Aims. Although readmission has historically been of primary interest, emergency department (ED) visits are increasingly a point of focus and can serve as a potentially unnecessary gateway to readmission. This study aims to analyze the difference between primary and revision total joint arthroplasty (TJA) cases in terms of the rate and reasons associated with 90-day ED visits. Methods. We retrospectively reviewed all patients who underwent TJA from 2011 to 2021 at a single, large, tertiary urban institution. Patients were separated into two cohorts based on whether they underwent primary or revision TJA (rTJA). Outcomes of interest included ED visit within 90-days of surgery, as well as reasons for ED visit and readmission rate. Multivariable logistic regressions were performed to compare the two groups while accounting for all statistically significant demographic variables. Results. Overall, 28,033 patients were included, of whom 24,930 (89%) underwent primary and 3,103 (11%) underwent rTJA. The overall rate of 90-day ED visits was significantly lower for patients who underwent primary TJA in comparison to those who underwent rTJA (3.9% vs 7.0%; p < 0.001). Among those who presented to the ED, the readmission rate was statistically lower for patients who underwent primary TJA compared to rTJA (23.5% vs 32.1%; p < 0.001). Conclusion. ED visits present a significant burden to the healthcare system. Patients who undergo rTJA are more likely to present to the ED within 90 days following surgery compared to primary TJA patients. However, among patients in both cohorts who visited the ED, three-quarters did not require readmission. Future efforts should aim to develop cost-effective and patient-centred interventions that can aid in reducing preventable ED visits following TJA. Cite this article: Bone Jt Open 2022;3(7):543–548

Purpose and background. Although clinical guidelines recommend that low back pain (LBP) is best managed in primary or community care, in the UK and globally, LBP accounts for around 4% of emergency department (ED) attendances. Organising and delivering healthcare to be safe, effective, and acceptable requires hearing patients’ perspectives; this study therefore aimed to explore patients’ experiences of attending the ED for LBP. Methods and results. This was a multisite qualitative interview study with 47 adults (aged 23–79 years) who, in the past six weeks, had attended one of four UK NHS emergency departments for LBP (all types and durations). Purposive sampling was used to gain variation in the recruiting site, and LBP and demographic characteristics. Data were collected using individual, semi-structured, telephone interviews (median 45mins). Interviews were audio-recorded, transcribed verbatim, and analysed thematically. We identified significant variation in patients’ experiences of ED care for LBP, which we argue reflects contrasting cultures of ED care. We present three cultures, emergency screening only, ‘cynicism and neglect’, and ‘kindness’; these cultures differ in how they navigate the tension between the ED remit and patients’ perceived needs of care. We draw on Bourdieu's notions of field and habitus and professional identity theory to help explain these findings. Conclusion. Our findings suggest unwarranted variation in ED care for LBP. Implications include the need for urgent access to primary and community care and clarity about best practice managing LBP in the ED; best practice guidance and strategies to implement this should be informed by notions of culture and professional identity. No conflicts of interest.  . Sources of funding. Health Education England & National Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Purpose. This study evaluated the acceptability of performing manipulations with intranasal diamorphine and inhaled Entonox to parents of children presenting to our Emergency Department. Method. 65 fractures were manipulated in the Emergency Department in a 4-month timespan. Parents were invited to complete a questionnaire to indicate their experience with the procedure. Fracture position post-reduction was calculated as well as conversion rate to surgery. 32 patients who were admitted and had their forearm fractures managed in theatre were also asked to complete the questionnaire as a comparison group. Results. Overall response rate was 82% . 100% of parents of children who had a manipulation in the emergency department would recommend the treatment to parents of children with similar injuries. Relative risk of perceived distress to parents was 2.42 (0.8–7.2) with manipulation in the emergency department compared to theatre management. Relative risk of distress to the child was 1.45 (0.7–3.3) with manipulation in the emergency department compared to theatre management. This was not statistically significant. Mean (S.D.) fracture displacement was 29.2 (13.0)° pre reduction and 5.8 (5.9)° post reduction. Mean (S.D.) length of stay was 5.5 (3.2) hours from time of injury to discharge for patients receiving manipulation in the Emergency Department and 27.9 (14.3) hours for patients receiving procedures in theatre (p< 0.001). Overall, parents and children were satisfied about manipulations in the Emergency Department. Operative re-intervention rate was 2% when protocol violations were excluded. Reduction was as effective as previous reports and within acceptable treatment limits. Conclusion. Manipulation of paediatric forearm fracture is an effective and acceptable technique when performed with a diamorphine and Entonox protocol

