Since NICE issued guidance on preventing venous thromboembolism (VTE), the use of chemoprophylaxis has increased dramatically in trauma and orthopaedics. However, enthusiasm is tempered by a lack of data regarding the true incidence of VTE in everyday practice. We investigated the epidemiology of VTE among ambulatory patients with lower limb injuries within our Trust. We identified all patients who suffered pulmonary embolism (PE) or deep vein thrombosis (DVT) over an 18 month period, and cross-referenced them with our trauma database. All lower limb injuries were included, whether operated or not. Hip fractures routinely receive dalteparin and were excluded. There were 11,594 new attendances or post-operative attendances in all fracture clinics over 18 months. Of these, 4530 had lower limb injuries and were immobilised. There were 21 DVTs and 7 PEs in these patients, an incidence of 0.43% and 0.14% respectively. Of note, three DVTs were in patients with Achilles tendon rupture. The incidence of symptomatic VTE is low in a population of ambulant patients with lower limb injuries in casts, without chemical thromboprophylaxis. Prophylaxis for VTE would thus have a large number needed to treat. The costs and complications of chemoprophylaxis should also be considered before it is introduced universally

Current health economics forces the clinician to consider the cost of treatment. Currently in Fife Hospitals, all lower limb injuries likely to require operative treatment are admitted from the Accident and Emergency department on the day of injury. The aim of this investigation was to see if non-emergency trauma cases could be managed pre-operatively as outpatients to reduce costs. We prospectively recorded all patients admitted with lower limb trauma excluding neck of femur fractures, requiring operative treatment over an eleven-week period. The senior author reviewed all patients and a clinical judgment was made as to whether the patient could have been safely managed as an outpatient pre-operatively. 61 patients met the inclusion criteria. Average age 41.8 (Range 8-66). The three most common fractures were 23(38%) ankle fractures, 15(25%) tibial fractures and 8(13%) femoral shaft fractures. 28(46%) fractures were deemed safe to have been managed preoperatively on an outpatient basis. 14/23(61%) ankle fractures were deemed safe to be discharged home. The average pre-operative stay was 1.38 nights (Range 1-4 nights). By initiating a simple policy of allowing uncomplicated ankle fracture patients to wait at home and return on the morning of surgery it is possible to reduce inpatient occupancy by 64 nights per year in our department. At a cost of £518 per patient per night, this could result in a saving of around £33,000 in unnecessary overnight inpatient stays. In order to achieve this, clear clinical guidance for admitting doctors is necessary and further prospective research should be conducted into the risk/benefit of implementing this policy

The timely management of anticoagulated elderly trauma patients remains a contentious issue. Presently, the literature consists of largely contradictory expert opinions without evidence from randomised control trials. This study seeks to audit the practices of a non-metropolitan orthopaedic service, as a prelude to developing a local protocol for optimal management. All orthopaedic admissions to Toowoomba Hospital from January 2004 to December 2008 were reviewed. Approximately 700 patients over the age of 60 years were admitted with lower limb trauma. Those patients with pre-injury medication with warfarin and clopidogrel were identified, along with chronologically matched untreated patients. Those patients with coexisting head-injures, and those with sub therapeutic INR (INR <1.5) on admission were excluded from the study groups. Groups were analysed with respect to age, Injury Severity Score, ASA, time to theatre, time to discharge, transfusion requirement, and complications. Statistical analysis was completed using the T-test. Of the 700 patients identified, 24 were treated with warfarin and 28 treated with clopidogrel. Two patients with pre-injury warfarin use were excluded due to sub therapeutic INR on admission (INR 1.0 and 1.3). The control and treatment groups were statistically similar with respect to age, Injury Severity Score, and ASA. Injury patterns were similar across groups with over 80% proximal femoral fractures in each group. In both the warfarin and clopidogrel groups there was a statistically significant increase in time from admission to theatre compared with their matched controls (P<0.001). Average number of days to theatre was seven days and five days for the clopidogrel and warfarin groups respectively, compared to two days for both control groups. There was no significant difference between the groups in length of time from operation to the end of their acute care. There was no increase in transfusion requirement in those patients with pre-injury clopidogrel use. Pre-injury warfarinisation demonstrated a trend toward increased transfusion requirement compared with the matched controls (P=0.052); however, this was not significant. There was no clinically significant increase in complications in those patients with pre-injury use of warfarin or clopidogrel. This study demonstrated no increased morbidity in elderly patients with lower limb trauma when being treated with anticoagulants prior to injury. However, there is a significant delay in operative intervention in these patients. We believe this presents a case for early reversal of anticoagulant therapy in order to expedite treatment

