Informed consent is vital for good patient-surgeon communication. It allows the patient to be given an unbiased and accurate view of the procedure as well giving an opportunity for patients to gain trust in their surgical team. The consent form is written evidence of this discussion and a poor consent form implies a sub-standard consenting process. The General Medical Council (GMC) have issued guidelines for consent in surgical procedures. These state that all common risks and rare but serious risks should be disclosed as well as all information being given in clear simple and consistent language.

Currently, the consent form for a hip fracture operation is hand written. Our hypothesis was that the quality of consenting is variable and that many important complications may not be identified.

The British Orthopaedic Association (BOA) blue book, ‘The care of patients with fragility fractures,’ has given guidance of common and serious complications associated with operative management of hip fractures. In addition to these procedure specific complications, we have identified general complications from standardised joint arthroplasty consent forms in our trust, such as deep vein thrombosis. Our standards based on GMC guidance are that the consent form should be legible, free from jargon, without abbreviations and should include the specific and general complications.

We retrospectively identified and analysed 30 consecutive consent forms of patients that underwent operative management for hip fractures between March and April 2011. Of all consent forms, 59% were completely or partly illegible, 77% had used abbreviations and medical jargon. Inclusion of general complications on the consent form varied; infection 100%, bleeding 100%, deep vein thrombosis 82%, MI 18%, pneumonia 12%, death 12% and haematoma 0%. Specific operative complications were poorly included, with no patients undergoing hemiarthroplasty being advised of the risk of prosthetic loosening, acetabular wear or periprosthetic fractures. For consent of patients undergoing fracture fixation, 67% had been informed of re-operation and 40% had been told of non-union.

This data shows that consent forms are generally poorly written and subject to great variation in complications for the same surgical procedure. This data is likely to apply to some extent to all hospitals that use blank consent forms. This has implications for patient care and safety, as well as medicolegal implications for medical professionals. In our hospital, consent forms have been standardised for joint arthroplasty, with all complication pre-printed with plain English explanations below. Our proposal is that all common operations should have pre-printed consent forms. This would standardise consenting and provide a much improved documentary evidence of the consenting process.

This data has a number of lessons that can be applied to other hospitals. Firstly, we suggest that other hospitals consider standardised consent forms. Secondly, individual trainees should be clear that consent forms remain the documentary evidence of the consenting process, long after you forget the verbal details and you should ensure that you include all complications, write clearly and without jargon or abbreviations.

The aims of this study were (1) to assess whether rotational stability testing in Gartland III supracondylar fractures can be used intra-operatively in order to assess fracture stability following fixation with lateral-entry wires and (2) to quantify the incidence of rotational instability following lateral-entry wire fixation in Gartland type III supracondylar humeral fractures in children.

Twenty-one consecutive patients admitted with Grade III supracondylar fractures at the Children's Hospital at Westmead were surgically treated according to a predetermined protocol. Following closed fracture reduction, 2 lateral-entry wires were inserted under radiographic control. Stability was then assessed by comparing lateral x-ray images in internal and external rotation. If the fracture was found to be rotationally unstable by the operating surgeon, a third lateral-entry wire was inserted and images repeated. A medial wire was used only if instability was demonstrated after the insertion of three lateral wires.

Rotational stability was achieved with two lateral-entry wires in 6 cases, three lateral-entry wires in 10 cases and with an additional medial wire in 5 cases. Our results were compared to a control group of 24 patients treated at our hospital prior to introduction of this protocol. No patients returned to theatre following introduction of our protocol as opposed to 6 patients in the control group. On analysis of radiographs, the protocol resulted in significantly less fracture position loss as evidenced by change in Baumann's angle (p<0.05) and lateral rotational percentage (p<0.05).

We conclude that the introduction of rotational stability testing allows intra-operative assessment of fracture fixation. Supracondylar fractures that are rotationally stable intra-operatively following wire fixation are unlikely to displace post-operatively. Only a small proportion (26%) of these fractures were rotationally stable with 2 lateral-entry wires. This may be a reflection of either the fracture configuration or inability to adequately engage the medial column.