Two discrete legal factors enable the surgeon to treat an injured patient the fully informed, autonomous consent of the adult patient with capacity via civil law; and the medical exception to the criminal law. This article discusses current concepts in consent in trauma; and also considers the perhaps less well known medical exception to the Offences against the Person Act 1861, which exempts surgeons from criminal liability as long as they provide ‘proper medical treatment’. Cite this article:
Compartment syndrome can be a life changing consequence of injury to a limb. If not diagnosed and treated early it can lead to permanent disability. Neurovascular observations done on the ward by nursing staff, are often our early warning system to those developing compartment syndrome. But are these adequate for detecting the early signs of compartment syndrome? Our aim was to compare the quality and variability of charts across the UK major trauma network. All major trauma centres in England and Scotland were invited to supply a copy of the neurovascular chart routinely used. We assessed how such charts record relevant information. Specific primary data points included were pain scores, analgesia requirements, pain on passive stretch and decreased sensation in the first web space specifically. As secondary objectives, we assessed how late signs were recorded, whether clear instructions were included, quantitative scores and the use of regional blocks recorded.Introduction
Materials & Methods
The use of intramedullary lengthening devices is becoming increasingly popular. There are no published data regarding the incidence of venous thromboembolism following intramedullary lengthening and no reports or guidance for current practices on use of thromboprophylaxis. Following a case of post-operative deep vein thrombosis in our institution, we felt that it is important to assess best practice. We conducted this survey to collect data that would describe current practice and help guide consensus for treatment. We have identified surgeons across the UK that perform intramedullary lengthening through the British Limb Reconstruction Society membership and a Precise Users database. Surgeons were contacted and asked to respond to an online survey (SurveyMonkey - SVMK Inc.). Responses to thromboprophylaxis regimes employed in their practice and cases of venous thromboembolism were collated.Introduction
Materials and Methods
The case of Montgomery in 2015 considered standards of risk disclosure, whether alternative treatments had been discussed, standards of professional performance, and the importance of patient autonomy. A survey was devised to investigate orthopaedic surgeons' knowledge of the law of consent and risk disclosure and distributed by Survey Monkey.Introduction
Methods
We analysed the functional and psychological outcomes in children and adolescents with complex tibial fractures treated with the Ilizarov method at our frame unit. An observational study with prospective data collection and retrospective analysis of clinical data was undertaken. Patients younger than 18 years and an open physis were included. The Ilizarov method (combined with percutaneous screw fixation in physeal injuries) was applied and immediate weightbearing recommended. Sixty four patients (50 male, 14 female) aged between 4 and 17 years were admitted to our Major Trauma Centre from 2013 until 2016 (25 tertiary referrals). Thirty one (48%) patients were involved in road traffic accidents, 12 (19%) sustained injuries in full contact sports. The average weight was 51 kg (range 16–105 kg). Twenty three open tibial fractures (14 Gustilo 3A and 9 Gustilo 3B) and 15 associated physeal injuries were treated among a cohort of closed tibial fractures with significant displacement (10 failed conservative treatment prior to frame treatment). We report a 100% union rate with a median hospital stay of 4 days (range 2–19) and a median frame time of 105 days (range 62–205 days). Malunions (> 5 degrees in any plane) were not observed. Three patients required bone transport. At the time of submission, 70% of patients and their parents reported functional outcomes using the Paediatric Quality of Life Inventory (PedsQL) at minimum six months post frame. The PedsQLTM 4.0 Generic Core Scales are comprised of parallel child self-report and parent proxy-report formats. Children's physical average scores were 79 out of 100 and average psychosocial scores were 80 out of 100 and for parent average physical scores were 78 out of 100 and the same for parent average psychosocial scores. These results suggest high levels of quality of life on the PedsQL. The median visual analogue health score (0–100) was 81 out of 100 (71–100), median Lysholm knee scores 98 (range 49–100) and median Olerud & Molander ankle scores 75 (range 40 – 100). Regardless of age, weight and soft tissue damage and complexity of fracture pattern, the Ilizarov method has shown to be safe and effective treating tibial fractures in the paediatric and adolescent population admitted to our Major Trauma Centre. Furthermore, patients reported high physical and psychosocial functioning following treatment. Level of evidence: IV (case series)
