Introduction

The available scoring methods and outcome analysis methods in lower extremity skeletal trauma with vascular injuries are not always specific. Biochemical parameters like venous blood lactate, bicarbonate and serum CPK (at the time of admission and serial monitoring) were measured to assess whether they supplement clinical parameters in predicting limb salvageability in lower extremity skeletal trauma with vascular injuries. Materials and methods: 74 adult patients with long bone fracture of lower limb associated with vascular injury (open and closed) were included in the study group. Patients with significant head injury (who cannot provide informed consent) and those with mangled extremities (MESS score>8) were excluded.

Aims. Weightbearing instructions after musculoskeletal injury or orthopaedic surgery are a key aspect of the rehabilitation pathway and prescription. The terminology used to describe the weightbearing status of the patient is variable; many different terms are used, and there is recognition and evidence that the lack of standardized terminology contributes to confusion in practice. Methods. A consensus exercise was conducted involving all the major stakeholders in the patient journey for those with musculoskeletal injury. The consensus exercise primary aim was to seek agreement on a standardized set of terminology for weightbearing instructions. Results. A pre-meeting questionnaire was conducted. The one-day consensus meeting, including patient representatives, identified three agreed terms only to be used in defining the weightbearing status of the patient: 1) non-weightbearing; 2) limited weightbearing; and 3) unrestricted weightbearing. Conclusion. This study represents the first and only exercise in standardizing rehabilitation terminology in orthopaedics, as agreed by all major stakeholders in the patient pathway and the patients themselves. The standardization of language allows for higher-quality and more accurate research to be conducted, and is one small part of the bigger picture in increasing the mobility of patients after orthopaedic injury or surgery. Cite this article: Bone Joint J 2024;106-B(9):1016–1020

Surfing has rapidly grown in popularity as the sport made its debut at the Tokyo 2020 Olympic Games. Surfing injuries are becoming more relevant with the globalisation and increasing risks of the sport, but despite this, little is known about surfing injuries or prevention strategies in either the competitive or recreational surfer. We reviewed the literature for the incidence, anatomical distribution, type and underlying mechanism of acute and overuse injuries, and discuss current preventative measures. Four online databases, including MEDLINE, PubMed, EMBASE and Cochrane Library were searched from inception to March 2020. This review finds that skin injuries represent the highest proportion of total injuries. Acute injuries most frequently affect the head, neck and face, followed by the lower limbs. Being struck by one's own board is the most common mechanism of injury. Surfers are injured at a frequency of 0.30–6.60 injuries per 1000 hours of surfing. Most prior studies are limited by small sample sizes, poor data collection methodology and geographical constraints. The scientific literature on surfing injuries under-represents overuse musculoskeletal injuries and the efficacy of prevention strategies for surfing-related overuse musculoskeletal injuries has not been studied. Injuries to the head and neck pose greater risks to a surfer's morbidity and mortality, yet there is no consensus on the management protocol of spinal injuries that occur in open water. Non-contact acute ligament injuries have increased as surfing manoeuvres have become more acrobatic, and overuse musculoskeletal injuries are highly correlated with paddling. Further research is needed to establish preventative measures for both acute and overuse surfing injuries and to ensure the increasing popularity of surfing is met with an improved understanding of sport risks and safety. Specifically, we recommend research be prioritised regarding the efficacy of training programmes to prevent surfing-related overuse musculoskeletal injuries

