Introduction

Lower limb immobilisation with full casts is commonly used to manage fractures. There may be the need to split casts in an emergency, such as compartment syndrome, with no current consensus as to which technique is most effective in reducing pressure quickly. Our study aims to compare the reduction in pressure across lower leg compartments using three different cast splitting techniques.

Background

Supination-external rotation (SER) injuries make up 80% of all ankle fractures. SER stage 2 injuries (AITFL and Weber B) are considered stable. SER stage 3 injury includes disruption of the posterior malleolus (or PITFL). In SER stage 4 there is either medial malleolus fracture or deltoid injury too. SER 4 injuries have been considered unstable, requiring surgery. The deltoid ligament is a key component of ankle stability, but clinical tests to assess deltoid injury have low specificity. This study specifically investigates the role of the components of the deep deltoid ligament in SER ankle fractures.

Aims

Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England.

There is little in the literature reporting on the incidence of heterotopic ossification (HO) after hip resurfacing arthroplasty. HO has long been recognized as a complication of THA, with a reported incidence that ranges between 5 – 90 %. We investigated the incidence of HO in a group of hip resurfacing patients, and compared this against the incidence of HO in a comparable group of patients managed with a conventional THA. We retrospectively reviewed patients who had a hip resurfacing procedure from January 2004 to December 2007 carried out by a single surgeon. To act as our comparative group, we selected a closely matched group of patients in terms of age and sex who underwent a THA over the same time period, under the same surgeon. 47 cases of resurfacing, 23 were female and 24 male. The 47 cases of the selected THA group consisted of 24 females and 23 males. Therefore the two groups were of a similar sex make up. Within the resurfacing group of patients, the ages ranged from 31 to 68 years, with the mean being 55.4 years, and the median being 56.5 years. The THA group possessed an age range of from 31 to 68 years, with the mean being 55.4 years, and the median being 56.5 years. The resurfacing group of patients had 5 cases showing HO, giving an overall rate of 10.6 percent. 3 were of the grade I variety, while 2 were grade II. The THA group had 6 cases showing HO, giving an overall rate of 12.8 percent. 5 of these were of the grade I variety, while 1 was of the grade III variety. We used a two tailed Fischer’s Exact test set at the 5th percentile significance level to compare the overall rate of HO occurrence between the 2 groups, namely 10.6 percent versus 12.8 percent. This gave a p value of 0.238. Therefore we can state that there is no significant difference in the rate of HO formation between the resurfacing and THA patients.

Goals: In this study we analysed the patients admitted with orthopaedic problems who had coffee ground vomitus for incidence, risk factors, investigations and the management. This project was to highlight this significant but rather neglected problem and to draw up local guidelines in the prevention.

Methods: This is a prospective study conducted for a period of six months from 1st of July 2005 to 31st of Dec 2005. All patients admitted with Orthopaedic problems who had coffee ground vomitus were included in the study after confirmation with haemoccult test. Their case notes were studied to identify the risk factors, preventive measures that could have been taken and their management.

Results: There were 34 (2.3%) patients who had coffee ground vomitus, out of 1427 orthopaedic admissions during the study period. There were 14 (41%) men and 20 (59%) women. The mean age was 73.7 yrs in men and 82.2 yrs in women. This problem was more common in 8th decade with 15 patients (45.5%). There were 6 patients each in 7th and 9th decade, 5 patients in 6th decade and only 2 patients in 5th decade.

There were 19 (55.5%) trauma admissions with fractures and 15 (45.5%) elective admissions. There were 12 (35.2%) patients with previous gastric problems. There were 20 (59%) patients who were on gastric irritant medications, out of which only 5 (25%) were on gastro protective medications. All 34(100%) patients were on low molecular weight heparin for thromboprophylaxis. There were 2 patients on steroids and 2 patients on warfarin.

Coffee ground vomitus occurred preoperatively in 4 (13.4%) and postoperatively in 26 (86.6%). It happened with in the first six hours after surgery in 25 (96.5%) patients. Only in one patient it happened after 3 weeks.

All patients were kept nil by mouth, started on fluid resuscitation and intravenous ranitidine followed by oral omeprazole. Patients who were haemodynamically unstable were investigated by endoscopy. 17 (50%) patients had oral gastroduodenoscopy. 2 patients had blood transfusion because of significant drop in haemoglobin and one died before the transfusion was started.

There were 5 (14.7%) deaths in our study group. The cause of 2 deaths was directly related to gastrointestinal bleeding and the other three were confirmed to have had concurrent chest infection.

Conclusions: Gastro intestinal bleeding is a neglected but not an uncommon problem in orthopaedic patients. Identification of high-risk patients and implementation of preventive measures could avoid this potential life threatening complication. We recommend withdrawal of gastric irritants and co-prescription of gastro protective medications for high-risk orthopaedic patients.

