OTA Annual Meeting Roundup

Foot and Ankle

In the field of foot and ankle trauma the idea of aspirating the haematoma from the injured ankle joint to provide pain relief in acute ankle fractures was investigated in a randomised controlled trial of 109 patients. Sadly, despite a novel approach, the investigators from Rochester (USA) found no benefit in terms of pain scores or opioid use.³ In a similarly designed study aimed at evaluating the administration of a popliteal block for pain control in ankle fracture surgery, the investigators reported a significantly reduced level of 'rebound pain' and of the need for oral opioid analgesia compared with single-shot regional anaesthetic after operatively treated ankle fractures over a 72-hour period.⁴ Further discussion time in the session was given to the question of open versus closed reduction of the syndesmosis with the conclusion that an open anatomic repair of the syndesmosis results in better radiographic outcomes compared with percutaneous screw fixation.⁵

Dan Deakin (Nottingham, UK) and Tim White (Edinburgh, UK) presented work around the idea of early fixation of pilon fractures, championed in Vancouver (Canada).^6,7 Both papers concluded that acute fixation is safe in the majority of cases when performed by experts. It is fair to say that the approach has still not gained any wider support in the trauma community despite some evidence from interested surgeons to support it.

Hip and Femur

The concept of augmenting established ununited diaphyseal fractures with additional lag screws or plates around the old nail, rather than exchanging the nail, was visited. This is an idea that was recently advanced in the UK by Bob Handley, among others, and takes the view that in cases where the fracture requires additional stability, this can be achieved with placement of one or more lag screws. The old nail remains in place and will therefore continue to provide neutralisation. In an interesting paper from Beijing (China) the authors experienced a cohort of 83 patients showing no difference between augmented fixation and exchange nailing.⁸

Chris Moran from Nottingham (UK) presented an approach to improving population-based care for hip fractures.⁹ Clearly there have been huge advances made in care, which may be impossible for any other system (such as that in the USA, without a nationalised healthcare scheme with one provider for acute care) to reproduce due to the inherent lack of integrated health care. Similar differences are likely to emerge in trauma care where the UK has taken the USA trauma system and been able to improve it through a nationwide approach and organisation, something with which the USA is currently struggling, with a disordered proliferation of major trauma centres.

The question of CT scanning acetabular fractures following fixation for quality control was investigated, something for which there is widespread variation across the world and within the UK.¹⁰ The paper from Cincinnati (USA) concluded that one in 40 patients would benefit from routine scanning – perhaps given the high dose of radiation to relatively young patients, this is something that should be reserved for patients when there is a clinical need.

Upper extremity trauma

The Edinburgh (UK) group presented their large series of non-operatively treated radial head fractures where the data would suggest that the conservative management of these injuries is a reliable treatment option, yielding an excellent or good long-term result in the majority of cases.¹¹ Despite a small number of patients reporting persistent pain and stiffness, patient satisfaction is high, the need for secondary intervention is negligible, and patients routinely return early to work and sports.

Knee and Tibia

Following the current trend for suprapatellar nail insertion, researchers in Tampa (USA) reported their experiences in a small randomised study of the suprapatellar nail approach to the tibia.¹² This is a technique used frequently in some centres, but is not yet widespread – with cited advantages of lower rates of anterior knee pain and easier reduction of proximal fractures but potentially at the cost of entering the knee, opinion is somewhat split. The authors concluded that in their study, at least, there are no significant differences in pain, disability, or knee range of motion between these two tibial intramedullary nailing techniques after 12 months of follow-up. The suprapatellar approach can be performed safely with comparable clinical and functional outcomes to the infrapatellar method.

The immediate administration of antibiotics in open fractures was also considered in a paper from Charlotte (USA).¹³ The authors were able to conclude in their study that the time from injury to antibiotics and to wound coverage independently predict infection of type III open tibial fractures. Both should be achieved as early as possible, with coverage being dependent on the condition of the wound. Given the relatively short therapeutic window for antibiotic prophylaxis (within an hour of injury), pre-hospital antibiotics may substantially improve outcomes for severe open fractures. There is a realistic possibility that such a move could occur in the UK, just as care-changing interventions such as the use of binders and TXA in the field have already been implemented. The OTA again provided a wealth of early information, dialogue and food for thought aimed at informing and engaging those involved in trauma care at every level.