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

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

Aims. This study aims to define the epidemiology of trauma presenting to a single centre providing all orthopaedic trauma care for a population of ∼ 900,000 over the first 40 days of the COVID-19 pandemic compared to that presenting over the same period one year earlier. The secondary aim was to compare this with population mobility data obtained from Google. Methods. A cross-sectional study of consecutive adult (> 13 years) patients with musculoskeletal trauma referred as either in-patients or out-patients over a 40-day period beginning on 5 March 2020, the date of the first reported UK COVID-19 death, was performed. This time period encompassed social distancing measures. This group was compared to a group of patients referred over the same calendar period in 2019 and to publicly available mobility data from Google. Results. Orthopaedic trauma referrals reduced by 42% (1,056 compared to 1,820) during the study period, and by 58% (405 compared to 967) following national lockdown. Outpatient referrals reduced by 44%, and inpatient referrals by 36%, and the number of surgeries performed by 36%. The regional incidence of traumatic injury fell from 5.07 (95% confidence interval (CI) 4.79 to 5.35) to 2.94 (95% CI 2.52 to 3.32) per 100,000 population per day. Significant reductions were seen in injuries related to sports and alcohol consumption. No admissions occurred relating to major trauma (Injury Severity Score > 16) or violence against the person. Changes in population mobility and trauma volume from baseline correlated significantly (Pearson’s correlation 0.749, 95% CI 0.58 to 0.85, p < 0.001). However, admissions related to fragility fractures remained unchanged compared to the 2019 baseline. Conclusion. The profound changes in social behaviour and mobility during the early stages of the COVID-19 pandemic have directly correlated with a significant decrease in orthopaedic trauma referrals, but fragility fractures remained unaffected and provision for these patients should be maintained. Cite this article: Bone Joint Open 2020;1-6:182–189

Intimate partner violence (IPV) causes significant morbidity and its unlikely to be reported compared to other forms of gender-based violence (GBV). For early detection, understanding Orthopaedic injuries from GBV is vital. This study assesses the pattern of musculoskeletal injuries from GBV and determines the factors associated with it. It is a retrospective observational study of patients aged ≥18 years, with GBV-related acute Orthopaedic injuries. Data was reviewed from January 2021 to December 2021, including, demographic information, soft tissue and bony injuries, relationship to assailant, substance abuse and the day and time of injury. Frequencies and percentages for categorical data were analysed. Chi-square test was used to calculate association. T-test was used to compare groups for continuous & categorical variables. Multivariate analysis was conducted to find the odds ratio and a p-value <0.05 was statistically significant. 138 patients were included, the mean age at presentation being 35.02 years (SD=11). 92.75% of GBV victims were females. Most were unemployed (66.7%). 30.43% (n-42) had a soft tissue injury; superficial laceration being the most common (23.1%), flexor tendon injury (10.87%), hand abscess (5.8%), and extensor tendon injury (5.07%). 71.02 % (n=98) sustained appendicular fractures. 51.45% (n=71) sustained upper limb fractures; distal radius fractures (10.86%) and distal 3rd ulnar fractures (9,42%). 19.57% (n=27) had lower limb fractures; 7.25% (n=10) had lateral malleolus ankle fractures. 63.7% (n=80) of cases were by an intimate partner on weekends (50.73%). 62.31% occurred between 16h00 and 0h00. 41.1% (n=65) reported alcohol abuse. 63.04% had surgery. GBV likely occurs in early middle-aged females by intimate partners influenced by alcohol over the weekends between 16h00 to 0h00. Distal radius/distal 3rd ulnar fractures are the most common bony injuries. Superficial wrist laceration is the commonest soft tissue injury. These findings may assist with early detection and intervention to prevent adverse outcomes in GBV

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 Royal Marines regularly deploy to Norway to conduct Cold Weather, Arctic and Mountain Warfare training. A total of 1200 personnel deployed to Norway in 2010 over a 14-week period. Patients, whose injuries prevented them from continuing training, were returned to the UK via AEROMED. The aim of this investigation was to describe the epidemiology of musculoskeletal injuries during cold weather training. All data on personnel returned to the UK was prospectively collected and basic epidemiology recorded. 53 patients (incidence 44/1,000 personnel) were returned to the UK via AEROMED. 20/53 (38%) of cases were musculoskeletal injuries (incidence 17/1000 personnel). 15/20 musculoskeletal injuries were sustained while conducting ski training (incidence 13/1,000): 4/20 were non-alcohol related injuries, 1/20 was related to alcohol consumption off duty. Injuries sustained whilst skiing: 5/15 sustained anterior shoulders dislocation, 5/15 Grade 1-3 MCL/LCL tears, 2/15 sustained ACJ injuries, 1/15 crush fracture T11/T12, 1/15 tibial plateau fracture and 1/15 significant ankle sprain. Non-Training injuries: 1 anterior shoulder dislocation, 1 distal radial fracture, 1 olecranon fracture, 1 Scaphoid Fracture and one 5th metatarsal fracture. 60% of injuries were upper limb injuries. The most common injury was anterior shoulder dislocation 6/20 (Incidence 5/1000). Our results suggest that cold weather warfare training has a high injury rate requiring evacuation: 4% of all people deployed will require AEROMED evacuation, and 2% have musculoskeletal injuries. Ski training causes the majority of injuries, possibly due to the rapid transition from non-skier to skiing with a bergen and weapon. Military Orthopaedic and rehabilitation units supporting the Royal Marines, should expect sudden increases in referrals when large scale cold weather warfare training is being conducted. Further research is required to see if musculoskeletal injury rates can be decreased in cold weather warfare training

