Isolated Weber B fractures usually heal uneventfully but traditionally require regular review due to the possibility of medial ligament injury allowing displacement. Following recent studies suggesting delayed talar shift is uncommon we introduced a functional treatment protocol and present the early results. 141 consecutive patients presenting acutely with Weber B fractures without talar shift between January and December 2015 were included. Patients were splinted in a removable boot and allowed to weight bear. ED notes and radiographs were reviewed by an Orthopaedic consultant. Patients without signs of medial injury were discharged with an information leaflet and advice. If signs of medial ligament injury were noted or the medial findings were not documented the patient was reviewed in fracture clinic at 4 weeks post-injury. If talar shift developed the patient was to be converted to operative treatment. Olerud and Molander scores were collected between 6 and 12 months post-injury..Introduction
Methods
The aim of this study was determine if the detection of pathology in children with a limp can be optimised by screening with blood tests for raised inflammatory markers. The entry criteria for the study were children (0–15 years) presenting to our hospital Emergency Department from 2012–2015 with a non-traumatic limp or pseudoparalysis of a limb, and no sign of fracture or malignancy on plain radiographs. ESR and CRP blood tests were performed along with other standard investigations. Children with ESR or CRP over 10 underwent MRI scan of their area of pain or tendernesss, with those under 7 years old having general anaesthetic. MRI provided the diagnosis in cases of osteomyelitis, pyomyositis, fasciitis, cellulitis, discitis, as well as non-infective conditions such as malignancy and fracture not visible on plain radiographs. Where a joint effusion was present, the diagnosis of septic arthritis was made from organisms cultured following surgical drainage, or high white cell count in joint fluid if no organisms were cultured. The study was completed once data from 100 consecutive children was available. 64% of children had an infective cause for their symptoms (osteomyelitis, septic arthritis, pyomyositis, fasciitis, cellulitis or discitis). A further 11% had positive findings on MRI from non-infective causes (juvenile idiopathic arthritis, cancer, or occult fracture). The remaining 25% had either a normal scan, or transient synovitis. ESR was a more sensitive marker than CRP, since ESR was raised in 97% of those with abnormal scans, but CRP in only 70%. There were no complications from any of the GA MRI scans. Conclusion: This shows that MRI imaging of all children with a limp and either raised ESR or CRP is a sensitive method to minimise the chance of missing important pathology in this group, and is not wasteful of MRI resources.
The current standard for treatment of humeral shaft fractures is in a functional humeral brace. Aims: To further assess the union rate for this mode of treatment and to delineate and any fracture type less likely to go on to union. Retrospective radiographic and clinical review of 199 consecutive acute adult humeral shaft fractures. 43 operated on acutely (including all open fractures). Remaining 156 fractures treated in a humeral brace. Non union was determined as delayed fracture fixation or no evidence of union at 1 year. Union rate 82.9% with 88.5% follow-up. 16 of the 24 non unions were proximal third (all but one spiral/oblique): 71.4% union rate. Middle third fractures 87.3% and distal third shaft fractures 88.9 % union rate. Union rate of fractures with 3+ parts inclusive of all regions of the shaft was 95.6%. The union rate in this study is not as high as has previously been reported for functional brace treatment. A lower threshold for intervention in proximal third spiral/oblique humeral shaft fractures may be indicated. Fracture site comminution is a very good prognostic indicator.
Our Trust's prophylactic antibiotic regime for elective hip and knee replacements recently changed, following the publication of Department of Health guidelines aimed at reducing the incidence of Clostridium Difficile associated diarrhoea (CDAD). We aimed to assess whether this change has reduced the incidence of post-operative CDAD. We reviewed all primary and revision total hip and knee replacements performed in Gloucestershire Royal Hospital between April 2007 and March 2010. Up to August 2008, patients received prophylaxis with cefuroxime (Group A). This subsequently changed to flucloxacillin and gentamicin (Group B). All patients who developed CDAD within one month of surgery were identified and their case-notes were reviewed for the presence of CDAD risk factors, such as concomitant use of broad-spectrum antibiotics. 3117 patients were included and 15 developed CDAD (0.48%); 12 patients (0.77%) from Group A and 3 from Group B (0.19%), representing a four-fold decrease. Analysis of a 2×2 contingency table with Fisher's exact test showed that the difference between the two groups was statistically significant (P=0.0347). Case-note analysis revealed that 8/12 patients in Group A and 1/3 patients in Group B had other risk factors for developing CDAD. Excluding these patients, the difference between the two groups was not statistically significant (P=0.218). CDAD is exceedingly rare following total joint replacement surgery, especially when the only antibiotics given are prophylactic. Our figures are in line with a general decline in CDAD nationally from 2007. This decline is most likely due to multiple factors, such as hand-washing, barrier nursing and restrictive antibiotic policies. The effect of the change in prophylaxis is therefore difficult to quantify. Choice of prophylactic antibiotics should be based upon their efficacy alone, not their potential to reduce CDAD.