Segmental tibia fractures are high-energy injuries that are difficult to treat. We report on the use of the Ilizarov Method to treat 40 consecutive AO42C (35) and AO42B3 (5) fractures by a single surgeon. Fractures with bone loss requiring transport were excluded, as were fractures initially treated with nail or plate. 28 adult males, 12 adult females, average age 43. The most common mechanism of injury was RTA (50%). 12 (30%) had associated injuries. 19 (48%) fractures were open (6 3A, 13 3B) and 21 closed. 24 (60%) had temporary monolateral external fixation before definitive treatment. The mean time from injury to definitive Ilizarov frame was 8 days.Introduction
Patients
Reaming of the canal is an important step in the debridement phase of treating intramedullary infections. Numerous techniques of radical canal debridement have been successfully reported. The use of the Reamer-Irrigation-Aspiration system (RIA-Synthes) is currently expanding to include this clinical scenario. Prospective collection of data related to infected cases treated with the use of the RIA in a tertiary referral centre referring to a 3 year period. Peri-operative details, microbiology results, and follow-up outcome over a minimum period of 12 months post-surgery are reported.Introduction
Materials and methods
The purpose of this study was to evaluate the efficacy of human recombinant osteogenic protein 1 (rhBMP-7) for the treatment of fracture non-unions and to estimate the health economics aspect of its administration. Twenty-four patients (18 males, mean age 39.1 (range 18-79)) with 25 fracture non-unions were treated with rhBMP-7 in our institution (mean follow-up 15.4 months (range 6-29)). Successful completion of treatment was defined as the achievement of both clinical and radiological union. The cost of each treatment episode was estimated including hospital stay, theatre time, orthopaedic implants, drug administration, investigations, clinic attendances, and physiotherapy treatments. The total cost of all episodes up to the point of receiving BMP-7 and similarly following treatment with BMP-7 were estimated and analysed. Of the 25 cases, 21 were atrophic (3 associated with bone loss) and 4 were infected non-unions. The mean number of operations performed prior to rhBMP-7 application was 3.4, including autologous bone graft in 9 cases and bone marrow injection in one case. In 21 out of the 25 cases (84%), both clinical and radiological union occurred. Mean hospital stay before and after receiving rhBMP-7 was 26.84 days per fracture and 7.8 days per fracture respectively. Total cost of treatments prior to BMP-7 was £346,117 [£13,844.68 per fracture]. Costs incurred following BMP-7 administration were estimated as £183,460 [£7,338.4 per fracture]. rhBMP-7 was used as a bone stimulating agent with or without conventional bone grafting with a success rate of 84% in this series of patients with persistent fracture non-unions. The average cost of its application was £7,338 [53.0% of the total costs of previous unsuccessful treatment of non –unions, p<0.05). Treating non-union is costly, but the financial burden could be reduced by early rhBMP-7 administration when a complicated or persistent non-union is present or anticipated. Therefore, this study supports the view that rhBMP-7 is a safe and power adjunct to be considered in the surgeon's armamentarium for the management of such difficult cases.
Guidelines on the care of the seriously injured have led to widespread changes in clinical practice. The ‘hub and spoke’ model of trauma care means increasing numbers of patients with complex problems are concentrated into regional centres. Though providing the highest standards of treatment, this has cost implications for the receiving unit, particularly given the Department of Health's move towards a ‘Payment by Results’ model of health provision. We undertook an economic evaluation of complex limb reconstruction within our tertiary referral unit. Patients referred to the complex trauma service were identified. Patients were assigned to either a ‘complicated’ or ‘straightforward’ group by two consultant surgeons, based on the nature of their treatment. 5 cases from each group were randomly selected for further analysis. Data pertaining to the direct healthcare costs for these patients was analysed. Costs per investigation/intervention were obtained relating to hospital stay, outpatient care, operative interventions and investigations. Overall 26 patients were referred to our complex trauma service from other units over 6 months. A mean of £8,375 (6,163) per patient was recouped using current Service Level Agreements. This amounts to a £26,587 deficit per patient, or £1,394,905 per year assuming current referral rates. Those planning a service treating complex trauma must allow for the considerable costs involved and make provisions to recoup this from the referring Primary Care Trust.
