Aims. The first death in the UK caused by COVID-19 occurred on 5 March 2020. We aim to describe the clinical characteristics and outcomes of major trauma and orthopaedic patients admitted in the early COVID-19 era. Methods. A prospective trauma registry was reviewed at a Level 1 Major Trauma Centre. We divided patients into Group A, 40 days prior to 5 March 2020, and into Group B, 40 days after. Results. A total of 657 consecutive trauma and orthopaedic patients were identified with a mean age of 55 years (8 to 98; standard deviation (SD) 22.52) and 393 (59.8%) were males. In all, 344 (approximately 50%) of admissions were major trauma. Group A had 421 patients, decreasing to 236 patients in Group B (36%). Mechanism of injury (MOI) was commonly a fall in 351 (52.4%) patients, but road traffic accidents (RTAs) increased from 56 (13.3%) in group A to 51 (21.6%) in group B (p = 0.030). ICU admissions decreased from 26 (6.2%) in group A to 5 (2.1%) in group B. Overall, 39 patients tested positive for COVID-19 with mean age of 73 years (28 to 98; SD 17.99) and 22 (56.4%) males. Common symptoms were dyspnoea, dry cough, and pyrexia. Of these patients, 27 (69.2%) were nosocomial infections and two (5.1%) of these patients required intensive care unit (ICU) admission with 8/39 mortality (20.5%). Of the patients who died, 50% were older and had underlying comorbidities (hypertension and cardiovascular disease, dementia, arthritis). Conclusion. Trauma admissions decreased in the lockdown phase with an increased incidence of RTAs. Nosocomial infection was common in 27 (69.2%) of those with COVID-19. Symptoms and comorbidities were consistent with previous reports with noted inclusion of dementia and arthritis. The mortality rate of trauma and COVID-19 was 20.5%, mainly in octogenarians, and COVID-19 surgical mortality was 15.4%. Cite this article: Bone Joint Open 2020;1-7:330–338

The arrival of major trauma centres (MTC) to Scotland highlights the need for structured management of polytrauma patients. The aim was to report the epidemiological profile of polytrauma patients (Injury Severity Score (ISS) 15) admitted to a large trauma unit in the UK and gather information about the initial management of this severely injured cohort. Prospectively collected data from the Scottish Trauma Audit Group (STAG) database of 366 polytrauma patients (ISS <15 & aged ≥13 years) admitted to a single trauma unit, from 1st January 2013 to 31st October 2017 was analysed. Data included patient demographics, injury characteristics, length of stay (LOS) and survivorship. The median age was 49 years (range 13–93) and females made up 31.1% of the population. There was a mean ISS of 25.7 (range 15–75) and mean LOS of 19 days. The overall mortality rate was 21%. Higher mortality occurred among females (p<0.001), patients ≥60 years age (p<0.001), patients who sustained their injury at home (p<0.0001), and those with head injuries (p<0.01). Orthopaedic injuries were present in 187 patients (51.1%) with a mortality rate of 10.7%. The most common mechanism of injury was road traffic collision (41.5%) and these patients had a significantly higher ISS (p<0.01). A fall from height <2m was associated with higher mortality (p=0.01). This study is the largest of its kind and presents a detailed epidemiological profile of patients attending a large UK trauma unit. This knowledge will help guide initial management and aid in resource and capacity planning for the future

Aims. The use of fluoroscopy in orthopaedic surgery creates risk of radiation exposure to surgeons. Appropriate personal protective equipment (PPE) can help mitigate this. The primary aim of this study was to assess if current radiation protection in orthopaedic trauma is safe. The secondary aims were to describe normative data of radiation exposure during common orthopaedic procedures, evaluate ways to improve any deficits in protection, and validate the use of electronic personal dosimeters (EPDs) in assessing radiation dose in orthopaedic surgery. Methods. Radiation exposure to surgeons during common orthopaedic trauma operations was prospectively assessed using EPDs and thermoluminescent dosimeters (TLDs). Normative data for each operation type were calculated and compared to recommended guidelines. Results. Current PPE appears to mitigate more than 90% of ionizing radiation in orthopaedic fluoroscopic procedures. There is a higher exposure to the inner thigh during seated procedures. EPDs provided results for individual procedures. Conclusion. PPE currently used by surgeons in orthopaedic trauma theatre adequately reduces radiation exposure to below recommended levels. Normative data per trauma case show specific anatomical areas of higher exposure, which may benefit from enhanced radiation protection. EPDs can be used to assess real-time radiation exposure in orthopaedic surgery. There may be a role in future medical wearables for orthopaedic surgeons. Cite this article: Bone Jt Open 2022;3(11):907–912

Aims. Fractures of the distal radius are common, and form a considerable proportion of the trauma workload. We conducted a study to examine the patterns of injury and treatment for adult patients presenting with distal radius fractures to a major trauma centre serving an urban population. Methods. We undertook a retrospective cohort study to identify all patients treated at our major trauma centre for a distal radius fracture between 1 June 2018 and 1 May 2021. We reviewed the medical records and imaging for each patient to examine patterns of injury and treatment. We undertook a binomial logistic regression to produce a predictive model for operative fixation or inpatient admission. Results. Overall, 571 fractures of the distal radius were treated at our centre during the study period. A total of 146 (26%) patients required an inpatient admission, and 385 surgical procedures for fractures of the distal radius were recorded between June 2018 and May 2021. The most common mechanism of injury was a fall from a height of one metre or less. Of the total fractures, 59% (n = 337) were treated nonoperatively, and of those patients treated with surgery, locked anterior-plate fixation was the preferred technique (79%; n = 180). Conclusion. The epidemiology of distal radius fractures treated at our major trauma centre replicated the classical bimodal distribution described in the literature. Patient age, open fractures, and fracture classification were factors correlated with the decision to treat the fracture operatively. While most fractures were treated nonoperatively, locked anterior-plate fixation remains the predominant method of fixation for fractures of the distal radius; this is despite questions and continued debate about the best method of surgical fixation for these injuries. Cite this article: Bone Jt Open 2022;3(8):623–627

The February 2023 Trauma Roundup. 360. looks at: Masquelet versus bone transport in infected nonunion of tibia; Hyperbaric Oxygen for Lower Limb Trauma (HOLLT): an international multicentre randomized clinical trial; Is the T-shaped acetabular fracture really a “T”?; What causes cut-out of proximal femur nail anti-rotation device in intertrochanteric fractures?; Is the common femoral artery at risk with percutaneous fragility pelvis fixation?; Anterior pelvic ring pattern predicts displacement in lateral compression fractures; Differences in age-related characteristics among elderly patients with hip fractures

The December 2022 Trauma Roundup. 360. looks at: Anterior approach for acetabular fractures using anatomical plates; Masquelet–Ilizarov for the management of bone loss post debridement of infected tibial nonunion; Total hip arthroplasty – better results after low-energy displaced femoral neck fracture in young patients; Unreamed intramedullary nailing versus external fixation for the treatment of open tibial shaft fractures in Uganda: a randomized clinical trial; The Open-Fracture Patient Evaluation Nationwide (OPEN) study: the management of open fracture care in the UK; Cost-utility analysis of cemented hemiarthroplasty versus hydroxyapatite-coated uncemented hemiarthroplasty; Unstable ankle fractures: fibular nail fixation compared to open reduction and internal fixation; Long-term outcomes of randomized clinical trials: wrist and calcaneus; ‘HeFT’y follow-up of the UK Heel Fracture Trial

Aims. This is a multicentre, prospective assessment of a proportion of the overall orthopaedic trauma caseload of the UK. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements. Methods. Data capture was by collaborative approach. Patients undergoing procedures from 22 August 2022 and operated on before 31 October 2022 were included. Arm one captured weekly caseload and theatre capacity. Arm two concerned patient and injury demographics, and time to surgery for specific injury groups. Results. Data was available from 90 hospitals across 86 data access groups (70 in England, two in Wales, ten in Scotland, and four in Northern Ireland). After exclusions, 709 weeks' of data on theatre capacity and 23,138 operations were analyzed. The average number of cases per operating session was 1.73. Only 5.8% of all theatre sessions were dedicated day surgery sessions, despite 29% of general trauma patients being eligible for such pathways. In addition, 12.3% of patients experienced at least one cancellation. Delays to surgery were longest in Northern Ireland and shortest in England and Scotland. There was marked variance across all fracture types. Open fractures and fragility hip fractures, influenced by guidelines and performance renumeration, had short waits, and varied least. In all, nine hospitals had 40 or more patients waiting for surgery every week, while seven had less than five. Conclusion. There is great variability in operative demand and list provision seen in this study of 90 UK hospitals. There is marked variation in nearly all injuries apart from those associated with performance monitoring. There is no evidence of local network level coordination of care for orthopaedic trauma patients. Day case operating and pathways of care are underused and are an important area for service improvement. Cite this article: Bone Jt Open 2023;4(6):463–471

Aims. Evidence exists of a consistent decline in the value and time that medical schools place upon their undergraduate orthopaedic placements. This limited exposure to trauma and orthopaedics (T&O) during medical school will be the only experience in the speciality for the majority of doctors. This review aims to provide an overview of undergraduate orthopaedic training in the UK. Methods. This review summarizes the relevant literature from the last 20 years in the UK. Articles were selected from database searches using MEDLINE, EMBASE, ERIC, Cochrane, and Web of Science. A total of 16 papers met the inclusion criteria. Results. The length of exposure to T&O is declining; the mean total placement duration of two to three weeks is significantly less than the four- to six-week minimum advised by most relevant sources. The main teaching methods described in the literature included didactic lectures, bedside teaching, and small group case-based discussions. Students preferred interactive, blended learning teaching styles over didactic methods. This improvement in satisfaction was reflected in improvements in student assessment scores. However, studies failed to assess competencies in clinical skills and examinations, which is consistent with the opinions of UK foundation year doctors, approximately 40% of whom report a “poor” understanding of orthopaedics. Furthermore, the majority of UK doctors are not exposed to orthopaedics at the postgraduate level, which only serves to amplify the disparity between junior and generalist knowledge, and the standards expected by senior colleagues and professional bodies. Conclusion. There is a deficit in undergraduate orthopaedic training within the UK which has only worsened in the last 20 years, leaving medical students and foundation doctors with a potentially significant lack of orthopaedic knowledge. Cite this article: Bone Jt Open 2022;3(7):549–556

Aims. The current global pandemic due to COVID-19 is generating significant burden on the health service in the UK. On 23 March 2020, the UK government issued requirements for a national lockdown. The aim of this multicentre study is to gain a greater understanding of the impact lockdown has had on the rates, mechanisms and types of injuries together with their management across a regional trauma service. Methods. Data was collected from an adult major trauma centre, paediatric major trauma centre, district general hospital, and a regional hand trauma unit. Data collection included patient demographics, injury mechanism, injury type and treatment required. Time periods studied corresponded with the two weeks leading up to lockdown in the UK, two weeks during lockdown, and the same two-week period in 2019. Results. There was a 55.7% (12,935 vs 5,733) reduction in total accident and emergency (A&E) attendances with a 53.7% (354 vs 164) reduction in trauma admissions during lockdown compared to 2019. The number of patients with fragility fractures requiring admission remained constant (32 patients in 2019 vs 31 patients during lockdown; p > 0.05). Road traffic collisions (57.1%, n = 8) were the commonest cause of major trauma admissions during lockdown. There was a significant increase in DIY related-hand injuries (26% (n = 13)) lockdown vs 8% (n = 11 in 2019, p = 0.006) during lockdown, which resulted in an increase in nerve injuries (12% (n = 6 in lockdown) vs 2.5% (n = 3 in 2019, p = 0.015) and hand infections (24% (n = 12) in lockdown vs 6.2% (n = 8) in 2019, p = 0.002). Conclusion. The national lockdown has dramatically reduced orthopaedic trauma admissions. The incidence of fragility fractures requiring surgery has not changed. Appropriate provision in theatres should remain in place to ensure these patients can be managed as a surgical priority. DIY-related hand injuries have increased which has led to an increased in nerve injuries requiring intervention

Aims. Preprint servers allow authors to publish full-text manuscripts or interim findings prior to undergoing peer review. Several preprint servers have extended their services to biological sciences, clinical research, and medicine. The purpose of this study was to systematically identify and analyze all articles related to Trauma & Orthopaedic (T&O) surgery published in five medical preprint servers, and to investigate the factors that influence the subsequent rate of publication in a peer-reviewed journal. Methods. All preprints covering T&O surgery were systematically searched in five medical preprint servers (medRxiv, OSF Preprints, Preprints.org, PeerJ, and Research Square) and subsequently identified after a minimum of 12 months by searching for the title, keywords, and corresponding author in Google Scholar, PubMed, Scopus, Embase, Cochrane, and the Web of Science. Subsequent publication of a work was defined as publication in a peer-reviewed indexed journal. The rate of publication and time to peer-reviewed publication were assessed. Differences in definitive publication rates of preprints according to geographical origin and level of evidence were analyzed. Results. The number of preprints increased from 2014 to 2020 (p < 0.001). A total of 38.6% of the identified preprints (n = 331) were published in a peer-reviewed indexed journal after a mean time of 8.7 months (SD 5.4 (1 to 27)). The highest proportion of missing subsequent publications was in the preprints originating from Africa, Asia/Middle East, and South America, or in those that covered clinical research with a lower level of evidence (p < 0.001). Conclusion. Preprints are being published in increasing numbers in T&O surgery. Depending on the geographical origin and level of evidence, almost two-thirds of preprints are not subsequently published in a peer-reviewed indexed journal after one year. This raises major concerns regarding the dissemination and persistence of potentially wrong scientific work that bypasses peer review, and the orthopaedic community should discuss appropriate preventive measures. Cite this article: Bone Jt Open 2022;3(7):582–588

