- Email: [email protected]
Adequacy of post operative instruction in trauma patients
152
Abstracts / Injury Extra 42 (2011) 95–169
Fig. 2. INR pattern with gradual decrease – no vitamin administration.
Fig. 3. INR pattern with a transient INR increase.
Table 1 Patients groups, number of patients in each group and percentages. Patients’ groups
Subgroups
Number of patients
Percent
10
Group 2
Group 2A Group 2B
22 9
Group 3
Group 3A Group 3B
13 21
Group 1
Total percentages after excluding group 1
gest cephalomedullary device (CMD) for fixation over a sliding hip screw (DHS), due to lack of posteromedial support. Clinical studies suggest no difference in outcome between the treatment modalities in terms of revision and function. Methods: 132 orthopaedic consultants were contacted from the North West NHS Deanery. An X-ray of an intertrochanteric fracture with posteromedial comminution was shown and consultants provided opinion on fixation preference. Data was collected for sub-specialty and experience of consultant. Results: 74 of 132 consultants (56%) participated in the study. 29% held consultant post for <5 years, 25% 5–10 years, 25% 10–15 years, and 21% >15 years. 24% use a CMD for fracture fixation, compared with 76% DHS. 40% of consultants in the CMD group belonged to a subspecialty other than lower limb surgery, compared with 41% in the DHS group. 41% of consultants in the CMD group held a consultant post for <5 years, compared with just 22% in the DHS group. Conclusions: Despite evidence suggesting no difference in outcomes between DHS and CMD for unstable intertrochanteric fractures, a quarter of consultants use CMD as primary treatment modality. Sub-specialty did not affect choice of fixation, however, recently qualified consultants used CMD more than more experienced colleagues. Our study suggests a difference in practice for consultants of different experience which may be due to a number of factors. doi:10.1016/j.injury.2011.06.360
Total numbers
Total percentages
13.3%
10
13.3
29.3% 12.0%
31
41.3
47.7
Adequacy of post operative instruction in trauma patients
17.3% 28.0%
34
45.3
52.3
R. Badge, J. Corrin, R. Mohan
4.3
North Manchester General Hospital, UK Table 2 Correlation (Pearson’s) between INR change and other blood values. Variable
Pearson correlation
N (number)
Significance (2-tailed)
WCC Hb Htc MCV Plt Sodium K Urea Creatine
r = .045 r = .159 r = .171 r = −138 r = −.174 r = .016 r = .184 r = .008 r = .045
N = 58 N = 58 N = 58 N = 58 N = 58 N = 58 N = 51 N = 58 N = 58
p = .738 p = .232 p = .201 p = .300 p = .191 p = .902 p = .184 p = .954 p = .740
doi:10.1016/j.injury.2011.06.359 4.2 Current practice in the treatment of unstable intertrochanteric hip fractures: Does sub-specialty and experience of surgeon determine type of fixation? D.J. Murray, A. Chougle North Manchester General Hospital, United Kingdom Purpose: To assess current practice in treatment of unstable intertrochanteric hip fractures, in consultant orthopaedic surgeons, from a single NHS deanery, and observe whether experience and sub-specialty determines type of fixation. Introduction: The treatment of unstable intertrochanteric hip fractures is debated throughout the literature. Some authors sug-