Background. Many Accident and Emergency units employ a “one size fits all” policy with regard to referring patients with musculoskeletal injury for further review in fracture clinic. This may result in inappropriate timings of review in the clinic wasting patient time, clinic time and hospital resources. Aim. Our firm employs a rapid review of all radiographs and A&E notes of all musculoskeletal injury patients referred to our fracture clinic on a weekly basis. We aimed to investigate the impact this review has on the running of our clinic and what benefits were gained. Patients and Methods. Over a three month period all the rapid trauma review meetings were audited with respect to time taken; number of referrals; outcome of referral and staff members present. During this time an audit of the number of patients reviewed in fracture clinic by the Consultant orthopaedic surgeon was also undertaken to allow the average time taken for review of a patient in the clinic to be established. Results and Discussion. Over the three month period 117 patients were reviewed with 44(38%) being given a later appointment; 6(5%) being given an earlier appointment; 8(7%) being discharged to general practice or physiotherapy and 4(3%) being referred to a different clinic. Man time taken to review was 2.4minutes per patient. Mean time for review in fracture clinic was 12.6minutes. Taking the changes to later appointment, discharges and changes to different clinic to be inappropriate referrals, 4.7 occurred per review meeting. This equated to a mean time saved per fracture clinic of 60.6 minutes. Conclusion. This data supports the use of a rapid trauma review meeting to ensure appropriate timing of review of musculoskeletal injury patients. It saves time wasted on inappropriate reviews, saves patient dissatisfaction with being seen unnecessarily and allows patients who should be reviewed more promptly to be identified and reviewed appropriately

Beside spine and pelvis surgery, computer-assisted guidance systems are not used frequently for musculoskeletal injuries. Main reason is the dependence on a fixed reference array that must be firmly attached to all moving parts. We investigated a novel fluoroscopy-based image guidance system in orthopaedic trauma surgery that uses a different technique. This was a prospective, not randomised single centre case series at a level I trauma centre. 45 patients with 46 injuries (foot 12, shoulder 10, long bones 7, hand and wrist 7, ankle 7, spine and pelvis 4) were included. Different surgical procedures were examined following the basic principles of the AO/ASIF. Main outcome measurements were the number of trials for implant placement, total surgery time, usability via user questionnaire and system failure rate. Furthermore we wanted to test the ability of the new system to be integrated in existing surgical workflows. In all cases, the trajectory function was used, inserting a total of 56 guided implants. The trajectory was the most popular feature used by surgeons (n=43, 93.5%), followed by the length measurement tool (n=29, 63%) and the bending function (n=17, 37%). The functions could be freely activated by the performing surgeon. The system failed when used in pelvic and spinal injuries, resulting in a total failure rate of 6.5% (n=3) of all included cases. The overall usability was rated as good, scoring 84.3%. This study examined the clinical application of a fluoroscopy-based image guidance system for different musculoskeletal injuries. Its major advantage is the high integrability in the accustomed surgical workflow and its connectivity with existing technical equipment. It can hardly be compared to known navigation solutions, since instruments are not tracked and fixed reference arrays are not required. Expected advantages should be explored in randomised studies