Wire crossing angle affects the stability of circular fine wire frames. Anatomical atlases document safe ‘corridors’ to avoid neurovascular structures, although this may limit crossing angle. In the distal tibia the furthest posteriolateral safe corridor described is through the fibula. The present study describes a new and safe ‘retro-fibular’ corridor for wire placement in the distal tibia that provides a greater crossing angle. Two different methods of wire insertion are considered to determine which provides greater protection to neurovascular structures. A dissection based study of 20 embalmed lower limbs divided into two groups. 1.8mm wires were inserted at increments along the tibia, from posterolateral to antero-medial, at 30–45 degrees to the sagittal plane. In the first group wires were placed against the posterior surface of the fibula and ‘stepped’ medially onto the tibia. In the second wires were inserted midway between the border of the fibula and tendoachilles. Standard dissection techniques were used to identify the path of wires and distance from neurovascular structures. In group one distal tibial wires avoided the posterior tibial neurovascular bundle (mean distance 21.7mm) although passed close to the peroneal artery (mean distance 1.2mm). In group two both the posterior tibial and peroneal structures were avoided (mean distances 15.5mm and 7.1mm respectively). Comparison of the two groups shows a significant difference (p<
0.001). Retrofibular wire placement is safe in the distal quarter of the tibia and facilitates an optimal crossing angle, although is not described in standard atlases. Insertion of wires mid-way between the posteromedial border of the fibula and the tendoachilles appears the most reliable technique.
97 grade III open fractures in 95 patients 64 required temporary spanning ex-fix: 23 applied at trauma centre/41 at DGH 14/64 ex-fixes required revision (prior to definitive Ilizarov): poor plastics access(6)/instability(2)/both(6) All 14 revised had been applied in a DGH, i.e. 14/41 DGH ex-fix needed revision (34%) Ex fixes revised after application at trauma centre vs. DGH = 0/23 vs. 14/41, p<
0.01 ×2 Revision of Hoffman hybrid vs. monolateral ex fix = 4/4 vs. 10/60 p<
0.001 ×2 Non modular system (Orthofix) vs. modular systems (Hoffman II/AO) = 7/17 vs. 0/39 p<
0.001
All Hoffman hybrids needed revision, due to both instability and plastics access. Significantly more non modular (Orthofix) ex-fixes required revision compared to modular (Hoffmann II/AO), due to poor plastics access.
Consideration of natural history of the injury – characteristics of the injury and existing knowledge of healing times. The appearance of remodelling bridging callus (often endosteal) on anteroposterior and lateral radiographs. Clinical behaviour of the injured limb within a dynamised frame – after 1 and 2 are met, rods connecting the rings stabilising the fracture are loosened. The frame is removed when the patient can stand on the affected limb and dynamised frame without pain, and after weightbearing without pain on the dynamised frame for 3–4 weeks.
It is said “It is better to leave a frame on one month too long than to remove it a day too soon”, but this merely emphasises that timing of frame removal remains an art rather than an exact science. Marsh and Montgomery have previously suggested use of CT scanning to assess union in peri-articular fractures. We recommend that in high energy tibial fractures whose fracture pattern geometry lies outwith the antero-posterior and lateral radiograph views, a CT scan should be considered to detect stiff non-union and avoid premature frame removal.
Mean age 45.3 years, male: female = 26:4. Seven fractures were Grade 3 open. Patients were grouped as follows:
43-A .1/.2/.3 = 1/2/2 43-B .1/.2/.3 = 1/0/4 43-C .1/.2/.3 = 3/4/13. Two patients with 43-C.3 fracture had additional corticotomy for bone loss. Twenty-nine pilons united. Overall mean time to union was 20 weeks. Times to union (weeks):
Group 43-A: - median = 20, mean = 21. Group 43-B: - median = 11, mean = 12. Group 43-C: -median = 20, mean = 21. Group 43-C.3: -median = 20, mean = 21 24 patients had no major complications. One Grade 3B open 43-C.3 fracture had deep sepsis prior to transfer to our unit which could not be eradicated – this led to transtibial amputation. Two patients had valgus mal-union and One had stiff nonunion requiring a second frame. Eleven patients experienced superficial pinsite infection that resolved with oral antibiotic therapy. Two deep pinsite infections were eradicated by overdrilling.