Introduction: The quality of trauma care varies greatly across the NHS Hospitals in the UK and needs to improve in several areas. According to the Darzi report there has been an emphasis to improve the quality of patient care and that applies to all trauma patients as well. Post-operative instructions following operative intervention for trauma patients are crucial for continuing care after surgery. Due to different fracture patterns and management plans there is no standardised postoperative instructions protocol yet. Material and methods: We conducted an audit to look into the adequacy of post-operative instruction written for 4 common trauma operations which includes MUA+ K-wire fixation for Distal Radius Fracture, ORIF for Ankle Fracture, DHS for Extra-capsular NOF fracture and Hemiarthroplasty for intra-capsular NOF fracture. This prospective study included 68 patients. We looked at the legibility of hand written operation notes, inclusion of immediate post-op care plan and the need for procedure specific instruction like thromboprophylaxis, removal of suture/clips, further followup. Result: This audit revealed 10% of notes had illegible hand writing. We found immediate post-op care was mentioned 100% of notes. The thromboprophylaxis regime was lacking in 75% notes for lower limb surgeries. 62% of notes did not mention the exact timings for suture/clips removal. 63% of notes were lacking about the exact duration for follow-up. This lack of uniformity creates lot of confusion amongst the ward nurses, junior doctors and to organise a further follow-up. Conclusion: Therefore we recommend the typed standardised operation notes along with preset procedure specific postopera-
Abstracts / Injury Extra 42 (2011) 95–169
tive instructions to improve the quality of patient care in trauma management. doi:10.1016/j.injury.2011.06.361 5.1 An OK technique for mini-invasive fixation of a trans-articular coronal shear fracture of the distal humerus C.S. Modi, A. Saithna, D. Wainwright University Hospital Coventry, UK Trans-articular coronal shear fractures of the distal humerus pose a significant challenge to the surgeon in obtaining an anatomical reduction and rigid fixation and thereby return of good function. A variety of approaches have been described which include the extended lateral and anterolateral approaches and arthroscopically assisted fixation for non-comminuted fractures. Fixation methods include open or percutaneous cannulated screws and headless compression screws directed either anterior to posterior or posterior to anterior. We describe a novel approach to this fracture which is minimally invasive but enables an anatomical reduction to be achieved. A 15 year old male presented with a Bryan and Morrey type 4 fracture as described by McKee involving the left distal humerus. He was placed in a lateral position with the elbow over a support. A posterior longitudinal incision and a 6 cm triceps split from the tip of the olecranon was made. The olecranon fossa was exposed and a fenestration made with a 2.5 mm drill and nibblers as in the OK (Outerbridge–Kashiwagi) procedure. A bone lever was then passed though the fenestration and used to reduce the capitellar and trochlear fracture fragments into an anatomical position with use of an image intensifier to confirm reduction. The fracture was then fixed with two headless compression screws from posterior to anterior into the capitellar and trochlear fragments (see images). Early mobilisation and rehabilitation were commenced. Follow-up clinical examination and radiographs at six weeks revealed excellent range-of-motion and function with anatomical bony union. We believe that this novel approach to this fracture reduces the amount of soft tissue dissection associated with conventional approaches and their associated risks and also enables earlier return to function with restoration of anatomy. doi:10.1016/j.injury.2011.06.362 5.2 Has the outcome for distal femoral fractures improved following the introduction of locking plate fixation? C. 1 2
Ashton 1 ,
S.
