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Dupuytren's disease continues to present many challenges for the surgeon. A variety of surgical approaches and their variations have been described in the literature, further complicated by the degree of skin shortage and/or the need for local flap procedures or a full thickness skin graft. In the face of all these decisions - none of which is supported by Level 1 evidence - it can be very difficult to plan the best incision(s). We describe a safe and reproducible technique to plan fasciectomy incisions in primary or recurrent Dupuytren's disease. Our short communication and accompanying artwork demonstrates the anatomical landmarks and a simple decision-making algorithm based on just 3 key stages: (1) Proximal incision planning and execution of the palmar release(s); (2) Extension distally into the digit(s) based on the tissue quality, with either with zigzag (Brunner's) or a midline longitudinal (McIndoe) incision(s); (3) Flap assisted closure or coverage with a full thickness skin graft where required.
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Introduction British Orthopaedic Association Standards for Trauma (BOAST) guidelines state that a radiograph of the wrist at the time of removal of immobilisation is not required in conservatively managed distal radius fracture (DRF) patients unless there is clinical cause for concern. The aim of this pilot audit was to investigate local compliance with these guidelines. Materials and methods The first cycle of a retrospective audit was performed on conservatively managed DRF patients presenting between August and October 2021. An intervention was introduced in the form of education to highlight current guidelines. A second cycle was then performed prospectively on patients presenting between February and April 2022. Data was analysed to assess whether radiographs were taken at the time of cast removal, if the indication for the radiograph was documented and whether it affected the management plan. Results In the first cycle, 20 of 46 patients (43.5%) had repeat radiographs at the time of cast removal compared to 12 of 41 patients (29.3%) in the second cycle (p=0.170). None of the first-cycle patients had any documentation on the indication for radiograph at the time of cast removal and none of the radiographs altered the management plan. In the second cycle documentation on the indication for the radiograph was present for seven of the 12 radiographs and two altered the management plan. Conclusion Through education on adherence to national guidelines, the number of radiographs in patients with conservatively managed DRFs was reduced.
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A 67-year-old woman underwent a routine and uneventful elective total knee arthroplasty for osteoarthritis at our centre. No intraoperative nor immediate postoperative complications were noted clinically nor radiologically. At 5 weeks postoperative, she began to notice some new discomfort in her upper calf area, with no preceding history of trauma. A Doppler ultrasound scan ruled out a deep vein thrombus. Only on further re-imaging of her knee with X-rays and CT was there shown to be a fibular fracture of the proximal third with evidence of callus formation. The pain arising from her stress fracture delayed her rehabilitation slightly, going on to require a successful manipulation under anaesthetic (0°-95°). She went on to have excellent function in her knee and the pain from the stress fracture had settled by 5 months.