Effective radiation dose of skeletal surveys performed for suspected physical abuse.

BACKGROUND: A skeletal survey is an important diagnostic tool for patients presenting with suspected physical abuse. A relatively recent change in guidelines for skeletal surveys by the Royal College of Radiologists (RCR) in 2017 has led to more initial and follow-up images for these patients, which would be expected to have led to an increase in effective radiation dose. OBJECTIVE: To estimate the effective dose following the change in guidelines and to ascertain the difference between doses before and after the change in guidelines. MATERIALS AND METHODS: Data were collected retrospectively on children younger than 3 years old referred for skeletal surveys for suspected physical abuse at a tertiary paediatric centre. A Monte Carlo radiation patient dose simulation software, PCXMC v 2.0.1, was used to estimate the effective dose, expressed in millisieverts (mSv). RESULTS: Sixty-eight children underwent skeletal surveys for suspected physical abuse. The total estimated effective dose for skeletal surveys with the previous RCR guidelines was found to be 0.19 mSv. For initial skeletal surveys with the current RCR guidelines, the estimated effective radiation dose was 0.19 mSv. Eighteen children had both initial and follow-up skeletal surveys as indicated by the current RCR guidelines, with an estimated effective total radiation dose of 0.26 mSv. CONCLUSION: Skeletal surveys deliver a relatively low estimated effective radiation dose equivalent to 1 month of United Kingdom background radiation, with no significant change in dose following the change in guidelines. Therefore, the benefits of having a skeletal survey outweigh the main radiation risk. However, accurate data regarding the radiation dose are important for clinicians consenting parents/guardians for imaging in suspected physical abuse.

Teaching Medical Students How to Interpret Chest X-Rays: The Design and Development of an e-Learning Resource.

INTRODUCTION: The teaching of radiology to medical students has often been criticised for being inadequate and unstructured, with students reporting lack of confidence in assessing x-rays. In this paper, we describe how an e-learning resource, on how to interpret a chest x-ray for medical students, was designed and developed. The aim of the resource was to provide medical students with knowledge of how to interpret a chest x-ray in a systematic approach. METHODS: The technology used to design the e-learning resource was Xerte Online Toolkits. The design and development of the e-learning resource was based upon andragogical principles and followed Overbaugh's guidelines and Mayer's 12 multimedia principles. An instructional design model called ADDIE was used to help develop the resource and its content. These included cases of common conditions, a quiz and summary table at the end. The paper focuses mainly on the way in which instructional design, education and multimedia principles were used to inform the development of the resource. FINDINGS: A preliminary evaluation was completed by 18 medical students from year 3-5 who completed the e-learning resource. The feedback was positive with an average rating of 9/10 and 100% of students saying they would recommend the resource to a colleague. Students commented that they liked the resource as it was easy to navigate, had good visual learning and contained good explanations with relevant content. CONCLUSION AND FUTURE IMPLICATIONS: This paper demonstrates how, with the use of instructional models, educational theories and principles, an e-learning resource can be created. Preliminary evaluation showed that students were satisfied with the resource and felt it helped them acquire knowledge on how to interpret chest x-rays. This resource can be further utilized either as a standalone resource or before starting clinical placements and may prove particularly useful in the current and challenging learning environment where there is an increased need for digital resources.

Supra-patellar nailing for isolated closed tibial shaft fractures: Medium term functional outcomes from an Academic Level 1 Trauma centre.

Aims The aim of this study was to assess functional outcome, at medium-term follow up, in patients undergoing intra-medullary nailing of tibial shaft fractures, using the supra-patellar approach. Materials and methods The study included patients with intra-medullary nailing, for diaphysial tibia fractures, between March 2013 to August 2015. An initial audit compared short-term functional outcomes at 15 months, between the supra and infra-patellar approaches, using a cohort of 20 patients (10 in each group). Subsequently, a larger cohort of 22 patients with supra-patellar nailing, were reviewed for medium term assessment of their functional outcomes at average 60 months (50 - 78 months) and the results between all 3 groups were compared. All patients were assessed using the Kujala and Oxford Knee Scores. Results The mean age of the cohorts was 38 years (18-87years). The mean follow-up was 15 months for the initial audit and 60 months for the medium-term results. The initial audit showed that the supra-patellar group had statistically significantly better Oxford and Kujala scores when compared to infra-patellar group (p < 0.05). At 5 years following supra-patellar nailing, the medium-term cohort showed improved outcome scores compared to the infra-patellar group at 1 year (p < 0.01) but showed no difference with the supra-patellar group at 1 year (p value >0.1). Conclusion Our study suggests that patients undergoing supra-patellar tibial nailing have better outcomes at 15 months compared to traditional infra-patellar nailing and more importantly, they continue to do well even at 5 years, despite perceived risks associated with this technique.