Aims. COVID-19 necessitated abrupt changes in trauma service delivery. We compare the demographics and outcomes of patients treated during lockdown to a matched period from 2019. Findings have important implications for service development. Methods. A split-site service was introduced, with a COVID-19 free site treating the majority of trauma patients. Polytrauma, spinal, and paediatric trauma patients, plus COVID-19 confirmed or suspicious cases, were managed at another site. Prospective data on all trauma patients undergoing surgery at either site between 16 March 2020 and 31 May 2020 was collated and compared with retrospective review of the same period in 2019. Patient demographics, injury, surgical details, length of stay (LOS), COVID-19 status, and outcome were compared. Results. There were 1,004 urgent orthopaedic trauma patients (604 in 2019; 400 in 2020). Significant reductions in time to theatre and LOS stay were observed. COVID-19 positive status was confirmed in 4.5% (n = 18). The COVID-19 mortality rate was 1.8% (n = 7). Day-case surgery comprised 47.8% (n = 191), none testing positive for COVID-19 or developing clinically significant COVID-19 symptoms requiring readmission, at a minimum of 17 days follow-up. Conclusion. The novel split-site service, segregating suspected or confirmed COVID-19 cases, minimized onward transmission and demonstrated improved outcomes regarding time to surgery and LOS, despite altered working patterns and additional constraints. Day-surgery pathways appear safe regarding COVID-19 transmission. Lessons learned require dissemination and should be sustained in preparation for a potential second wave or, the return of a “normal” non-COVID workload. Cite this article: Bone Joint Open 2020;1-9:568–575

Background. The decision to attempt limb salvage vs to amputate in a significant traumatic limb injury is based on patient´s best predicted outcome. When amputation cannot be avoided the aim is to provide a pain free limb whilst preserving the soft tissue and limb length. Methods. Retrospective study covering 5 years (2011–2016), all the trauma patients requiring lower limb amputation (LLA) included. Demographics, mechanism, type of injury, amputation type, cause and level, theatre trips for stump management were analysed. Results. 19 patients aged 27–93 included. RTC was the leading cause (47%) of LLA. Amputation type: traumatic, caused by the injury itself (31.5%) acute surgical, amputation performed in a limb threatening injury (37%); 72% of them had vascular compromise delayed amputations after failure of limb salvage surgery (31.5%); failed soft tissue coverage and poorly functioning limb were the lead cause (33% each) Type of injury: open fractures (89%), isolated to a limb segment (53%). One level/extended level=9/10 patients. More than 50% of initial amputations were extended with multiple subsequent theatre trips (33/10 patients) for stump management. Conclusions. It was difficult to predict the patients needing an extended amputation. Early MDT and prosthetic rehab service involvement is crucial in LLA decision. When consenting patients for LLA consider a 50% change to extend the initial level of amputation with subsequent theatre trips

Aims. Europe has found itself at the epicentre of the COVID-19 pandemic. Naturally, this has placed added strain onto healthcare systems internationally. It was feared that the impact of the COVID-19 pandemic could overrun the Irish healthcare system. As such, the Irish government opted to introduce a national lockdown on the 27 March 2020 in an attempt to stem the flow of admissions to hospitals. Similar lockdowns in the UK and New Zealand have resulted in reduced emergency department presentations and trauma admissions. The aim of this study is to assess the effect of the national lockdown on trauma presentations to a model-3 hospital in Dublin, Ireland. Methods. A retrospective study was conducted. All emergency department presentations between 27 March 2019 to 27 April 2020 and 27 March 2020 to 27 April 2020 were cross-referenced against the National Integrated Medical Imaging System-Picture Archiving Communication System (NIMIS-PACS) radiology system to identify those with radiologically proven skeletal trauma. These patients were grouped according to sex, age, discharge outcome, mechanism of injury, and injury location. Results. A 21% decrease in radiologically proven trauma was observed on comparison with the same time-period last year. Additionally, a 40% reduction in trauma admissions was observed during the COVID-19 lockdown. A 60% reduction in sports-related injuries and road traffic accident-related injuries was noted during the national lockdown. However, a 17% increase was observed in patients sustaining trauma because of domestic accidents. Conclusion. Variation was observed in both the volume and nature of trauma presentations during the COVID-19 lockdown. As would be expected, a reduction was seen in the number of injuries resulting from outdoor activities. Interestingly, increased rates of domestic injuries were seen during this period which could represent an unintended consequence of the prolonged period of lockdown. Cite this article: Bone Joint Open 2020;1-6:261–266

There is increasing popularity in the use of artificial intelligence and machine-learning techniques to provide diagnostic and prognostic models for various aspects of Trauma & Orthopaedic surgery. However, correct interpretation of these models is difficult for those without specific knowledge of computing or health data science methodology. Lack of current reporting standards leads to the potential for significant heterogeneity in the design and quality of published studies. We provide an overview of machine-learning techniques for the lay individual, including key terminology and best practice reporting guidelines. Cite this article: Bone Joint J 2021;103-B(12):1754–1758

Aims. Frailty greatly increases the risk of adverse outcome of trauma in older people. Frailty detection tools appear to be unsuitable for use in traumatically injured older patients. We therefore aimed to develop a method for detecting frailty in older people sustaining trauma using routinely collected clinical data. Methods. We analyzed prospectively collected registry data from 2,108 patients aged ≥ 65 years who were admitted to a single major trauma centre over five years (1 October 2015 to 31 July 2020). We divided the sample equally into two, creating derivation and validation samples. In the derivation sample, we performed univariate analyses followed by multivariate regression, starting with 27 clinical variables in the registry to predict Clinical Frailty Scale (CFS; range 1 to 9) scores. Bland-Altman analyses were performed in the validation cohort to evaluate any biases between the Nottingham Trauma Frailty Index (NTFI) and the CFS. Results. In the derivation cohort, five of the 27 variables were strongly predictive of the CFS (regression coefficient B = 6.383 (95% confidence interval 5.03 to 7.74), p < 0.001): age, Abbreviated Mental Test score, admission haemoglobin concentration (g/l), pre-admission mobility (needs assistance or not), and mechanism of injury (falls from standing height). In the validation cohort, there was strong agreement between the NTFI and the CFS (mean difference 0.02) with no apparent systematic bias. Conclusion. We have developed a clinically applicable tool using easily and routinely measured physiological and functional parameters, which clinicians and researchers can use to guide patient care and to stratify the analysis of quality improvement and research projects. Cite this article: Bone Joint J 2024;106-B(4):412–418

Background:. Lower limb reconstruction is performed in trauma centres where uplifted tariffs support the treatment of severely injured patients. Calculation of Healthcare Resource Groups (HRG4) codes is affected by the accuracy of clinical coding, determining the financial viability of this service in a district general hospital (DGH). Methods:. A prospective review of coding was performed for 17 sequential patients treated using ring fixation. Relevant clinical codes and HRG4 tariffs were obtained, allowing comparison with operation notes (including pertinent diagnostic information) and implant costs. Hexapod and paediatric cases were excluded. Results:. Mean implant costs were £3,300 and mean tariffs were £9,300. However, the tariffs for the care episodes which did not attract a code for ‘reconstruction’ were lower, averaging £4,300. Clinical outcomes were comparable to published literature. No uplift was received. Discussion:. Despite attempts to avoid mis-coding for the fledgling service and factoring ancillary costs of patient care, the ring fixation procedures which resulted in HRG4 codes other than those for limb reconstruction cost the trust more than it received. Conclusion:. Lower limb reconstruction is barely financially viable even when coding is carefully performed. It is financially easier for this Trust to transfer patients to a trauma centre

At-home softcast removal with no routine clinical follow-up has shown to be safe and effective following paediatric orthopaedic trauma. It minimises clinician contact time and reduces cost. However, there is limited data on the caregiver experience. Retrospective analysis of paediatric fractures requiring application of circumferential softcast that was later removed at home. Two time points were included: (1)July–September 2022, (2)February–April 2023. Demographics data included age, fracture classification, angulation, manipulation requirement, complications or unplanned re-attendance. Caregivers were given an information leaflet on cast removal. Caregivers completed a telephone Likert questionnaire reviewing time taken to remove cast, qualitative descriptors of cast removal and overall satisfaction. 77 families were contacted at mean 93 days post injury. Mean age was 7.5 years. 41(53%) were distal radius and 20(26%) both-bone forearm fractures. The remaining were hand, elbow or tibia injuries. 40(52%) injuries required manipulation under procedural sedation with mean sagittal angulation 24 degrees. 13(17%) patients re-attended with cast problems. Caregivers estimated a mean 13 minutes to remove cast. 83% found it ‘extremely’ or ‘somewhat’ easy. 75% were ‘extremely’ or ‘somewhat’ satisfied. 71% were ‘extremely’ or ‘somewhat’ likely to recommend at-home cast removal. Qualitative descriptors ranged from from ‘traumatising’ to ‘fun’ and ‘straightforward’. The experience at our tertiary centre confirms at-home softcast removal with no further orthopaedic follow-up is safe and feasible, even in those requiring manipulation under sedation. The majority of families reported a positive experience; this however is not universal. Adequate patient information resources are integral to a positive caregiver's experiences

Aims. To compare the early management and mortality of older patients sustaining major orthopaedic trauma with that of a younger population with similar injuries. Patients and Methods. The Trauma Audit Research Network database was reviewed to identify eligible patients admitted between April 2012 and June 2015. Distribution and severity of injury, interventions, comorbidity, critical care episodes and mortality were recorded. The population was divided into young (64 years or younger) and older (65 years and older) patients. Results. Of 142 765 adults sustaining major trauma, 72 942 (51.09 %) had long bone or pelvic fractures and 45.81% of these were > 65 years old. Road traffic collision was the most common mechanism in the young (40.4%) and, in older people, fall from standing height (80.4%) predominated. The 30 day mortality in older patients with fractures is greater (6.8% versus 2.5%), although critical care episodes are more common in the young (18.2% versus 9.7%). Older people are less likely to be admitted to critical care beds and are often managed in isolation by surgeons. Orthopaedic surgery is the most common admitting and operating specialty and, in older people, fracture surgery accounted for 82.1% of procedures. . Conclusion. Orthopaedic trauma in older people is associated with mortality that is significantly greater than for similar fractures in the young. As with the hip fracture population, major trauma in the elderly is a growing concern which highlights the need for a review of admission pathways and shared orthogeriatric care models. . Cite this article: Bone Joint J 2017;99-B:1677–80

The Trauma Triage clinic (TTC) is a Virtual Fracture clinic which permits the direct discharge of simple, isolated fractures from the Emergency Department (ED), with consultant review of the clinical notes and radiographs. This study details the outcomes of patients with such injuries over a four-year period. All TTC records between January 2014 and December 2017 were collated from a prospective database. Fractures of the radial head, little finger metacarpal, fifth metatarsal, toe phalanges and soft tissue mallet finger injuries were included. Application of the direct discharge protocol, and any deviations were noted. All records were then re-assessed at a minimum of three years after TTC triage (mean 4.5 years) to ascertain which injuries re-attended the trauma clinic, reasons for re-attendance, source of referral and any subsequent surgical procedures. 6709 patients with fractures of the radial head (1882), little finger metacarpal (1621), fifth metatarsal (1916), toe phalanges (920) and soft tissue mallet finger injures (370) were identified. 963 (14%) patients were offered in-person review after TTC, of which 45 (0.6%) underwent a surgical intervention. 299 (4%) re-attended after TTC direct discharge at a mean time after injury of 11.9 weeks and 12 (0.2%) underwent surgical intervention. Serious interventions, defined as those in which a surgical procedure may have been avoided if the patient had not undergone direct discharge, occurred in 1 patient (0.01%). Re-intervention after direct discharge of simple injuries of the elbow, hand and foot is low. Unnecessary deviations from protocol offer avenues to optimise consumption of service resources

The aim of this study was to identify the effect of COVID-19 lockdown on the rates, types, mechanisms and mortality of musculoskeletal trauma across Scotland. Data for all musculoskeletal trauma requiring operative treatment was collected prospectively from five orthopaedic units across Scotland during the initial lockdown period (23/03/2020-28/05/2020). This was compared with data for the same timeframe in 2018 and 2019. Data collected included all cases requiring surgery, injury type, mechanism of injury, and inpatient mortality. 1315 patients received operative treatment in 2020 compared to 1791 in 2019 and 1719 in 2018. The numbers of all injury types decreased, but the relative frequency of hip fractures increased(36.3% 2020 vs 30.2% 2019, p<0.0001 & 30.7% 2018, p<0.0001). Significant increases were seen in proportion of DIY-related injuries(3.1% 2020 vs 1.7% 2019, p=0.01 & 1.6% 2018, p<0.01) and injuries caused by falls(65.6% 2020 vs 62.6% 2019, p=0.08 & 61.9% 2018, p=0.05). Significant decreases were seen in proportion of RTCs(2.6% 2020 vs 5.4% 2019, p<0.0001 & 4.2% 2018, p=0.02) and occupational injuries(1.8% 2020 vs 3.0% 2019, p=0.03 & 2.3% 2018, p=0.01). A significant increase in proportion of self-harm injuries was seen(1.7% 2020 vs 1.1% 2019, p=0.19 & 0.5% 2018, p<0.0001). Mortality of trauma patients was significantly higher in 2020 (4.9%), than in 2019 (3.2%, p=0.02) and 2018 (2.6%, p<0.0001). In conclusion, lockdown has resulted in a marked reduction of musculoskeletal trauma requiring surgery in Scotland. There have been major changes in types and mechanisms of injury, and mortality of trauma patients has risen significantly

The October 2014 Trauma Roundup. 360 . looks at: proximal humeral fractures in children; quadrilateral surface plates in transverse acetabular fractures; sleep deprivation and poor outcomes in trauma; bipolar hemiarthroplasty; skeletal traction; forefoot fractures; telemedicine in trauma; ketamine infusion for orthopaedic injuries; and improved functional outcomes seen with trauma networks

