Evaluating the potential for cone beam CT to improve the suspected scaphoid fracture pathway: InSPECTED: A single-centre feasibility study.

BACKGROUND: The suspected scaphoid fracture remains a diagnostic conundrum with over-treatment a common risk-averse strategy. Cross-sectional imaging remains the gold standard with MRI recommended but CT used by some because of easier access or limited MRI availability. The aim of this feasibility study was to evaluate whether cone beam computed tomography (CBCT) could support early diagnosis, or exclusion, of scaphoid fractures. METHODS: Patients with a suspected scaphoid were recruited fracture between March and July 2020. All underwent a 4-view X-ray. If this examination was normal, they were immediately referred for a CBCT scan of the wrist. Those with a normal scan were discharged to research follow-up at 2 and 6-weeks. RESULTS: 68 participants were recruited, 55 had a normal or equivocal X-ray and underwent CBCT. Nine additional radiocarpal fractures (16.2%) were demonstrated on CBCT, the remainder were discharged to research follow-up. Based on the 2-week and 6-week follow up three patients (4.4%) were referred for MRI to investigate persistent symptoms with no bony injuries identified. CONCLUSIONS: CBCT scans enabled a rapid pathway for the diagnosis or exclusion of scaphoid fractures, identifying other fractures and facilitating early treatment. The rapid pathway also enabled those with no bony injury to start rehabilitation, suggesting that patients can be safely discharged with safety-net advice following a CBCT scan.

Efficacy of Prehospital Analgesia with Fascia Iliaca Compartment Block for Femoral Bone Fractures: A Systematic Review.

IntroductionFemoral fractures are painful injuries frequently encountered by prehospital practitioners. Systemic opioids are commonly used to manage the pain after a femoral fracture; however, regional techniques for providing analgesia may provide superior targeted pain relief and reduce opioid requirements. Fascia Iliaca Compartment Block (FICB) has been described as inexpensive and does not require special skills or equipment to perform, giving it the potential to be a suitable prehospital intervention.ProblemThe purpose of this systematic review is to summarize published evidence on the prehospital use of FICB in patients of any age suffering femoral fractures; in particular, to investigate the effects of a prehospital FICB on pain scores and patient satisfaction, and to assess the feasibility and safety of a prehospital FICB, including the success rates, any delays to scene time, and any documented adverse effects. METHODS: A literature search of MEDLINE/PubMED, Embase, OVID, Scopus, the Cochrane Database, and Web of Science was conducted from January 1, 1989 through February 1, 2017. In addition, reference lists of review articles were reviewed and the contents pages of the British Journal of Anaesthesia (The Royal College of Anaesthetists [London, UK]; The College of Anaesthetists of Ireland [Dublin, Ireland]; and The Hong Kong College of Anaesthesiologists [Aberdeen, Hong Kong]) 2016 along with the journal Prehospital Emergency Care (National Association of Emergency Medical Service Physicians [Overland Park, Kansas USA]; National Association of State Emergency Medical Service Officials [Falls Church, Virginia USA]; National Association of Emergency Medical Service Educators [Pittsburgh, Pennsylvania USA]; and the National Association of Emergency Medical Technicians [Clinton, Mississippi USA]) 2016 were hand searched. Each study was evaluated for its quality and its validity and was assigned a level of evidence according to the Oxford Centre for Evidence-Based Medicine (OCEBM; Oxford, UK). RESULTS: Seven studies involving 699 patients were included (one randomized controlled trial [RCT], four prospective observational studies, one retrospective observational study, and one case report). Pain scores reduced after prehospital FICB across all studies, and some achieved a level of significance to support this. Out of a total of 254 prehospital FICBs, there was a success rate of 90% and only one adverse effect reported. Few studies have investigated the effects of prehospital FICB on patient satisfaction or scene time delays. CONCLUSIONS AND RELEVANCE: The FICB is suitable for use in the prehospital environment for the management of femoral fractures. It has few adverse effects and can be performed with a high success rate by practitioners of any background. Studies suggest that FICB is a useful analgesic technique, although further research is required to investigate its effectiveness compared to systemic opioids. HardsM, BrewerA, BessantG, LahiriS. Efficacy of prehospital analgesia with Fascia Iliaca Compartment Block for femoral bone fractures: a systematic review. Prehosp Disaster Med. 2018;33(3):299-307.