Management of scaphoid fractures with CT scanning and virtual fracture clinic pathway reduces need for face-to-face clinic appointments.

INTRODUCTION: Early diagnosis is key to managing scaphoid fractures effectively. Computed tomography (CT) imaging can be effective if plain radiographs are negative. With increasing pressure on face-to-face clinics, consultant-led virtual fracture clinics (VFCs) are becoming increasingly popular. This study evaluates the management of patients with suspected scaphoid fractures using a standardised treatment protocol involving CT imaging and VFC evaluation. METHODS: The study was conducted at a busy district general hospital. The pathway began in February 2018. Patients presenting to the emergency department with a clinically suspected scaphoid fracture but an indeterminate radiograph had a CT scan, which was then reviewed in the VFC. Patients with a confirmed fracture were seen in a face-to-face clinic; patients without a confirmed fracture were discharged. Patient pathway outcome measures were analysed pre- and post-pathway, and a cost analysis was performed. RESULTS: A total of 164 pre-pathway patients (93%) were given a face-to-face fracture clinic appointment; 76 were discharged after their first visit. Nine patients seen in clinic had a CT scan and were discharged with no fracture. If these patients had been referred to the VFC, had CT scans and been directly discharged, it would have saved £1,629. A total of 41 patients from the post-pathway group (37%) had a CT scan and were discharged from the VFC. Avoiding face-to-face clinic appointments saved £7,421. Extrapolating, the annual savings would be £29,687. CONCLUSIONS: This study shows that a VFC/CT pathway to manage patients with a suspected scaphoid fracture is cost-effective. It limits face-to-face appointments by increasing use of CT to exclude fractures.

Effect of an anaesthetic screening drape on vertical laminar airflow.

BACKGROUND: Effective operating room ventilation is required to reduce the risk of surgical site infection. Vertical laminar airflow from above the surgical field provides a source of 'ultra-clean' air, carrying contaminants away from the operative site. An anaesthetic screening drape is often used to shield the operative site from the anaesthetic team, and this defies the principles of vertical laminar airflow. METHODS: A mock theatre set-up for a total knee replacement was constructed with and without the use of an anaesthetic screening drape. A 10×10 grid was set up within the surgical canopy, and the downward air velocities were measured using a hot air anemometer. The average velocity and range of velocities at each grid point were measured in both set-ups. The range was used as the marker of turbulence. FINDINGS: Within the surgical canopy, the average downward air velocity was 0.35m/s. With the use of an anaesthetic screening drape, the mean downward air velocity in the area above the patient decreased from 0.36m/s to 0.29m/s (P=0.02). In the area immediately above the drape, the average velocity was 0.18m/s. Turbulent air currents were produced in the areas adjacent to the drape near to the mock surgical site. For the area above the patient, the range increased from an average of 0.034m/s to 0.05m/s (P=0.04). In the area directly above the drape, the average range was 0.08m/s. CONCLUSION: Use of an anaesthetic screening drape causes disruption to normal vertical laminar airflow.

A rare complication of acute appendicitis: Superior mesenteric vein thrombosis.

INTRODUCTION: Very few cases of superior mesenteric vein thrombosis have been reported as a complication of appendicitis. In these handful of cases, the thrombosis was identified early with computerised tomography scan and patients have been managed conservatively with antibiotics and anticoagulation. PRESENTATION OF CASE: A 45-year-old gentleman presented to the emergency department with a 13-day history of right lower quadrant abdominal pain and rigors. CT scan of the abdomen revealed an appendicular mass and superior mesenteric vein thrombosis. The patient was initially managed by anticoagulation and antibiotics for two weeks and was discharged after satisfactory clinical improvement. He represented after discharge for increased severity of his abdominal pain and abnormal inflammatory markers. Emergency open appendicectomy for complicated appendicitis was performed and his postoperative course was unremarkable. He was discharged on the 7th postoperative day with anticoagulation. Outpatient review at two months was unremarkable. DISCUSSION: Acute appendicitis is a common surgical presentation where history and examination is key in clinching the diagnosis. Inflammatory markers and imaging modalities such as a CT scan can be helpful. Although surgical intervention is the mainstay of treatment, conservative management with antibiotics is an option if the diagnosis of appendicitis is equivocal. Recent evidence has revealed that elective appendicectomy is not necessary upon successful conservative management. Acute appendicitis can lead to local perforations and abscesses. Complications such as thrombosis in the superior mesenteric vein are rare and can be managed successfully with anticoagulants. CONCLUSION: Although this is a rare complication of appendicitis, the case was managed successfully with a conservative approach. This is inline with the general consensus which is to treat superior mesenteric vein thrombosis secondary to appendicitis conservatively unless the patient deteriorates.