Re-fractures of the paediatric radius and/or ulna: A systematic review.

BACKGROUND: Fractures of the radius and/or ulna are one of the most common injuries in children. Evidence identifying risk factors for refracture, however, has not been summarised in a systematic review. Guidance for counselling patients and parents to minimise the risk of refracture is limited. The aims of this study are to 1) to determine if casting time 6 weeks or less is a risk factor for refracture after paediatric radius and/or ulna fractures, 2) to identify other risk factors for refracture after paediatric radius and/or ulna fractures and 3) to develop more accurate guidelines for counselling parents after a radius and/or ulna fracture in their child. METHODS: A thorough search was performed in accordance with the Joanna Briggs Institute (JBI) guidelines for systematic review. JBI Critical Appraisal checklists were used for risk of bias assessment. RESULTS: Diaphyseal both-bone fractures treated non-surgically should be casted for longer than 6 weeks. Surgically treated patients can be casted for less than 6 weeks. Diaphyseal and greenstick fractures have a higher risk of refracture. Residual angulation and incomplete healing in greenstick fractures may lead to a higher risk of refracture. Gender does not affect refracture risk. Falls, use of wheeled vehicles, playground activities and trampolining confer high-risk of refracture. Refracture risk is greatest up to 9 months from initial fracture. CONCLUSION: Further case-controlled studies with sub-group analysis are required to further investigate risk factors for refracture after radius and/or ulna fractures in children.

Gabapentoids in knee replacement surgery: contemporary, multi-modal, peri-operative analgesia.

Pain remains a significant barrier to rapid patient recovery and rehabilitation post-surgery, particularly after joint replacement surgery. Historically, protocols used for peri-operative pain management have been largely reactive and dependent on opioid use, with adjunctive non-steroidal and other simple analgesia. This review explores the evidence supporting the use of gabapentoids (eg. Lyrica®) in surgical fields, then in orthopaedics more specifically, and finally in the targeted domain of total knee replacement (TKR) surgery. The concept of 'pre-emptive' analgesia is also explored. Gabapentoids have shown clinical value in reducing the patient-reported pain experience and also decreasing concurrent opioid requirements in the post-surgical period in a number of surgical areas, however there remains no consensus for their optimal use in patients undergoing knee arthroplasty. Reported adverse effects including sedation and potential respiratory depression should herald some caution, and monitored use in 'at risk' patient groups. There have been a small number of clinical trials conducted around the use of gabapentoids in TKR, however the validity and generalisability of these results have been limited by small sample sizes, and cross-study analysis is confounded by adoption of inconsistent analgesic protocols, non-comparable dosing regimes, poor (or absent) control selection, and cohort heterogeneity. High-quality trials are needed to allow the role of gabapentoids in multi-modal peri-operative analgesic pathways to be better defined, to permit wider endorsement for main-stream or standardised care.