Objectives. The aim of this study was to review the current evidence and future application for the role of diagnostic and therapeutic ultrasound in fracture management. Methods. A review of relevant literature was undertaken, including articles indexed in PubMed with keywords “ultrasound” or “sonography” combined with “diagnosis”, “fracture healing”, “impaired fracture healing”, “nonunion”, “microbiology”, and “fracture-related infection”. Results. The use of ultrasound in musculoskeletal medicine has expanded rapidly over the last two decades, but the diagnostic use in fracture management is not routinely practised. Early studies have shown the potential of ultrasound as a valid alternative to radiographs to diagnose common paediatric fractures, to detect occult injuries in adults, and for rapid detection of long bone fractures in the resuscitation setting. Ultrasound has also been shown to be advantageous in the early identification of impaired fracture healing; with the advent of 3D image processing, there is potential for wider adoption. Detection of implant-related infection can be improved by ultrasound mediated sonication of microbiology samples. The use of therapeutic ultrasound to promote union in the management of acute fractures is currently a controversial topic. However, there is strong in vitro evidence that ultrasound can stimulate a biological effect with potential clinical benefit in established nonunions, which supports the need for further investigation. Conclusion. Modern ultrasound image processing has the potential to replace traditional imaging modalities in several areas of trauma practice, particularly in the early prediction of impaired fracture healing. Further understanding of the therapeutic application of ultrasound is required to understand and identify the use in promoting fracture healing. Cite this article: J. A. Nicholson, S. T. J. Tsang, T. J. MacGillivray, F. Perks, A. H. R. W. Simpson. What is the role of ultrasound in fracture management? Diagnosis and therapeutic potential for fractures, delayed unions, and fracture-related infection. Bone Joint Res 2019;8:304–312. DOI: 10.1302/2046-3758.87.BJR-2018-0215.R2

Open limb fractures are typically due to a high energy trauma. Several recent studied have showed treatment's superiority when a multidisciplinary approach is applied. World Health Organization reports that isolate limb traumas have an incidence rate of 11.5/100.000, causing high costs in terms of hospitalization and patient disability. A lack of experience in soft tissue management in orthopaedics and traumatology seems to be the determining factor in the clinical worsening of complex cases. The therapeutic possibilities offered by microsurgery currently permit simultaneous reconstruction of multiple tissues including vessels and nerves, reducing the rate of amputations, recovery time and preventing postoperative complications. Several scoring systems to assess complex limb traumas exist, among them: NISSSA, MESS, AO and Gustilo Anderson. In 2010, a further scoring system was introduced to focus open fractures of all locations: OTA-OFC. Rather than using a single composite score, the OTA-OFC comprises five components grades (skin, arterial, muscle, bone loss and contamination), each rated from mild to severe. The International Consensus Meeting of 2018 on musculoskeletal infections in orthopaedic surgery identified the OTA-OFC score as an efficient catalogue system with interobserver agreement that is comparable or superior to the Gustilo-Anderson classification. OTA-OFC predicts outcomes such as the need for adjuvant treatments or the likelihood of early amputation. An orthoplastic approach reconstruction must pay adequate attention to bone and soft tissue infections management. Concerning bone management: there is little to no difference in terms of infection rates for Gustilo-Anderson types I–II treated by reamed intramedullary nail, circular external fixator, or unreamed intramedullary nail. In Gustilo-Anderson IIIA-B fractures, circular external fixation appears to provide the lowest infection rates when compared to all other fixation methods. Different technique can be used for the reconstruction of bone and soft tissue defects based on each clinical scenario. Open fracture management with fasciocutaneous or muscle flaps shows comparable outcomes in terms of bone healing, soft tissue coverage, acute infection and chronic osteomyelitis prevention. The type of flap should be tailored based on the type of the defect, bone or soft tissue, location, extension and depth of the defect, size of the osseous gap, fracture type, and orthopaedic implantation. Local flaps should be considered in low energy trauma, when skin and soft tissue is not traumatized. In high energy fractures with bone exposure, muscle flaps may offer a more reliable reconstruction with fewer flap failures and lower reoperation rates. On exposed fractures several studies report precise timing for a proper reconstruction. Hence, timing of soft tissue coverage is a critical for length of in-hospital stay and most of the early postoperative complications and outcomes. Early coverage has been associated with higher union rates and lower complications and infection rates compared to those reconstructed after 5-7 days. Furthermore, early reconstruction improves flap survival and reduces surgical complexity, as microsurgical free flap procedures become more challenging with a delay due to an increased pro-thrombotic environment, tissue edema and the increasingly friable vessels. Only those patients presenting to facilities with an actual dedicated orthoplastic trauma service are likely to receive definitive treatment of a severe open fracture with tissue loss within the established parameters of good practice. We conclude that the surgeon's experience appears to be the decisive element in the orthoplastic approach, although reconstructive algorithms may assist in decisional and planification of surgery