Aims. The aims of this study were to report the outcomes of patients with a complex fracture of the lower limb in the five years after they took part in the Wound Healing in Surgery for Trauma (WHIST) trial. Methods. The WHIST trial compared negative pressure wound therapy (NPWT) dressings with standard dressings applied at the end of the first operation for patients undergoing internal fixation of a complex fracture of the lower limb. Complex fractures included periarticular fractures and open fractures when the wound could be closed primarily at the end of the first debridement. A total of 1,548 patients aged ≥ 16 years completed the initial follow-up, six months after injury. In this study we report the pre-planned analysis of outcome data up to five years. Patients reported their Disability Rating Index (DRI) (0 to 100, in which 100 = total disability), and health-related quality of life, chronic pain scores and neuropathic pain scores annually, using a self-reported questionnaire. Complications, including further surgery related to the fracture, were also recorded. Results. A total of 1,015 of the original patients (66%) provided at least one set of outcome data during the five years of follow-up. There was no evidence of a difference in patient-reported disability between the two groups at five years (NPWT group mean DRI 30.0 (SD 26.5), standard dressing group mean DRI 31.5 (SD 28.8), adjusted difference -0.86 (95% CI -4.14 to 2.40; p = 0.609). There was also no evidence of a difference in the complication rates at this time. Conclusion. We found no evidence of a difference in disability ratings between NPWT compared with standard wound dressings in the five years following the surgical treatment of a complex fracture of the lower limb. Patients in both groups reported high levels of persistent disability and reduced quality of life, with little evidence of improvement during this time. Cite this article: Bone Joint J 2024;106-B(8):858–864

Aims. The aim of this study is to determine the effects of the UK lockdown during the COVID-19 pandemic on the orthopaedic admissions, operations, training opportunities, and theatre efficiency in a large district general hospital. Methods. The number of patients referred to the orthopaedic team between 1 April 2020 and 30 April 2020 were collected. Other data collected included patient demographics, number of admissions, number and type of operations performed, and seniority of primary surgeon. Theatre time was collected consisting of anaesthetic time, surgical time, time to leave theatre, and turnaround time. Data were compared to the same period in 2019. Results. There was a significant increase in median age of admitted patients during lockdown (70.5 (interquartile range (IQR) 46.25 to 84) vs 57 (IQR 27 to 79.75); p = 0.017) with a 26% decrease in referrals from 303 to 224 patients and 37% decrease in admissions from 177 to 112 patients, with a significantly higher proportion of hip fracture admissions (33% (n = 37) vs 19% (n = 34); p = 0.011). Paediatric admissions decreased by 72% from 32 to nine patients making up 8% of admissions during lockdown compared to 18.1% the preceding year (p = 0.002) with 66.7% reduction in paediatric operations, from 18 to 6. There was a significant increase in median turnaround time (13 minutes (IQR 12 to 33) vs 60 minutes (IQR 41 to 71); p < 0.001) although there was no significant difference in the anaesthetic time or surgical time. There was a 38% (61 vs 38) decrease in trainee-led operations. Discussion. The lockdown resulted in large decreases in referrals and admissions. Despite this, hip fracture admissions were unaffected and should remain a priority for trauma service planning in future lockdowns. As plans to resume normal elective and trauma services begin, hospitals should focus on minimising theatre turnaround time to maximize theatre efficiency while prioritizing training opportunities. Clinical relevance. Lockdown has resulted in decreases in the trauma burden although hip fractures remain unaffected requiring priority. Theatre turnaround times and training opportunities are affected and should be optimised prior to the resumption of normal services. Cite this article: Bone Joint Open 2020;1-8:494–499

Aims. The UK government declared a national lockdown on 23 March 2020 to reduce transmission of COVID-19. This study aims to identify the effect of lockdown on the rates, types, mechanisms, and mortality of musculoskeletal trauma across Scotland. Methods. Data for all musculoskeletal trauma requiring operative treatment were collected prospectively from five key orthopaedic units across Scotland during lockdown (23 March 2020 to 28 May 2020). This was compared with data for the same timeframe in 2019 and 2018. Data collected included all cases requiring surgery, injury type, mechanism of injury, and inpatient mortality. Results. A total of 1,315 patients received operative treatment from 23 March 2020 to 28 May 2020 compared with 1,791 in 2019 and 1,719 in 2018. The numbers of all injury types decreased, but the relative frequency of hip fractures increased (36.3% in 2020 vs 30.2% in 2019, p < 0.0001 and 30.7% in 2018, p < 0.0001). Significant increases were seen in the proportion of DIY-related injuries (3.1% in 2020 vs 1.7% in 2019, p = 0.012 and 1.6% in 2018, p < 0.005) and injuries caused by falls (65.6% in 2020 vs 62.6% in 2019, p = 0.082 and 61.9% in 2018, p = 0.047). Significant decreases were seen in the proportion of road traffic collisions (2.6% in 2020 vs 5.4% in 2019, p < 0.0001 and 4.2% in 2018, p = 0.016), occupational injuries (1.8% in 2020 vs 3.0% in 2019, p = 0.025 and 2.3% in 2018, p = 0.012) and infections (6.8% in 2020 vs 7.8% in 2019, p = 0.268 and 10.3% in 2018, p < 0.012). Cycling injuries increased (78 in 2020 vs 64 in 2019 vs 42 in 2018). A significant increase in the proportion of self-harm injuries was seen (1.7% in 2020 vs 1.1% in 2019, p = 0.185 and 0.5% in 2018, p < 0.0001). Mortality of trauma patients was significantly higher in 2020 (5.0%) than in 2019 (2.8%, p = 0.002) and 2018 (1.8%, p < 0.0001). Conclusion. The UK COVID-19 lockdown has resulted in a marked reduction in musculoskeletal trauma patients undergoing surgery in Scotland. There have been significant changes in types and mechanisms of injury and, concerningly, mortality of trauma patients has risen significantly. Cite this article: Bone Joint Open 2020;1-9:541–548

In response to the COVID-19 pandemic public health measures were implemented to limit virus spread. After initial implementation of a province-wide lockdown (Stage 1), there followed a sequential ease of restrictions through Stages 2 and 3 over a 6-month period from March to September 2020 (Table 1). We aimed to determine the impact of COVID-19 public health measures on the epidemiology of operative paediatric orthopaedic trauma and to determine differential effects of each stage of lockdown. A retrospective cohort study was performed comparing all emergency department (ED) visits for musculoskeletal trauma and operatively treated orthopaedic trauma cases at a Level-1 paediatric trauma center during Mar-Sep 2020 (pandemic), compared with Mar-Sep 2019 (pre-pandemic). All operative cases were analyzed based on injury severity, mechanism of injury (MOI) and anatomic location (AL). Comparisons between groups were assessed using chi-square testing for categorical variables, and student t-tests and Fisher's exact tests for continuous variables. During the pandemic period, ED visits for orthopaedic trauma decreased compared to pre-pandemic levels by 23% (1370 vs 1790 patients) and operative treatment decreased by 28% (283 vs 391 patients). There was a significant decrease in the number of operative cases per day in lockdown Stage 1 (1.25 pandemic vs 1.90 pre- pandemic; p < 0 .001) and Stage 2 (1.65 pandemic vs 3.03 pre-pandemic; p< 0.001) but no difference in operative case number during Stage 3 (2.18 pandemic vs 2.45 pre-pandemic; p=0.35). Significant differences were found in MOI and AL during Stage 1 (p < 0 .001) and Stage 2 (p < 0 .001) compared to pre-pandemic. During Stage 1 and 2, playground injuries decreased by 95% and 82%, respectively; sports injuries decreased by 79% and 13%, and trampoline injuries decreased 44% and 43%, compared to pre-pandemic. However, self-propelled transit injuries (bicycles/skateboards) increased during Stage 1 and Stage 2 by 67% and 28%, respectively compared to pre- pandemic. During lockdown Stage 3 there were no differences in MOI nor AL. There were no significant differences in injury severity in any lockdown stage compared to pre-pandemic. COVID-19 lockdown measures significantly reduced the burden of operative paediatric orthopaedic trauma. Differences in volume, mechanism and pattern of injuries varied by lockdown stage offering evidence of the burden of operative trauma related to specific childhood activities. These findings will assist health systems planning for future pandemics and suggest that improvements in safety of playgrounds and self-propelled transit are important in reducing severe childhood injury requiring operative intervention. For any figures or tables, please contact the authors directly

The June 2015 Trauma Roundup. 360 . looks at: HIV-related implant surgery in trauma; Major transfusion under the spotlight; Surgery and mortality in elderly acetabular fractures; Traction pin safety; Obesity and trauma; Salvage of acetabular fixation in the longer term

Abstract. Background. Alcohol has been associated with up to 40% trauma-related deaths globally. In response to the Covid-19 pandemic, the United Kingdom (UK) entered a state of ‘lockdown’ on 23. rd. March 2020. Restrictions were most significantly eased on 1. st. June 2020, when shops and schools re-opened. This study aimed to quantify the effect of lockdown on trauma admissions specifically regarding alcohol-related trauma. Methods. All adult patients admitted as ‘trauma calls’ to a London Major Trauma Centre (MTC) during April 2018 and April 2019 (pre-lockdown; N=316), and 1. st. April – 31. st. May 2020 (lockdown; N=191) had electronic patient records (EPR) analysed. Patients’ blood alcohol level (BAC) combined with records of intoxication were used to identify alcohol-related trauma. Multiple regression analyses were performed to compare pre- and post-lockdown alcohol-related trauma admissions. Results. Alcohol-related trauma was present in a significantly higher proportion of adult trauma calls during lockdown (lockdown 60/191 (31.4%), versus pre-lockdown 62/316 (19.6%); Odds Ratio (OR 0.83, 95% CI 0.38 to 1.28, p<0.001). Lockdown was also associated with increased weekend admissions of trauma (lockdown 125/191 weekend (65.5%) vs pre-lockdown 179/316 (56.7%); OR -0.40, 95% CI -0.79 to -0.02, p=0.041). No significant difference existed between the age, gender, or mechanism between pre-lockdown and lockdown cohorts (p>0.05). Conclusion. UK lockdown was independently associated with an increased proportion of alcohol-related trauma. Furthermore, trauma admissions were increased during the weekend when staffing levels are reduced. With the possibility of multiple global ‘waves’ of Covid-19, the risk of long-term repercussions of dangerous alcohol-related behaviour must be addressed

Aims. COVID-19 represents one of the greatest global healthcare challenges in a generation. Orthopaedic departments within the UK have shifted care to manage trauma in ways that minimize exposure to COVID-19. As the incidence of COVID-19 decreases, we explore the impact and risk factors of COVID-19 on patient outcomes within our department. Methods. We retrospectively included all patients who underwent a trauma or urgent orthopaedic procedure from 23 March to 23 April 2020. Electronic records were reviewed for COVID-19 swab results and mortality, and patients were screened by telephone a minimum 14 days postoperatively for symptoms of COVID-19. Results. A total of 214 patients had orthopaedic surgical procedures, with 166 included for analysis. Patients undergoing procedures under general or spinal anaesthesia had a higher risk of contracting perioperative COVID-19 compared to regional/local anaesthesia (p = 0.0058 and p = 0.0007, respectively). In all, 15 patients (9%) had a perioperative diagnosis of COVID-19, 14 of whom had fragility fractures; six died within 30 days of their procedure (40%, 30-day mortality). For proximal femoral fractures, our 30-day mortality was 18.2%, compared to 7% in 2019. Conclusion. Based on our findings, patients undergoing procedures under regional or local anaesthesia have minimal risk of developing COVID-19 perioperatively. Those with multiple comorbidities and fragility fractures have a higher morbidity and mortality if they contract COVID-19 perioperatively; therefore, protective care pathways could go some way to mitigate the risk. Our 30-day mortality of proximal femoral fractures was 18.2% during the COVID-19 pandemic in comparison to the annual national average of 6.1% in 2018 and the University Hospital Coventry average of 7% for the same period in 2019, as reported in the National Hip Fracture Database. Patients undergoing procedures under general or spinal anaesthesia at the peak of the pandemic had a higher risk of contracting perioperative COVID-19 compared to regional block or local anaesthesia. We question whether young patients undergoing day-case procedures under regional block or local anaesthesia with minimal comorbidities require fourteen days self-isolation; instead, we advocate that compliance with personal protective equipment, a negative COVID-19 swab three days prior to surgery, and screening questionnaire may be sufficient. Cite this article: Bone Joint Open 2020;1-9:520–529

The December 2015 Trauma Roundup. 360 . looks at: Delay to surgery in hip fracture; Hexapod fixators in the management of hypertrophic tibial nonunions; Thromboembolism after nailing pathological fractures; Tibial plateau fracture patterns under the spotlight; The health economic effects of long bone nonunion; Adverse outcomes in trauma; The sacral screw in children; Treating the contralateral SUFE

Aims. Virtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on the demographic details of injuries presenting to the VFC, and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines. Methods. This is a national cross-sectional cohort study comprising centres with VFC services across the UK. All consecutive adult patients assessed in VFC in a two-week period pre-lockdown (6 May 2019 to 19 May 2019) and in the same two-week period at the peak of the first lockdown (4 May 2020 to 17 May 2020), and a randomly selected sample during the ‘second wave’ (October 2020) will be eligible for the study. Data comprising local VFC practice, patient and injury characteristics, unplanned re-attendances, and complications will be collected by local investigators for all time periods. A telephone questionnaire will be used to determine patient satisfaction and patient-reported outcomes for patients who were discharged following VFC assessment without face-to-face consultation. Ethics and dissemination. The study results will identify changes in case-mix and numbers of patients managed through VFCs and whether this is safe and associated with patient satisfaction. These data will provide key information for future expert-led consensus on management of trauma injuries through the VFC. The protocol will be disseminated through conferences and peer-reviewed publication. This protocol has been reviewed by the South East Scotland Research Ethics Service and is classified as a multicentre audit. Cite this article: Bone Jt Open 2021;2(3):211–215

