Femoral nerve blocks in fractures of femur: variation in the current UK practice and a review of the literature.

Fractures of the femur are common orthopaedic emergencies presenting to emergency departments (ED). Femoral nerve block (FNB) is a fast, safe and effective means of providing pain relief to these patients. With the aim to analysing the variation in current practice of giving FNB in patients with fractured femur in the UK, we carried out a telephonic national survey. Out of 252 EDs contacted, 230 departments participated in the survey (91% response rate). The survey showed that 74% EDs in the UK had access to ultrasound, but only 10% EDs gave FNB regularly under ultrasound guidance. In total, 46% of EDs gave FNB by blind technique. Therefore, ultrasound-guided FNB is an underutilised method of providing pain relief for fractured femur patients. The main reasons for not using ultrasound for FNB were: lack of training, participants' confidence in giving an effective and safe FNB block blindly and time constraints. The literature review suggests that ultrasound-guided FNB has a faster onset of action, is more effective and safer than the FNB given with nerve stimulator (NS) or blindly, and probably needs lower local anaesthetic dose. The use of NS for FNB in ED might not be practical because of the likelihood of the pain resulting from the movement of the affected limb due to the contraction of the muscles caused by nerve stimulation and because of additional training needed in using NS. The studies comparing FNB given using ultrasound or NS, or given blindly, have been done in the perioperative settings. To date, there has been no randomised controlled trial in ED setting comparing FNB given blindly or under ultrasound guidance. Such a study might have provided a good evidence for modifying the current practice of blind FNB.

Pelvic girdle pain and low back pain in pregnancy: a review.

Pregnancy-related pelvic girdle pain (PGP) and pregnancy-related low back pain (PLBP) are common problems with significant physical, psychological, and socioeconomic implications. There are several management options that are underutilized because of lack of comprehensive knowledge by health-care professionals and fear of harmful effects of treatment on the developing fetus. Interventions such as patient education, the use of pelvic belts, acupuncture, and aquatic and tailored postpartum exercises can be of some benefit to these patients. This article will focus on the diagnosis and management of PGP and PLBP, with discussion of terminology, epidemiology, risk factors, pathophysiology, and prognosis.

Management of ipsilateral pilon and calcaneal fractures: a report of 2 cases.

Although uncommon, the management of ipsilateral pilon and calcaneal fractures is a challenging problem for foot and ankle surgeons. There are several issues that may affect the outcome. Aside from damage to the soft-tissue envelope, technical issues such as positioning of the patient, application of traction, and tourniquet time may complicate surgical intervention. The authors present their experience with 2 patients who sustained this fracture pattern and highlight the mechanism, management, and possible complications of these injuries.

Isolated volar dislocation of distal radioulnar joint: how easy to miss!

Volar dislocation of the distal radioulnar joint without concomitant fracture of the radius or ulna is a very rare but a commonly missed injury in emergency situations. If left untreated, this injury can lead to significant functional disability. We report a case of a young man who sustained an acute, isolated, volar dislocation of the distal radioulnar joint, and highlight the important clinical and radiological features, which can help in diagnosing the condition in the Accident and Emergency Department where the patients with such injuries present first.

Multiple trauma and scapula fractures: so what?

UNLABELLED: BACKGROUND Scapula fractures are rare and are presumed to indicate severe underlying trauma. We studied injury patterns and overall outcome in patients with multiple injuries with scapula fractures. METHODS: We carried out a retrospective review of patients with multiple injuries (Injury Severity Score [ISS] > or = 16) with chest and musculoskeletal injuries admitted to our institution between 1993 and 1999 to investigate whether the presence of a scapula fracture is a marker of increased morbidity and mortality. RESULTS: There were 1,164 patients admitted with multiple trauma. Seventy-nine (6.8%) of the 1,164 sustained a scapula fracture, forming the study group. The remainder of the patients (n = 1,085) formed the control group of the study. Both groups of patients were similar with regard to age and Glasgow Coma Scale score (age, 42 +/- 17.8 [+/- SD] vs. 40 +/- 22; GCS score, 11.2 +/- 5.1 vs. 11 +/- 5 in the study and control groups, respectively). The overall ISS was significantly higher in those with scapula fractures (27.12 +/- 15.13 vs. 22.8 +/- 14.4, p = 0.01). Patients with scapula fractures also had more severe chest injuries (Abbreviated Injury Scale score of 3.46 +/- 1.1 vs. 3.1 +/- 1.0, respectively), but not significantly so. However, the incidence of rib fractures was significantly higher in the patients with scapula fractures (p < 0.05). The incidence and severity of head and abdominal injuries were similar in the two groups. The severity of extremity injuries in patients with scapula fractures was significantly lower (2.4 +/- 0.6 vs. 2.7 +/- 0.7, p = 0.001). The rate of admission, the length of intensive care unit stay, and the overall length of hospital stay were similar in the two groups. The overall mortality rate was 11.4% in patients with scapula fractures and 20% in those without scapula fractures (p = 0.1). CONCLUSION: Patients with scapula fractures have more severe underlying chest injuries and overall ISS. However, this did not correlate with a higher rate of intensive therapy unit admission, length of hospital stay, or mortality.