A prospective, observational cohort study of patients presenting to an emergency department with acute shoulder trauma: the Manchester emergency shoulder (MESH) project.

BACKGROUND: Fracture and dislocation of the shoulder are usually identifiable through the use of plain radiographs in an emergency department. However, other significant soft tissue injuries can be missed at initial presentation. This study used contrast enhanced magnetic resonance arthrography (MRA) to determine the pattern of underlying soft tissue injuries in patients with traumatic shoulder injury, loss of active range of motion, and normal plain radiography. METHODS: A prospective, observational cohort study. Twenty-six patients with acute shoulder trauma and no identifiable radiograph abnormality were screened for inclusion. Those unable to actively abduction their affected arm to 90° at initial presentation and at two week's clinical review were consented for MRA. RESULTS: Twenty patients (Mean age 44 years, 4 females) proceeded to MRA. One patient had no abnormality, three patients showed minimal pathology. Four patients had an isolated bony/labral injury. Eight patients had injuries isolated to the rotator cuff. Four patients had a combination of bony and rotator cuff injury. Four patients were referred to a specialist shoulder surgeon following MRA and underwent surgery. CONCLUSIONS: Significant soft tissue pathology was common in our cohort of patients with acute shoulder trauma, despite the reassurance of normal plain radiography. These patients were unable to actively abduct to 90° both at initial presentation and at two week's post injury review. A more aggressive management and diagnostic strategy may identify those in need of early operative intervention and provide robust rehabilitation programmes.

BET 1: A glass half full? Thrombolysis for the treatment of submassive pulmonary embolism.

A short-cut review was carried out to establish whether thrombolysis in addition to therapeutic anticoagulation could be of benefit in submassive (intermediate risk) pulmonary embolism (PE). 64 directly relevant papers were found using the reported search strategy. Of these, three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that there is insufficient evidence to support the routine use of adjuvant thrombolytic therapy at any dose for patients with submassive PE. Carefully selected patients with a low bleeding risk who attribute high importance to functional outcome may stand to benefit.

BET 2: Striking the right balance: anticoagulation and isolated distal deep vein thrombosis.

A short-cut review was carried out to establish whether treatment of isolated distal deep vein thrombosis with therapeutic anticoagulation can reduce adverse clinical outcomes. A meta-analysis from 2011 and 11 subsequent directly relevant papers were found using the reported search strategy. Of these, 7 in total presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that patients diagnosed with isolated distal deep vein thrombosis should be individually risk assessed and treated according to their risk of thrombotic complication, bleeding with anticoagulation and personal preference.

Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. Evidence exists to guide thromboembolic prophylaxis in ambulatory patients with temporary lower limb immobilisation.

A short-cut review was carried out to establish whether patients requiring lower limb immobilisation should have thromboprophylaxis. A total of 148 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. The clinical bottom line is that ambulatory patients with temporary lower leg immobilisation who are over 50, in a rigid cast, non-weight bearing or with a severe injury should be considered as an at risk group for venous thromboembolism (VTE). If there are any other current proven VTE risk factors, patients should be considered as high risk.