Introduction

Needle guided biopsy of a suspected musculoskeletal malignancy has become increasingly popular as an effective modality for diagnosis. Biopsy performed in a safe manner should be performed in a centre which is also capable of performing the definitive management of such conditions. Our aim was to determine accuracy and success rates of the image guided biopsies performed by our service.

Fifth metatarsal fractures are common and the majority unite regardless of treatment. A sub-type of these fractures carries a risk of non-union and for this reason many centres follow up all 5^th metatarsal fractures. In 2011, a standardised protocol was introduced to promote weight-bearing as pain allowed with a tubigrip or Velcro boot according to symptoms. No routine fracture clinic appointments were made from A&E but patients were provided with information and a help-line number to access care if required. Some patients still attended fracture clinics, but only after review of their notes/X-rays by an Orthopaedic Consultant, or after self-reported “failure to progress” using the special help-line number.

Audit of a year prior to the introduction of the protocol and the year following it was performed. All x-rays taken at presentation in A&E were reviewed and classified independently (KBF/JM) for validation.

During 2009/2010, 279 patients presented to A&E with a 5^th metatarsal fracture and were referred to a fracture clinic. 106(38%) attended 1 appointment, 130(47%) attended 2 appointments and 31 (11%) attended 3 or more appointments – 491 appointments in total. 3% failed to attend the clinic. Operative fixation was performed in 3 patients (1.07%).

In 2011/2012, of 339 A&E fractures, only 63 (19%) attended fracture clinic. 37 (11%) attended 1 appointment, 12 (4%) 2 and 9 (3%) 3 or more appointments – 96 appointments in total. Four patients (1.17%) required operative fixation.

Our study did not demonstrate any added value for routine outpatient follow-up of 5^th metatarsal fractures. Patients can be safely allowed to weight bear and discharged at the time of initial presentation in the A&E department if they are provided with appropriate information and access to a “help line” run by experienced fracture clinic staff. The result is a more efficient, patient-centred service.

We undertook a retrospective audit to assess quality of service provided by Nurse-Led Review Clinic at Glasgow Royal Infirmary for patients sustaining ankle fracture requiring surgical stabilisation. Nursing staff had received training from the senior author regarding clinical examination and radiograph interpretation.

We retrospectively reviewed the clinical documentation and radiographs of 104 patients who attended from January 2009 to December 2009. Any clinical issues were identified and radiographs were scrutinised by two of the authors to assess accuracy of interpretation. Nurse-led management was then assessed as to its appropriateness. Finally two retrospective questionnaires were used to assess both the nurses and patients satisfaction with the clinic.

Nurse-led clinic protocol: First appointment 10 days: Wound review, application of lightweight plaster. Second appointment 6 weeks: Removal of plaster, check radiographs. Final appointment 12 weeks: Clinical assessment, radiographs, discharge. Clinical assessment: ensure wound satisfactory, range of movement and weight-bearing are improving. Radiographic criteria: 6 weeks: Assess for talar shift, lucency or metal-work concerns. 12 weeks: Assess evidence of fracture union, infection, loosening or backing out. If any concerns with the patients' progress nursing staff would discuss with the consultant.

First appointment: 7 wound problems. 5 managed by nurses and resolved. 2 discussed with surgeon, 1 settled, 1 required oral antibiotics. 3 radiographs discussed with surgeon. 2 conservative management. 1 re-operation. Second appointment: 7 wounds managed by nurses. 1 failure of fixation, discussed for re-operation. 2 concerns regarding metal in joint – treated conservatively. Final appointment: 7 referred to physiotherapy as slow to fully weight-bear. 5 discussed for removal of syndesmosis screw. 1 screw in joint, admitted for re-operation.

Clinical care provided at Nurse-Led clinic is appropriate and effective. Both nursing staff and patients were satisfied with the care provided. Nurse-led clinic reduces demands on fracture clinic appointments and is a safe, cost effective initiative.

The exact action of the Peroneus Longus muscle on the foot is not fully understood. It is involved in a number of pathological processes like tendonitis, tenosynovitis, chronic rupture and neurological conditions. It is described as having a consistent insertion to the base of the first metatarsal, but there have also been reports of significant variations and additional slips.

Our aim was to further clarify the anatomy of the main insertion of the Peroneus Longus tendon and to describe the site and frequency of other variable insertion slips.

The course of the distal peroneus longus tendon and its variable insertion was dissected in 20 embalmed, cadaveric specimens. The surface area of the main insertion footprint was measured using an Immersion Digital Microscibe and 3D mapping software. The site and frequency of the other variable insertion slips is presented.

There was a consistent, main insertion to the infero-lateral aspect of the first metatarsal in all specimens. The surface area of this insertion was found to be proportional to the length of the foot. The insertion in males was found to be significantly larger than females. The most frequent additional slip was to the medial cuneiform. Other less frequent insertion slips were present to the lesser metatarsals.

The main footprint of the Peroneus Longus tendon is on the first metatarsal. There appears to an additional slip to the medial cuneiform frequently. Although we are unsure about the significance of these additional slips, we hope it will lead to a better understanding of the mechanism of action of this muscle and its role both in the normal and pathological foot.

Hyponatraemia is one of the most common electrolyte disorders in the elderly and has considerable associated morbidity and mortality. In this study we report the prevalence and independent risk factors for the development of post-operative hyponatraemia after surgery for hip fracture.

We conducted a retrospective cohort study of 144 consecutive patients who underwent surgery after sustaining a hip fracture. Patient medical case-notes, operative notes and online biochemistry results were used to obtain relevant data which was entered into a database.

Pre-operative (30/144, 21%) and post-operative hyponatraemia (49/144, 34%) was common. However, most cases were mild (plasma sodium >130 mmol/l) and only 1% of pre-operative and 6% of post-operative patients had moderate/severe hyponatraemia (plasma sodium <130mmol/l). One of 3 post-operative deaths involved a patient with moderate hyponatraemia as a consequence of severe congestive cardiac failure. In order to determine the independent relationship between several reported risk factors and hyponatraemia we constructed a multivariable logistic regression model. Female gender, pre-operative hyponatraemia and hypotonic fluid administration were all significantly associated with the development of post-operative hyponatraemia. Age and thiazide diuretics both had positive risk associations however were not statistically significant.

Hyponatraemia is a common problem in hip fracture patients. While the majority of cases in this series were mild, 6% of patients suffered from moderate/severe hyponatraemia post-operatively. Female gender, pre-operative hyponatraemia and hypotonic fluid administration are all important and independent risk factors for the development of hyponatraemia. Hypotonic intravenous fluids should be avoided unless clinically indicated in this patient group.