Surgical patients have cost the NHS 1.3 billion GBP from 1995. Spinal pathologies can present diagnostic challenges, and the consequences of delayed diagnosis or surgical complications can be devastating and so creating high indemnity costs. We aim to highlight the spinal associated litigation patterns within the United Kingdom. Data was obtained from the NHS Litigation Authority from 2002 to 2010.Background
Method
Lumbar spinal pain can be a consequence of discogenic pain. After failure of conservative management, lumbar fusions are popular and considered the gold standard. However, these techniques are associated with significant morbidity. A percutaneous trans-sacral technique may address these for L4/L5 and/or L5/S1 alone spinal fusions. Our unit has adopted this technique and presents our initial experience of 51 patients and preliminary results. Patients with a confirmed clinical and radiological evidence of degenerate intervertebral disc with or without prior surgical intervention were selected. Patients with a history of pelvic surgery/radiotherapy were excluded. Data was collected prospectively using the Global Patient Outcome Scoring System and Oswestry Disability Index (ODI) scores at clinical follow-up.Introduction
Method
The majority of diaphyseal forearm fractures in children are treated by closed reduction and plaster immobilisation. There is a small subset of patients where operative treatment is indicated. Recent reports indicate that elastic intramedullary nailing (EIN) is gaining popularity over plate fixation. We report the results of EIN for diaphyseal fractures of the forearm in 44 children aged between 5 and 15 years during a three-year period. The indications were instability (26), redisplacement (14), and open fractures (4). Closed reduction and nailing was carried out in 18 cases. A single bone had to be opened in 16 cases and in 10 cases both bones were opened for achieving reduction. Out of the 39 both bone forearm fractures, 35 patients had stabilisation of both radius and ulna and in 4 cases only a single bone was nailed (Radius 3, Ulna 1). Union was achieved in all the 44 cases at an average time of 7 weeks with one delayed union. All patients regained full flexion and extension of the elbow and wrist. Pronation was restricted by an average of 20° in 30% patients. Complications were seen in 10 patients (20%). 4 patients had prominent metal work which required early removal. There was refracture in one case, which was treated by nail removal and re-fixation. Two patients developed post operative compartment syndrome requiring fasciotomy. EIN of the radius alone in a patient with fractures of both the bones of forearm, led to secondary displacement of the ulna. This resulted in ulnar malunion and a symptomatic distal radio-ulnar joint subluxation. This was successfully treated by ulnar osteotomy. Compared to forearm plating EIN involves minimal scarring, easier removal and less risk of nerve damage. We therefore recommend EIN for the treatment of unstable middle and proximal third forearm fractures.
Efficient utilisation of the trauma list is an important aspect of trauma care in the NHS. An audit of the trauma theatre time utilisation was done from April 1999 to March 2000. Ideally the first case should start at 8:30 am. However, we found that the first patient was on the operating table only by 9:40 am (mean). The main reasons for the delay were the time required for the anaesthetist to see the patient and the other staff to set up the necessary equipments. We decided to identify the first case of the trauma list the day before, so that the anaesthetist can review the patient the previous day. We felt that this would also give adequate time for the theatre staff to set up their instruments. However, this did not improve the theatre timings. We introduced the novel idea of performing a carpal tunnel decompression at the beginning of each trauma list to make use of the redundant time without an extra financial burden to the hospital. Carpal tunnel decompression can be performed under local anaesthetic by a basic grade surgeon. This would also give time for the anaesthetist and the consultant surgeon to review the patients on the trauma list. The theatre time utilisation was re-audited a year following the introduction of carpal tunnel release. The patient for carpal tunnel decompression was on table at 8:44 am (mean). The first trauma case was on operating table at 9:46 am (mean). Therefore, in spite of performing an additional surgery on the list, there was a delay of only 6 minutes. This simple idea has helped us to do an additional case every day with only a 6 minute delay to the trauma list.
We describe a patient with fractures of both bones of the forearm in whom flexible intramedullary nail fixation of the radius alone led to ulnar malunion and a symptomatic distal radio-ulnar joint subluxation. This was successfully treated by ulnar osteotomy.