153
The records of 42 patients with 43 distal femoral fractures who had undergone IM nailing or locking plating at Lancashire Teaching Hospitals Trust over a 4 year period were reviewed retrospectively. Pre-operative, operative and post-operative information was obtained from in-patient notes and information regarding recovery and return to function was obtained from clinic letters in order to compare the outcome of the two groups following surgery. There were 20 fractures fixated by IM nailing and 23 fractures fixated by locking plating. Results: Results show that IM nailing is preferred when there is an ipsilateral total knee replacement. IM nailing more commonly resulted in implant failure than locking plating. It appears that locking plating may yield better outcomes but following a longer healing time than IM nailing. The data also suggests that certain preoperative variables are important when considering which implant to use. Conclusions: Despite the limitations of this study, the findings support the idea that there is no perfect fracture fixation method, but rather that certain fixation methods are superior in particular situations. doi:10.1016/j.injury.2011.06.363 5.3 A fracture of the transverse process of L5 is a predictor of pelvic fracture instability I. Starks, A. Frost, P. Wall, J. Lim University Hospital of North Staffordshire, Stoke on Trent, Staffordshire, UK The aim of our study was to determine if a fracture of the transverse process of L5 is a predictor of pelvic fracture instability. The Hospital Trauma database was reviewed. Between 2006 and 2010, 80 pelvic fractures were identified (32 women, 48 men) with a mean age of 40 (range 10–96). The majority of patients sustained their injuries in either a road traffic accident (RTA) or as a result of a fall from a great height. 51% of patients had associated injuries. The pelvic fractures were classified according to the Burgess and Young classification. There were 45 stable and 35 unstable fractures. 17 patients had an associated fracture of the transverse process of L5; 14 were associated with an unstable fracture pattern and 3 with a stable injury (40%vs. 7%; p = 0.001). The odds ratio was 9.3; the relative risk 2.5. A fracture of the transverse process of L5 is associated with an increased risk of pelvic fracture instability. Its presence should alert the attending physicians to the possibility of an unstable injury. doi:10.1016/j.injury.2011.06.364
Canty 2
University of Manchester, UK Lancashire Teaching Hospitals Trust, UK
Although the management of distal femoral fractures has evolved over many years they are still difficult to treat and there is little consensus on the most appropriate fixation method for particular situations. Aims: To determine whether the outcome has improved following the introduction of locking plate fixation as opposed to intramedullary (IM) nailing for the surgical treatment of distal femoral fractures. It is also hoped that any factors that render one treatment more appropriate than the other will become apparent.
6.1 Hook plate fixation for osteoporotic lateral malleolus fractures A.S. Baig, P. Harrington Department of Orthopaedics, Our Lady of Lourdes Hospital, Drogheda, Ireland Internal fixation in elderly patients with osteoporotic ankle fractures can be technically difficult, not least because of poor purchase of hardware in the distal fibula. Since 2001, we have routinely addressed this concern by using a hook plate modification of the standard small fragment one third tubular plate. The hook plate is fashioned by cutting the plate at the most distal hole and then
Abstracts / Injury Extra 42 (2011) 95–169
Fig. 2. INR pattern with gradual decrease – no vitamin administration.
Fig. 3. INR pattern with a transient INR increase.
Table 1 Patients groups, number of patients in each group and percentages. Patients’ groups
Subgroups
Number of patients
Percent
10
Group 2
Group 2A Group 2B
22 9
Group 3
Group 3A Group 3B
13 21
Group 1
Total percentages after excluding group 1
gest cephalomedullary device (CMD) for fixation over a sliding hip screw (DHS), due to lack of posteromedial support. Clinical studies suggest no difference in outcome between the treatment modalities in terms of revision and function. Methods: 132 orthopaedic consultants were contacted from the North West NHS Deanery. An X-ray of an intertrochanteric fracture with posteromedial comminution was shown and consultants provided opinion on fixation preference. Data was collected for sub-specialty and experience of consultant. Results: 74 of 132 consultants (56%) participated in the study. 29% held consultant post for <5 years, 25% 5–10 years, 25% 10–15 years, and 21% >15 years. 24% use a CMD for fracture fixation, compared with 76% DHS. 40% of consultants in the CMD group belonged to a subspecialty other than lower limb surgery, compared with 41% in the DHS group. 41% of consultants in the CMD group held a consultant post for <5 years, compared with just 22% in the DHS group. Conclusions: Despite evidence suggesting no difference in outcomes between DHS and CMD for unstable intertrochanteric fractures, a quarter of consultants use CMD as primary treatment modality. Sub-specialty did not affect choice of fixation, however, recently qualified consultants used CMD more than more experienced colleagues. Our study suggests a difference in practice for consultants of different experience which may be due to a number of factors. doi:10.1016/j.injury.2011.06.360