Abstract. Objective. Open fracture management in the United Kingdom and several other countries is guided by the British Orthopaedic Association's Standards for Trauma Number 4 (BOAST-4). This is updated periodically and is based on the best available evidence at the time. The aim of this study is to evaluate the evidence base forming this guidance and to highlight new developments since the last version in 2017. Methods. Searches have been performed using the PubMed, Embase and Medline databases for time periods a) before December 31, 2017 and from 01/01/2018–01/02/2021. Results have been summarised and discussed. Results. Several contentious issues remain within the 2017 guideline. Antibiotic guidance, the use of antibiotic impregnated PMMA beads and intramedullary devices, irrigation in the emergency department, time to theatre and the use of negative pressure dressings and guidance regarding the management of paediatric injuries have all demonstrated no clear consensus. Conclusion. The advent of the BOAST-4 guideline has been of huge benefit, however the refinement and improvement of this work remains ongoing. There remains a need for further study into these contentious issues previously listed

Aims

Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. This national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK.

Introduction

Following publication of the Ankle Injury Management (AIM) trial in 2016 which compared the management of ankle fractures with open reduction and internal fixation (ORIF) versus closed contact casting (CCC), we looked at how the results of this study have been adopted into practice in a trauma unit in the United Kingdom.

In the time since Letournel popularised the surgical treatment of acetabular fractures, more than 25 years ago, there have been many changes within the field, related to patients, surgical technique, implants and post-operative care. However, the long-term outcomes appear largely unchanged. Does this represent stasis or have the advances been mitigated by other negative factors? In this article we have attempted to document the recent changes within the surgery of patients with a fracture involving the acetabulum, outline contemporary management, and identify the major problem areas where further research is most needed.

Cite this article: Bone Joint J 2017;99-B:1125–31

Title. 3D distribution of cortical bone thickness in the proximal humerus, implications for fracture management. Introduction. CT imaging is commonly used to gain a better understanding of proximal humerus fractures. the operating surgeon however has a limited capacity to evaluate the internal bone geometry from these clinical CT images. our aim was to use clinical CT in a novel way of accurately mapping cortical bone geometry in the proximal humerus. we planned to experimentally define the cortico-cancellous border in a cadaveric study and use CT imaging software to map out cortical thickness distribution in our specimens. Methodology. With ethical approval we used fifteen fresh frozen human proximal humeri. These were stripped of all soft tissue and transverse CT images taken with a GE VCT Lightspeed scanner. The humeral heads were then subsequently resected to allow access to the methaphyseal area. Using currettes, cancellous bone was removed down to hard cortical bone. Another set of CT images of the reamed specimen were then taken. Using Mimics imaging software[Materialise, Leuven] and a CAD interface, 3-matic [Materialise, Leuven], we built 3D model representations of our intact and reamed specimens. We first had to define an accurate CT density threshold for visualising cortical contours. We then analysed cortical thickness distribution based on that experimented threshold. Results. we were able to statistically determine the CT threshold, in Hounsfield Units, that represents the cortico-cancellous interface in the proximal humerus. Our 3D colour models provide an accurate depiction of the distribution of cortical thickness in the proximal humerus. Discussion/Conclusions. Our Hounsfield value for the cortico-cancellous interface in the proximal humerus agrees with a similar range of 400 to 800 HU reported in the literature for the proximal femur. Knowledge of regional variations in cortical bone thickness has direct implications for basic science studies on osteoporosis and its treatment, but is also important for the orthopaedic surgeon since our decision for treatment options is often guided by local bone quality