The purpose of this study was to review the outcomes and complications of all circular external fixators (frames) used for the management of acute lower limb trauma in our institution over a twenty year period. We retrospectively reviewed a prospectively compiled database of all frames applied in our institution and identified all frames which were applied for acute lower limb trauma. We identified 68 fractures in 63 patients. There were 11 femoral fractures and 57 tibial fractures. All fractures were classified using the AO Classification system, and most fractures were Type C fractures. We used an Ilizarov frame in 53 patients and a Taylor Spatial Frame in 15 patients. The mean time in frame was 365 days for a femoral fracture and 230 days for a tibial fracture. There were five tibial non-unions giving an overall union rate of 93%. Factors associated with non-union included high energy trauma and cigarette smoking. The vast majority of lower limb fractures can be treated using ‘conventional’ methods. Complex fractures which are not amenable to open reduction and internal fixation or cast immobilisation can be treated in a frame with excellent results. The paucity of published reports regarding the use of frames for complex trauma reflects the under-utilisation of the technique

Introduction

Pain after trauma has received relatively little research attention compared with surgical techniques and functional outcomes, but is important to patients. We aimed to describe nerve dysfunction and pain characteristics using tibial fractures as a model. We hypothesized that early nerve dysfunction was associated with neuropathic and chronic pain.

The literature states pre-operative angiography of open tibial fractures (OTFs) should only be considered if abnormal pedal pulses are present.

Introduction. The regionalisation of major trauma in the UK has significantly improved outcomes for patients with severe, lower limb injuries. Chronic pain after complex lower limb injuries is well documented, but seems to remain a problem despite better clinical and radiological outcomes. We hypothesised that pain was mediated through the saphenous nerve, especially as most tibial injuries affected the soft tissues medially. As a proof of concept, we undertook adductor canal blocks to understand pain aetiology. Materials & Methods. Patients with chronic pain following complex lower limb trauma or congenital deformity correction have been selected and underwent an adductor canal block by one of our trauma anaesthetist that specialises in this procedure. Their outcomes were recorded in their clinical records and patients were contacted by phone to document their experiences. Results. 14 patients with chronic, treatment refractory lower limb pain who were being managed in our orthoplastics clinic following complex, lower limb trauma were identified. Six of those patients had required plastic coverage. Of these 14 patients, all stated their pain completely resolved after the procedure and then returned between 24 hours and 4 weeks after the procedure. Two patients underwent a saphenous nerve diversion after conduction of the blocks, reporting subsequent resolution of their complaints. Conclusions. As a proof of concept, we report that the saphenous nerve underlies chronic pain in patients with complex lower limb injuries. An adductor canal block is an effective diagnostic tool for these patients. Saphenous diversion may offer a permanent solution in patients who respond well to saphenous nerve block. A prospective study is planned to objectively measure pain and quality of life scores after treatment of complex injuries and pre and post adductor canal block