Surgical Diabetic Foot Debridement: Improving Training and Practice Utilizing the Traffic Light Principle.

Comprehensive management of a severe diabetic foot infection focus on clear treatment pathways. Including rapid, radical debridement of all infection in addition to intravenous antibiotics and supportive measures. However, inexperienced surgeons can often underestimate the extent of infection, risking inadequate debridement, repeated theatre episodes, higher hospital morbidity, and hospital length of stay (LOS). This study aims to assess protocolized diabetic-foot-debridement: Red-Amber-Green (RAG) model as part of a value-based driven intervention. The model highlights necrotic/infected tissue (red-zone, nonviable), followed by areas of moderate damage (amber-zone), healthy tissue (green-zone, viable). Sequential training of orthopedic surgeons supporting our emergency service was undertaken prior to introduction. We compared outcomes before/after RAG introduction (pre-RAG, n = 48; post- RAG, n = 35). Outcomes measured included: impact on number of debridement/individual admission, percentage of individuals requiring multiple debridement, and length-of-hospital-stay as a function-of-cost. All-patients fulfilled grade 2/3, stage-B, of the Texas-Wound-Classification. Those with evidence of ischemia were excluded. The pre-RAG-group were younger (53.8 ± 11.0 years vs 60.3 ± 9.2 years, P = .01); otherwise the 2-groups were matched: HbA1c, white blood cell count, and C-reactive protein. The post-RAG-group underwent significantly lower numbers of debridement's (1.1 ± 0.3 vs 1.5 ± 0.6/individual admission, P = .003); equired fewer visits to theatre (8.6% vs 38%, P = .003), their LOS was reduced (median LOS pre-RAG 36.0 vs post-RAG 21.5 days, P = .02). RAG facilitates infection clearance, fewer theatre-episodes, and shorter LOS. This protocolized-management-tools in acute severely infected diabetic foot infection offers benefits to patients and health-care-gain.

Poncet's disease (tubercular rheumatism) with primary involvement of the foot - A case report.

We present a rare case with primary tubercular involvement of the foot, accomapanied by a reactionary (aseptic) effusion in the knee. The diagnosis was delayed due to unusual presentation and also because of failure to elicit a detailed history. Incision and drainage of the foot abscess and antitubercular drug therapy resulted in satisfactory control of tubercular infection. Polyarticular presentation may not always signify active tubercular focus in every joint; it may reflect reactive synovitis known as Poncet's disease, which resolves with multidrug antitubercular therapy.A multidispilinary approach should be adopted and chest physicians, rheumatologists and orthopaedic surgeons should work in close association to correctly diagnose and treatthis condition.

Early clinical and radiological results of total knee arthroplasty using patient-specific guides in obese patients.

PURPOSE: Total knee arthroplasty (TKA) is a challenging procedure in patients with a high body mass index (BMI). The aim of our study was to assess the outcome and accuracy of restoration of mechanical alignment in TKA using patient-specific guides (PSG) involving patients with high BMI. MATERIALS AND METHODS: Patients with BMI of 30 or above were enrolled in the study. The mean age of the patients was 65.15 years. The study comprised of 46 males and 54 females. Total knee arthroplasty was planned after a pre-operative MRI and long leg x-ray films using customized PSG. RESULTS: Of the 105 knees (100 patients) in the study, average BMI was 35.42 kg/m(2) (30-56). Twenty patients (20 %) had class III obesity (≥40 kg/m(2)). The average blood loss and operative time were 236.1 ml (range 50-700 ml) and 92.2 min (65-130 min), respectively. The average post-operative mechanical axis was noted to be 1.85° varus (range 4° valgus to 6° varus). Eighty-eight patients (86.27 %) had mechanical alignment within 3° of neutral. There were no adverse intraoperative events. One patient had deep infection that required a two-stage revision. The average post-operative range of motion at 1-year follow-up was 105.8° (range 80°-130°). CONCLUSION: Patient-specific guides technology restores the coronal mechanical axis reliably in obese patients without adversely affecting outcomes. Our short-term follow-up has shown favorable outcomes. Surgeons should use these customized jigs as a guide and adjust the size of components, alignment and rotation according to normal surgical principles.