Aims. To identify the prevalence of neuropathic pain after lower limb fracture surgery, assess associations with pain severity, quality of life and disability, and determine baseline predictors of chronic neuropathic pain at three and at six months post-injury. Methods. Secondary analysis of a UK multicentre randomized controlled trial (Wound Healing in Surgery for Trauma; WHiST) dataset including adults aged 16 years or over following surgery for lower limb major trauma. The trial recruited 1,547 participants from 24 trauma centres. Neuropathic pain was measured at three and six months using the Doleur Neuropathique Questionnaire (DN4); 701 participants provided a DN4 score at three months and 781 at six months. Overall, 933 participants provided DN4 for at least one time point. Physical disability (Disability Rating Index (DRI) 0 to 100) and health-related quality-of-life (EuroQol five-dimension five-level; EQ-5D-5L) were measured. Candidate predictors of neuropathic pain included sex, age, BMI, injury mechanism, concurrent injury, diabetes, smoking, alcohol, analgaesia use pre-injury, index surgery location, fixation type, Injury Severity Score, open injury, and wound care. Results. The median age of the participants was 51 years (interquartile range 35 to 64). At three and six months post-injury respectively, 32% (222/702) and 30% (234/787) had neuropathic pain, 56% (396/702) and 53% (413/787) had chronic pain without neuropathic characteristics, and the remainder were pain-free. Pain severity was higher among those with neuropathic pain. Linear regression analyses found that those with neuropathic pain at six months post-injury had more physical disability (DRI adjusted mean difference 11.49 (95% confidence interval (CI) 7.84 to 15.14; p < 0.001) and poorer quality of life (EQ-5D utility -0.15 (95% CI -0.19 to -0.11); p < 0.001) compared to those without neuropathic characteristics. Logistic regression identified that prognostic factors of younger age, current smoker, below knee fracture, concurrent injuries, and regular analgaesia pre-injury were associated with higher odds of post-injury neuropathic pain. Conclusion. Pain with neuropathic characteristics is common after lower limb fracture surgery and persists to six months post-injury. Persistent neuropathic pain is associated with substantially poorer recovery. Further attention to identify neuropathic pain post-lower limb injury, predicting patients at risk, and targeting interventions, is indicated. Cite this article: Bone Joint J 2021;103-B(6):1047–1054

The October 2015 Trauma Roundup. 360 . looks at: PCA not the best in resuscitation; Impact of trauma centre care; Quality of life after a hip fracture; Recovery and severity of injury: open tibial fractures in the spotlight; Assessment of the triplane fractures; Signs of an unstable paediatric pelvis; Safe insertion of SI screws: are two views required?; Post-operative delirium under the spotlight; Psychological effects of fractures; K-wires cost effective in DRAFFT

Introduction. Patient Reported Outcome Measures (PROMs) are used as outcome of many surgical treatments such as Hip and knee joint replacements, varicose vein and groin hernia surgery. Outcome scores in orthopaedics tend to be site and/or pathology specific. Trauma related pathology uses a surrogate outcome scores. A unified outcome score for trauma is needed to help with the measurement of outcomes in trauma patients and evaluate the actual impact that trauma inflicts to patients' lives. Materials & Methods. We have designed a PROM especially for Trauma patients, in order to measure the extent of recovery to pre-injury state. This score uses as baseline the pre-injury status of the patient and has the aim to determine the percentage of rehabilitation after any form of treatment. This PROM is not site specific and can be used for every Trauma condition. It uses simple wording, user friendly and accessed via phone conversation. The outcome score consists of eleven questions. The first ten questions use the 5-point Likert scale and the final question a scale from zero to ten. The questions are divided into three subgroups (Symptoms, Function and Mental status). The final question assesses the extent of return to pre-injury status. The SF-12v2 questionnaire was used for the validation of the COST questionnaire. We gathered COST and SF-12v2 questionnaires from patients who were at the end of their follow-up after treatment for various trauma conditions, treated either conservatively either operatively. Results. A total of 50 COST questionnaires were gathered in out outpatients department. The participants were 33 male and 17 female patients (aged 44.2 ±18.9 years) and the questionnaires collected at mean 9.7 months post-injury. A Cronbach's Alpha value of 0.89 was identified for the whole construct. The three dimensions of the scale had good internal consistency as well (Cronbach's Alpha test values 0.73, 0.85 and 0.81 for symptoms, function and mental status respectively). Strong/moderate correlation (Spearman's Rho test 0.45–0.65) was observed between the respective physical/mental dimensions of the COST and SF-12v2 questionnaires. Conclusion. There is a need for a specific PROM for Trauma pathology which is not site specific and easy to use and understand. COST is a useful tool to Trauma surgeons to measure the outcomes of their patients and has high internal consistency

The Victorian state government introduced a trial electronic scooter sharing scheme on 1. st. February 2022 in inner city Melbourne. Despite epidemiological data from other jurisdictions that show these devices are associated with significant trauma. This is a descriptive study from the largest trauma centre in Victoria demonstrating the “scope of the problem” after introduction of this government-approved, ride sharing scheme. Retrospective case series. Our hospital orthopaedic department database was searched from 1/1/2021 to 30/6/22 to identify all presentations associated with electronic scooter trauma, the mechanism of injury and admission information was confirmed via chart review. Data collected included: mode of arrival, alcohol/drug involvement, hospital LOS, injury severity score, ICU admission, list of injuries, operations undertaken, surgical procedures, discharge destination, death. In the 12 months prior to and 5 months since introduction of the ride share scheme, 43 patients were identified. 18 patients (42% of our cohort) presented in the 5 months since ride sharing was introduced, and 25 patients in the preceding 12 months. 58% were found to be alcohol or drug affected. All patients were admitted to hospital, 14% of which included ICU admission. 44% were polytrauma admissions. Median hospital length of stay was 2 days. The longest individual hospital stay was 69 days. No patients in this series died. There were 49 surgical procedures in 35 patients including neurosurgical, plastics and maxillofacial operations. Mean Injury Severity Score was 10. Despite data demonstrating their danger in other jurisdictions, the Victorian state government approved a trial of an electronic scooter ride share scheme in inner Melbourne in February 2022. These devices are associated with a significant trauma burden and the rate has increased since the introduction of the ride-sharing scheme. This data may be combined with other hospital data and could be used to inform policy makers

Venous Thromboembolism (VTE) prophylaxis is an essential part of orthopaedic surgeries in preventing life-threatening thromboembolic events such as Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). Orthopaedic surgery has the highest incidence rate of thromboembolic events as compared to any other surgical specialities, making it an essential component in managing any orthopaedic case. At Queen's Medical Centre (QMC), a major trauma centre in the United Kingdom (UK), sees up to 750 NOF fracture cases annually, making it one of the busiest trauma and orthopaedic centres in the UK. Our study aims to evaluate how VTE Prophylaxis is conducted in a UK Major Trauma Centre for NOF and pelvic fragility fractures and how human factors can improve its efficacy. The Nottingham University Hospitals (NUH) Trust has implemented new guidelines from August 2019 that patients with fragility fractures such as NOF and pelvic fractures are prescribed with 28 days VTE prophylaxis with Enoxaparin, or their own anti-coagulants if risk of thrombosis exceed the risk of bleeding. This is an adaptation from the trust to align their guidelines closer to the NICE 2018 guidelines. We will be evaluating the initial compliance of VTE Prophylaxis, identify and utilise human factors, then re-analyse the department after implementing interventions on the same batch of junior doctors working in the department. Data of 100 patients with fragility fractures were collected, 50 consecutive patients in the pre-intervention window during August 2019 and 50 in the post-intervention window during November 2019. The pre-intervention data had 43 NOF and 7 Pelvic fractures. Our study showed that 93% of NOF fracture and 100% of pelvic fracture received the correct course of VTE prophylaxis. The data was presented at the local department junior doctor academic session. Three simple human factor interventions were implemented over the course of September and October: Education to the trauma and orthopaedic department on the new guideline, extended VTE labels on drug charts for patients with fragility fractures, VTE reminder labels at doctors' stations. Another 50 consecutive patients' data were collected during November 2019. Data shows that 97.8% of NOF (p>0.05) and 60% of pelvic fracture (p>0.05) received the correct course of VTE prophylaxis. Our data has shown an increase in correct VTE prescription for NOF fracture patients, which is the main bulk of our fragility fracture patients whilst we see a drop in pelvic fracture patients. Due to the limited time frame of four months where junior doctors in the UK rotate between specialities, we are only able to collect data during the first month, implement interventions between datasets and collect data on the final month of the four-month rotation. A future bigger study might provide a more significant result on the department. We believe that the key to achieving 100% VTE prophylaxis in the T&O department is optimising human factors, educating junior doctors, who are not orthopaedic trained, with sufficient information of the guidelines, and evidence of the risk and benefits of providing prolonged VTE prophylaxis for orthopaedic patients. In conclusion, we found that QMC, a major trauma centre with high patient volume and turnover, has a high level of compliance with VTE prophylaxis for fragility fractures and it is imperative that utilising human factors will inch the department closer to its goal of 100% VTE compliance

The June 2014 Trauma Roundup. 360 . looks at: BMP use increasing wound complication rates in trauma surgery; can we predict re-admission in trauma?; humeral bundle nailing; how best to treat high-angle femoral neck fractures?; hyperglycaemia and infection; simultaneous soft-tissue and bony repair in terrible triad injuries; metaphyseal malunion in the forearm leading to function restrictions; delayed fixation of the distal radius: not a bad option; and fasciotomies better with shoelaces

The October 2013 Trauma Roundup. 360 . looks at: Radiological, electromagnetic or just leave it out altogether?: distal locking in intramedullary nailing; Internal fixation of radiation-induced pathological fractures of the femur has a high rate of failure; Obesity and trauma; Short and sweet?: antibiotics in open fractures; Extremity injuries more important than previously thought?; Cement nails tiptop for osteomyelitis; Oxygen measurements for compartment syndrome?

The December 2012 Trauma Roundup. 360. looks at: whether tranexamic acid stops bleeding in trauma across the board; antibiotic beads and VAC; whether anaesthetic determines the outcome in surgery for distal radial fractures; high complications in surgery on bisphosphonate-hardened bone; better outcomes but more dislocations in femoral neck fractures; the mythical hip fracture; plate augmentation in nonunion surgery; and SIGN intramedullary nailing and infections

The February 2015 Trauma Roundup. 360 . looks at: Evaluating the syndesmosis in ankle fractures; Calcaneal fracture management an ongoing problem; Angular stable locking in low tibial fractures did not improve results; Open fractures: do the seconds really count?; Long-term outcomes of tibial fractures; Targeted performance improvements in pelvic fractures

The April 2015 Trauma Roundup. 360 . looks at: Negative presure wound therapy in open tibial fractures; Priority-driven approach to pelvic injuries; Early surgery essential in hip fracture management; Sheer fractures to the posteromedial plateau; Fasciotomy closure under the spotlight; Why do patients die from hip fracture?; Acetabular fractures down the line; Biomechanics of femoral neck fractures reviewed

The December 2014 Trauma Roundup. 360 . looks at: infection and temporising external fixation; Vitamin C in distal radial fractures; DRAFFT: Cheap and cheerful Kirschner wires win out; femoral neck fractures not as stable as they might be; displaced sacral fractures give high morbidity and mortality; sanders and calcaneal fractures: a 20-year experience; bleeding and pelvic fractures; optimising timing for acetabular fractures; and tibial plateau fractures

The June 2024 Trauma Roundup. 360. looks at: Skin antisepsis before surgical fixation of limb fractures; Comparative analysis of intramedullary nail versus plate fixation for fibula fracture in supination external rotation type IV ankle injury; Early weightbearing versus late weightbearing after intramedullary nailing for distal femoral fracture (AO/OTA 33) in elderly patients: a multicentre propensity-matched study; Long-term outcomes with spinal versus general anaesthesia for hip fracture surgery; Operative versus nonoperative management of unstable medial malleolus fractures: a randomized clinical trial; Impact of smoking status on fracture-related infection characteristics and outcomes; Reassessing empirical antimicrobial choices in fracture-related infections; Development and validation of the Nottingham Trauma Frailty Index (NTFI) for older trauma patients

The August 2015 Trauma Roundup. 360 . looks at: Thromboprophylaxis not required in lower limb fractures; Subclinical thyroid dysfunction and fracture risk: moving the boundaries in fracture; Posterior wall fractures refined; Neurological injury and acetabular fracture surgery; Posterior tibial plateau fixation; Tibial plateau fractures in the longer term; Comprehensive orthogeriatric care and hip fracture; Compartment syndrome: in the eye of the beholder?

The August 2014 Trauma Roundup. 360 . looks at: On-table CT for calcaneal fractures; timing of femoral fracture surgery and outcomes; salvage arthroplasty for failed internal fixation of the femoral neck; screw insertion in osteoporotic bone; fibular intramedullary nailing on the ascendant; posterior wall acetabular fractures not all that innocent; bugs, plating and resistance and improving outcomes in olecranon tension band wiring

Purpose. To examine the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss. Method. A retrospective review was conducted identifying patients from our trauma database. Inclusion criteria were age (4–17 years) and open lower-limb trauma. Outcome measures included time to soft tissue coverage, surgical techniques, trauma impact scores, health-related quality of life, union and complication rates. Results. We identified 26 patients. 24 patients had open tibia fractures including 10 patients with bone loss. In 9 patients primary skin closure was achieved by acute shortening. 17 patients required soft tissue coverage including 14 free vascularised muscle flaps (89% within 48 hours). The surgical techniques applied were: circular fine wire frame (16), external fixateur (5) and open reduction internal fixation (5). Median follow up time was 8 (3–45) months. The trauma impact scores showed one in three patients were at risk of PTSD. All fractures went on to unite over a median time of 4.2 (2–9) months. No deep infections occurred. Conclusion. All our patients had limb salvage, fracture union and near normal levels of physical scores in the short term. Close psychological follow up is advisable to minimise the risk of PTSD

The February 2013 Trauma Roundup. 360 . looks at: the risk of ankle fractures; absorbable implants; minimally invasive heel fracture fixation; pertrochanteric fractures; arthroplasty and intracapsular hip fractures; and extensor mechanism disruption

The June 2013 Trauma Roundup. 360 . looks at: open foot fractures; the diagnostic accuracy of continuous compartment pressure monitoring; conservative treatment for supracondylar fractures; high complication rates in patellar fractures; vitamin D and fracture; better function with K-wires; and tensionless bands

The April 2014 Trauma Roundup. 360 . looks at: is it safe to primarily close dog bite wounds?; conservative transfusion evidence based in hip fracture surgery; tibial nonunion is devastating to quality of life; sexual dysfunction after traumatic pelvic fracture; hemiarthroplasty versus fixation in displaced femoral neck fractures; silver VAC dressings “Gold Standard” in massive wounds; dual plating for talar neck fracture; syndesmosis and fibular length easiest errors in ankle fracture surgery; and dual mobility: stable as a rock in fracture

