A comparison between the Major Trauma Centre management of complex open lower limb fractures in children and the elderly.

INTRODUCTION: Open lower limb fractures can be devastating with outcomes determined by tissue damage and adherence to strictly defined care pathways. Managing such injuries in paediatric and elderly populations presents logistical and technical challenges to achieve best outcomes. Orthoplastic principles were developed mainly in the young adult population whereas requirements for paediatric and elderly patients need further understanding. METHODS: A retrospective analysis was performed on two groups of patients at the extremes of age, with type IIIb (severe) open lower limb fractures, presenting to a Major Trauma Centre (MTC) with orthoplastic services over a six-year period - the first group being under 16 years; the second group being over 65. The timelines of combined surgery to both fix the fracture and flap the soft-tissue defect were strictly observed. Each group were followed-up for a minimum of nine months. Data were analysed according to patient demographics, mechanism of trauma, time to wound excision, time to definitive surgery, fixation technique, soft-tissue reconstruction type, deep infection rate, flap survival, bony union, secondary amputation and functional outcome (Enneking score). RESULTS: 33 paediatric patients and 99 elderly patients were identified. Paediatric: The median age was 12 years. All the children were ASA Grade I. Open tibial fractures were most common (76%) followed by ankle fracture dislocation (12%). The majority were high-energy injuries and were commonly managed with external fixators (or frames) and free flap coverage. Median hospital stay was 12 days, and time to union 114 days, with median Enneking scores of 85%. There was one flap failure and no deep infections. Elderly: The median age was 76 years. ASA grades varied and reflected multiple comorbidities. High-energy injuries required free flaps, while more common, low-energy fragility fractures were covered with loco-regional flaps. Internal fixation with intramedullary nails was most commonly used. Median hospital stay was 13 days, and time to union was 150 days, with median Enneking scores of 70%. There was one flap failure, one deep infection, and one delayed amputation. DISCUSSION: These results reflect both similarities and important differences in managing open fractures in the extremes of age. The specific challenges of each group of patients are discussed, including surgical aspects, but also the importance of orthoplastics infrastructure within the MTC and input from allied professionals to facilitate patient pathways.

Dishwasher-related injuries: survey and literature review.

Domestic injuries are quite common among children aged 0-4 years old. Hazards lurking in the kitchen area can cause serious injuries in children. Through this study, we aim to raise public awareness of the potential and underreported risk of injuries related to dishwashers. Anonymous questionnaires consisting of 12 questions were distributed to adult females with children under 5 years old, including nurses, secretarial staff and outpatients. Commonly used dishwashers were surveyed by visiting high-street stores, and each brand's user manual was studied. A literature search using Medline and Pubmed was conducted for examining reported dishwasher-related sharp injuries. Forty households filled out survey questionnaires. Their responses indicated that 10% and 12.5% of children participate in unloading or loading dishwashers, respectively. Results showed that the incidence of related injuries was 12.5% among adults and 5% among children, and young children are at risk of sharp injuries in households with dishwashers. The dangerous loading and unloading of sharp objects and the direct involvement of toddlers should be discouraged, with the help of manufacturers.

A simple dynamic external fixator for complex phalangeal fractures.

Complex compound and comminuted phalangeal fractures are often surrounded by soft tissue injuries. Stabilising such fractures is not easy but is essential before early mobilisation to prevent stiffness and regaining hand function. Several designs of external fixators have been advocated but could not simultaneously offer simplicity, affordability, stability, and freedom of movement. We propose a design that is easy to make without expert assistance. It is cheap, available in most theatres, and offers required stability and freedom of movement in the immediate postoperative period. Our claim is strongly supported by long-term follow-up results.