RESULTS: One thousand four hundred twenty-seven patients were included in the SF-12 PCS and MCS linear regression models. Smoking, lower preinjury SF-12 PCS and MCS, and work-related injuries were significantly associated with lower SF-12 PCS and MCS at 12-month postfracture. A lower extremity fracture and a wound that was not closed at initial irrigation and debridement were significantly associated with lower 12-month SF-12 PCS but not MCS. Only the adjusted mean difference for lower extremity fractures approached the minimally important difference for the SF-12 PCS. CONCLUSIONS: We identified a number of statistically significant baseline factors associated with lower HRQoL; however, only the presence of a lower extremity fracture approached clinical significance. More research is needed to quantify the impact of these factors on patients and to determine whether changes to modifiable factors at baseline will lead to clinically significant improvements in HRQoL after open fractures. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Wound Surface Area as a Risk Factor for Flap Complications among Patients with Open Fractures.

BACKGROUND: Soft-tissue complications often dictate the success of limb salvage and the overall outcome of open fractures. Based on prior work at the R Adams Cowley Shock Trauma Center, the authors hypothesize that wounds larger than 200 cm are associated with a greater likelihood of both flap-related reoperation and wound complications among patients requiring soft-tissue reconstruction with a rotational flap or free tissue transfer. METHODS: This study was a secondary analysis of Fluid Lavage in Open Wounds trial data that included all patients who received a rotational or free tissue flap transfer for an open fracture. The primary outcome was flap-related reoperation within 12 months of injury. The secondary outcome was wound complication, which included events treated operatively or nonoperatively. Multivariable logistic regression was used to assess the association between wound size and outcomes, adjusting for confounders. RESULTS: Seventeen percent of the 112 patients required a flap-related reoperation. A wound size greater than 200 cm(2) was not associated with reoperation in an unadjusted model (p = 0.64) or adjusting for Gustilo type (p = 0.70). The sample had an overall wound complication rate of 47.3 percent. Patients with a wound size of greater than 200 cm(2) were three times more likely to experience wound complications (OR, 3.05; 95 percent CI, 1.08 to 8.62; p = 0.04) when adjusting for moderate to severe wound contamination and wound closure in the operating room. CONCLUSION: The findings of this study demonstrate that wound surface area is an integral determinant for wound complication following soft-tissue flap treatment, but found no association between wound surface area and flap-related reoperation rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Predicting and Preventing Loss to Follow-up of Adult Trauma Patients in Randomized Controlled Trials: An Example from the FLOW Trial.

BACKGROUND: High loss-to-follow-up rates are a risk in even the most rigorously designed randomized controlled trials (RCTs). Consequently, predicting and preventing loss to follow-up are important methodological considerations. We hypothesized that certain baseline characteristics are associated with a greater likelihood of patients being lost to follow-up. Our primary objective was to determine which baseline characteristics are associated with loss to follow-up within 12 months after an open fracture in adult patients participating in the Fluid Lavage of Open Wounds (FLOW) trial. We also present strategies to reduce loss to follow-up in trauma trials. METHODS: Data for this study were derived from the FLOW trial, a funded trial in which payments to clinical sites were tied to participant retention. We conducted a binary logistic regression analysis with loss to follow-up as the dependent variable to determine participant characteristics associated with a higher risk of loss to follow-up. RESULTS: Complete data were available for 2,381 of 2,447 participants. One hundred and sixty-three participants (6.7%) were lost to follow-up. Participants who received treatment in the U.S. were more likely to be lost to follow-up than those who received treatment in other countries (odds ratio [OR] = 3.56, 95% confidence interval [CI]: 2.46 to 5.17, p < 0.001). Male sex (OR = 1.75, 95% CI: 1.15 to 2.67, p = 0.009), current smoking (OR = 1.82, 95% CI: 1.28 to 2.58, p = 0.001), high-risk alcohol consumption (OR = 1.88, 95% CI: 1.16 to 3.05, p = 0.010), and an age of <30 years (OR = 2.16, 95% CI: 1.19 to 3.95, p = 0.012) all significantly increased the odds of a patient being lost to follow-up. Conversely, participants who had sustained polytrauma (OR = 0.52, 95% CI: 0.37 to 0.73, p < 0.001) or had a Gustilo-Anderson type-IIIA, B, or C fracture (OR = 0.60, 95% CI: 0.38 to 0.94, p = 0.024) had lower odds of being lost to follow-up. CONCLUSIONS: Using a number of strategies, we were able to reduce the loss-to-follow-up rate to <7%. Males, current smokers, young participants, participants who consumed a high-risk amount of alcohol, and participants in the U.S. were more likely to be lost to follow-up even after these strategies had been employed; therefore, additional strategies should be developed to target these high-risk participants. CLINICAL RELEVANCE: This study highlights an important need to develop additional strategies to minimize loss to follow-up, including targeted participant-retention strategies. Male sex, an age of <30 years, current smoking, high-risk alcohol consumption, and treatment in a developed country with a predominantly privately funded health-care system increased the likelihood of participants being lost to follow-up. Therefore, strategies should be targeted to these participants. Use of the planning and prevention strategies outlined in the current study can minimize loss to follow-up in orthopaedic trials.

Management of displaced ankle fractures.