Introduction. By utilising the inherent variability achievable with circular frames, surgeons can manage a wide spectrum of complex injuries, and can deal with deformity at multiple levels, in multiple planes. The aim of this study was to assess functional outcomes utilising patients reported outcome measures (PROMs) of patients being treated with circular (Ilizarov) frame fixation for complex lower limb injuries and assess these results in conjunction with the observed postoperative alignment of the patients’ limbs. Materials & Methods. Cases were identified using a prospectively collected database of adult patients presenting between July 2018 and August 2021. Functional outcomes were assessed using the American Orthopaedic Foot and Ankle Score (AOFAS), the 5-level EQ-5D (EQ5D5L), the Lysholm Knee Scoring Scale (LKSS), the Olerud-Molendar Ankle Score (OMAS), and the Tegner Activity Scale (TAS). Postoperative radiographs were analysed for fracture union and to quantify malunion (as described in Dror Paleys Principles of Deformity Correction). Results. The mean AOFAS, EQ5D5L, LKSS and OMAS scores showed an initial drop from pre-op to early time points and then steady increase over the early, mid, late and frame-off time points, with a resultant score higher than pre-op. Malunion was found in 35 (41.7%) patients, 7 patients had a malunion within 5 degrees of normal, 15 from 5–10 degrees of normal, 12 from 10–15 degrees of normal and 2 out with 15 degrees of normal. Conclusions. Circular frame fixation is an attractive option in complex lower limb trauma where alternative fixation methods are unsuitable. Whilst post-operative success to the surgeon might be determined radiographically, patient reported outcomes give a functionally important, objective measure of the success of the surgery to the patient

Surgical site infections following orthopaedic surgery are a serious complication associated with increased morbidity and mortality. Intra-wound antibiotic powder may be able to provide infection prophylaxis locally with less systemic adverse effects, and promising results have been reported in systematic reviews of its use in spine surgery. This study aims to analyse the efficacy and adverse effect profile of intra-wound antibiotics in reducing surgical site infections in orthopaedic surgery for traumatic pelvic and lower limb fractures. A systematic review was conducted for studies reporting on the incidence of surgical site infections following administration of intra-wound antibiotic powder in pelvic and lower limb trauma surgery. Randomised controlled trials, cohort and case-control studies were included. A meta-analysis was conducted for deep surgical site infections. Seven studies were included in the systematic review including six retrospective case-control studies and one randomised controlled trial. Results of the meta-analysis suggest a potential 23% reduction in the odds of developing a deep surgical site infection in patients treated with intra-operative antibiotic powder compared with those managed with intravenous antibiotics alone (OR 0.77, 95% CI 0.52 – 1.13), although the results did not reach statistical significance. Notable selective bias against intra-wound antibiotics and suboptimal study design were found in the retrospective studies, however the randomised controlled trial reported a significant reduction in deep surgical site infections with intra-wound vancomycin powder. There were no reports of systemic adverse outcomes and minimal risk of wound complications with the use of intra-wound antibiotics. This review suggests the use of intra-wound antibiotic powder in pelvic and lower limb trauma surgery may reduce the incidence of deep surgical site infections. Further powered studies including randomised controlled trials are required to confirm the results highlighted in this study

Introduction. Circular external fixators are fundamental to lower limb reconstruction, primarily in situations with a high risk of infection such as open fractures. During the Covid-19 pandemic, use of circular frames in our unit decreased, following departmental approval, due to resource management and in keeping with BOA guidelines as we opted to “consider alternative techniques for patients who require soft tissue reconstruction to avoid multiple operations”. These alternatives included the use of internal fixation (plate osteosynthesis and intramedullary nailing) as a measure to reduce the number of hospital attendances for patients and to conserve resources. This change in practice has continued in part following the pandemic with the increased use of internal fixation in cases previously deemed unsuitable for such techniques. We present our experience of this treatment strategy in the management of complex lower limb injuries, focusing on outcomes and consider the lessons learnt. Materials & Methods. Data of patients with complex lower limb injuries treated before, during and after the pandemic were collected from our in-house trauma database, theatre records and follow up clinics. The rationale for choosing other techniques over a circular frame, the type of alternative technique used, the cost of such alternatives, the need for soft tissue reconstruction, time to recovery, complications and amputation rates were compared among groups. Results. These data suggest comparable outcomes between circular frames and alternative techniques can be achieved. A notable reduction in the number of circular frames applied during the review period was observed. Furthermore, frame fixation was associated with more frequent outpatient review and the associated implications for resource management. Conclusions. Conclusion: The Covid-19 pandemic has posed great challenges to the Trauma and Orthopaedic community, forcing us to be flexible by adopting alternative treatment methods to traditional circular external fixation. These alternatives have proven feasible and potentially more cost effective, prompting their adoption in the post pandemic era. However, this change of practice is not without potential consequences and continued investigation is warranted

