Regional anaesthesia is integral to best practice analgesia for patients with neck of femur fractures (NOFFs). These patients are generally frail and are vulnerable to side effects of opioid analgesia. Femoral nerve block (FNB) or fascia-iliaca block (FIB) can reduce opioid requirement. Literature supports good efficacy for extra-capsular NOFFs however it is acknowledged to be suboptimal for intracapsular fractures.

We present a novel technique, using point of care ultrasound guidance to perform hip ultrasound guided haematoma (HUSH) aspiration, and injection of local anaesthetic (block) for intracapsular NOFFs.

This a case control series. A consecutive series of cognitively intact patients, with an isolated intra-capsular NOFF, received a HUSH block using 10mls of 0.75% Ropivicaine. Haematoma was aspirated and volume recorded. This was performed in addition to standard NOFF pathway analgesia that includes a FIB and multimodal analgesia including opioids. Visual Analogue Scale (VAS)pain scores at rest and on movement were recorded pre and post procedure as well as combined morphine equivalent units administered post HUSH block. The control arm was a retrospective group of similar patients who followed the routine care pathway including a FIB. VAS pain scores from observation charts and usage of morphine equivalent units were calculated.

Ten patients consented to receive HUSH blocks and we included thirty-eight patients in our control series. The HUSH block group showed mean VAS pain score of 4.2/10 at rest and 8.6 on movement prior to block. In the time after the block, VAS pain scores reduced to 1.5 at rest (p=0.007) and 3.1 on movement (p=0.0001) with a mean total morphine equivalent use of 8.75mg. This is significantly different from the control group's mean VAS pain at rest score 6.9 (p=0.0001) and 24.1mg total morphine equivalent (p=0.07).

HUSH Block in addition to fascia iliaca block appears to significantly better pain relief in intracapsular neck of femur fracture patients when compared to fascia iliaca block alone. We believe it is relatively easy to perform with readily available ultrasound scanners in emergency departments.

Objective: Appendicular soft tissue tumours are rare. They represent less than 1% of all malignancy in Ireland. Consequently they are considered to difficult to diagnose and often require several opinions and investigations before a definitive diagnosis is arrived at. Mistakes in this process have been documented to result in the unnecessary loss of limb and life. The Bone and Soft Tissue Service in Cappagh National Orthopaedic Hospital treats a significant proportion of the tertiary referrals in this field. We looked at the referrals to the service of a newly appointed surgeon with an interest in this field.

Method: We prospectively reviewed the charts of all patients (26) with a soft tissue tumour referred to the senior author in his first year of practice and excluded all patients (1) who had an established and treatment instigated by an Orthopaedic Tumour specialist. Where information was not available in the chart the patients GP was contacted for further information.

Results: The most common presenting complaint was swelling (100%), only 3(12%) of the patients complained of pain. The mean time between observation of symptoms and seeking medical advice was 5.2 months (range 3–12 months). All the patients first sought attention from a GP. The mean number of doctors seen prior to presentation was 2 (range 1–4). 21 (84%) patients presented with MRI imaging.8 out of 20 (40%) secondary referrals had histological diagnosis on presentation however 3 of these were incidental findings from surgery performed without malignancy suspicion. Therefore only 5 out of 17 (29%) referrals for management of suspected malignancy had undergone biopsy at the referring institution. A mosaic of histological diagnoses was found, in proportion to previous epidemiological studies. 21 (84%) of the patients went on to have excisional surgery, one had amputation.

Conclusion: Although 40% of secondary referrals had undergone invasive procedures prior to presentation, only 29% had undergone intentional biopsy with a pre-operative suspicion for neoplasia. A pre biopsy referral rate of 71% compares favourably with published international rates. These tumours are rare and benign masses are 150 times more common however we must remain vigilant and consultation with a Tumour service should precede any invasive procedure whenever there is an element of doubt.