Introduction: In 2003 the Ministry of Health in Israel added hip fractures to the DRG listing. The rational behind this move was aiming at the shortening of hip fractures waiting time to surgery and shortening of hospitalization period. Some hospitals in Israel have assigned an additional OR shift for this purpose. Hip fracture patients consist of two main sub-groups: patients who undergo hemi-arthroplasty (HA Group) and those who undergo internal fracture fixation (IFF Group). The new policy determines that DRG of internal fixation patients ends at the fifth day of their initial hospitalization after surgery. The aim of this study was to evaluate the practical effect of this policy on hip fracture management. Patients and Methods: We retrospectively compared two major groups of patients (total 808) with hip fractures: the first group of patients was treated in 2001 (377 patients) (before the new policy came into effect) and the second in 2005 (431 patients). Each of these groups included the HA group and the IFF group. In each of the groups we compared the time to surgery, length of hospitalization, mortality rates after six months and the diurnal distribution of the operations. Results: The length of hospitalization in 2005 was found to be shorter in the IFF group by 2.82 days (2001 – mean stay of 12.52, 2005 - 9.7 days) as opposed to the HA group where hospitalization was shorter in 2005 by a mean of only 0.42 day. Mortality rates at six months following surgery, when comparing the two major groups, were 11.3% in 2001 and 7.9% in 2005. 90% of the operations in 2005 were performed between 15:00–19:30 compared to 2001 when 90% of surgeries were evenly distributed between 15:00 and 24:00. We did not find statistically significant differences between the groups in relation to the time to surgery before and after the new policy. There was a trend towards a longer waiting time to surgery in the HA group in 2001 as well as in 2005. Discussion: The presence of a dedicated shift, according to the new policy, made more room available for other emergency list surgeries. Hospitalization stay became shorter due to the fact that the insurer is committed to discharge patients from the IFF group after 4 days of hospitalization and to finance each additional day. In spite of the fact that waiting time to surgery was not shortened following the new policy, the majority of surgeries were performed during the afternoon sessions. It should be noted that in 2001 waiting time to surgery was already very short. Mortality data are interesting and necessitate further investigation

Kirschner wires are commonly used in paediatric fractures, however, the requirement for removal and the possibility of pin site infection provides opportunity for the development of new techniques that eliminate these drawbacks. Bioabsorbable pins that remain in situ and allow definitive closure of skin at the time of insertion could provide such advantages.

Three concurrent studies were performed to assess the viability of bioabsorbable pins across the growth plate. (1) An epidemiological study to identify Kirschner wire infection rates. (2) A mechanical assessment of a bioabsorbable pin compared to Kirschner wires in a simulated supracondylar fracture. (3) The insertion of the implants across the physis of sheep to assess effects of the bioabsorbable implant on the growth plate via macroscopic, pathohistological and micro-CT analysis.

An infection rate of 8.4% was found, with a deep infection rate of 0.4%. Mechanically the pins demonstrated comparable resistance to extension forces (p=) but slightly inferior resistance to rotation (p=). The in vivo component showed that at 6 months: there was no leg length discrepancy (p=0.6), with micro-CT evidence of normal physeal growth without tethering, and comparable physeal width (p=0.3).

These studies combine to suggest that bioabsorbable pins do not represent a threat to the growth plate and may be considered for physeal fracture fixation.

We present a series of 14 patients presenting to the senior surgeon’s practice who sustained thoracolumbar burst fractures, with no neurological loss. The patients were treated with early mobilisation and extension bracing. We assessed their pain and disability, using VAS and ODI, and their fracture morphology. There was no statistical correlation between any measured parameter of fracture morphology and pain or disability. There was correlation between age at injury, time elapsed from injury and psychosocial aspects of the injury and the subsequent disability.

The measured disability was low and compared favourably with the results of studies of patients treated surgically.

We continue to treat all our neurologically intact burst fractures by early mobilisation and bracing, and take no account of fracture morphology in our decision making.

The closed management of fractures and the application of plasters remains a core component of orthopaedic trauma management. A prospective audit was undertaken to analyse the quality of plasters presenting from various sources to the Fracture Clinic Plaster Technicians. A prospective audit was conducted of 120 consecutive cases that presented to the Plaster Technicians at Western Health which had plasters applied by other institutions or other departments. The plasters were assessed on a number of criteria for adequacy and appropriateness using a standardised questionnaire and set guidelines. 63% of plasters applied were found to be deficient, inadequate or needed improvement. Of those applied by Theatre doctors, only 20% were appropriate. Of plasters applied by Emergency doctors only 10% were appropriate and those applied by General Practitioners were consistently deficient. Only trained plaster technicians had an acceptable rate of >90%. A large portion of the errors were due to incorrect moulding, joint position and fracture alignment. Improperly applied plasters lead to increased morbidity, require reapplication or unnecessary operative procedures due to loss of position. Ongoing education and review is critical to address this situation, and a national online database is being designed and implemented to monitor this situation nationally

1. The management of fractures in five patients with haemophilia is described: two patients had antibodies to antihaemophilic globulin. 2. The principles of management of injured haemophilia patients are described, as are the special problems in patients with antibodies to AHG. 3. Stability of the fragments must be achieved to prevent the hazards of displacement of the fracture, recurrent bleeding and pseudotumour formation which may threaten viability of the limb. 4. Stabilisation of potentially unstable fractures can be achieved at the onset by internal fixation. Plaster casts should be reserved for stable fractures or fractures occurring in young children

An audit was carried out to assess the management of patients with fragility fractures in fracture clinic and primary care. NICE guidelines advise these patients require treatment for osteoporosis if 75 years or older, and a DEXA scan if below this age.