Abstract. Source of Study: London, United Kingdom. This intervention study was conducted to assess two developing protocols for quadriceps and hamstring rehabilitation: Blood Flow Restriction (BFR) and Neuromuscular Electrical Stimulation Training (NMES). BFR involves the application of an external compression cuff to the proximal thigh. In NMES training a portable electrical stimulation unit is connected to the limb via 4 electrodes. In both training modalities, following device application, a standardised set of exercises were performed by all participants. BFR and NMES have been developed to assist with rehabilitation following lower limb trauma and surgery. They offer an alternative for individuals who are unable to tolerate the high mechanical stresses associated with traditional rehabilitation programmes. The use of BFR and NMES in this study was compared across a total of 20 participants. Following allocation into one of the training programmes, the individuals completed training programmes across a 4-week period. Post-intervention outcomes were assessed using Surface Electromyography (EMG) which recorded EMG amplitude values for the following muscles: Vastus Medialis, Vastus Lateralis, Rectus Femoris and Semitendinosus. Increased Semitendinosus muscle activation was observed post intervention in both BFR and NMES training groups. Statistically significant differences between the two groups was not identified. Larger scale randomised-controlled trials are recommended to further assess for possible treatment effects in these promising training modalities

Introduction. External fixators are attached to bones with percutaneous pins and wires inserted through soft tissues and bone increasing the risk of infections. Such infections compromise patient outcomes e.g., through pin loosening or loss, failure of fixator to stabilise the fracture, additional surgery, increased pain, and delayed mobilisation. These infections also impact the healthcare system for example, increased OPD visits, hospitalisations, treatments, surgeries and costs. Nurses have a responsibility in the care and management of patients with external fixators and ultimately in the prevention of pin-site infection. Yet, evidence on best practices in the prevention of pin-site infection is limited and variation in pin-site management practices is evident. Various strategies are used for the prevention of pin-site infection including the use of different types of non-medicated and medicated wound dressings. The aim of this retrospective study was to investigate the use of dry gauze or iodine tulle dressings for the prevention of pin-site infections in patients with lower limb external fixators. Methodology. A retrospective study of patients with lower limb external fixators who attended the research site between 2015–2022. Setting & Sample: The setting was the outpatient's (OPD) orthopaedic clinic in a University Teaching Hospital in Dublin, Ireland. Eligibility Criteria:. Over the age of 16, treated with an Ilizarov, Taylor Spatial frame (TSF) or Limb Reconstruction System (LRS) external fixators on lower limbs,. Pin-sites dressed with dry gauze or iodine tulle,. Those with pre-existing infected wounds close to the pin site and/or were on long term antibiotics were excluded. Follow Up Period: From time of external fixator application to first pin-site infection or removal of external fixator. Outcome Assessment: The primary outcome was pin-site infection, secondary outcomes included but were not limited to frequency of pin-site infection according to types of bone fixation, frequency of pin/wire removal and hospitalisation due to infection. Data analysis: IBM SPSS Version 25 was used for statistical analysis. Descriptive and inferential statistics were conducted as appropriate. Categorical data were analysed by counting the frequencies (number and percentages) of participants with an event as opposed to counting the number of episodes for each event. Differences between groups were analysed using Chi-square test or Fisher's exact test, where appropriate. Continuous variables were reported using mean and standard deviations and difference analysed using a two-sample independent t-test or non-parametric test (Mann-Whitney), where appropriate. Using Kaplan-Meier, survival analysis explored time to development of infection. Ethical approval: granted by local institute Research Ethics Committee on 12th March 2018. Results. During the study period, 97 lower limb external fixators were applied with 43 patients meeting the study eligibility criteria. The mean age was 38 (SD 14.1; median 37) and the majority male (n=32, 74%). At least 50% (n=25) of participants had an IIizarov fixator, with 56% (n=24) of all fixators