BACKGROUND: Ankle fractures excluding pilon fractures, account for approximately 9% of all fractures with the majority being OTA type B injuries. Although surgeons generally treat undisplaced or minimally displaced injuries nonoperatively and displaced fractures operatively, opinions diverge regarding the management of those displaced fractures with acceptable closed reduction. There is also debate about the use of biodegradable implants in operatively managed ankle fractures, the type and technique of fixation for operatively treated syndesmotic injuries as well as the approach to postoperative rehabilitation. OBJECTIVE: We aimed to review the highest level of available evidence on the operative management of ankle fractures. We focused specifically on studies comparing (1) nonoperative versus operative management of displaced ankle fractures, (2) biodegradable versus metal implants, (3) syndesmotic fixation, and (4) postoperative rehabilitation protocols.

The epidemiology of metatarsal fractures.

BACKGROUND: Metatarsal fractures are common injuries; however little has been written regarding their epidemiology in an adult population. METHODS: All patients with metatarsal fractures during a 1-year time period were included in the study. Demographic information, grade, and mechanism of injury, associated injuries, and fracture location and type were recorded. RESULTS: Three hundred and fifty-five patients with 411 metatarsal fractures were identified. The average age of the patients was 42 years. There was a higher proportion of women in the higher age groups, and the most common fracture was that of the fifth metatarsal. Multiple metatarsal fractures occurred in contiguous metatarsals, and 63% of third metatarsal fractures were associated with a fracture of either the second or fourth metatarsal. CONCLUSION: Knowledge of the epidemiology and injury patterns of metatarsal fractures can aid in the accurate identification and subsequent treatment of fractures of the metatarsals.

The Use of Combined Magnetic Field Treatment for Fracture Nonunions: A Prospective Observational Study.

This study evaluated the effectiveness and safety of bone growth stimulation using combined magnetic field (CMF) for the treatment of fracture nonunions. In this prospective multicenter study, patients were assessed monthly for 9 mo, or until they demonstrated a healed nonunion, and were assessed at a final follow-up 3 mo after treatment completion. The primary outcome was the presence or absence of fracture healing at the nonunion site, determined by clinical and radiographic assessment. Enrolled in this study were 112 patients with 116 fracture nonunions. Fifty-two (44.8%) patients demonstrated a healed nonunion between treatment initiation and 12-mo- posttreatment initiation (9 mo of treatment plus 3 mo posttreatment follow-up). Tibial nonunions had a higher percentage of healed fractures compared to other fracture types (78% vs. 46.5%, respectively; p = 0.004). This study demonstrated that noninvasive CMF technology healed 78% of tibial fracture nonunions and 45% of all fracture nonunions (p = 0.004). Additionally, pain at rest, with stress, and on weight bearing all decreased following treatment with CMF, with no adverse events reported. These results indicate that CMF is a beneficial noninvasive treatment modality for nonunions.

Patient opinions of screening for intimate partner violence in a fracture clinic setting: P.O.S.I.T.I.V.E.: a multicenter study.

BACKGROUND: Approximately one-third of injured women presenting to fracture clinics have experienced some form of intimate partner violence in the past year. The aim of the current study was to determine patients' perceptions on screening for intimate partner violence during visits to a surgical fracture clinic. METHODS: We conducted a cross-sectional study to evaluate patients' perceptions and opinions on screening for intimate partner violence in an orthopaedic fracture clinic. Eligible patients anonymously completed a self-reported written questionnaire, which included questions on patient demographics, attitudes toward intimate partner violence in general, the acceptability of screening for intimate partner violence in an orthopaedic fracture clinic, and opinions on how, when, and by whom the screening should be conducted. RESULTS: The study included 750 patients (421 male and 329 female) at five clinical sites in Canada and the Netherlands. The majority (554, 73.9%) of the respondents either "agreed" or "strongly agreed" that the fracture clinic was a good place for health-care providers to ask about intimate partner violence. The majority (671, 89.5%) also agreed that health-care providers should screen for intimate partner violence by means of face-to-face interactions rather than other, more passive methods. Increased openness to screening was significantly associated with female sex, higher income, and higher education (F3595 = 21.950, p < 0.001). CONCLUSIONS: Our findings demonstrated that the majority of patients endorse active screening for intimate partner violence in orthopaedic fracture clinics.

Measuring foot and ankle injury outcomes: common scales and checklists.

Functional health outcome measures are increasingly being used in both clinica trials and practice as measures of patient health. Whilst outcome measures can be generic, there are a number of foot and ankle specific measures available and in use. These are being used as not only region specific but also disease specific measures of patient function. Unfortunately not all of these outcome measures have been completely validated which leads to challenges in applying the results of outcomes research to specific patients. Continued work however is being done in this area and these challenges provide opportunities for further investigation into the role of functional outcome scores specific to the foot and ankle.

Selection of outcome measures for patients with hip fracture.

In designing a study protocol relating to hip fracture treatment and outcomes, it is important to select appropriate outcome instruments. Before beginning the process of instrument selection, investigators must gain a comprehensive understanding of the condition of interest and have a thorough knowledge of the expected benefits and harms of the proposed intervention. Adequate evidence of an intervention's effectiveness includes indication of impact on the patient's health. We provide a brief discussion about different ways that health and health measurement have been defined, including the International Classification of Function, Disability and Health (ICF), health-related quality of life (HRQOL), and cost-to-benefit analyses. We outline important properties (reliability, validity, sensitivity to change, and responsiveness) that a measurement instrument must demonstrate before being considered an acceptable means to measure outcome. Potential outcome measures relevant to patients with hip fracture are summarized, and important points to consider in the selection of outcome measures for a hypothetical research question in a hip fracture population are discussed.