The February 2014 Trauma Roundup. 360 . looks at: predicting nonunion; compartment Syndrome; octogenarian RTCs; does HIV status affect decision making in open tibial fractures?; flap timing and related complications; proximal humeral fractures under the spotlight; restoration of hip architecture with bipolar hemiarthroplasty in the elderly; and short versus long cephalomedullary nails for the treatment of intertrochanteric hip fractures in patients over 65 years

Trauma and elective orthopaedic demands in New Zealand are increasing. In this study, prospective and retrospective data has been collected at Nelson Hospital and across New Zealand to identify the percentage of elective theatre time lost due to cancellation for acute patient care. Data has been collected from theatre management systems, hospital data systems and logged against secretarial case bookings, to calculate a percentage of elective theatre time lost to acute operating or insufficient bed capacity. Data was collected over a five-month period at Nelson Hospital, with a total of 215 elective and 226 acute orthopaedic procedures completed. A total of 95 primary hip or knee arthroplasties were completed during this trial while 53 were cancelled. The total number of elective operative sessions (one session is the equivalent of a half day operating theatre time) lost to acute workload was 47.9. Thirty-three percent of allocated elective theatre time was cancelled - an equivalent of approximately one-full day elective operating per week. Over a five-week period data was collected across all provincial hospitals in New Zealand, with an average of 18% of elective operating time per week lost due to acute workload. Elective cancellations were due to acute operating 40% of the time and bed shortages 60% of the time. The worst effected centre was Palmerston North which had an average of 33% of elective operating cancelled per week to accommodate acute surgery or due to bed shortages. New Zealand's provincial orthopaedic surgeons are under immense pressure from acute operating that impedes provision of elective surgery. The New Zealand government definition of an ‘acute case’ does not reflect the nature of today's orthopaedic burden. Increasing and aging populations along with staff and infrastructure shortages have financial and societal impacts beyond medicine and require better definitions, further research, and funding from governance

Introduction. Blunt trauma of the lower limb can lead to vascular injury causing devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). Secondary aims included establishing the patient complications and outcomes. Materials and Methods. Retrospective analysis found that from 2013–18, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury. Long-term functional outcomes were determined using postal and telephone questionnaires. Results. Twenty-four patients were male and 6 were female, their mean ages were 32 and 49 respectively. Of the 32 limbs, 27 (84%) were salvaged. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Eleven limbs had prophylactic fasciotomies, 3 limbs developed compartment syndrome – all successfully treated, and three contracted deep infections – one of which necessitated amputation. All but 1 patient survived their injuries and were discharged from hospital. Of the 15 questionnaire responses, self-reported limb function was understandably worse post-injury with patients experiencing mild pain on average. In addition, there was a long-standing psychological impact and the injuries altered many patients’ normal lives significantly, 10 experiencing financial difficulties and 6 having changed or lost jobs post-injury. Conclusions. Fortunately, 27 (84%) limbs were salvaged and nearly all patients survived these injuries when treated at an MTC. Whilst the number of complications was low, the future challenges these patients face are wide-ranging and significant

The April 2013 Trauma Roundup. 360 . looks at: ankle sprains; paediatric knee haemarthroses; evidence to support a belief; ‘Moonboot’ saves the day; pamphlets and outcomes; poor gait in pilons; lactate and surgical timing; and marginal results with marginal impaction

The December 2013 Trauma Roundup. 360 . looks at: Re-operation for intertrochanteric hip fractures; Are twin incisions better than one round the acetabulum?; Salvage osteotomy for calcaneal fractures; Posterior dislocation; Should MRSA be covered in open fractures?; Characterising the saline load test; Has it healed: hip fractures under the spotlight; and stem cells present in atrophic non-union

The August 2012 Trauma Roundup. 360. looks at: pelvic fractures, thromboembolism and the Japanese; venous thromboembolism risk after pelvic and acetabular fractures; the displaced clavicular fracture; whether to use a nail or plate for the displaced fracture of the distal tibia; the dangers of snowboarding; how to predict the outcome of lower leg blast injuries; compressive external fixation for the displaced patellar fracture; broken hips in Morocco; and spinal trauma in mainland China

Hip fractures in elderly patients are managed at both major trauma centers (MTC) and trauma units (TU). Previous evidence has demonstrated the importance of early surgery to reduce the morbidity and mortality related to the injury. The aim of this study is to compare the ‘time to theatre' and ‘30 day mortality' in TUs versus MTC in UK. A retrospective review of prospectively collected data on NHFD was performed. The average ‘time to theatre' in hours and ‘30 day mortality' of all hospitals were analysed between January and December 2018. Further subgroup analysis was done to check for any regional variations; in each instance a Shapiro-Wilk test was used to check for normal distribution, followed by a one-way ANOVA with a Tukey's post hoc test. Data from 158 hospitals in England (ENG), Wales (WAL) and Northern Ireland (NI) were used; 18 of which were MTC. There were 57,936 operative cases in TUs and 8606 in MTC's. The mean time (hours) to surgery from presentation was 32.51 and 32.64 for TUs and MTC respectively (p=0.513). There was no significant difference in ‘30 day mortality' (p=0.635) between TUs (6%) and 5.7% MTC's (5.7%), MTC's and TUs in ENG, WAL and NI (p=0.555), and MTC and WAL, NI and the different regions of ENG (p=0.209). A significant difference was observed, between the regional practice for TUs versus MTC's in ENG, WAL and NI (p=0.001) and between MTC's and TUs in WAL, NI and the different regions of ENG (p=0.001), with patients waiting significantly longer in NI for their procedure (mean=60.25 hours, p=0.001). There was no significant difference in time to surgery or 30 day mortality between TUs and MTC's, demonstrating comparable hip fracture care, despite MTCs need to prioritise more serious injuries

Abstract. Background. University Hospital of Wales (UHW) went live as a Major Trauma Centre (MTC) on the 14th September 2020. New guidelines have been set up by the Wales Trauma Network. Aim. Prospective audit to see how many admissions, correct pathways were followed?. Materials & Methods. Prospective data collection prospective over a period of 3 months: starting from 8.11.2020 to 31.01.2021. Results. Spinal admissions represent around 22% of MTC admissions. The closing loop showed higher amount of admission (45 in comparison with the first audit 28). 42 patients had fractures where three had cord syndromes. 13 patients out of the 45 (29%) were managed operatively. After changing to MTC, more indirect referral from other hospitals representing 64% of total admission with one wrong referral (2.2%) that came to the MTC and could have been managed locally. On the other hand, repatriation rate has improved from 61% to 84%, however, repatriation time was longer than expected with >1 week represents 78%. Conclusions. Changing to MTC had a great impact with increased work load in the trust. Repatriation would be aimed for within 72 hours from treatment either conservative or postoperative. More attention should be paid towards the appropriate referral pathways to avoid wrong referral

The June 2012 Trauma Roundup. 360. looks at: nerve injuries of warfare; the medical complications of earthquakes; the measuring of tissue pressures in compartment syndrome; the risk of plunging through the bone when drilling; bony nonunion and negative pressure therapy; surgery for the posteriorly dislocated hip; whether to use the sliding screw or intramedullary nail for the trochanteric fracture; antegrade interlocking nailing for the distal femoral fracture; and gunshot wounds to the pancreas

The August 2024 Trauma Roundup. 360. looks at: Does topical vancomycin prevent fracture-related infections in closed fractures undergoing open reduction and internal fixation? A randomized controlled trial; Is postoperative splinting advantageous after upper limb fracture surgery?; Does suprapatellar nailing resolve knee pain?; Locking versus non-locking plate fixation in comminuted talar neck fractures: a biomechanical study using cadaveric specimens; Revolutionizing recovery metrics: PROMIS versus SMFA in orthopaedic trauma care; Dorsal hook plating of patella fractures: reliable fixation and satisfactory outcomes; The impact of obesity on subtrochanteric femur fracture outcomes; Low-dose NSAIDs (ketorolac) and cytokine modulation in orthopaedic polytrauma: a detailed analysis

Introduction. Open fractures are managed in the UK guided by standards issued by the BOAST-4 standards. A study was undertaken to evaluate compliance with these standards in a regional trauma unit (MTU), and compared following upgrading to a Major Trauma Centre (MTC). Methods. Compliance was assessed against 11 of the 15 BOAST-4 standards (7, 9, 10 and 15 were not assessed). Patients were included with open diaphyseal tibial fractures (AO 42-), admitted to the department in the year before and the year after the Major Trauma Centre opened. Results. A total of 78 patients were evaluated; 30 within the MTU and 48 as a MTC. Of the 11 standards assessed, 6 (at least in part), achieved 100% compliance in the MTU study, and 5 in the MTC study. Compliance was poor for; antibiotic use in relation to definitive wound closure, formulating a joint plan, and undergoing surgery on a planned trauma list. In contrast, following MTC status antibiotic compliance had improved, as had evidence of joint planning, although antibiotic administration time on admission had declined. Consultant-level orthopaedic and plastic surgeon involvement at first intervention had improved, although plastic surgical input remained predominantly registrar-led. Time from injury to definitive stabilisation improved following MTS status. Discussion. This study demonstrates improvements in many aspects of care for open fracture since the MTC opened. However, further improvements can be made, particularly regarding the early treatment pathway. Since this audit a plastic surgeon with specific interest in lower limb reconstruction has been appointed

The August 2013 Trauma Roundup. 360 . looks at: reverse oblique fractures do better with a cephalomedullary device; locking screws confer no advantage in tibial plateau fractures; it’s all about the radius of curvature; radius of curvature revisited; radial head replacement in complex elbow reconstruction; stem cells in early fracture haematoma; heterotrophic ossification in forearms; and Boston in perspective

Aims. Machine-learning (ML) prediction models in orthopaedic trauma hold great promise in assisting clinicians in various tasks, such as personalized risk stratification. However, an overview of current applications and critical appraisal to peer-reviewed guidelines is lacking. The objectives of this study are to 1) provide an overview of current ML prediction models in orthopaedic trauma; 2) evaluate the completeness of reporting following the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement; and 3) assess the risk of bias following the Prediction model Risk Of Bias Assessment Tool (PROBAST) tool. Methods. A systematic search screening 3,252 studies identified 45 ML-based prediction models in orthopaedic trauma up to January 2023. The TRIPOD statement assessed transparent reporting and the PROBAST tool the risk of bias. Results. A total of 40 studies reported on training and internal validation; four studies performed both development and external validation, and one study performed only external validation. The most commonly reported outcomes were mortality (33%, 15/45) and length of hospital stay (9%, 4/45), and the majority of prediction models were developed in the hip fracture population (60%, 27/45). The overall median completeness for the TRIPOD statement was 62% (interquartile range 30 to 81%). The overall risk of bias in the PROBAST tool was low in 24% (11/45), high in 69% (31/45), and unclear in 7% (3/45) of the studies. High risk of bias was mainly due to analysis domain concerns including small datasets with low number of outcomes, complete-case analysis in case of missing data, and no reporting of performance measures. Conclusion. The results of this study showed that despite a myriad of potential clinically useful applications, a substantial part of ML studies in orthopaedic trauma lack transparent reporting, and are at high risk of bias. These problems must be resolved by following established guidelines to instil confidence in ML models among patients and clinicians. Otherwise, there will remain a sizeable gap between the development of ML prediction models and their clinical application in our day-to-day orthopaedic trauma practice. Cite this article: Bone Jt Open 2024;5(1):9–19

Aims

It is imperative to understand the risks of operating on urgent cases during the COVID-19 (SARS-Cov-2 virus) pandemic for clinical decision-making and medical resource planning. The primary aim was to determine the mortality risk and associated variables when operating on urgent cases during the COVID-19 pandemic. The secondary objective was to assess differences in the outcome of patients treated between sites treating COVID-19 and a separate surgical site.

The beneficial effects of therapeutic hypothermia have been capitalised upon in fields such as cardiac surgery for several decades. Hypothermia not only slows metabolism and consumption of metabolic substrates, but also confers cellular protection against ischaemia and reperfusion. Hypothermia has historically been considered as something to avoid in trauma casualties, with coagulopathy being the main concern. There is now increasing evidence for the role of controlled therapeutic hypothermia in trauma, particularly improved functional outcomes following brain injury and the utility of ‘suspended animation’ or ‘emergency preservation’ in the resuscitation of severe haemorrhagic shock. With the ongoing ‘Eurotherm’ trial of hypothermia in the treatment of traumatic brain injury, and the imminent launch of the ‘Emergency Preservation and Resuscitation (EPR) for Cardiac Arrest From Trauma’ clinical trial in the USA, this presentation will provide a timely overview of the developments of therapeutic hypothermia in trauma management

Aims. The Edinburgh Trauma Triage Clinic (TTC) streamlines outpatient care through consultant-led ‘virtual’ triage of referrals and the direct discharge of minor fractures from the Emergency Department. We compared the patient outcomes for simple fractures of the radial head, little finger metacarpal, and fifth metatarsal before and after the implementation of the TTC. Patients and Methods. A total of 628 patients who had sustained these injuries over a one-year period were identified. There were 337 patients in the pre-TTC group and 289 in the post-TTC group. The Disabilities of the Arm, Shoulder and Hand Score (QuickDASH) or Foot and Ankle Disability Index (FADI), EuroQol-5D (EQ-5D), visual analogue scale (VAS) pain score, satisfaction rates, and return to work/sport were assessed six months post-injury. The development of late complications was excluded by an electronic record evaluation at three years post-injury. A cost analysis was performed. Results. Outcomes were as good or better post-TTC, compared with pre-TTC scores. At three years, the pre-TTC group required a total of 496 fracture clinic appointments compared with 61 in the post-TTC group. Mean cost per patient was nearly fourfold less after the commencement of the TTC. Conclusion. Management of minor fractures through the Edinburgh TTC results in clinical outcomes that are comparable with the previous system of routine face-to-face consultation. Outpatient workload for these injures was reduced by 88%. Cite this article: Bone Joint J 2018;100-B:959–65