applied to the tibia and fibula. Pin/wire sites were dressed using iodine (n=26, 61%) or dry gauze dressings (n=15, 35%). The mean age of participants in the iodine group was significantly higher than the dry gauze group (p=.012). The only significant difference between the iodine and dry gauze dressing groups at baseline was age. A total of 30 (70%) participants developed a pin-site infection with 26% (n=11) classified as grade 2 infection. Clinical presentation included redness (n=18, 42%), discharge (n=16, 37%) and pain (n=15, 35%). Over half of participants were prescribed oral antibiotics (n=28, 65%); one required intravenous antibiotics and hospitalization due to pin-site infection. Ten (23%) participants required removal of pin/wires; two due to pin-site infection. There was no association between baseline data and pin-site infection. The median time to developing an infection was 7 weeks (95%, CI 2.7 to 11.29). Overall, there were 21 (81%, n=26) pin-site infections in the iodine group and nine (60%, n=15) in the dry gauze group, difference in proportion and relative risk between the dressing groups were not statistically significant (RR 1.35, 95% CI 0.86–2.12; p= .272). There was no association between baseline data, pin-site infection, and type of dressing. Conclusions. At the research site, patients are referred to the OPD orthopaedic clinic from internal and external clinical sites e.g., from Hospital Consultants, General Practitioners and occasionally from multidisciplinary teams, throughout Ireland. Our retrospective observation study found that 97 lower limb external fixators were applied over a seven-year period which is lower than that reported in the literature. However, the study period included the COVID pandemic years (2020 and 2021) which saw a lower number of external fixators applied due to lack of theatre availability, cancelled admissions and social/travel restrictions that resulted in fewer accidents and lower limb trauma cases requiring external fixator application. The study highlighted a high infection rate with 70% of participants developing pin-site infection which is in keeping with findings reporting in other studies. Our study showed that neither an iodine nor dry gauze dressing was successful in preventing pin-site infection. In the iodine group 81% of participants developed infection compared to 60% in the dry gauze group. Given the lack of difference between the two groups consideration needs to be given to the continued use of iodine dressings in the prevention of pin-site infection. Pin-site infections result in a high portion of participants being prescribed antibiotics and, in an era, that stresses the importance of antimicrobial stewardship there is a need to implement effective infection prevention and control strategies that minimise infection. Further research is therefore needed to investigate more innovative medicated dressings such as those that contain anti-microbial or anti-bacterial agents

Introduction. We aimed to determine whether there are differences in patient-reported quality of life (QoL) outcome between local flap versus free flap. Materials and Methods. All patients admitted with lower limb open fractures were retrospectively reviewed. Patient notes were assessed for demographics, time to fracture union, wound healing and patient-reported QoL with EQ-5D-5L, alongside a novel flap assessment tool. Results. A total of 40 patients had flap reconstruction of their lower limb injury; 23 local flap (Group I) and 17 free flaps (Group II). The average length of follow-up was 33.8 months. Group I - 10 revisions of flaps (43.5%) and 14 surgical complications (60.9%). Fracture union was 171 days and wound healing 130 days. EQ-5D index and EQVAS scores were 0.709 and 79.3, respectively. Group II – 8 revision of flaps (47.1%) and 12 surgical complications (70.6%). Fracture union was 273 days and wound healing 213 days. EQ-5D index and EQ-VAS scores were 0.525 and 57.2, respectively. Aesthetic appeal - 48% Group I vs. 66% Group II. Significant differences were found between the two flap groups with higher scores for daily living in Group I (p–0.007) compared to higher overall flap ratings in Group II (p–0.049). Both groups were comparable in terms of complications, while flap congestion and dehiscence were more common with free flaps. statistical interrogation did not elicit significance (p > 0.05). Conclusions. Local flap and free flap techniques offer distinct advantages. Local flaps have a better surgical outcome and patient-reported QoL in the first few years post soft tissue reconstruction. Differences between local and free reconstructive techniques in terms of patient health and function are ameliorated in the longer term