- 10/22 participants had not previously attended an ex-fix course. - Pre- vs. post-course score (out of 4) = 2.5 vs. 3.7 (p<
0.001, Mann-Whitney U) - All participants Teaching Hospitals vs. DGHs: - Pre-course scores = 2.9 vs. 1.9 (p<
0.01) - Post-course scores = 3.6 vs. 3.8 (not significant) - Pre-course scores by grade of participant: - SHO vs. Senior SHO = 2.6 vs. 1.5 (p<
0.05) - SpR vs. Senior SHO = 3.0 vs. 1.5 (p<
0.05) - SpR vs. SHO = 3.0 vs. 2.6 (not significant) - Post-course scores by grade: - SpR vs. Senior SHO vs. SHO = 4.0 vs. 3.8 vs. 3.3 (not significant).
Participation in a simple ex-fix course improves knowledge of ex-fix design. Retention of knowledge must be reassessed after several months. This course fills a gap in education of basic external fixation for orthopaedic trainees. We recommend every region with a tertiary referral system for complex trauma utilises this course.
- Ex-fix trays per unit (all manufacturers) mean = 4.14 (1–9) - Majority equipment in unit = Orthofix (11), Hoffman II (5), AO (1) - 12/15 SpRs reported insufficient ex-fix equipment for pelvis, 4 long bones and bridging knees (Damage Control Orthopaedics = DCO) - 7/15 SpRs reported insufficient ex-fix for 4 long bones/ bridging knees
- mean year of training = 2.2 - Experience: Generic trauma course (9) Specific ExFix (6) Manufacturer (9) - 14/15 would value specific regional ex-fix course - DCO patient scenario SpR unable to fix -lack of knowledge vs. lack of equipment 7/15 vs. 12/15 p<
0.01
- 7/31 aware of transfer protocol - 31/31 want referral routes clearly identified - 12/15 would value regular regional audit
All trainees had attended ex-fix teaching. Those who had only attended generic courses were less confident in DCO scenarios. Most favoured a specific regional ex-fix course. Tertiary care protocols have been distributed, but many units are unaware of their existence. A regular regional audit of trauma referrals would provide protocol reinforcement and opportunity for feedback.
- 97 grade III open fractures in 95 patients - 64 required temporary spanning ex-fix: - 23 applied at trauma centre / 41 at DGH - 14/64 ex-fixes required revision (prior to definitive Ilizarov): - poor plastics access (6) / instability (2) /both (6) - All 14 revised were applied in a DGH, i.e. 14/41 DGH ex-fix needed revision (34%) - Ex fixes revised after application at trauma centre vs. DGH = 0/23 vs. 14/41, p<
0.01 X2 - Revision of Hoffman hybrid vs. monolateral ex fix = 4/4 vs. 10/60 p<
0.001 X2 - Non modular system (Orthofix) vs. modular systems (Hoffman II / AO) = 7/17 vs. 0/39 (p<
0.001)
All Hoffman hybrids needed revision, due to instability and plastics access. Significantly more non modular (Orthofix) ex-fixes required revision compared to modular, for poor plastics access. We recommend modular external fixator application (Hoffman II or AO) to avoid problems with temporary external fixation of open tibial fractures. Hybrid temporary external fixation should be abandoned in such injuries.
Gustilo grade, 3A/3B/3C = 6/13/2. Both 3C fractures required early amputation. Wound closure, 5/6 fractures with bone loss required free tissue transfer (FTT); however only 3/15 fractures without bone loss required FTT to achieve soft tissue cover, most requiring fasciocutaneous flap or split skin graft only. Median time in Ilizarov frame was 160 days for patients without bone loss. For those fractures with bone loss frame time ranged from 180–540 days, with some patients still requiring ongoing Ilizarov treatment. All fractures without bone loss united. At mean 14 month follow up only one fracture of 21 had clinical evidence of deep sepsis. 1 tibial fracture showed a 12 degree malunion, while 7/18 patients had a superficial pinsite infection requiring a course of oral antibiotics. One free tissue transfer failed in a grade 3C fracture, leading to early amputation (in conjunction with the recognised vascular injury).
Flap and Frame appears to be a very satisfactory method of treating grade 3 open fractures, with low deep sepsis rate, high union rate, satisfactory times to union, and reduced requirement for free tissue transfer to obtain soft tissue coverage.