Distal radius and proximal humeral fractures were identified in a retrospective review of letters from 10 fracture clinics. Current medication of all patients ≥ 75 years was accessed and DEXA scan requests identified for patients < 75 years.

There were 69 fragility fractures: 53 distal radius and 16 proximal humerus. 4 letters (6%) mentioned fragility fracture and advised treatment and 3 (3%) correctly advised a DEXA scan. Only 3 of 25 (10%) patients ≥ 75yrs not previously on osteoporosis medication had treatment started by their GPs. 3 of a possible 29 (10%) patients < 75 years were referred for a DEXA scan.

A text box highlighting fragility fractures and NICE guidelines was added to all clinic letters for patient ≥ 50 years old. Re-audits showed an improvement in management of these fractures, with 45% of patients ≥ 75 years being started on treatment and 39% of patients < 75 years being referred for a DEXA scan.

Background: Ankle fractures are the second commonest lower limb fractures after hip fractures and as opposed to the latter occur commonly in younger population of working age. Due to a host of different factors including the state of soft tissues and delayed presentation, there is often a delay of several days between fracture and operation, resulting in longer admissions. It is hypothesised that early intervention may shorten hospital stay and hence save on hospital resources.

Aims: To ascertain the impact of timing of ankle fracture surgery on length of post operative and total hospital stay and its implication on resources.

Methodology: Consecutive ankle fractures that underwent open reduction and internal fixation at Newcastle General Hospital over a 4-year period were studied as a retrospective cohort. Data collection from Theatre records, PAS system, case notes and radiographs was undertaken and entered in SPSS database.

Results: 431 cases of ankle fracture open reduction and internal fixation were included in the study. 41% were female and 59% were male patients, with a mean age of 39.1 years (SD±17.8), with age range from 16 to 89 years.

298 patients were operated within 48 hours of admission (early surgery group), and 136 patients after 48 hours (delayed surgery group). The mean hospital stay in the early operation group was mean 5.3 days (SD±4.9) and in the delayed surgery group it was 12.2 days (SD±8.4). The patients who were operated early had shorter total hospital stay (p< 0.001) and also had shorter post-operative stay (p< 0.05). Increasing age and female gender appeared to predispose to longer hospital stay but this was not statistically significant. Mean age, gender and ASA grade, fracture class and operating surgeon’s grade distribution were not significantly different in the early and late surgery groups.

Each patient in delayed surgery group spent an extra 6.9 days in hospital stay compared to the early surgery group, translating into an extra 937 hospital bed days. The average extra cost of hospital stay per case in the delayed surgery group (£1414) exceeds the average expense of surgery per case in that group. The delayed surgery group resulted in added expenditure of £192085 to the trauma division solely for extra hospital stay.

Conclusion: Timing of surgery in ankle fracture appears to be the most significant determinant affecting the hospital stay. This has a significant resource implication, financially and in freeing up of hospital resources, as well as impacting on the lives of this large group of patients.

Clavicle fractures represent 45% of all shoulder girdle injuries. Although clavicle fractures are usually readily recognisable and unite uneventfully with treatment, they can be associated with difficult early and late complications. Fractures of the middle third of the clavicle represent 80% of all clavicular fractures. Traditionally clavicle fractures are treated conservatively, with surgical treatment reported as being associated with an increased rate of complications. Indications for primary open fixation include significant displacement, fracture comminution and tenting of the skin, threatening its integrity which fail to respond to closed reduction. What constitutes significant displacement, is usually not defined; nor is consideration for open reduction of displaced fractures, which are not comminuted and do not threaten the integrity of the overlying skin. This paper reports on the technique indications and use of the “Rockwood Intramedullary Clavicle Pin” and the results achieved using this technique.

Aim: To assess the impact of a proforma pathway on the care of patients following fractured neck of femur at Maidstone General Hospital compared to the gold standard set out in the British Orthopaedic Association and British Geriatric Society Blue Book – The Care of Patients with a Fragility Fracture.