Background. Orthopaedic surgeons are increasingly pressured to consider thromboprophylaxis for patients when little evidence exists. The aim of this study was to determine the incidence of fatal pulmonary embolism following office attendance in our outpatient fracture clinic. Methods. Between October 2004 and September 2006 details of all new patients referred to our orthopaedic fracture clinic were prospectively entered into an audit database. Patients did not receive any form of thromboprophylaxis. Data was cross referenced with a national mortality database to identify all patients who subsequently died within 90 days of attendance in fracture clinic. Results. 11,502 new patient fracture clinic appointments occurred during the study period. 5604 patients had lower limb injuries. Twenty three patients died within 90 days of being seen. The mean age of these patients was 75 years (range 52–100). Two of the 23 patients attended fracture clinic with lower limb injuries. Review of the medical records showed no evidence of pulmonary embolism. Assuming a worst case scenario that both died of fatal pulmonary embolism the incidence of fatal pulmonary embolism following attendance in fracture clinic with a lower limb injury is no higher than 0.036% (95% CI 0.09%–0.33%). Conclusion. The incidence of fatal PE following outpatient management of lower limb fractures is very low. This incidence data will inform decisions on the risk-benefit analyisis of thromboprophylaxis in this group of patients

Most of current literatures advise on thromboprophylaxis with injectable LMWH for trauma patients. Injectable anticoagulants have got inherent problems of pain, bruising and difficulty in administering the drug, which leads to low compliance. Clexane is derived from a pig's intestinal mucosa, hence could be objectionable to certain proportion of patients because of their religious beliefs. Oral anticoagulants have been used as thromboprophylactic agents in hip and knee arthroplasty. However there is not enough literature supporting their use as thromboprophylactic agent in ambulatory trauma patients with ankle fracture being managed non-operatively as out-patient. This study looks into the efficacy of oral anticoagulant in preventing VTE in ambulatory trauma patients requiring temporary lower limb immobilisation for management of ankle fracture. The end point of this study was symptomatic deep vein thrombosis (either proximal or distal) and pulmonary embolism. Routine assessment with a VTE assessment risk proforma for all patients with temporary lower limb immobilisation following lower limb injury requiring plaster cast is done in the fracture clinic at this university hospital. These patients are categorised as low or high risk for a venous thromboembolic event depending on their risk factor and accordingly started on prophylactic dose of oral anticoagulant (Rivaroxaban - Factor Xa inhibitor). Before the therapy is started these patients have a routing blood check, which includes a full blood count and urea and electrolyte. Therapy is continued for the duration of immobilisation. Bleeding risk assessment is done using a proforma based on NICE guideline CG92. If there is any concern specialist haematologist advice is sought. A total of 200 consecutive patients who presented to the fracture clinic with ankle fracture, which was managed in plaster cast non-operatively, were included in this study. They were followed up for three months following injury. This was done by checking these patients’ radiology report including ultrasound and CT pulmonary scan (CTPA) test on hospital's electronic system. Fracture of the lateral malleolus which include Weber-A, Weber-B and Weber-C fractures were included in the study. Also included were bimalleolar fractures and isolated medial malleolus fractures. Complex pilon fractures, polytrauma and paediatric patients were excluded from the study. Only one case of plaster associated isolated distal deep vein (soleal vein) thrombosis was reported in this patient subgroup. There was no incidence of proximal deep vein thrombosis or pulmonary embolism. No significant bleeding event was reported. Injectable low molecular weight heparin (LMWH) rather than oral anticoagulant has been recommended by most of the studies and guidelines as main thromboprophylactic agent for lower limb trauma patients

