The use of the anterolateral thigh vascular free flap in complex open elbow fractures after major trauma - An illustrated report of an interesting case.

Major trauma may result in severe open elbow fractures with significant soft tissue injury and skin loss. Reconstruction of those defects can be complicated and inadequate cover can result in severely limited functional outcome. The free anterolateral thigh flap (ALT) is one of the ways to reconstruct those defects. Its utilisation in severe complex open elbow fractures is recently being increased due to its advantages. The purpose of this article is to present an interesting case where the ALT flap was used with success in a challenging situation of a severe elbow bony, ligamentous and soft tissue injury. Our case has demonstrated that the ALT flap presents an effective method in treating successfully severe open elbow fractures, and its advantages include 1)large amount of available skin and subcutaneous tissue for coverage of the elbow joint without creating strictures, 2)potential of using the vascularised vastus lateralis muscle to minimise the residual dead space in order to prevent infection and as a vascular bed for nerve grafting and 3) the ability to harvest fascia lata grafts and use them to reconstruct ligamentous and tendinous injuries. We recommend the use of the vascularised ALT flap when treating severe open elbow fractures.

Surgical Management of Multiple Rib Fractures Reduces the Hospital Length of Stay and the Mortality Rate in Major Trauma Patients: A Comparative Study in a UK Major Trauma Center.

OBJECTIVES: To investigate and assess the effectiveness of surgical fixation of rib fractures in complex traumatic chest injuries compared with traditional nonoperative management. DESIGN: Retrospective observational comparative study. SETTING: Level 1 Major Trauma Centre in North West England. PATIENTS/PARTICIPANTS: A total of 83 patients who were admitted urgently to our hospital after major trauma, between August 2012 and March 2015, and fulfilled the criteria for surgical fixation of their multiple rib fractures. Patients who had concomitant nonsurvivable injuries or did not consent for surgery were excluded. INTERVENTION: Open reduction and internal fixation (ORIF) of multiple rib fractures and flail chest segments versus traditional nonoperative management. MAIN OUTCOME MEASUREMENTS: The primary outcome of interest was the total hospital length of stay (LOS). Secondary outcomes included the incidence of intensive care unit (ICU) admission and the incidence of respiratory complications such as hospital-acquired pneumonia, need for mechanical ventilation, and/or tracheotomy. The mortality rate was also investigated. RESULTS: A total of 83 patients were included, 47 of these in the ORIF group and 36 in the non-ORIF group. The mean hospital LOS for patients in the non-ORIF group was 30.41 days (SD 30.1). This was markedly reduced in the ORIF group to a mean of 14.53 days (SD 11.7), with the difference being statistically significant (P < 0.01). Twenty-eight patients (77.7%) in the nonoperatively managed group required admission to the ICU compared with a significantly lower 48.9% (23 patients) in the ORIF group (P < 0.01). The incidence of respiratory complications was lower in the ORIF group but this difference was not statistically significant. The mortality rate was 2.1% for the group that was treated surgically compared with 13.9% for the conservative group (P < 0.05). CONCLUSIONS: Surgical fixation of multiple displaced rib fractures reduced the total hospital LOS and the overall mortality in our major trauma patients and decreased the incidence of ICU admission. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Improving venous thromboembolism (VTE) prophylaxis in acute urological admissions during out of hours through the introduction of a urological admission proforma.

Venous thromboembolism (VTE) kills more people than breast cancer, road traffic accidents, and AIDS combined, accounting for approximately 25,000 in-hospital deaths in England annually. The cost to the NHS is estimated at £640 million/annum. The most important element of VTE risk assessment strategy in England is to risk assess all patients for VTE on admission. The aim of our quality improvement programme (QIP) was to monitor our practice regarding VTE prophylaxis of the patients' admitted urgently in our department, and then implement a measure to increase compliance if found to be poor. Our standards were based on the National Institute for Health and Care Excellence (NICE) guidelines which state that all urgently admitted patients must have a completed VTE assessment form within 24 hours of admission and receive appropriate VTE prophylaxis including low molecular weight heparin (LMWH) and/or TED stockings. Our initial audit was conducted over a period of five weeks. All adult patients acutely admitted out of hours (5pm to 8am) were included. We then introduced a specially designed urological admissions proforma and organised several teaching sessions for junior doctors who facilitated acute admissions. Re-audit was performed using the same methods and timescale measuring improvement. Second re-audit six months after the introduction of the proforma, following the induction of the new cohort of junior doctors. - Primary audit: n=44. Proportion of: completed VTE form=56%, LMWH appropriately prescribed=65%,TEDS=35%. VTE related complications=3 - 1st re-audit: n=42. Proportion of: completed VTE form=93%, LMWH appropriately prescribed=83%,TEDS=64%. VTE related complications=0 - 2nd re-audit:n=43. Proportion of: completed VTE form=92%, LMWH prescribed=84%, TEDS=76%. VTE related complications=1 There has been a significant increase of compliance with the NICE guidelines regarding VTE prophylaxis within our department through introducing the specially designed urological admissions proforma and delivering teaching sessions for junior doctors. The implementation of the proforma also led to decreased prevalence of VTE related complications and their subsequent morbidity and mortality.