Glenohumeral dislocation is complicated with a greater tuberosity fracture in 16% of cases. Debate regarding the safety of closed reduction in the emergency department exists, with concerns over fracture propagation during the reduction manoeuvre. The study aim was to report the results of closed reduction, identify complications and define outcome for these injuries. 188 consecutive glenohumeral dislocations with a tuberosity fracture were identified from a prospective database from 2014–2017. 182 had an attempted closed reduction under appropriate sedation using standard techniques, five were manipulated in theatre due to contra-indications to sedation. Clinical, radiographic and patient reported outcomes, in the form of the QuickDASH and Oxford Shoulder Score (OSS), were collected. A closed reduction in the emergency department was successful in 162 (86%) patients. Two iatrogenic fractures of the proximal humerus occurred, one in the emergency department and one in theatre, representing a 1% risk. 35 (19%) of patients presented with a nerve lesion due to dislocation. Surgery was performed in 19 (10%) cases for persistent or early displacement (< 2 weeks) of the greater tuberosity fragment. Surgery resulted in QuickDASH and OSS scores comparable to those patients in whom the tuberosity healed spontaneously in an anatomical position (p=0.13). 18 patients developed adhesive capsulitis (10%). Glenohumeral dislocation with greater tuberosity fracture can be safely treated by closed reduction within the emergency department with a low risk of humeral neck fracture. Persistent or early displacement of the tuberosity fragment will occur in 10% of cases and is an indication for surgery

Introduction: Limp in a child is a common presentation to the emergency department. Most patients have no serious pathology. However, it is important not to miss specific problems and delay treatment. We therefore established a limping child protocol in conjunction with the emergency department, which was implemented in 2003. We aimed to assess our performance against agreed standards; 100% investigated as per protocol, and 100% admitted or seen in the next fracture clinic. Methods: We examined all emergency department case notes of children aged less than 14 years old who presented with a lower limb problem over a 1 year period. Patients diagnosed as having soft tissue injuries or fractures were excluded. We were left with 58 patients. Information concerning investigations and disposal from the emergency department was sought from the case notes and the hospital computer system. Results: Average age was 5.1 years. The protocol was followed correctly in only 21% of cases. 33% were followed-up incorrectly, and 22% received no documented follow-up. Discussion: There was poor compliance in the emergency department. Incomplete investigations, follow-up and documentation were the main problems. Up to one quarter of serious pathology may have been missed. We attribute these problems to high staff turn over and poor awareness of the protocol. We have introduced changes to improve our performance

Aims. To determine the role of early MRI in the management of suspected scaphoid fractures. Methods. A total of 337 consecutive patients presenting to an emergency department (ED) following wrist trauma over a 12-month period were prospectively included in this service evaluation project. MRI was not required in 62 patients with clear diagnoses, and 17 patients were not managed as per pathway, leaving a total of 258 patients with normal scaphoid series radiographs who were then referred directly from ED for an acute wrist MRI scan. Patient demographics, clinical details, outcomes, and complications were recorded at a minimum of a year following injury. Results. The median time from injury to ED presentation was one day and the median number of positive clinical signs was two out of three (snuffbox tenderness, tubercle tenderness, pain on telescoping). Of 258 patients referred for acute MRI, 208 scans were performed as 50 patients either did not tolerate (five patients) or did not attend their scan (45 patients). MRI scans demonstrated scaphoid fracture (13%), fracture of another bone (22%), scaphoid contusion (6%), other contusion/ligamentous injury (20%), or solely degenerative pathology (10%). Only 29% of scans showed no abnormality. Almost 50% of those undergoing MRI (100 patients) were discharged by ED with advice, with only one re-presentation. Of the 27 undisplaced occult scaphoid fractures, despite prompt cast immobilization, two experienced delayed union which was successfully treated with surgery. Conclusion. The use of MRI direct from ED enables prompt diagnosis and the early discharge of a large proportion of patients with normal radiographs following wrist trauma. Cite this article: Bone Jt Open 2021;2(6):447–453

