Recent changes in health care policy relating to pre hospital triage and closure of acute services in district general hospitals have placed unanticipated strains on financially challenged larger trusts in London. The financial implications for the presumed ‘designated’ regional trauma centre have previously not been scrutinised. Our study investigates how these changes and the resultant ‘out of area’ trauma has impacted on workload at our London teaching hospital and looks at the financial implications for the Trauma and Orthopaedics department.

A retrospective analysis of all attendances to the A& E department over a four month period (July – October) in 2006 was compared to a similar period in 2005. All admitted, major orthopaedic trauma cases bought in by ambulance or HEMS services were included. Review of case notes and phone interviews were used to ascertain how many of the incidents had occurred outside our region of referral.

An 83% increase in major trauma admissions was observed (32 cases in 2005, 53 cases in 2006; P value = 0.03). Of these cases, 27/32 and 46/53 could be assessed. Two patients in 2005 (7%) and twelve patients in 2006 (26%) were out of area (P value = 0.07). As these patients were bought in as ‘local’ cases, and not as regional referrals for treatment, the Trust was not reimbursed appropriately. Fiscal analysis of the out of area trauma cases was carried out to ascertain the shortfall incurred by the department.

Our study describes a posterolateral approach to the distal humerus for open reduction and internal fixation of displaced fractures of the lateral condyle. A total of 20 patients had open reduction and internal fixation over a four-year period using this approach, and at a mean follow-up of 12 months had full union, range of movement and no complications, either clinical or radiological. This approach is well suited to the exact visualisation and accurate reduction of this difficult fracture with minimal dissection of tissues.