The conflict in Afghanistan has been epitomised by the emergence of the Improvised Explosive Device(IEDs). Improvements in medical treatments have resulted in increasing numbers of casualties surviving with complex lower extremity injuries. To date, there has been no analysis of foot and ankle blast injuries as a result of IEDs. Therefore the aims of this study are to firstly report the pattern of injury and secondly determine which factors were associated with a poor clinical outcome in order to focus future research. Using a prospective trauma registry, UK Service Personnel who sustained lower leg injuries following an under-vehicle explosion between Jan 2006 and Dec 2008 were identified. Patient demographics, injury severity, the nature of lower limb injury and clinical management was recorded. Clinical endpoints were determined by (i)need for amputation and (ii)need for ongoing clinical output at mean 33.0 months follow-up. 63 UK Service Personnel (89 injured limbs) were identified with lower leg injuries from explosion. 50% of casualties sustained multi-segmental injuries to the foot and ankle complex. 26(29%) limbs required amputation, with six amputated for chronic pain 18 months following injury. Regression analysis revealed that hindfoot injuries, open fractures and vascular injuries were independent predictors of amputation. Of the 69 limbs initially salvaged, the overall infection rate was 42%, osteomyelitis 11.6% and non-union rates was 21.7%. Symptomatic traumatic osteoarthritis was noted in 33.3% salvaged limbs. At final follow-up, 66(74%) of injured limbs had persisting symptoms related to their injury, with only 9(14%) fit to return to their pre-injury duties. This study demonstrates that foot and ankle injuries from IEDs are frequently associated with a high amputation rate and poor clinical outcome. Although, not life-threatening, they remain a source of long-term morbidity in an active population. Primary prevention of these injuries remain key in reducing the injury burden

Trauma patients have the highest risk of VTE among hospitalised patients1, with a reported 13-fold increase of risk2. Due to the heterogeneity of injuries, the true incidence of VTE in trauma patients is difficult to obtain. This study examines the incidence of VTE and associated complications in trauma patients with lower limb injuries. Between 2005 and 2009, patients over 18 years of age with lower limb injuries and/or fractures that were either isolated or a part of multi-systemic injuries were included in the study. Further stratification was performed according to the Injury Severity Score: an ISS greater than 15 was a major (trauma); less than 15, a minor. The mode of VTE prophylaxis, type of surgery, and bleeding complications were also examined. There were 5528 patients in the minor trauma group, and 509 in the major trauma group. Minor trauma: the mean age was 58.1 years (range: 18 – 104). The VTE incidence was 1.2%: 0.67% for DVT, and 0.5% for PE. The readmission rate within a three-month period was 11%, of which 2.8% were due to VTE with 13 cases of DVT, and 5 cases of PE. The 30-day mortality rate was 2.2%. Seven patients died from PE during admission, while one died from PE within three months after discharge. Major trauma: the mean age was 42.5 years (range: 18 – 95). The overall VTE incidence was 7.8%: 5.9% for DVT, and 0.9% for PE. The readmission rate within a three-month period was 7.6%, of which 5% were due to VTE with 2 cases of DVT. The overall 30-day mortality rate was 11.1%, and there was no formally-diagnosed fatal PE during admission or post-discharge. Major trauma patients had a 7-fold increased risk of developing VTE during admission when compared to minor trauma patients, although minor trauma patients had more fatal PEs. Additionally, major trauma patients had a 10-fold increased risk for DVT, and a 3-fold risk for PE, when compared with minor trauma patients. No significant difference was detected between the two groups for the 30-day readmission rate due to VTE