Aims. To assess the impact of the declaration of the state of emergency due to the COVID-19 pandemic on the number of visits to a traumatology emergency department (ED), and on their severity. Methods. Retrospective observational study. All visits to a traumatology ED were recorded, except for consultations for genitourinary, ocular and abdominal trauma and other ailments that did not have a musculoskeletal aetiology. Visit data were collected from March 14 to April 13 2020, and were subsequently compared with the visits recorded during the same periods in the previous two years. Results. The number of visits dropped from a mean of 3,212 in 2018 to 2019 to 445 in 2020. Triage 1 to 3 level visits rose from 21.6% in 2018 to 2019% to 40.4% in 2020, meaning a reduction in minor injury visits and an increase in major ones. There was a relative reduction of 13.2% in femoral fractures in the elderly. The rate of justified visits rose from 22.3% to 48.1%. Conclusion. A marked drop in the total number of visits to our traumatology ED was observed, as well as a relative increase in major injury visits and a relative fall in the minor ones. Cite this article: Bone Joint Open 2020;1-10:617–620

Introduction: Acute elbow trauma is commonly seen in the emergency department. The purpose of the present study was to evaluate in our emergency department the assessment of elbow trauma radiographs in children. Methods: 136 patients aged between 0 and 16 presented at our institution for an elbow trauma over a 6 months period. All the radiographs were digitalised and stored in a commercially available computerised X ray system. All the radiographs were reviewed at the daily clinical radiological conference by an orthopaedic surgeon and a radiologist. Results: There were 64 fractures, 2 dislocations, 37 radial head subluxations and 33 simple contusions. Of these, 15 (11 per cent) were considered to have been misinterpreted. There were 12 undisplaced fractures (5 supra-condylar fractures, 3 radial head fractures, one fracture of the lateral condyle, 3 fractures of the olecranon and 3 false-positive diagnoses of fractures. All patients were reviewed within a few days and were correctly reassessed and treated. Conclusions: Compared to other fractures, children’s elbow trauma are commonly misdiagnosed in the emergency department. In this short series, correct diagnosis was missed 15 times (11%) by various physicians working in the Emergency Department (trainees, emergency physicians). The senior specialists (orthopaedic surgeon and radiologist) used real time digital contrast enhancement, as well as magnification and soft tissue assessment with the digitizer to correctly analyse the missed diagnosis. X ray review by senior specialists at the daily clinical radiological conference is time consuming and sometimes difficult but appears to be clearly beneficial to patients ‘care

We present a complete audit cycle of Emergency Department (ED) management of paediatric buckle fractures of the distal radius at Derriford Hospital. Local hospital management guidelines state that the limb should be supported in a wrist splint for 3 weeks following injury and, provided parents are adequately educated, no formal follow-up is required. Auditable standards were obtained from the local guidance. An initial audit cycle of 54 cases identified shortcomings in compliance with guidelines. These included: Inappropriate immobilisation in 34 (63%) cases, omission of written advice in 35 (65%) cases and arrangement of unnecessary follow-up in 31 (57%) cases. Following circulation of the results, ‘aide-memoir’ icons were added to the emergency department computer coding system, teaching sessions for emergency department staff were organised and new paediatric specific wrist splints were introduced. A re-audit of 33 patients evaluated the effect of the changes. This demonstrated a 27% improvement in correct wrist support usage (27/33, 82%) and 25% fewer unnecessary referrals to fracture clinic (27/33, 82%). Staff training and provision of appropriate wrist splints were crucial to improving the adherence to guidance. This resulted in standardisation of care, fewer unnecessary appointments for patients and cost savings to the hospital trust

