Talar head fracture: A case report, systematic review and suggested algorithm of treatment.

INTRODUCTION: Talar head fractures are uncommon. This rarity contributes to the lack of structure and clarity in its management. The purpose of this systematic review is to analyse the published literature on management of these injuries and suggest a treatment plan that was followed in our case. METHODS: A search of Medline, EMBASE, AMED and Google Scholar was performed on 1st September 2014. Any article reporting case(s) of talar head fractures were included and studies of other anatomical types of talar fractures, stress fractures or paediatric cases were excluded. The paucity of data precluded data synthesis and instead a narrative synthesis was performed. RESULTS: Of 45 studies identified, five publications with seven case reports met the inclusion criteria. One occurred secondary to snowboarding, one wakeboarding, one inversion injury whilst walking and one gymnastic injury. Two patients were managed operatively and two non-surgically with one requiring surgery for a symptomatic mal-union. CONCLUSION: Talar head fractures are rare and high quality literature regarding management of these injuries is lacking. A suggested algorithm for treatment is proposed, but further robust studies are required to substantiate this approach.

Total proximal interphalangeal joint arthroplasty for osteoarthritis versus rheumatoid arthritis--a systematic review.

Osteoarthritis (OA) and rheumatoid arthritis (RA) of the proximal interphalangeal joints (PIPJ) can be treated with arthroplasty, although the complicated anatomy of the joint makes surgery challenging. Controversy exists regarding outcomes in relation to disease aetiology. This study aims to compare functional outcomes and re-operation rates in these two conditions. The electronic databases MEDLINE, EMBASE, Cochrane database and Google scholar were searched in accordance with PRISMA. The study quality was assessed using the Methodological Index for Non-Randomised Studies (MINOR). A total of 16 studies were reviewed including 506 cases in the OA and 542 in the RA group. Five studies assessed function and patient satisfaction, demonstrating a non-significant improvement in the OA group. Five studies reported re-operation rate; three showing it to be lower in the OA group and two reporting similar rates. This review suggests that those undergoing PIPJ arthroplasty for OA may have a better functional outcome and lower re-operation rate.

Rupture rate following primary flexor tendon repair of the hand with potential contributing risk factors.

This study aimed to investigate rupture rates following primary flexor tendon repair and to identify potential risk factors of rupture. Fifty-one patients with 100 flexor tendon injuries who underwent primary repair over a one-year period were reviewed. We collected demographic and surgical data. Causes of rupture were examined. Ruptured primary tendon repairs were compared with those that did not rupture. Univariate and multivariate analysis were undertaken to identify significant risk factors. Eleven percent of repaired tendons ruptured with a higher rupture rate noted in the non-dominant hand (p value = 0.009), in Zone II (0.001), and when more than 72 hours surgical delay occurred (0.01). Multivariate regression analysis identified repair in Zone II injuries to be the most significant predictor. Our rate of rupture of 11% was associated with delay in surgery, repair on non-dominant hand, and Zone II repairs. Careful consideration of these factors is crucial to reduce this rate.

Prevalence and management of atrial fibrillation in primary care: a case study.

AIM: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a major predisposing risk factor for stroke. Current UK guidelines propose stroke-risk stratification of AF patients. Anticoagulation with warfarin is recommended for high risk patients, whereas treatment with aspirin alone is advised for those at low risk. The aim of this audit was to review practice at our institution and ascertain if guidelines on AF treatment were being followed. METHODS: A retrospective review of all patients diagnosed with non-valvular AF in June 2010 was undertaken. Patient records were reviewed to collect demographic and co-morbidity data relevant to stroke risk stratification. This was subsequently used to stratify patients according to stroke-risk using the CHADS2 scoring system. The use of anticoagulation and anti-platelet medication as well as any documented reasons for the omission of anticoagulation in high risk patients was noted. RESULTS: The prevalence of non-valvular AF in our practice population was 1.5% (151/10,155); 70% (105/151) of AF patients were found to be at high risk of stroke; 36% (38/105) of high risk patients were not on anticoagulation and the majority (58%) of these patients had no clear reason documented for the omission of warfarin. Of the 15 patients at low risk of stroke, 12 (80%) were on warfarin. Seven (4.4%) of the 151 AF patients were on both warfarin and aspirin and six (4%) were on neither medication. The commonest documented reasons for omission of warfarin in the high risk group were dementia and a history of gastrointestinal bleeding. DISCUSSION: The lack of documentation on withholding a proven beneficial treatment in high risk patients could potentially leave physicians open to medico-legal scrutiny. Maintaining low risk patients on anticoagulation may expose them to unnecessary risk. We recommend the use of automated audit tools designed to improve compliance with national guidelines.