Aim: Inability to lose weight is often attributed to restriction of mobility due to painful arthritic joints. We hypothesise that removing the pain by total hip replacement or knee replacement will improve patients exercise tolerance thereby helping them lose weight.

Method: A prospective study of obese patients (BMI > 30) undergoing consecutive primary total hip or knee replacement. BMI was measured pre operatively and 1 year post operatively. Patients with medical conditions or complications of surgery that would limit mobility were excluded. A questionnaire detailing pre and postoperative activity levels, walking distance/aids and diet was completed.

Results: 37 patients were included in the study. All patients had symptomatic osteoarthritis. There were 21 female and 16 male patients with an average age of 70 (range 51 – 85). 23 patients had total knee replacements and 14 had total hip replacement. The average follow up was 11.4 months (range 8 – 12 months).

The International classification of adult weight according to BMI was used to categorise patients. Obesity is defined as a BMI greater than 30 and is graded in severity. Class I is a BMI of 30.0 – 34.9, Class II is 35.0 – 39.9 and Class III is greater than 40.0

There were 14 patients in obese class I. 5 patients increased their BMI, 4 patients remained the same and 5 patients decreased their BMI. There was an average increase in BMI of 0.36. 13 patients had an improvement in walking distance and in 1 patient it remained unchanged.

There were 16 patients in obese class II. 6 patients increased their BMI, 5 patients remained the same and 5 patients decreased their BMI. There was an average increase in BMI of 0.62. 14 patients had an improvement in walking distance and in 2 patients it remained unchanged.

There were 7 patients in obese class III. 1 patient increased their BMI, 1 patient remained the same and 5 patients decreased their BMI. There was an average decrease in BMI of 1.3. 5 patients had an improvement in walking distance and in 2 patients it remained unchanged.

There was an average increase of BMI of 0.19 in all patients. All patients reported an improvement in activity levels and a reduction in the use of walking aids.

Conclusion: Overall there was an increase in the BMI of obese patients undergoing total knee or hip replacement. This study suggests that total knee or hip replacement in obese patients for osteoarthritis despite improved activity levels does not result in a reduction in BMI. This is either as the improvement in mobility is not sufficient to confer a significant loss of weight or that pre-operative obesity is unrelated to inactivity due to osteoarthritis. Interestingly, the weight loss in obese class III patients (BMI > 40) who undergo total hip or knee replacement suggests that they benefit more from surgery than other classes of obesity.

Background: The aim of this study was to analyse mid-shaft clavicle fractures in children and adults to find out the factors that would influence the healing time and the necessity of surgical intervention.

Methods: We identified all the midshaft clavicle fractures treated at Chesterfield Hospital between January 2003 and January 2006. We studied the case notes and radiographs of these patients. We grouped the midshaft fractures into those in children and those in adults. Each group was further subdivided into two part and three part fractures. It was also noted whether a vertical butterfly fragment was present in the three or more part fractures. The fractures were analysed for their incidence, presence of comminution, degree of displacement, type of treatment and the follow-up time before discharge.

Results: – Over the 3 year period, 242 middle 1/3 clavicle shaft fractures were treated. Among the mid shaft fractures there were one hundred and eight (44.6%) children and one hundred and thirty four (55.3%) adults.

There were one hundred and three children with two part clavicle fracture (95.3%) and one required surgical fixation (1%). There were only five children with three or more fracture fragments (4.7%) and one required surgical fixation (20%). All five children who had three or more fracture fragments were found to have vertical fragment on x-ray. The average time for discharge was 27.48 days for two part fractures and 49 days for three part fractures.

There were seventy-five (55.5%) adults with two part fractures and ten of them required surgical fixation (13.3%). There were fifty-nine (44.0%) with three or more fragments and eleven of them required surgical fixation (18.6%). Out of the fifty-nine fractures, which had three or more fragments, forty-eight had vertical fragment on x-ray (81.3%). Among the three part fractures, there were ten fractures with vertical fragment that required surgical fixation (20.8%).

The average time for discharge was 52.07 days for two part fractures and 93.56 days for fractures with three or more fragments. There was no difference in the discharge time for non operated three part fractures with or without vertical fragment.

Conclusion: The incidence of clavicle fractures in children is nearly as high as in adults. In children the number of days for discharge is nearly double for three part fractures when compared to two part fractures.

The presence of vertical fragment predicts higher rate of surgical intervention required due to either delayed/non union or localised skin tenting. We recommend that we should have a lower threshold to fix the 3 or more part clavicle fractures with vertical fragment.