The “Golden Patient” is suitability worked up to be the first theatre case of the day; the aim being to improve theatre efficiency. A previous audit of theatre activity demonstrated that the average knife to skin time being achieved across 3 daily trauma lists was 10.12. Over 2-months we introduced a Golden Patient Pathway and completed the audit cycle. The pathway involved a checklist to ensure the completion of essential clinical tasks for each designated golden patient. Activities from 74 trauma theatre cases were reviewed. 47 golden patients remained first whilst 27 were deferred for reasons including non-suitability for golden patient status and emergent cases given clinical priority. The average theatre call time was 24 minutes earlier and the average knife-to-skin time was 15 minutes earlier than non-golden patients during the re-audit. However, when compared to the initial audit the knife-to-skin time had only improved by 3 minutes. Reasons effecting theatre efficiency are multifactorial and other organisational changes had occurred between the audits. This study demonstrates that while the Golden Patient Pathway can improve theatre start times it is not the whole solution. Communication, anaesthetic job plans, portering arrangements, equipment storage and theatre staffing also need to be reviewed

Abstract. Background. Different surgical sub specialities rely on fixed number of porters each morning to bring patients to operating theatre. In daily morning trauma meetings usual practice is to present the whole list of one theatre and then move on to next theatre list. Once all the theatres trauma list are presented, porters are sent to get patients to theatre. With different sub-specialities starting simultaneously and competing for fixed numbers of porters, this can cause significant delay in getting the patients to anaesthetic room. Methods. Retrospective pilot project in level 1 major trauma centre were more that two trauma list a day is a common norm. Pilot project:. First (Golden) patient for every trauma list would be presented at the start of the trauma meeting. Meeting would pause and consultant chairing the meeting would request the trauma theatre representative to send for these patients. Once this is done the meeting would recommence as usual. Results. (a). The porters were sent on an average more than 30 minutes earlier in the pilot week. (b). This was further reflected in the patients being brought into holding bay. (c). The patients were in the anaesthetic room on an average 40 minutes before in pilot group compared to usual practice. Conclusion/Findings. Presenting first patient of each trauma list and then asking theatre to send porter to get the patient to theatre can save appreciable time. Implications. To run an hour of theatre costs £1200. This initiative can save lot of money for NHS

Aims. Hand trauma, consisting of injuries to both the hand and the wrist, are a common injury seen worldwide. The global age-standardized incidence of hand trauma exceeds 179 per 100,000. Hand trauma may require surgical management and therefore result in significant costs to both healthcare systems and society. Surgical site infections (SSIs) are common following all surgical interventions, and within hand surgery the risk of SSI is at least 5%. SSI following hand trauma surgery results in significant costs to healthcare systems with estimations of over £450 per patient. The World Health Organization (WHO) have produced international guidelines to help prevent SSIs. However, it is unclear what variability exists in the adherence to these guidelines within hand trauma. The aim is to assess compliance to the WHO global guidelines in prevention of SSI in hand trauma. Methods. This will be an international, multicentre audit comparing antimicrobial practices in hand trauma to the standards outlined by WHO. Through the Reconstructive Surgery Trials Network (RSTN), hand surgeons across the globe will be invited to participate in the study. Consultant surgeons/associate specialists managing hand trauma and members of the multidisciplinary team will be identified at participating sites. Teams will be asked to collect data prospectively on a minimum of 20 consecutive patients. The audit will run for eight months. Data collected will include injury details, initial management, hand trauma team management, operation details, postoperative care, and antimicrobial techniques used throughout. Adherence to WHO global guidelines for SSI will be summarized using descriptive statistics across each criteria. Discussion. The Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) will provide an understanding of the current antimicrobial practice in hand trauma surgery. This will then provide a basis to guide further research in the field. The findings of this study will be disseminated via conference presentations and a peer-reviewed publication. Cite this article: Bone Jt Open 2024;5(4):361–366

There is evidence that fracture healing is delayed in severely injured patients. We recently demonstrated that a blunt chest trauma, which induced posttraumatic systemic inflammation, considerably impaired fracture healing in rats. Because the complement anaphylatoxin C5a is an important trigger of systemic inflammation, we tested the hypothesis, whether the impairment of fracture healing observed after a severe trauma resulted from systemically activated complement. 16 male Wistar rats received a thoracic trauma and a femur osteotomy stabilized by an external fixator. Immediately and 12 h after the trauma, half of the animals received a C5aR-antagonist to prevent the C5a-dependent systemic inflammation. Control rats received a nonsense peptide, which does not provoke any biological effect. The animals were killed after 35 days and the calli were analyzed by three point bending testing, μCT and histomorphometry. Statistics: Mann-Whitney U test, level of significance to p<0.05. The treatment with the C5aR-antagonist increased flexural rigidity significantly by 55%, improved bony bridging of the fracture gap and led to a slightly larger and qualitatively improved callus as evaluated by μCT and histological measurements. This study shows, that the immunomodulation by a C5aR-antagonist significantly reduced the deleterious effects of a thoracic trauma on fracture healing. C5a could possibly represent a target to prevent delayed bone healing in patients with severe trauma

Queensland is in the phase to develop a comprehensive, integrated state wide Trauma System with support from the Queensland Health and Emergency Services. A strategic step in this circumstance is benchmarking the current trauma system with other established trauma systems, to compare performance and indicators of trauma care. Queensland’s first recognized Adult Major Trauma Service, the Princess Alexandra Hospital (PAH) in Brisbane, was compared with the results of the established Trauma Registry of the German Trauma Society (DGU). This study analysed the whole range of trauma care, from the scene of the accident to discharge from the hospital. Methodology: The study populations were retrospectively identified and extracted from the Queensland Trauma Registry and the DGU Trauma Registry. Both databases contain all primary and secondary admitted trauma patients of all ages, with an Injury Severity Score (ISS) > 15, for the year 2005. The collected patient data included demographics, mechanism of injury, details on pre-hospital phase, injury, treatment, complications and outcome. Results: At the PAH 309 patients with an ISS > 15 were treated, compared to 2537 in the DGU Registry. The demographics (age and gender) and trauma mechanisms (blunt vs penetrating injuries) were comparable, even the average ISS scores were higher in the DGU registry (29) than at PAH (25). The primary referrals from the accident scene to the PA Hospital were significantly lower (52%) than to the German Trauma centres (82%). The secondary referrals arrived at PA Hospital on average 13.5 hrs post accident compared to 3.4 hrs in the DGU registry. PAH patients less often needed surgery (61% versus 78%), ICU-admission (49% versus 88%) and mechanical ventilation (44% versus 72%). The average time of the patients in ED was significantly higher with almost 4 hrs compared to 1 hrs in the German trauma centres. Nevertheless the overall mortality was lower at PA Hospital: 10% versus 18%, with an equal time to death, age and injury severity of deaths. Conclusions: Queensland’s enormous size entails significant implications for trauma care. The results of the benchmarking study may reflect an suboptimal care in the first crucial hours after the accident leading to a higher secondary referral rate and a lower ISS score of the arriving patients to PA Hospital. The relatively low number of in-hospital deaths was presumably due to a higher number of prehospital deaths, although we are unable to quantify this at present. The in hospital clinical course was elongated in the ED at PA Hospital, and several reasons can be discussed for this. This benchmarking study helps to reflect the current trauma care coming to PA Hospital, even many issues remain unanswered in a retrospective study. This presentation will review the integrated approach of Queensland to streamline the trauma care and highlights the first steps taken to improve the efficiency of the system

The February 2024 Trauma Roundup. 360. looks at: Posterior malleolus fractures: what about medium-sized fragments?; Acute or delayed total hip arthroplasty after acetabular fracture fixation?; Intrawound antibiotics reduce the risk of deep infections in fracture fixation; Does the VANCO trial represent real world patients?; Can a restrictive transfusion protocol be effective beyond initial resuscitation?; What risk factors result in avascular necrosis of the talus?; Pre-existing anxiety and mood disorders have a role to play in complex regional pain syndrome; Three- and four-part proximal humeral fractures at ten years

The June 2023 Trauma Roundup. 360. looks at: Aspirin or low-molecular-weight heparin for thromboprophylaxis?; Lateral plating or retrograde nailing for distal femur fractures?; Sciatic nerve palsy after acetabular fixation: what about patient position?; How reliable is the new OTA/AO classification for trochanteric hip fractures?; Young hip fractures: is a medial buttress the answer?; When is the best time to ‘flap’ an open fracture?; The mortality burden of nonoperatively managed hip fractures

The October 2023 Trauma Roundup. 360. looks at: Intramedullary nailing versus sliding hip screw in trochanteric fracture management: the INSITE randomized clinical trial; Five-year outcomes for patients with a displaced fracture of the distal tibia; Direct anterior versus anterolateral approach in hip joint hemiarthroplasty; Proximal humerus fractures: treat them all nonoperatively?; Tranexamic acid administration by prehospital personnel; Locked plating versus nailing for proximal tibia fractures: a multicentre randomized controlled trial; A retrospective review of the rate of septic knee arthritis after retrograde femoral nailing for traumatic femoral fractures at a single academic institution

Trauma, across the United Kingdom, is managed using several software, paper based lists on Microsoft Word/Excel or Teams. There is usually poor handover or no handover in a standard format- during the on call, in the trauma meetings or in the wards. The software in the market for trauma management are not cost friendly or adaptable to local demands. The alternatives like Microsoft WORD based lists are fraught with their own problems. We endeavoured to make our trauma management effective. A Quality Improvement Project was done. The goals to achieve at end of a year were:. Daily Trauma Handover in standardised format >90%. Ward Handover in standardised format >90%. Availability of outcomes of patients in clinic >80%. Reduction of paper usage >90% at the end of six months. Availability of updated “outliers” information >90% at the weekend ward round. Documentation from the Trauma Meeting > 90%. On-Call documentation in standardised format >90%. Doctor Satisfaction >75% in terms of: ease of us;, searchability of patient; ward round experience; morning trauma meeting experience; handover experience; inter-specialty communication; reliability; daily time saving; on-call time saving; patient care/safety; overall satisfaction. We used Microsoft Sharepoint List to manage our trauma workload and have named the tool as “The List”. The List has achieved all objectives as above in one year's time, except Outlier information which was at 67% in a recent PDSA (Plan-Do-Study-Act) cycle. The survey showed excellent doctor satisfaction and 90% respondents felt that The List saved an hour or more during the on-call and also during the ward rounds. We conclude that The List is a very powerful tool making trauma meetings efficient and handover effective. It is indigenous, adaptable, safe, sustainable, cost neutral and easy to use

The August 2023 Trauma Roundup. 360. looks at: A comparison of functional cast and volar-flexion ulnar deviation for dorsally displaced distal radius fractures; Give your stable ankle fractures some AIR!; Early stabilization of rib fractures – an effective thing to do?; Locked plating versus nailing for proximal tibia fractures: A multicentre randomized controlled trial; Time to flap coverage in open tibia fractures; Does tranexamic acid affect the incidence of heterotropic ossification around the elbow?; High BMI – good or bad in surgical fixation of hip fractures?

The December 2023 Trauma Roundup. 360. looks at: Distal femoral arthroplasty: medical risks under the spotlight; Quads repair: tunnels or anchors?; Complex trade-offs in treating severe tibial fractures: limb salvage versus primary amputation; Middle-sized posterior malleolus fractures – to fix?; Bone transport through induced membrane: a randomized controlled trial; Displaced geriatric femoral neck fractures; Risk factors for reoperation to promote union in 1,111 distal femur fractures; New versus old – reliability of the OTA/AO classification for trochanteric hip fractures; Risk factors for fracture-related infection after ankle fracture surgery

Determine the prevalence, etiologies, and risk factors of unplanned return to the OR (UROR) in adult orthopaedic trauma patients. Retrospective review of a trauma prospective registry from 2014 – 2019 at a Level 1 academic hospital. An UROR was defined as a patient returning to OR unexpectedly following a planned definitive surgery to either readdress the presenting diagnosis or address a complication arising from the index procedure. Univariate and multivariate logistic regression was performed comparing those patients with an UROR versus those without. A total of 1568 patients were reviewed. The rate of UROR was 9.8% (153 patients). Symptomatic implant was the leading cause of UROR (60%). Other significant UROR causes were infection (15%) and implant failure (9%). The median time between index procedure and UROR was 301 days. For the univariate and multivariate analysis, open fracture (p< 0.05), fracture complexity (p<0.01), and weekend procedure (p< 0.01) were all associated with increased risk of UROR. All other variables were not statistically significant for any associations. Those patients with an UROR for reasons other than symptomatic implants were more likely to have polyorthopaedic injuries (p < 0.05), ISS > 15 (p < 0.05), osteoporosis (p < 0.01), ICU status (p < 0.05), psychiatric history (p < 0.05), compartment syndrome (p < 0.05), neurovascular injury (p < 0.01), open fracture (p < 0.05), and fracture complexity (p < 0.05). The rate of UROR in the orthopaedic trauma patient population is 10%. Most of these cases are due to implant-related issues. UROR for reasons other than symptomatic implants tend to be polytraumatized patients with higher-energy injuries, multiple complex fractures, and associated soft tissue injuries. Future focus on improved implant development and treatments for polytraumatized patients with complex fractures is warranted to decrease a relatively high UROR rate in orthopaedic trauma

The April 2024 Trauma Roundup. 360. looks at: The infra-acetabular screw in acetabular fracture surgery; Is skin traction helpful in patients with intertrochanteric hip fractures?; Reducing pain and improving function following hip fracture surgery; Are postoperative splints helpful following ankle fracture fixation?; Biomechanics of internal fixation in Hoffa fractures: a comparison of four different constructs; Dual-plate fixation of periprosthetic distal femur fractures; Do direct oral anticoagulants necessarily mean a delay to hip fracture surgery?; Plate or retrograde nail for low distal femur fractures?

Abstract. Introduction. Skeletal muscle wasting is an important clinical issue following acute traumatic injury, and can delay recovery and cause permanent functional disability particularly in the elderly. However, the fundamental mechanisms involved in trauma-induced muscle wasting remain poorly defined and therapeutic interventions are limited. Objectives. To characterise local and systemic mediators of skeletal muscle wasting in elderly patients following acute trauma. Methods. Experiments were approved by a local NHS Research Ethics Committee and all participants provided written informed consent. Vastus lateralis biopsies and serum samples were taken from human male and female patients shortly after acute trauma injury in lower limbs (n=6; mean age 78.7±4.4 y) and compared to age-matched controls (n=6; mean age 72.6±6.3 y). Atrogenes and upstream regulators (MuRF1; MAFbx; IL6, TNFα, PGC-1α) mRNA expression was assessed in muscle samples via RT-qPCR. Serum profiling of inflammatory markers (e.g. IL6, TNFα, IL1β) was further performed via multiplex assays. To determine whether systemic factors induced by trauma directly affect muscle phenotype, differentiated primary human myotubes were treated in vitro with serum from controls or trauma patients (pooled; n=3 each) in the final 24 hours of differentiation. Cells were then fixed, stained for myogenin and imaged to determine minimum ferret diameter. Statistical significance was determined at P<0.05. Results. There was an increase in skeletal muscle mRNA expression for E3 ligase MAFbx and inflammatory cytokine IL-6 (4.6 and 21.5-fold respectively; P<0.05) in trauma patients compared to controls. Expression of myogenic determination factor MyoD and regulator of mitochondrial biogenesis PGC-1α was lower in muscle of trauma patients vs controls (0.5 and 0.39-fold respectively; P<0.05). In serum, trauma patients showed increased concentrations of circulating pro-inflammatory cytokines IL-6 (14.5 vs. 0.3 pg/ml; P<0.05) and IL-16 (182.7 vs. 85.2 pg/ml; P<0.05) compared to controls. Primary myotube experiments revealed serum from trauma patients induced atrophy (32% decrease in diameter) compared to control serum-treated cells (P<0.001). Conclusion. Skeletal muscle from patients following acute trauma injury showed greater expression of atrophy and inflammatory markers. Trauma patient serum exhibited higher circulating pro-inflammatory cytokine concentrations. Primary human myotubes treated with serum from trauma patients showed significant atrophy compared to healthy serum-treated controls. We speculate a mechanism(s) acting via circulating factors may contribute to skeletal muscle pathology following acute trauma. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aims. Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries. Methods. This multicentre case-control study comprised 200 patients with post-traumatic elbow HO and 229 patients who had elbow trauma but without HO formation between July 2019 and December 2020. Features possibly associated with HO formation were obtained. The least absolute shrinkage and selection operator regression model was used to optimize feature selection. Multivariable logistic regression analysis was applied to build the new nomogram: the Shanghai post-Traumatic Elbow Heterotopic Ossification Prediction model (STEHOP). STEHOP was validated by concordance index (C-index) and calibration plot. Internal validation was conducted using bootstrapping validation. Results. Male sex, obesity, open wound, dislocations, late definitive surgical treatment, and lack of use of non-steroidal anti-inflammatory drugs were identified as adverse predictors and incorporated to construct the STEHOP model. It displayed good discrimination with a C-index of 0.80 (95% confidence interval 0.75 to 0.84). A high C-index value of 0.77 could still be reached in the internal validation. The calibration plot showed good agreement between nomogram prediction and observed outcomes. Conclusion. The newly developed STEHOP model is a valid and convenient instrument to predict HO formation after surgery for elbow trauma. It could assist clinicians in counselling patients regarding treatment expectations and therapeutic choices. Cite this article: Bone Joint J 2022;104-B(8):963–971

Over the last 10 years atypical femoral fractures (AFFs) have become recognised as a complication of standard-dose bisphosphonate use. In 2014 the American Society for Bone and Mineral Research published updated diagnostic criteria for AFF. We undertook a 5-year retrospective analysis of the trauma admission database at a major trauma centre to establish the incidence of this problem in our patient population. Initial screening was performed using keyword-matching methodology to produce a shortlist of patients with low-energy femoral fractures. These patients’ case notes, radiographs, and electronic discharge summaries were reviewed to discriminate AFF from typical femoral fractures. Initial filtering identified a total of 112 low energy femoral fractures. Of these, 12 were confirmed as AFFs. 58% (7/12) of the AFF group were on bisphosphonates compared to 15% (15/100) of the typical femoral fracture group. This finding was statistically significant (p = 0.0004). These data show that there is a link between bisphosphonate use and AFF. However, a causal relationship cannot be inferred. The incidence of AFF in our study is broadly in line with the published data

The April 2023 Trauma Roundup. 360. looks at: Displaced femoral neck fractures in patients aged 55 to 70 years: internal fixation or total hip arthroplasty?; Tibial plateau fractures: continuous passive motion approves range of motion; Lisfranc fractures: to fuse or not to fuse, that is the question; Is hardware removal after clavicle fracture plate fixation beneficial?; Fixation to coverage in Grade IIIB open fractures – what’s the time window?; Nonoperative versus locking plate fixation in the proximal humerus; Retrograde knee nailing or lateral plate for distal femur fractures?

The TRISS methodology is used in by both the UK and US military trauma registries and relies on dividing casualties according to mechanism: penetrating or blunt. The UK and US military trauma registries use the original coefficients devised in 1987 and it is not clear how either registry analyses explosive casualties according to the TRISS methodology. This study aims to use the UK military trauma registry (JTTR) to calculate new TRISS coefficients for contemporary battlefield casualties injured by either gunshot or explosive mechanisms. The JTTR was searched for all UK Casualties injured or killed between 2003 and 2014. A logistic regression analysis was performed to devise new TRISS coefficients, these were then used to re-examine survival over the 12 years of the study. Comparing the predictions from the GSW TRISS model to the observed outcomes, it demonstrates a sensitivity of 98.1% and a specificity of 96.8% and an overall accuracy 97.8%. With respect to the explosive TRISS model, there is a sensitivity of 98.6%, a specificity of 97.4% and an overall accuracy of 98.4%. When this improved TRISS methodology was used to measure changes in survival, there was a sustained improvement over the 12-year study period

Training time in Trauma & Orthopaedics is pressured. In this action research project, we develop a feedback/self-reflection model for trainers and trainees, emphasising the contribution both groups make to training, to maximise cohesion and efficacy. Starting in 2013, trainees completed anonymous feedback forms after each 6-month post. The 18-point quantitative questionnaire covers four training domains: WBA engagement, teaching/feedback, research/audit, operative training. Consultant trainers completed a once-off corresponding 18-point self-reflection questionnaire. Additionally, trainers were asked for their expectations of and advice for trainees. Individual trainer profiles were generated from trainee feedback questionnaires, allowing comparison between trainer-group-average, trainer-specific and trainer-self-reflection scores across 18 fields. Trainer profiles were uploaded to ISCP and used for recognition of trainer status for SOAR. This data provided basis for local service provision review with amendments to maximise training efficacy. Results of thematic analysis of trainer feedback was shared with the trainee group. This and subsequent group self-reflection formed the basis of our ‘Trainee Charter’. Trainee feedback illustrates high levels of satisfaction with local training (average global score 4.2/5). Strengths included ‘feedback’ and ‘operative teaching’; relative weaknesses included ‘research time’ and ‘OPD teaching’. The ‘Trainee Charter’ details specific desirable behaviours that embody eight trainee-qualities consistently identified by trainers as important, including ‘honesty’ and ‘being organised’. The charter emphasises trainee contribution to training. For the first time, trainers have the benefit of serial and individualised feedback. Trainees are better informed and empowered in relation to maximising their own training. Most importantly, both halves of the training-team are explicitly acknowledged

Musculoskeletal (MSK) injuries are one of the leading causes of disability worldwide. Despite improvements in trauma-related morbidity and mortality in high-income countries over recent years, outcomes following MSK injuries in low and middle-income countries, such as South Africa (SA), have not. Despite governmental recognition that this is required, funding and research into this significant health burden are limited within SA. This study aims to identify research priorities within MSK trauma care using a consensus-based approach amongst MSK health care practitioners within SA. Members from the Orthopaedic Research Collaborative (ORCA), based in SA, collaborated using a two round modified Delphi technique to form a consensus on research priorities within orthopaedic trauma care. Members involved in the process were orthopaedic healthcare practitioners within SA. Participants from the ORCA network, working within SA, scored research priorities across two Delphi rounds from low to high priority. We have published the overall top 10 research priorities for this Delphi process. Questions were focused on two broad groups - clinical effectiveness in trauma care and general trauma public health care. Both groups were represented by the top two priorities, with the highest ranked question regarding the overall impact of trauma in SA and the second regarding the clinical treatment of open fractures. This study has defined research priorities within orthopaedic trauma in South Africa. Our vision is that by establishing consensus on these research priorities, policy and research funding will be directed into these areas. This should ultimately improve musculoskeletal trauma care across South Africa and its significant health and socioeconomic impacts

Laminar flow theatres were first introduced in the United Kingdom in the 1960s and 1970s and have become standard in orthopaedic surgery involving implants. A study from 1982 showed a 50% reduction in infections with joint arthroplasties when compared to conventional theatres and laminar flow became standard in the following decades. Recent evidence including a meta-analysis from 2017 questions the effectiveness of these theatre systems. Most of the evidence for Laminar flow use is based on arthroplasty surgery. We aimed to determine the effect of using non-laminar flow theatres on our trauma patients. A total of 1809 patients who had trauma surgery were identified from 2019 to 2021. 917 patients were operated on in a laminar theatre and 892 in a non-laminar theatre across two operating sites. We identified the surgical site infections as reported through our surveillance program within the first 90 days of infection. Patient co-morbidities were noted through patient records and procedure length was also noted. Of the 1809 trauma patients identified between the years of 2019 and 2021, 917 patients had operations in a laminar flow theatre and 892 in a non-laminar theatre. Of the 892 operated in non-laminar flow theatres, 543 were operated in the University Hospital of Wales (UHW) and 349 at the University Hospital of Llandough (UHL). An analysis of soft tissue infections and hospital acquired infections post-operatively demonstrated 15/543 and 71/543 respectively for non-laminar UHW infections and 4/349 and 21/349 for non-laminar UHL infections. A look at laminar flow patients showed 25/917 with soft tissue infections and 86/917 hospital acquired infections. There was no difference between laminar and non-laminar flow theatre infection rates showing rates of 12.1% and 12.2% respectively. In our trauma patients we noticed no significant advantage of using laminar flow theatres when compared to non-laminar flow theatres. This is in keeping with some recently published literature. Laminar flow theatres have been shown to decrease airborne pathogen counts under controlled conditions, but we conclude in the day to day environment of trauma theatres these conditions are either not met or that the theoretical advantage of laminar flow does not translate to a direct advantage of reduction of infections which may be achieved by standard prophylactic antibiotics

First rib fractures (FRFs) have historically been a marker for severe trauma and poor outcomes. The aim of this study was to assess whether an association still exists between a fractured first rib and global trauma scores suffered by the patient, examine mortality rate and identify other commonly associated injuries. This study examined patients who presented to the Rockhampton Hospital with a traumatic FRF between the dates of July 2015 to June 2020. Patient demographics, mortality rate and additional injuries sustained by the patients were collected. The Injury Severity Score (ISS) was utilised and calculated for each patient. Analysis was conducted to determine associations between trauma scores and FRFs, mortality rate and other injuries sustained at the time of rib fracture. In total, 545 patients had a rib fracture with 48 patients identified as having an FRF. Median age was 50 years. Thirty-seven (77%) were male. The most common mechanism of FRF was motor vehicle/motorbike accidents (71%). Fifty percent of patients with an observed FRF had the highest global ISS of very severe, with 13% severe, 22% moderate and 15% mild. No patients died from their injuries. Of those with an FRF, 79% experienced fractures other than ribs, 75% had other rib fractures and 52% had chest injuries. A larger than expected proportion of FRFs were not associated with severe trauma scores or high mortality. These findings suggest that patients with an FRF may have a greater chance of surviving their traumatic FRF than previously reported. Clinicians should be aware of the potential for severity and other associated injuries, such as chest wall fractures and thoracic injuries, when treating a patient with a fracture of their first rib

Introduction. The Patient Archiving and Communication System (PACS) has revolutionised the way that radiographs are stored and viewed in orthopaedic surgery. A recent advance has been the ability to upload images directly from the image intensifier to PACS. We postulated that this facility may reduce the need for post operative ‘check’ radiographs following many orthopaedic trauma procedures. Patients and Method. We performed an audit of post-operative radiographs requested in our University Hospital over three time periods: 31 days immediately before the direct upload facility was introduced, 31 days immediately after and a 31 day period two months later. Details from the operating lists were cross-referenced with image intensifier records to identify cases where it had been used. PACS records were then checked to determine if these images were available to view and if a formal ‘check’ radiograph was performed in the period prior to discharge. Results. A total of 624 orthopaedic trauma operations were reviewed. In the period before direct-upload of images began, 62% of all trauma procedures utilised the image intensifier and in 26% post-operative ‘check’ radiographs were taken. In the period immediately after uploading began, the image intensifier was used in 66% of cases with 84% of these images being uploaded. Fifteen percent of the patients had a check radiograph during this period. Two months later the image intensifier was used in 67% of cases. Although 96% of these images were uploaded, 14% still had a formal post-operative radiograph. Conclusion. The facility to upload images from the image intensifier in the operating theatre directly onto the PACS system has reduced the number of post-operative ‘check’ radiographs requested in our trauma department by 11%. This has reduced both the cost and radiation exposure involved in orthopaedic trauma surgery but has not eliminated the need for post-operative radiographs completely

Aims. Hand trauma accounts for one in five of emergency department attendances, with a UK incidence of over five million injuries/year and 250,000 operations/year. Surgical site infection (SSI) in hand trauma surgery leads to further interventions, poor outcomes, and prolonged recovery, but has been poorly researched. Antimicrobial sutures have been recognized by both the World Health Organization and the National Institute for Clinical Excellence as potentially effective for reducing SSI. They have never been studied in hand trauma surgery: a completely different patient group and clinical pathway to previous randomized clinical trials (RCTs) of these sutures. Antimicrobial sutures are expensive, and further research in hand trauma is warranted before they become standard of care. The aim of this protocol is to conduct a feasibility study of antimicrobial sutures in patients undergoing hand trauma surgery to establish acceptability, compliance, and retention for a definitive trial. Methods. A two-arm, multicentre feasibility RCT of 116 adult participants with hand and wrist injuries, randomized to either antimicrobial sutures or standard sutures. Study participants and outcome assessors will be blinded to treatment allocation. Outcome measures will be recorded at baseline (preoperatively), 30 days, 90 days, and six months, and will include SSI, patient-reported outcome measures, and return to work. Conclusion. This will inform a definitive trial of antimicrobial sutures in the hand and wrist, and will help to inform future upper limb trauma trials. The results of this research will be shared with the medical community through high impact publication and presentation. Cite this article: Bone Jt Open 2022;3(7):529–535