Total numbers
Total percentages
13.3%
10
13.3
29.3% 12.0%
31
41.3
47.7
Adequacy of post operative instruction in trauma patients
17.3% 28.0%
34
45.3
52.3
R. Badge, J. Corrin, R. Mohan
4.3
North Manchester General Hospital, UK Table 2 Correlation (Pearson’s) between INR change and other blood values. Variable
Pearson correlation
N (number)
Significance (2-tailed)
WCC Hb Htc MCV Plt Sodium K Urea Creatine
r = .045 r = .159 r = .171 r = −138 r = −.174 r = .016 r = .184 r = .008 r = .045
N = 58 N = 58 N = 58 N = 58 N = 58 N = 58 N = 51 N = 58 N = 58
p = .738 p = .232 p = .201 p = .300 p = .191 p = .902 p = .184 p = .954 p = .740
doi:10.1016/j.injury.2011.06.359 4.2 Current practice in the treatment of unstable intertrochanteric hip fractures: Does sub-specialty and experience of surgeon determine type of fixation? D.J. Murray, A. Chougle North Manchester General Hospital, United Kingdom Purpose: To assess current practice in treatment of unstable intertrochanteric hip fractures, in consultant orthopaedic surgeons, from a single NHS deanery, and observe whether experience and sub-specialty determines type of fixation. Introduction: The treatment of unstable intertrochanteric hip fractures is debated throughout the literature. Some authors sug-
Introduction: The quality of trauma care varies greatly across the NHS Hospitals in the UK and needs to improve in several areas. According to the Darzi report there has been an emphasis to improve the quality of patient care and that applies to all trauma patients as well. Post-operative instructions following operative intervention for trauma patients are crucial for continuing care after surgery. Due to different fracture patterns and management plans there is no standardised postoperative instructions protocol yet. Material and methods: We conducted an audit to look into the adequacy of post-operative instruction written for 4 common trauma operations which includes MUA+ K-wire fixation for Distal Radius Fracture, ORIF for Ankle Fracture, DHS for Extra-capsular NOF fracture and Hemiarthroplasty for intra-capsular NOF fracture. This prospective study included 68 patients. We looked at the legibility of hand written operation notes, inclusion of immediate post-op care plan and the need for procedure specific instruction like thromboprophylaxis, removal of suture/clips, further followup. Result: This audit revealed 10% of notes had illegible hand writing. We found immediate post-op care was mentioned 100% of notes. The thromboprophylaxis regime was lacking in 75% notes for lower limb surgeries. 62% of notes did not mention the exact timings for suture/clips removal. 63% of notes were lacking about the exact duration for follow-up. This lack of uniformity creates lot of confusion amongst the ward nurses, junior doctors and to organise a further follow-up. Conclusion: Therefore we recommend the typed standardised operation notes along with preset procedure specific postopera-
Abstracts / Injury Extra 42 (2011) 95–169
tive instructions to improve the quality of patient care in trauma management. doi:10.1016/j.injury.2011.06.361 5.1 An OK technique for mini-invasive fixation of a trans-articular coronal shear fracture of the distal humerus C.S. Modi, A. Saithna, D. Wainwright University Hospital Coventry, UK Trans-articular coronal shear fractures of the distal humerus pose a significant challenge to the surgeon in obtaining an anatomical reduction and rigid fixation and thereby return of good function. A variety of approaches have been described which include the extended lateral and anterolateral approaches and arthroscopically assisted fixation for non-comminuted fractures. Fixation methods include open or percutaneous cannulated screws and headless compression screws directed either anterior to posterior or posterior to anterior. We describe a novel approach to this fracture which is minimally invasive but enables an anatomical reduction to be achieved. A 15 year old male presented with a Bryan and Morrey type 4 fracture as described by McKee involving the left distal humerus. He was placed in a lateral position with the elbow over a support. A posterior longitudinal incision and a 6 cm triceps split from the tip of the olecranon was made. The olecranon fossa was exposed and a fenestration made with a 2.5 mm drill and nibblers as in the OK (Outerbridge–Kashiwagi) procedure. A bone lever was then passed though the fenestration and used to reduce the capitellar and trochlear fracture fragments into an anatomical position with use of an image intensifier to confirm reduction. The fracture was then fixed with two headless compression screws from posterior to anterior into the capitellar and trochlear fragments (see images). Early mobilisation and rehabilitation were commenced. Follow-up clinical examination and radiographs at six weeks revealed excellent range-of-motion and function with anatomical bony union. We believe that this novel approach to this fracture reduces the amount of soft tissue dissection associated with conventional approaches and their associated risks and also enables earlier return to function with restoration of anatomy. doi:10.1016/j.injury.2011.06.362 5.2 Has the outcome for distal femoral fractures improved following the introduction of locking plate fixation? C. 1 2
Ashton 1 ,
S.