Introduction. Virtual fracture clinics (VFCs) are being increasingly used to offer safe and efficient orthopaedic review without the requirement for face-to-face contact. With the onset of the COVID-19 pandemic, we sought to develop an online referral pathway that would allow us to provide definitive orthopaedic management plans and reduce face-to-face contact at the fracture clinics. Methods. All patients presenting to the emergency department from 21March 2020 with a musculoskeletal injury or potential musculoskeletal infection deemed to require orthopaedic input were discussed using a secure messaging app. A definitive management plan was communicated by an on-call senior orthopaedic decision-maker. We analyzed the time to decision, if further information was needed, and the referral outcome. An analysis of the orthopaedic referrals for the same period in 2019 was also performed as a comparison. Results. During the study period, 295 patients with mean age of 7.93 years (standard error (SE) 0.24) were reviewed. Of these, 25 (9.8%) were admitted, 17 (5.8%) were advised to return for planned surgical intervention, 105 (35.6%) were referred to a face-to-face fracture clinic, 137 (46.4%) were discharged with no follow-up, and seven (2.4%) were referred to other services. The mean time to decision was 20.14 minutes (SE 1.73). There was a significant difference in the time to decision between patients referred to fracture clinic and patients discharged (mean 25.25 minutes (SE 3.18) vs mean 2.63 (SE 1.42); p < 0.005). There were a total of 295 referrals to the fracture clinic for the same period in 2019 with a further 44 emergency admissions. There was a statistically significant difference in the weekly referrals after being triaged by the VFC (mean 59 (SE 5.15) vs mean 21 (SE 2.17); p < 0.001). Conclusion. The use of an electronic referral pathway to deliver a point of care virtual fracture clinic allowed for efficient use of scarce resources and definitive management plan delivery in a safe manner. Cite this article: Bone Joint Open 2020;1-6:293–301

Objective. To evaluate the effect of claiming compensation on health status for people with mild to moderate injuries sustained in road traffic collisions (RTC). Methods. The design was a prospective cohort study in the Australian Capital Territory (ACT), Australia and a fault based compensation system. The subjects were people with mild to moderate musculoskeletal injuries who presented to the emergency department within 7 days of an RTC. Outcome Measures were Physical Component Score (PCS) and Mental Component Score (MCS) of the Short Form 36 (SF-36) health status measure; Hospital Anxiety and Depression Scale (HADS); and the Functional Rating Index (FRI). These measures were recorded immediately RTC, and at 6 and 12 months. Results. Ninety-five people were enrolled a mean of 8.6 days following RTC; 86% were followed up at 12 months. Mean age was 37 years; 61% were female; and 91% were employed at the time of injury. Compensation was claimed by 33% of enrolled subjects, and 25% engaged a lawyer. There were no significant differences in patient demographics or injury-related factors between the groups. As expected, passengers and people involved in multiple vehicle crashes more frequently claimed compensation. At each time-point, claiming compensation resulted in significantly worse scores for SF-36 PCS (-5.5 (95%CI -8.6 to -2.4), p = 0.001), HADS Anxiety (1.7 (95%CI 0.17 to 3.3), p = 0.048), and FRI (11.2 (95%CI 3.9 to 18.5), p = 0.003). For both groups, health status improved at the same rate, with significant improvement between baseline and 6 months, but no further improvement between 6 and 12 months. Conclusion. Claiming compensation had a significant negative effect on health status following mild to moderate musculoskeletal injuries sustained in RTC. However, whether this negative effect was due to claiming compensation itself or the presence of other unmeasured factors cannot be determined

Anterior Cruciate Ligament injuries are a common cause of downgrade in Service personnel. The Multidisciplinary Injury Assessment Clinic (MIAC) is a service which patients can be referred to for expert musculoskeletal injury management. MIAC has a Fast Track (FT) referral system in place for imaging, and can subsequently refer isolated ACL injuries to a private provider for reconstruction. We examined this pathway in the South West region which has an overall population at risk of 19775. Over 4 years 173 knee injuries were referred to MIAC, of which 32 were ACL injuries. Of the 29 patients referred for MRI, the median time to imaging was 8 days with FT (n=13, range 2–14) and. 15 days via the NHS (n=16, range 5–64). The majority of injuries were found to involve multiple pathologies (n=19), excluding them from FT surgery. Time to NHS clinic from point of referral took a median time of 54 days, and onward delay to surgery was 47 days. None of the referrals to the private provider for reconstruction were accepted (n=3). We have identified aspects of current referral and treatment pathways that are inefficient and discuss a current solution utilising Military surgeons