Introduction. Current undergraduate trauma and life-support training inadequately equips medical students with the knowledge, practical skills and confidence to manage trauma patients. Often first to the scene of medical emergencies, it is imperative junior doctors feel confident and competent from day one. No UK university currently includes advanced trauma and life support (ATLS) in their curriculum. This study piloted an ATLS course for Cardiff final-year medical students to improve confidence and knowledge in management of the trauma patient. Aim. To assess the immediate effect of a one-day undergraduate ATLS course on medical student's confidence in management of the trauma patients. Methods. Twelve final-year students attended a one-day, practical-skills based and interactive course led by trauma surgeons. Students' confidence managing a trauma patient were assessed pre and post-course using a six-item-MCQ with a 5-point Likert scale. Paired t-tests were carried out on SPSS for comparison pre and post-course across the six items. Qualitative feedback was also collected. Results. The students' confidence in managing a trauma patient's ‘airway and breathing’, ‘circulation’ and ‘C-spine’ all significantly improved after attending the course (p=0.023, p=0.045 and p=000 respectively). Students felt significantly more confident completing practical skills related to trauma (p= 0.001) and their confidence in managing trauma patients overall at the level expected of a Foundation doctor increased significantly (p= 0.003). Qualitative feedback demonstrated high faculty-to-student ratio, practical and interactive teaching methods were particularly helpful. Conclusion. The content and delivery of this course proved beneficial for final-year medical students imminently becoming Foundation doctors, evidencing the requirement for increased trauma training. We advocate the expansion and continuation of this novel student course to continue improving the trauma training within the undergraduate curriculum

Aims. This study reviews the past 30 years of research from the Canadian Orthopedic Trauma Society (COTS), to identify predictive factors that delay or accelerate the course of randomized controlled trials in orthopaedic trauma. Methods. We conducted a methodological review of all papers published through the Canadian Orthopaedic Trauma Society or its affiliates. Data abstracted included: year of publication; journal of publication; study type; number of study sites; sample size; and achievement of sample size goals. Information about the study timelines was also collected, including: the date of study proposal to COTS; date recruitment began; date recruitment ended; and date of publication. Results. In total, 22 studies have been published through the COTS working group, 13 of which are randomized controlled trials (RCTs). In total, 1,423 individual patients have been involved in COTS studies, a mean of 110 patients per trial (22 to 424). Each study was conducted across a mean of approximately six centres (1 to 11) and took nearly ten years (mean 119.9 months (59 to 188)) from presentation of concept to publication. The mean length of enrolment was 63 months (26 to 113) and the mean time from cessation of enrolment to publication 51 months (19 to 78). Regardless of sample size, the only factor associated with a decreased length of enrolment was a higher number of clinical sites (p = 0.041). Neither study sample size nor length of enrolment were associated with total time to publication. Conclusion. Over the last three decades, COTS has developed a multinational strategy to produce high-quality evidence in the field of orthopaedic trauma through 13 multicentre RCTs. Future efficiencies can be realized by recruitment of more clinical sites, improving connectivity between the sites, and the promotion of national streamlined ethics processes. Cite this article: Bone Joint J 2021;103-B(5):898–901

Introduction. Lower limb amputation is associated with significant morbidity and mortality. Reflecting the predominance of vascular or diabetic disease as a cause for lower limb amputation, much of the available literature excludes lower limb amputation secondary to trauma in the reporting of complication rates. This paucity in the literature represents a research gap in describing the incidence of complications in lower limb amputation due to trauma, which we aim to address. Materials and Methods. Retrospective analysis of a prospectively collected database of all traumatic lower limb amputations secondary to trauma from a regional multidisciplinary amputee service at Queen Mary's Hospital. Electronic patient records and paper notes were consulted for evidence of re-operation, infection (superficial or deep), phantom limb pain and neuroma. 222 patients were screened and 108 included in the data analysis. Results. Records identified 108 lower limb amputations secondary to trauma in 99 patients with a mean age of 34 years (at time of amputation). Average follow-up was 225 months. 33.6% of patients underwent re-operation, 25.2% had at least one episode of infection. Of those who underwent re-operation, 47.2% had evidence of infection. 42% and 3.7% of patients described phantom limb pain and neuroma respectively. Conclusions. Lower limb amputations secondary to trauma exhibit higher rates of re-operation and infection compared to vascular or diabetic amputees. This first study to provide high quality data describing the incidence of complications such as re-operation, infection, phantom limb pain and neuroma in lower limb amputations secondary to trauma

Informed consent is vital to good surgical practice. Pain, sedative medication and psychological distress resulting from trauma are likely to adversely affect a patient's ability to understand and retain information thus impairing the quality of the consent process. This study aims to assess whether provision of written information improves trauma patient's recall of the risks associated with their surgery. 121 consecutive trauma patients were randomised to receive structured verbal information or structured verbal information with the addition of supplementary written information at the time of obtaining consent for their surgery. Patients were followed up post-operatively (mean 3.2 days) with a questionnaire to assess recall of risks discussed during the consent interview and satisfaction with the consent process. Recall of risks discussed in the consent interview was found to be significantly improved in the group receiving written and verbal information compared to verbal information alone (mean questionnaire score 41% vs. 64%), p=0.0014 using the Mann-Whitney U test. Patient satisfaction with the consent process was significantly improved in the group receiving written and verbal information, 97.9% of patients reported that they understood the risks of surgery when they signed the consent form compared to 83.2% who received verbal information alone (p=0.01). The majority of patients who received written information reported finding it helpful (93.8%) and most of the patients who did not receive written information reported they would have found it useful had it been offered (66%). Patients awaiting surgery following trauma can pose a challenge to adequately inform about benefits conferred, the likely post operative course and potential risks. Written information is a simple and cost-effective means to improve the consent process and was popular with patients

Counter-insurgency warfare in recent military operations has been epitomised by the use of Improvised Explosive Devices (IED) against coalition troops. Emerging patterns of skeletal fractures, limb amputations and organ injuries, which are caused by these weapons have been described over recent years. This paper describes a retrospective case series of knee dislocations caused by IEDs in recent conflict. Data was obtained about military personnel from 2006 to 2011, who had sustained a knee dislocation while serving in Afghanistan from a prospectively gathered database, the Joint Theatre Trauma Registry (JTTR), maintained by the Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine. The diagnosis of knee dislocation and its associated skeletal injuries was assessed by review of all relevant plain radiographs, computed tomography scans and magnetic resonance images. The mechanism of injury, incidence of vascular injuries and other skeletal injuries was recorded. During the study period, 23 casualties sustained a knee dislocation caused by an IED. Four casualties had an associated popliteal vascular injury. Eleven injuries were caused in enclosed spaces, and 10 injuries caused by IEDs out in the open. Anterior dislocations were common in the group caused in enclosed spaces. 19/20 patients had at least one other skeletal fracture. Knee dislocations represent an uncommon but important diagnosis in modern warfare. Urgent and careful assessment for any associated vascular injuries or other skeletal injuries may help ensure timely treatment and promote future recovery. Mitigation against knee dislocation may be possible in the enclosed environment because of the predictable pattern of injury

Background. Exeter Trauma Stem (ETS) is a polished tapered collarless monopolar prosthesis used for cemented hemiarthroplasty for fracture neck of femur. Two modular rasps are available on the instrumentation set. The larger rasp, in practice, rarely fits into the femur making trial reduction impossible. Our hypothesis was that the absence of a trial reduction could affect leg length and stability of the prosthesis. Aim. To evaluate the leg length discrepancy following use of Exeter Trauma Stem for intracapsular fracture neck of femur. Methods. All patients who underwent ETS hemiarthroplasty between June 2009 to March 2010 (n = 100) were included in the study. Radiographic assessment of leg length was performed by two independent assessors based on measurements by Woolson et al. Results. Upto half of the patients had equal leg length measurements. Forty four patients had lengthening of the operated leg with a mean of 10mm (5–25). Further complications included four dislocations. There was no statistical significance between leg lengths and dislocations. Conclusion. Care is needed with regards to correct positioning of the ETS prosthesis to achieve equal leg lengths. Following this study a new intermediate sized modular rasp has been introduced to the instrumentation set

Fractures of the distal radius are common, and form a considerable proportion of the trauma workload. We conducted a study to examine the patterns of injury and treatment for adult patients presenting with distal radius fractures to a major trauma centre serving an urban population. We undertook a retrospective cohort study to identify all patients treated at our major trauma centre for a distal radius fracture between 1 June 2018 and 1 May 2021. We reviewed the medical records and imaging for each patient to examine patterns of injury and treatment. We undertook a binomial logistic regression to produce a predictive model for operative fixation or inpatient admission. Overall, 571 fractures of the distal radius were treated at our centre during the study period. A total of 146 (26%) patients required an inpatient admission, and 385 surgical procedures for fractures of the distal radius were recorded between June 2018 and May 2021. The most common mechanism of injury was a fall from a height of one metre or less. Of the total fractures, 59% (n = 337) were treated nonoperatively, and of those patients treated with surgery, locked anterior-plate fixation was the preferred technique (79%; n = 180). The epidemiology of distal radius fractures treated at our major trauma centre replicated the classical bimodal distribution described in the literature. Patient age, open fractures, and fracture classification were factors correlated with the decision to treat the fracture operatively. While most fractures were

Aims. This study aims to estimate economic outcomes associated with 30-day deep surgical site infection (SSI) from closed surgical wounds in patients with lower limb fractures following major trauma. Methods. Data from the Wound Healing in Surgery for Trauma (WHiST) trial, which collected outcomes from 1,547 adult participants using self-completed questionnaires over a six-month period following major trauma, was used as the basis of this empirical investigation. Associations between deep SSI and NHS and personal social services (PSS) costs (£, 2017 to 2018 prices), and between deep SSI and quality-adjusted life years (QALYs), were estimated using descriptive and multivariable analyses. Sensitivity analyses assessed the impact of uncertainty surrounding components of the economic analyses. Results. Compared to participants without deep SSI, those with deep SSI had higher mean adjusted total NHS and PSS costs (adjusted mean difference £1,577 (95% confidence interval (CI) -951 to 4,105); p = 0.222), and lower mean adjusted QALYs (adjusted mean difference -0.015 (95% CI -0.032 to 0.002); p = 0.092) over six months post-injury, but this difference was not statistically significant. The results were robust to the sensitivity analyses performed. Conclusion. This study found worse economic outcomes during the first six months post-injury in participants who experience deep SSI following orthopaedic surgery for major trauma to the lower limb. However, the increase in cost associated with deep SSI was less than previously reported in the orthopaedic trauma literature. Cite this article: Bone Jt Open 2022;3(5):398–403

Since the emergence of the COVID-19 pandemic, the NHS has been under unprecedentedpressure. Elective surgery had ceased, and trauma surgery has decreased dramatically. Surgical training is multi-faceted and requires a specialist trainee to have a timetable which includes regular elective non-emergency operating, trauma operating and training in outpatient clinics. Consequently, training in theatre and the achievement of operative numbers and index procedures had not been possible for Trauma and Orthopaedic (T&O) specialist trainees. The Joint Committee on Surgical Training (JCST) has clear training index requirements for all T&O specialist trainees. In this study, we surveyed specialist trainees in the North West London deanery against the annual requirements set by the JCST guidelines. In addition, we retrospectively assessed the total number of trauma referrals and operations scheduled in our unit during the COVID-19 outbreak compared to that one year previously. The aim of this study is to objectively assess the effect the pandemic has on T&O specialist training. A total of 24 responses were collected from specialist trainees. The results of the survey showed 87% of trainees believed that their training had been affected. 75% of trainees felt they were not on track to meet operative numbers for the year, and 71% felt index number achievement had been affected. Trauma case numbers dropped by 20% compared to that one year previously. We recommend timely, planned and conscientious remediation for specialist trainees’ educational requirements. Specialist trainees must take responsibility for their training and use of additional educational opportunities. Clinical supervisors and training programme directors must provide additional support and guidance to achieve ARCP outcomes however in some scenarios extension of training may be necessary

Fracture risks are the most common argument against the use of Ceramic on ceramic (CoC) hip implants. Question: is ceramic material at risk in case of severe local trauma?. Over a long period, we tried to identify patients with a CoC prosthesis (Ceraver Osteal°)who did sustain a trauma. This was conducted in three different institutions. Eleven patients were found: 9 males and 2 females aged 17 to 70 years at time of index surgery. Accident occurred 6 months to 15 years after index: one car accident, five motorcycle accident, five significant trauma after a fall, including one ski board accident. Consequences of these trauma were: six fractures of the acetabulum with socket loosening in 4 that needed revision, two femoral shaft fracture, one orifed and one stem exchanged, one traumatic hip dislocation associated to loosening of the socket revised at 10 years, and one traumatic loosening of the socket. Ten had no consequence on ceramic integrity. One experienced a fracture of the patella from a dashboard trauma, a liner shipping was discovered during socket revision 2 years later. This is the only case of possible relation between trauma and ceramic fracture. In a more recent longitudinal study on 1856 CoC prosthesis performed from 2010 to 2021, 29 severe traumas were identified with no consequence on Ceramic material. From this limited case study, it can be assumed that Pure Alumina Ceramic well designed and manufactured, will not break after a significant trauma

Aims

It has been generally accepted that open fractures require early skeletal stabilization and soft-tissue reconstruction. Traditionally, a standard gauze dressing was applied to open wounds. There has been a recent shift in this paradigm towards negative pressure wound therapy (NPWT). The aim of this study was to compare the clinical outcomes in patients with open tibial fractures receiving standard dressing versus NPWT.