Objectives: Initial audit of care prior to the introduction of the Proforma

Development of a multidisciplinary care pathway and proforma following BOA Standards for Trauma (BOAST) and National Hip Fracture Database (NHFD) guidelines

Background: The recent publication of the BOA and BGS Blue Book guidelines for care of patients with fragility fractures has defined a gold standard for the care of these patients. This has highlighted the areas of care that are commonly suboptimal and defined the requirements of a department providing ideal care. Both this, and the introduction of the NHFD and the resultant requirements for data collection and monitoring led us to develop a proforma for management and data collection.

Methods: An initial audit of care was performed. Notes were reviewed retrospectively for 62 patients and results were compared to the gold standard.

In June 2008 the proforma was implemented and data collected for reaudit (n=48). Direct comparison and statistical analysis was performed for the two groups of patients

Results: Comparison of the two audit groups shows dramatic and highly statistically significant differences in a number of areas of patient care, notably: mortality rates; appropriate A& E investigation and treatment; documentation of correct diagnosis and social history; mental test scoring; time to ward admission; time to surgery and osteoporosis treatment.

Discussion: The lack of a ring fenced, dedicated trauma ward leads to patients being admitted to outlying wards following fractured neck of femur. These wards are less likely to be as well equipped to deal with the unique requirements of these patients, which may explain the consistent problems with pressure area care and delay in discharge.

A strong recommendation for gold standard care is the provision of an orthogeriatric service with regular medical review both pre- and post-operatively. Currently no such dedicated service exists at Maidstone and this affects both the treatment of acute medical problems and the provision of falls investigation and treatment.

The introduction of the pathway has clearly benefitted the management of this difficult problem. With the support of the Rapid Improvement Program, further beneficial changes can be made to the care of patients following fractured NOF.

Distal radial fractures are amongst the most common trauma referrals, however controversy remains regarding their optimum management. We undertook a retrospective review of the management of distal radial fractures in our department.

The prospectively maintained trauma database was used to identify patients admitted for operative management of a dorsally displaced distal radial fracture between June 2008 and June 2009. Only extra-articular or simple intra-articular fractures were included (AO classification A2/A3/C1/C2). Operation notes were reviewed to determine the method of fixation. Patients were contacted by post and asked to complete a functional outcome score - Disabilities of the Arm, Shoulder and Hand (DASH). A further 12 patients with similar fractures who had been managed conservatively were also asked to complete a DASH score to provide a comparison between operative and non-operative management.

98 patients were identified - 67 female, 31 male. Mean age was 51 years, range 15-85 years. All patients were at least 1 year post-op.

26 patients had manipulation under anaesthesia (MUA). 48 patients had MUA and K-wire fixation, which was supplemented with synthetic bone substitute in 16 cases. 3 patients had MUA and bone graft and 21 patients had open reduction and internal fixation (ORIF) with a volar plate.

34 correctly completed DASH scores were returned. A lower score equates to a better functional outcome. Mean DASH scores were: MUA 14.8; MUA+K-wire 13.1; ORIF 13.6; conservative 47.1.

This data would indicate that patients with a significantly displaced distal radial fracture have a better functional outcome with operative management to improve the fracture alignment. However, all of the methods of fixation used resulted in similar functional outcomes at one year.

Background Our hospital operates a consultant led rapid review process of X-rays and case notes of patients referred to fracture clinic from Accident & Emergency (A& E) and General Practitioners (GP) on a daily basis. This compares with other centres where patients are reviewed in outpatient fracture clinics soon after injury.

Aim Evaluate effectiveness of consultant led rapid review process compared to standard consultant fracture clinics.

Patients and Methods Prospective study of the rapid review process over 4 weeks of all patients referred to fracture clinic by A& E and GPs. Total number of patients referred per day, time taken to review these patients case notes and X-rays, number of recalls and reason for recall were documented. This was compared to consultant led fracture clinics, which included time taken to review patients.

Results 797 patients were processed through the rapid review over 4 weeks. 53 (6%) patients were recalled, 32 (4%) for a change of management and 21 (2.6%) because of lack of information. The mean number of patients referred per day was 28 taking a mean of 28 minutes; thus the mean time to review one patient was 1.0 minute. The mean number of patients recalled per day was 2. The mean time taken to review a patient in a standard fracture clinic was 11 minutes. Therefore, the total time that would have taken to review 28 patients in the standard fracture clinic would be 308 minutes.

Conclusion A consultant led rapid review process of all patients referred to fracture clinic is a very efficient process. Rapid review process saves clinic time and resources, minimises delays in clinical decision-making and saves the patient an unnecessary visit to the outpatient department.