The purpose of the present study is to determine the incidence, location and rate of VTE following routine mechanical, chemical prophylaxis in trauma/elective patients and to understand what factors are responsible for the continuing high frequency of thromboembolic complication despite the fact that low molecular-weight heparin (LMWH) is now widely used for prophylaxis. All of the inpatients at the orthopaedics ward, Princess Alexandra Hospital (level one trauma centre, Brisbane) between the first May 2009 and 30th of April 2010 with the diagnosis of DVT/PE were included in this study. Patients were chosen based on the diagnosis of DVT with ultrasound or PE with CTPA during their admission in this period which was performed whenever clinical signs indicated DVT or PE. 64% of the included patients had DVT and 42% had PE which was developed during their admission. Included patients had a mean age ±SD age of 56years ± 23 years, 68% were men and 72% suffered trauma. The 18% of patients had previous history of PE or DVT. The incidence of VTE was significantly higher in men at ages between 20–40 .29% of the patients had ICU admission during their stay in hospital. 28%had spinal cord injury, 21%with head trauma, and 36%with multiple bone fractures. Most of the patients had lower limb injury or operation and just one patient was with isolated upper limb injury. The mean period of hospitalization for the included patients were 29 ± 19 days (range, 6–77). DVTs occurred 8 days ± 7 days(range, 1–31) post admission. PEs occurred 10 days ± 8 days (range, 3–30) after admission. Location of DVT was available for 14 patients: 9 (64%)lower and 6 (43 %)upper, with one(0.07%)having both. Twelve of 28 patients with VTE were started on prophylactic clexane (40mg once daily), and six patients were on heparin(5000 unit twice daily). All of the patients with PE had lower limb injury. Considering the number of orthopaedics ward patients during our study period our data show the incidence of VTE in one year is lower than that of literature and the common standard prophylaxis with early mechanical prophylaxis after admission and following pharmacological prophylaxis when it is safe has acceptable results

During two sequential deployments to Afghanistan, it was noticed that an inordinately high number of patients with bilateral lower limb injuries that resulted in amputations at Camp Bastion itself, had associated upper limb injuries. It was decided to study the incidence and distribution of the same. Permission was granted to conduct this study as it would throw a light on the pattern of injuries and allow a further study of the impact of this on rehabilitation. This was both a retrospective as well as a prospective study. Of the 221 cases, 68 were recorded and data collected prospectively whereas the data for the rest was gathered using the patients' scanned records from Camp Bastion, their radiology reports and clinical photographs (from the Joint Theatre Trauma Registry). A total of 221 patients were studied as described above. They included UK, NATO, US, ANA, ANP, EF and Afghan civilians (June 2009 - January 2011). There were 59 fatalities from these 221 cases. That data pertaining to these cases was discarded. Of the surviving 162 cases, 31 cases had no upper limb involvement. A number of these individuals were subjected to an IED attack when mounted, although dismounted injuries still accounted for the vast majority. 131 individuals had upper limb involvement of some sort or the other. The injuries were classified into anatomical distribution as well and the type of trauma (amputations, composite soft tissue, fractures, vascular, nerves etc). The predominance of the injuries was on the distal portion of the upper limb (i.e involving the digits, hands and forearm (digits and hands – 66 patients, wrist and forearm in 69 patients, elbow and arm in 42 patients). The most common form of involvement was a composite tissue injury (involving skin, muscle and vessels/nerves) in 85 patients. 27 patients ended up as triple amputees by the time they left the Camp Bastion Role 3 Hospital. From the pattern and severity of injuries it is obvious that dismounted individuals presented with a very severe spectrum of injuries. The predominance of the left upper limb being involved is in keeping with a dismounted right-handed soldier out on patrol with the left upper limb extended along the barrel of the rifle or his weapon. Using various cases (clinical photographs as well as radiographs) the spectrum of injuries is explained and a case is made for truly differentiating the debridement and radical treatment of upper limb versus lower limb trauma during initial surgery

The lower limbs of vehicle occupants are vulnerable to severe injuries during under vehicle explosions. Understanding the injury mechanism and causality of injury severity could aid in developing better protection. Therefore, we tested three different knee positions in standing occupants (standing, knee in hyper-extension, knee flexed at 20˚) of a simulated under‐vehicle explosion using cadaveric limbs in a traumatic blast injury simulator; the hypothesis was that occupant posture would affect injury severity. Skeletal injuries were minimal in the cadaveric limbs with the knees flexed at 20˚. Severe, impairing injuries were observed in the foot of standing and hyper‐extended specimens. Strain gauge measurements taken from the lateral calcaneus in the standing and hyper-extended positions were more than double the strain found in specimens with the knee flexed position. The results in this study demonstrate that a vehicle occupant whose posture incorporates knee flexion at the time of an under‐vehicle explosion is likely to reduce the severity of lower limb injuries, when compared to a knee extended position