153
The records of 42 patients with 43 distal femoral fractures who had undergone IM nailing or locking plating at Lancashire Teaching Hospitals Trust over a 4 year period were reviewed retrospectively. Pre-operative, operative and post-operative information was obtained from in-patient notes and information regarding recovery and return to function was obtained from clinic letters in order to compare the outcome of the two groups following surgery. There were 20 fractures fixated by IM nailing and 23 fractures fixated by locking plating. Results: Results show that IM nailing is preferred when there is an ipsilateral total knee replacement. IM nailing more commonly resulted in implant failure than locking plating. It appears that locking plating may yield better outcomes but following a longer healing time than IM nailing. The data also suggests that certain preoperative variables are important when considering which implant to use. Conclusions: Despite the limitations of this study, the findings support the idea that there is no perfect fracture fixation method, but rather that certain fixation methods are superior in particular situations. doi:10.1016/j.injury.2011.06.363 5.3 A fracture of the transverse process of L5 is a predictor of pelvic fracture instability I. Starks, A. Frost, P. Wall, J. Lim University Hospital of North Staffordshire, Stoke on Trent, Staffordshire, UK The aim of our study was to determine if a fracture of the transverse process of L5 is a predictor of pelvic fracture instability. The Hospital Trauma database was reviewed. Between 2006 and 2010, 80 pelvic fractures were identified (32 women, 48 men) with a mean age of 40 (range 10–96). The majority of patients sustained their injuries in either a road traffic accident (RTA) or as a result of a fall from a great height. 51% of patients had associated injuries. The pelvic fractures were classified according to the Burgess and Young classification. There were 45 stable and 35 unstable fractures. 17 patients had an associated fracture of the transverse process of L5; 14 were associated with an unstable fracture pattern and 3 with a stable injury (40%vs. 7%; p = 0.001). The odds ratio was 9.3; the relative risk 2.5. A fracture of the transverse process of L5 is associated with an increased risk of pelvic fracture instability. Its presence should alert the attending physicians to the possibility of an unstable injury. doi:10.1016/j.injury.2011.06.364
Canty 2
University of Manchester, UK Lancashire Teaching Hospitals Trust, UK
Although the management of distal femoral fractures has evolved over many years they are still difficult to treat and there is little consensus on the most appropriate fixation method for particular situations. Aims: To determine whether the outcome has improved following the introduction of locking plate fixation as opposed to intramedullary (IM) nailing for the surgical treatment of distal femoral fractures. It is also hoped that any factors that render one treatment more appropriate than the other will become apparent.
6.1 Hook plate fixation for osteoporotic lateral malleolus fractures A.S. Baig, P. Harrington Department of Orthopaedics, Our Lady of Lourdes Hospital, Drogheda, Ireland Internal fixation in elderly patients with osteoporotic ankle fractures can be technically difficult, not least because of poor purchase of hardware in the distal fibula. Since 2001, we have routinely addressed this concern by using a hook plate modification of the standard small fragment one third tubular plate. The hook plate is fashioned by cutting the plate at the most distal hole and then