Purpose and background. Cauda equina syndrome (CES) leads to nerve compression in the lumbar spine, and requires immediate treatment to prevent permanent neurological dysfunction, including urinary/anorectal incontinence. The consequences for the patient are significant as, in the decade to 2018, CES has cost the NHS £186,134,049. No study has reported patients’ experiences of being managed with suspected CES in an emergency department (ED), and this study explores patients’ experiences and how the NHS can optimise care for patients experiencing this condition. Methods and Results. In this qualitative secondary analysis, 14 participants (aged 23–63 years) with suspected CES were purposively sampled from 4 EDs in England. Online, semi-structed interviews were undertaken (in 2021, during the pandemic), and were audio-recorded and transcribed verbatim. Data were managed using a Framework approach and analysed thematically. Three themes were identified: quality of care; environmental factors; and expectations. The quality of care included managing uncertainty, the importance of communication, appropriate assessment and follow-up care. Environmental factors, including the chairs, waiting times and the busy nature of the ED, negatively impacted patients’ experiences. Furthermore, an expectation gap was identified, as most individuals came to the ED expecting to receive a scan, an accurate diagnosis and a cure. Despite frustrations, patients expressed gratitude towards the ED staff. Conclusion. This study highlights the importance of empathically acknowledging the patient's pain and providing comprehensive assessments and management plans for people attending ED with suspected CES. Optimising the ED environment to minimise patients’ pain and distress while waiting to access care is paramount and overdue. No conflicts of interest.  . Sources of funding. Funding for primary data: Health Education England & National Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Australian Football (AF) is a popular sport in Australia, with females now representing one-third of participants. Despite this, the injury profiles of females versus males in largely unknown. The current study investigated fractures, dislocations and tendon ruptures in females versus males presenting to emergency departments (ED) with an AF injury. All patients, regardless of age, presenting to one of 10 EDs in Victoria, Australia, with an AF injury were included. Data were prospectively collected over a 10-month period, coinciding with a complete AF season. Data were extracted from patient medical records regarding injury-type, body-part injured and treatments required. Female and male data were compared with chi-squared tests. Of the 1635 patients presenting with an AF injury, 595 (36.0%) had a fracture, dislocation or tendon rupture, of whom 85 (14.3%) were female and the average age was 20.5 years (SD 8.0). Fractures accounted for most injuries (n=478, 80.3% of patients had a fracture), followed by dislocations (n=118, 19.8%) and tendon ruptures (n=14, 2.4%). Upper limb fractures were more common than lower limb fractures (71.1% v 11.5% of fractures). Females were more likely to fracture their hands or fingers than males (45.7% v 34.3%). Males were more likely to fracture ribs (5.4% v 0%). Most fractures (91.2%) were managed in the ED, with the remainder being admitted for surgery (GAMP/ORIF). Males were more likely to be admitted for surgery than females (11.2% v 5.9%). Regarding dislocations (n=118), females were more likely to dislocate the patella (36.8% v 8.1% of dislocations). Only males sustained a tendon rupture (n=14): finger extensor or flexor (57.1%), achilles tendon (28.6%) and patella tendon (14.3%). Orthopaedic AF injuries are common presentations to EDs in Victoria, though few require specialist orthopaedic intervention. Injury profiles differed between genders suggesting that gender specific injury prevention and management might be required

Introduction and Objective. The coronavirus (Covid-19) pandemic, first identified in China in December 2019, halted daily living with mandatory lockdowns imposed in Israel in March 2020. This halt induced a sedentary lifestyle for most citizens as well as a decreased physical activity time. These are both common risk factors for the development of low back pain (LBP) which is considered a major global medical and economical challenge effecting almost 1 in 3 people and a leading cause of Emergency Department (ED) visits. It is hypothesized that prevalence of minor LBP episodes during the first total lockdown should have increased compared to previous times. However, due to “Covid-19 fear” we expect a decrease in ED visits. We also speculate that rate of visits due to serious spinal illness (causing either immediate hospitalization or spinal surgery within 30-days of presentation) did not change. Materials and Methods. Retrospective study based on patients visiting the ED in Tel Aviv Sourasky Medical Center During the first pandemic stage in 2020 compared to parallel periods in 2018 and 2019 due to LBP. Results. During the first lockdown period on March 11th-April 21st, only 171 patients attended the ED due to non-traumatic LBP compared to more than 330 patients in the corresponding time during the years 2018 and 2019. This represents a statistically significant drop of 52.5% (p-value < 0.01) and 48.7% (p-value < 0.01) in LBP ED visits during the first pandemic lockdown of 2020 compared to 2019 and 2018, respectively. Additionally, there was no significant drop in immediate hospitalization or spine surgeries within 30 days following the ED visit (p-value >0.10 for all analysis types). Conclusions. “Covid-19 fear” was probably the main reason for patients with an LBP episode to stay at home during the Covid-19 massive outbreak. Since no significant change was shown in the more severe cases, it seems that the minor LBP patients were able to contain the episode outside hospital walls. This presents an opportunity for clinicians and policy decisions makers to learn and find ways to improve our care of back pain in the community and to reduce unnecessary burden on EDs and the healthcare system

Canada is second only to the United States worldwide in the number of opioid prescriptions per capita. Despite this, little is known about prescription patterns for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to detail preoperative opioid use patterns and investigate the effect it has on perioperative quality outcomes in patients undergoing elective total hip and total knee arthroplasty surgery (THA and TKA). The study cohort was constructed from hospital Discharge Abstract Data (DAD) and National Ambulatory Care Reporting System (NACRS) data, using Canadian Classification of Health Intervention codes to select all primary THA and TKA procedures from 2017-2020 in Nova Scotia. Opioid use was defined as any prescription filled at discharge as identified in the Nova Scotia Drug Information System (DIS). Emergency Department (ED) and Family Doctor (FD) visits for pain were ascertained from Physician Claims data. Multivariate logistic regression was used to test for associations controlling for confounders. Chi-squared statistics at 95% confidence level used to test for statistical significance. In total, 14,819 TJA patients were analysed and 4306 patients (29.0%) had at least one opioid prescription in the year prior to surgery. Overall, there was no significant difference noted in preoperative opiate use between patients undergoing TKA vs THA (28.8% vs 29.4%). During the period 2017-2019 we observed a declining year-on-year trend in preoperative opiate use. Interestingly, this trend failed to continue into 2020, where preoperative opiate use was observed to increase by 15% and exceeded 2017 levels. Within the first 90 days of discharge, 22.9% of TKA and 20.9% of THA patients presented to the ED or their FD with pain related issues. Preoperative opiate use was found to be a statistically significant predictor for these presentations (TKA: odds ratio [OR], 1.45; 95% confidence interval [CI], 1.29 to 1.62; THA: OR, 1.46; 95% CI, 1.28 to 1.65). Preoperative opioid consumption in TJA remains high, and is independently associated with a higher risk of 90 day return to the FD or ED. The widespread dissemination of opioid reduction strategies introduced during the middle of the last decade may have reduced preoperative opiate utilisation. Access barriers and practice changes due to the COVID-19 pandemic may now have annulled this effect

Purpose and background. Cauda Equina Syndrome (CES), a rare (<1 per 100,000) and potentially devasting condition, involves compression of the lumbosacral nerve roots. If not quickly identified and treated, it can lead to lasting disability, and high medicolegal costs (>£186 million in the decade to 2018). This study identified why people with suspected CES attend the emergency department (ED) and explored any delays in attending. Methods and Results. The design was a secondary analysis of a qualitative dataset comprising patients with back pain who attended the ED, undertaken using an interpretivist approach. Fourteen patients (8M:6F, aged 23–63 years) with suspected CES were purposively sampled from 4 EDs (2 Northern and 2 Southern) in England between August and December 2021. Semi-structured interviews were conducted online, audio-recorded, transcribed verbatim and analysed thematically. Acopia with pain was the biggest factor in a participant's decision to attend the ED, along with the need for a diagnosis. This pain was the worst ever experienced and debilitating, leaving people unable to cope and desperate for relief. 12/14 were advised to attend the ED following identification of red flags by: GPs (n=9); physiotherapists (n=2); surgical colleague (n=1); and 111 (n=1). Factors such as guilt, previous experience of being disregarded, and symptom misattribution were seen to cause delays in seeking care. Conclusion. This paper revealed a disconnect between the priorities of patients and clinicians prior to attending the ED. Clinicians need to validate the pain experience, communicate clearly why signs and symptoms are concerning, and convey the urgency and potential impact of CES. Conflicts of interest. None. Sources of funding. Funding for primary data: Health Education England & National. Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Purpose and background. Low back pain (LBP), a leading cause of chronic disability, is associated with high and disproportionate socioeconomic costs. Clinical assessment and triage via the NHS 111 service aims to reduce pressure on the urgent and emergency care system. Studies show that many attend the emergency department (ED) against advice, when they could be better managed elsewhere. The aim of this research was to explore how patients with LBP perceive and interact with NHS 111, and how this may have influenced their decision to attend ED. Methods and Results. This was a secondary analysis of a cross-sectional, qualitative dataset of 47 patients (26M:21F, aged 23–79 years) purposively sampled with LBP, who attended 1 of 4 EDs in the UK in 2021, (during the pandemic). The participants took part in online, semi-structured interviews, mean duration 45-minutes (range 23–156 minutes), within six weeks of their ED visit. The interviews were audio-recorded, transcribed verbatim and thematically analysed. Three key themes were identified: purpose, process and performance. The themes showed mixed understanding and low awareness of the purpose of NHS 111, despite its strong triage role. Long waits for call backs however, sometimes resulted in patients attending ED, along with previous negative perspectives and experiences. Conclusion. This research suggests enhanced visibility and knowledge of NHS 111 would increase its use by people with LBP. Further exploration comparing outcomes of callers to NHS 111 with those who seek care elsewhere, could help evaluate how NHS 111 can best help people with LBP and prevent unnecessary ED attendance. No conflicts of interest.  . Sources of funding. Funding for primary data: Health Education England & National Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Introduction. Emergency department (ED) visits following primary total knee arthroplasty (TKA) can lead to poor patient satisfaction, potentially unnecessary readmissions, and greater overall healthcare costs. Reasons for post-operative ED visits are often entirely medical in nature and can be independent of the recent operation. Several strategies have been developed to help reduce ED visits. However, one major factor that can play a critical role in addressing potentially avoidable visits is provider and patient education. A major factor that can play a crucial role in addressing potentially avoidable visits is provider and patient education. It follows that a thorough understanding of which patients are visiting the ED and why can help in avoiding the visits. Therefore, the purpose of this study was to investigate: 1) causes and 2) patient-related factors (demographics and comorbidities) associated with ED visits following primary TKA. Methods. A national private payer database was queried for primary TKAs performed between 2007 and 2016 using the International Classification of Disease, ninth revision (ICD-9) procedural code 81.54. ED visits were identified using Current Procedural Terminology (CPT) codes 99281 to 99285. Patients with 90-day ED visits were in the study group (n=28,044) whereas those without 90-day ED visits served as controls (n=82,289). Causes for ED visits were divided into cardiopulmonary, gastrointestinal, renal, thromboembolic, leg pain, or wound-related. Patient demographics and risk factors assessed included age, gender, and body mass index (BMI) as well as several comorbidities (Table 1). Pearson's chi-square tests were performed to compare patient demographics and comorbidities between the cohorts. In order to adjust for potential confounders, multivariate binomial logistic regression analysis was performed to further evaluate the associations between patient factors and 90-day ED visits. A p-value less than 0.01 was considered statistically significant. Results. The most common reasons for ED visits were cardiopulmonary (51.30%), leg/back pain (46.20%), and gastrointestinal (31.60%) reasons. There was a greater proportion of women in the ED visit cohort compared to controls (p<0.0001; Table 1) and comorbidities (p<0.0001). Multivariate analysis revealed that patients with a history of COPD (odds ratio [OR] 1.48, p<0.001), depression (OR 1.42, p<0.0001), arrhythmias (OR: 1.38, p<0.0001), AIDS (O: 1.32, p<0.0001), and iron deficiency anemia (OR 1.28, p<0.0001), were at an increased risk of visting the ED within 90 days following primary TKA (Table 2). Conclusion. This analysis of over 100,000 patients identified that the most common reasons for ED visits are primarily medical in nature, and are not necessarily directly related to the recent operation. These findings should help guide pre-operative education and manage post-operative expectations to help limit potentially avoidable ED visits. Additionally, the data from this study can lend to policy changes targeting ED visits, particularly given the shift towards certain reimbursement models in arthroplasty. For figures, tables, or references, please contact authors directly

Paediatric distal radial and forearm fractures account for 37.4% of all fractures in children. We present our 2.5-year results of a novel safe approach to the treatment of simple distal radial and diaphyseal fractures using intranasal diamorphine and entonox in a designated fracture reduction room in the emergency department. All simple fractures of the distal radius and forearm admitted to our ED between March 2012 and August 2014 that could be reduced using simple manipulation techniques were included in this study. These included angulated diaphyseal fractures of the forearm, angulated metaphyseal fractures of the distal radius and Salter Harris types I and II without significant shortening. All children included were given intranasal diamorphine as well as entonox. The orthopaedic registrar on call performed all reductions. 100 children had their distal radius or forearm fracture reduced in the emergency department using entonox and diamorphine analgesia and had a same day discharge. Average age was 10 years (range 2.20–16.37 years). No complications were reported regarding the use of the analgesia and all children and parents were pleased with their treatment not requiring a hospital admission. The mean initial dorsal angulation of all fracture types was 28.05° degrees (23.91–32.23 95% CI) which was reduced to 7.03° (5.11–8.95 95% CI) post manipulation. There were 9 cases lost to follow up. Two cases lost the initial reduction of the fracture on subsequent clinic follow up and underwent internal fixation in theatre. The use of entonox and intranasal diamorphine is a safe, effective treatment of providing adequate analgesia for children with distal radial and forearm fractures to allow manipulation of displaced dorsally angulated fractures in the emergency department. By facilitating a same day discharge, over £45,000 was saved using this safe method of treatment

Introduction: Foot and ankle injuries are common in the Emergency Department (ED). 1. Of those which require radiographs, in accordance with the Ottawa Foot and Ankle Rules, approximately 22% have a fracture. 2. In the last decade ultrasound has been developing as a tool for emergency musculoskeletal assessment – it is inexpensive, rapid and visualises soft tissue and bony structures. Methods: This diagnostic cohort study was designed to determine whether ultrasound could detect acute bony and non-bony foot and ankle injuries. Ottawa Rules positive patients over 16 year of age without obvious dislocation/compound fracture were eligible. An ultrasound scan (USS) for bony injury was performed by a member of the ED, blinded to radiographic findings. Patient management was determined according to the radiographs. Significant fractures were defined as a breadth greater than 3 mm (as per the Ottawa Foot & Ankle Rules study group). 3. All radiographic reporting was conducted blind to the results of the USS. All USS operators received a specific 2-day training in musculoskeletal ultrasound prior to the trial. Results: One hundred and ten subjects were recruited. eleven had significant radiological fractures, ten of which were seen on ultrasound. The single missed fracture arose due to the operator not scanning proximally enough on the fibula. On re-scanning following radiographic review the fracture was clearly seen on ultrasound. To date the sensitivity of USS is 90.9%, with 95% CI (65.7, 98.3). The specificity is 90.9% with 95% CI (88.1, 91.7). The positive predictive value is 0.526, with a 95% CI (0.380, 0.569). The negative predictive value is 0.989, with a 95% CI (0.959, 0.998). The positive likelihood ratio is 10.00, with a 95% CI (5.526, 11.901) and the negative likelihood ratio is 0.100, with a 95% CI (0.018, 0.389). Conclusion: Our pilot study demonstrates that ultrasound shows great promise for the sensitive detection of foot and ankle fractures

Acute multiligament knee injuries (MLKI) are rare, high energy traumatic injuries associated with an increased risk of lower limb complications. The objectives of this study were to investigate the adequacy of clinical assessment for neurovascular status, compartment syndrome, and deep vein thrombosis in the emergency department (ED) following acute MLKI. The authors conducted a retrospective case note review of 19 patients with MLKI presenting at the ED of a Major Trauma Centre during a 7.5-year period between June 2009 and December 2016. MLKIs were diagnosed by MRI or examination under anaesthesia and confirmed intraoperatively. Arterial assessment consisted of documented capillary refill time, dorsalis pedis and posterior tibial pulse assessment (through palpation or Doppler ultrasound), and ankle-brachial pressure index (ABPI) calculation. Neural assessment was adequate if there was documented assessment of both sensory and motor function of the superficial peroneal, deep peroneal and tibial nerves individually. Data was collected for 19 patients (17 male, 2 female). The mean age was 34 (range: 14–61). The most common injury mechanism was road traffic accident. Neurovascular assessment was suboptimal in all categories: only one patient received a satisfactory lower limb neurological assessment and no patients received complete vascular assessments. Neurovascular assessment of multiligament knee injuries was suboptimal. Reasons for this included poor documentation and lack of certain specific clinical assessments, such as ABPI calculation. We propose the introduction of an acute knee injury pro forma highlighting the components of a full lower limb neurovascular examination to rectify this problem

We present a complete audit cycle of Emergency Department management of paediatric clavicle fractures at Derriford Hospital. Local guidelines divide the clavicle into three zones. Fractures with minimal displacement in the middle 3/5th heal in the majority of cases without complication and can be discharged without need for follow up, provided parents are adequately educated. An initial audit cycle of 63 cases identified short comings in adherence to the guidelines. These included: Unnecessary fracture clinic follow up of ‘Zone 2’ fractures in 85% and omission of written advice in 86%. The results were circulated, ‘aide memoir’ icons were added to the department's computer coding system, staff teaching sessions were organised and a patient advice sheet was produced. Following the implementation of changes, a 23 case re-audit showed fewer unnecessary referrals to fracture clinic (17% vs. 85%) and improvements in the number of parents being given written advice (43% vs. 14%). Staff training, provision of information leaflets and changes to the ED coding system dramatically improved the adherence to hospital guidance. This resulted in standardisation of care, fewer unnecessary appointments and cost savings to the trust. Following this audit, a telephone survey was completed to assess parent's satisfaction with their treatment