HIV and musculoskeletal trauma have reached epidemic proportions in the developing world especially in sub Saharan Africa. The epidemic has adversely affected health care delivery in limited resource settings. We assessed the outcome of HIV+ patients following spinal surgery for fractures and dislocations. Forty seven HIV+ patients were treated surgically over the past three years. The mean age was 32 years (19–53 years) and included 39 males. The dorsolumbar region was affected in 28 patients and the cervical spine in 19. Motor vehicle collisions (34) accounted for 72% of the injuries. Neurology occurred in 49% of patients (23). The mean CD4 count was 426 (range 98–742). The albumen was 29 gm/d? (range 26–34) and the lymphocyte count was 1.6c/cumm range 1.4–1.9). Twenty eight patients had generalized lymphadenopathy and recent weight loss was noted in 11 patients. Fifteen patients were treated for pulmonary TB and seven patients were on ARVs. The dislocations at the cervical spine commonly occurred at C5/6 (8). Three patients required a posterior cervical release with facetectomy prior to anterior cervical plating which was performed in all patients. The dislocations and unstable burst fractures of the dorsolumbar spine were treated by a one/two level posterior fusion. Post-operative sepsis due to S. aureus occurred in 8 (17%) patients. In four patients with deep infection vacuum dressings were used to clear the sepsis. Post-operative sepsis is best avoided by optimization of patients and meticulous surgery

Heterotopic ossification (HO) is the formation of bone at extra-skeletal sites. Genetic diseases, traumatic injuries, or severe burns can induce this pathological condition and can lead to severe immobility. While the mechanisms by which the bony lesions arise are not completely understood, intense inflammation associated with musculoskeletal injury and/or highly invasive orthopaedic surgery is thought to induce HO. The incidence of HO has been reported between 3% and 90% following total hip arthroplasty. While the vast majority of these cases are asymptomatic, some patients will present decreased range of motion and painful swelling around the affected joints leading to severe immobility. In severe cases, ectopic bone formation may be involved in implant failure, leading to costly and painful revision surgery. The effects of surgical-related intraoperative risk factors for the formation of HO can also play a role. Prophylactic radiation therapy, and anti-inflammatory and biphosphonates agents have shown some promise in preventing HO, but their effects are mild to moderate at best and can be complicated with adverse effects. Irradiation around surgery could decrease the incidence of HO. However, high costs and the risk of soft tissue sarcoma inhibit the use of irradiation. Increased trials have demonstrated that nonsteroidal anti-inflammatory drugs (NSAID) are effective for the prevention of HO. However, the risk of gastrointestinal side effects caused by NSAID has drawn the attention of surgeons. The effect of the selective COX-2 inhibitor, celecoxib, is associated with a significant reduction in the incidence of HO in patients undergoing THA. Bone morphogenetic proteins (BMP) such as BMP2 identified another novel druggable target, i.e., the remote application of apyrase (ATP hydrolyzing agent) in the burn site decreased HO formation and mitigated functional impairment later. The question is if apyrase can be safely administered through other, such as systematical, routes. While the systemic treatments have shown general efficacy and are used clinically, there may be great benefit obtained from more localised treatment or from more targeted inhibitors of osteogenesis or chondrogenesis. In the surgical setting, prophylaxis for HO is regularly indicated due to the considerable risk of functional impairment. Heterotopic ossification is a well-known complication of total hip arthroplasty, especially when the direct lateral approach is used. Possible intraoperative risks are the size of incision, approach, duration of surgery and gender that can be associated with higher rates of HO or increase of the severity of HO. Like inflammation and tissue damage/ischemia are likely to be the key in the formation of HO, kindness to the soft tissues, tissue preserving surgery, pulse lavage to remove bone inducing factors and avoiding damage to all tissues should be erased as a comorbidity. Incision length, tissue dissection and subsequent localised trauma and ischemia, blood loss, anesthetic type and length of surgery may all contribute to the local inflammatory response. Data suggest that the surgeon may control the extent and nature of HO formation by limiting the incision length and if possible the length of the operation. Currently resection of HO is generally suggested after complete maturation (between 14–18 months), since earlier intervention is thought to predispose to recurrence. Reliable indicators of maturation of HO are diminishing activity on serial bone scans and/or decreasing levels of alkaline phosphatase. Although usually asymptomatic, heterotopic bone formation can cause major disability consisting of pain and a decreased range of motion in up to 7% of patients undergoing THA. Patients benefit from early resection of the heterotopic ossification with a proper and reliable postoperative strategy to prevent recurrence of HO with clinical implications

Introduction. Intimate partner violence (IPV) is a pattern of coercive behaviours that include repeated physical, sexual and emotional abuse. Musculoskeletal injuries are common symptoms of IPV. We aimed to determine the proportion of female patients, attending orthopaedic fracture clinics, that have experienced IPV defined as physical, sexual, or emotional abuse within the past 12 months. Methods. We completed a cross-sectional study of 282 injured women attending two Level I trauma centres in Canada. Female patients presenting to the orthopaedic fracture clinics completed two validated self-reported written questionnaires; the Woman Abuse Screening Tool (WAST) and the Partner Violence Screen (PVS) to determine the prevalence of IPV. The questionnaire also contained questions that pertain to participant demographics, fracture characteristics, and experiences with health care utilisation. Results. The overall prevalence of IPV (emotional, physical, and sexual abuse) within the last 12 months was 32% (95% Confidence Interval 26.4% to 37.2%) amongst the 282 respondents. One in 12 injured women disclosed a history of physical abuse (24/282, 8.5%) in the past year. Seven women (2.5%) indicated the cause for their current visit was directly related to physical abuse, and 5 of these cases included fractures. We did not identify any significant trends in ethnicity, socioeconomic status, or injury patterns as markers of domestic abuse. Of 24 women with physical injuries, only 4 had been asked about IPV by a physician and none of the physicians were their treating orthopaedic surgeons. Conclusion. Our study confirms a high prevalence of IPV among female patients with injuries attending orthopaedic surgical clinics in Ontario. Similar to previous research, our study found that women of all ages, ethnicities, social economic status, and injury patterns may experience IPV. Surgeons should consider screening all injured women for domestic violence in their clinics

Algorithms for the treatment of multiply-injured patients with concomitant orthopaedic injuries have continued to evolve over the past several decades. Advances in surgical techniques and implants have revolutionised the treatment of specific musculoskeletal injuries. Improved understanding of the implications of applying these techniques to patients with compromised physiology has led to critical reevaluation of the issues surrounding definitive orthopaedic care. A discussion of these issues as they apply to the multiply-injured patient with associated femoral shaft fracture provides insight into how Damage Control Orthopaedics has evolved. As well as what questions remain unanswered in our ongoing efforts to decrease mortality and improve long-term functional recovery in this difficult and challenging patient population. While femur fracture patients in the 1950s and 1960s were often deemed ‘too sick’ for surgical treatment, the high morbidity and mortality associated with long-term traction as a primary treatment modality led to recognition of the benefits of early fracture care in the 1980s. Multiple studies demonstrating the benefit of early fixation of femur fractures in multiply-injured patients led to a dramatic shift in treatment protocols towards urgent, if not emergent, definitive stabilisation of the femur. However, weaknesses of these early studies exist and their results were often over-interpreted. In the late 1980s and early 1990s, evidence began to accumulate that early definitive treatment consisting of reamed intramedullary nailing of the femur might actually be detrimental in an at risk subgroup of patients. Early interpretation of these results led to a move toward ‘unreamed’ nails in multiply-injured patients in an effort to minimise the pulmonary impact of reaming. Our current level of understanding appears to indicate that there exists a much more complex interaction between multiple factors including patient characteristics, associated injuries, timing and mode of orthopaedic stabilisation employed. As the relative importance and influence of these multiple factors becomes clearer, our ability to appropriately select patients for early total care versus damage control orthopaedics should improve the potential for damaging physiological effects of treatment. In the meantime, application of the principles of damage control to those patients for whom it is clearly indicated, as well as to those for whom it may not be clear cut, appears to have minimal, if any, deleterious effect

Aims

The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture.