The effect of carbon fiber custom dynamic orthosis use and design on center of pressure progression and perceived smoothness in individuals with lower limb trauma.

BACKGROUND: Carbon-fiber custom dynamic orthoses are used to improve gait and limb function following lower limb trauma in specialty centers. However, the effects of commercially available orthoses on center of pressure progression and patient perception of orthosis smoothness during walking are poorly understood. METHODS: In total, 16 participants with a unilateral lower extremity traumatic injury underwent gait analysis when walking without an orthosis, and while wearing monolithic and modular devices, in a randomized order. Device alignment, stiffness, participant rating of perceived device smoothness, center of pressure velocity, and ankle zero moment crossing were assessed. FINDINGS: The modular device was approximately twice as stiff as the monolithic device. Alignment, smoothness ratings, peak magnitude of center of pressure velocity, and zero moment crossing were not different between study devices. The time to peak center of pressure velocity occurred significantly later for the modular device compared to the monolithic and no orthosis conditions, with large effect sizes observed. INTERPRETATION: Commercially available orthoses commonly used to treat limb trauma affect the timing of center of pressure progression relative to walking without an orthosis. Despite multiple design differences, monolithic and modular orthoses included in this study did not differ with respect to other measures of center of pressure progression. Perceived smoothness ratings were approximately 40% greater with the study orthoses as compared to previous studies in specialty centers, which may be due to a more gradual center of pressure progression, as indicted by lower peak magnitude of center of pressure velocity with both study orthoses.

Lower Extremity Trauma: A Multidimensional Reconstructive Approach with Hyperbaric Oxygen Therapy.

Background: Distal lower extremity reconstruction is challenging. This study aims to propose a protocol for the treatment of traumatic soft tissue defects. The key concept is to combine the surgical armamentarium of the reconstructive surgeon with the advantages provided by hyperbaric oxygen therapy. Methods: This retrospective study analyzed data of 57 patients affected with unilateral or bilateral lower extremity trauma distal to the knee and involving soft tissues with no indication of immediate reconstruction between 2010 and 2021. Before the reconstructive procedure, all the patients underwent a stick swab procedure for the collection of microbiological samples and debridement. Patients were divided into two treatment groups and only one group underwent a combined therapeutic procedure with hyperbaric oxygen therapy. Negative pressure wound therapy (NPWT) was employed only if deemed necessary according to the defect's depth and wound exudate. Surgical techniques, outcomes, and complications were discussed. Results: All patients achieved a complete recovery with no major complications and only minor complications observed. The study group treated with HBOT had a lower complication rate and lower percentages of minimal and partial graft loss compared with the same complications observed in the control group. No patients experienced HBOT-related complications. Significant reductions in the time to complete healing and the time from reconstruction to healing were found (p = 0.002 and p < 0.00001, respectively). Conclusions: A lower complication rate was observed in the group treated with HBOT. The administration of HBOT prior to soft tissue reconstruction significantly reduced the time to complete healing and the time interval from skin grafting to healing. However, prospective studies and randomized trials with larger cohorts should be designed to investigate the efficacy of HBOT for the treatment of lower extremity injuries with extensive soft tissue defects.

Vacuum sealing drainage technique combined with carbon nanomaterial dressings applied in the treatment of skin wounds.

Introduction: Limb trauma (LT) encompasses a variety of conditions and currently poses certain therapeutic challenges in clinical practice. Aim: To assess the effectiveness of applying the vacuum sealing drainage (VSD) technique combined with carbon nanomaterial (CNM) dressings in the nursing treatment of LT patients. Material and methods: Eighty-six LT patients were enrolled into a control (Ctrl) group and an experimental (Exp) group. Patients in the Ctrl group underwent conventional wound cleansing and drainage methods with regular dressings, while those in the Exp group received VSD combined with CNM dressings. Both groups received the same nursing procedures. Various indicators were observed and compared to analyse the final outcomes. Results: The Exp group exhibited a higher favourable wound healing (FWH) rate, overall limb functional recovery (LFR) rate, and nursing satisfaction compared to the Ctrl group (p < 0.05). Meanwhile, patients in the Exp group experienced a greatly lower incidence of complications (IOC), pain scores, and average hospital stays (HS), presenting statistically/significant differences compared to those in the Ctrl group (p < 0.05). The combination of the VSD technique with CNM dressings demonstrated advantages in nursing treatment of LT patients. This approach could enhance rates of FWH, reduce IOC, alleviate postoperative pain, facilitate LFR, and shorten HS. Furthermore, patients in the Exp group expressed higher nursing satisfaction. Conclusions: Results of this work yielded a novel therapeutic option for clinical practice, enhancing treatment outcomes and rehabilitation processes for LT patients.

White phosphorous civilian hand burns - An aid to timely treatment of a rare entity.

First discovered in 1669, white phosphorus is well known for its use in military warfare (Davis, 2002). Its application has since been expanded to include industrial disinfectants, fertilisers and fireworks (Davis, 2002). Exposure to white phosphorus can lead to severe chemical burns with high morbidity and potentially fatal systemic effects. Fortunately, civilian casualties from this potent agent are remarkably rare with few reports in the literature to date (Frank et al., 2008; Aviv et al., 2017). We present the case of a 27-year-old fisherman who sustained a chemical burn to his right hand from a substance suspected to be white phosphorus. We propose an evidence-based algorithm to guide non-military physicians literature on the acute management of white phosphorus burns to optimise timely emergency management of this uncommonly encountered substance.

The Impact of Regional Anesthesia in Masking Acute Compartment Syndrome after Limb Trauma.

Regional anesthesia has shown to be successful in controlling major pain in trauma patients. However, the possibility of masking acute compartment syndrome (ACS) after peripheral nerve blocks for limb injuries is still controversially discussed. Therefore, we aimed to summarize the current literature regarding this topic to shed light on the impact of peripheral regional anesthesia on the diagnosis of ACS in trauma patients. We searched Pubmed, Google Scholar and the Cochrane Library for literature following the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The analysis of these reports was included in the context of the current literature concerning this topic. We found no (randomized) studies, and only six case reports dealing with the impact of peripheral nerve blocks and ACS in patients after a limb trauma met our criteria and were included in our review. Only one reported a delay in the diagnosis of ACS. In most of the cases (5 of 6), the breakthrough pain, despite the nerve block, proved to be a good indicator of a developing ACS. However, despite some narrative articles about the topic including some recommendations about the possibly safe use of regional anesthesia techniques for limb trauma, there is still no international consensus and only one national guideline focusing on the possibly safe use of peripheral nerve blocks in trauma patients at risk of ACS. After reviewing the respective literature, we consider that intra-articular analgesia, sensory blocks, fascial plane blocks and low-concentration continuous peripheral nerve blocks are effective for analgesia and a low-risk analgesia tool for trauma and postsurgical patients at risk of ACS due to the fact that they do not lead to a dense block. Finally, we summarized suggestions based on the results of the literature for the different regional anesthesia modalities in these patients in a table to facilitate the use of these techniques.

The association between lower limb fractures and weight gain in adults: a prospective analysis of body mass index trends.

PURPOSE: Despite understanding the connection between obesity and fracture risk, there is limited research on the implications of lower limb fractures on subsequent changes in body mass index (BMI). Our study aimed to assess the impact of lower limb fractures on BMI alterations over an 18-month period. METHODS: A multi-center, prospective cohort study was conducted between January 2021 to June 2023, involving 494 adults with lower limb fractures. Participants were recruited within 2 weeks post-injury and were assessed for demographics, injury details, and weight at seven distinct time points. By 18 months, the primary outcome was the mean weight gain. RESULTS: The average age of the participants was 39 (± 12.7) with a baseline weight and BMI of 80.4 kg and 27.6, respectively. At the 18-month follow-up, 75% of patients experienced an average weight increase in 4 kg (± 5.39 kg), equating to a BMI rise of 1.39 (± 1.88). Most patients attributed weight changes to their injury, with nearly half expressing distress from their weight change. Only 37% believed that they had resumed their previous activity levels by the final follow-up. Approximately 31% of the patients sought some form of external weight management care in the form of nutritionist advice, training programs, medication and weight management procedures. CONCLUSIONS: Lower limb fractures significantly affect weight gain over an 18-month period, with substantial psychological and physical consequences. Healthcare providers should anticipate potential weight gain post-fracture and incorporate strategies addressing both physical and mental aspects of rehabilitation to enhance recovery outcomes. Early and even immediate weight bearing may play a pivotal role in mitigating weight changes and returning the patient to their previous level of activity. Further detailed studies focusing on different fractures and postoperative interventions are recommended.

Outcome predictors of patients who underwent limb amputation/s following trauma at a level I trauma center in North India.

PURPOSE: Limb amputation is one of the oldest medical operations, dating back over 2500 years to Hippocrates' time. In developing countries like India, most of the patients are young, and trauma is the primary cause of limb amputation. The objectives of this study were to investigate the factors that can predict the outcome of patients who underwent upper or lower limb amputations. MATERIALS AND METHODS: This was a retrospective analysis of the prospectively collected data of patients who underwent limb amputations from January 2015 to December 2019. RESULTS: From January 2015 to December 2019, 547 patients underwent limb amputations. Males predominated (86%). Road traffic injuries (RTI) were the most common (323, 59%) mechanism of injury. Hemorrhagic shock was present in 125 (22.9%) patients. Above-knee amputation was the most common (33%) amputation procedure performed. The correlation of hemodynamic status at presentation with the outcome was statistically significant (p-0.001). Outcome measures like delayed presentation, hemorrhagic shock, Injury severity scores (ISS), and the new injury severity scores (NISS) were statistically significant (p-0.001) when compared to the outcome. There were 47 (8.6%) mortalities during the study period. CONCLUSION: Factors that affected the outcome were delayed presentation, hemorrhagic shock, higher ISS, NISS, MESS scores, surgical-site infection, and associated injuries. Overall mortality during the study was 8.6%.

Successful Surgical Management of Post-traumatic Superficial Femoral Artery Pseudoaneurysm With Delayed Presentation.

Pseudoaneurysms of the superficial femoral artery are uncommon and typically iatrogenic. The majority of publications on this topic that have been published in English literature are case reports. It is unclear how often arterial pseudoaneurysms (APAs) caused by limb trauma occur, and their treatment is not standardised. A review of the literature usually follows the presentation of a case report, but no recent update with reliable data has been published. In this case study, a 24-year-old patient who had a piece of iron lodged in the middle third of his thigh and a pulsatile mass that revealed a pseudoaneurysm of the superficial femoral artery is described. The patient underwent an emergency operation without employing a venous graft. We directly sutured the arterial lesion, with positive outcomes.

Prehospital tourniquet use in civilian extremity trauma: an Australian observational study.

BACKGROUND: Prehospital tourniquets (PHTQ) for trauma have been shown to be safe and effective in the military environment and in some civilian settings. However, the supporting civilian data are mostly from North America with a differing case mix and trauma system and may not be applicable to the Australian environment. The aim of this study is to describe our initial experience with PHTQ from safety and efficacy viewpoints. METHOD: Retrospective review of all patients with PHTQ from 1 August 2016 to 31 December 2019 was conducted. Data were matched from the RMH Trauma Registry and Ambulance Victoria Registry. Clinical presentation including prehospital observations, PHTQ times, limb outcomes and complications are described. RESULTS: Thirty-one cases met inclusion criteria, for whom median age was 37 (IQR: 23.9-66.3), median ISS 17 (13-34) and 80.6% were male. The majority (n = 19, 61.3%) were as a result of road traffic crash, and six (19.4%) from penetrating mechanisms, usually glass. Over a quarter (29.0%) suffered a traumatic amputation. The median prehospital SBP was 100 (IQR: 80-110), the median prehospital HR was 101 (IQR: 77.0-122.3) and was the median PHTQ time was 124 min (IQR: 47-243). Complications attributable to the tourniquet were seen in 4/30 cases (13.3%). CONCLUSION: This Australian series differs from North American civilian PHTQ series with a lower penetrating trauma rate and longer PHTQ times. Despite this, complication rates are within the published literature's range. Concerns regarding limited transferability of overseas studies to the Australian context suggests that ongoing audit is required.

Sural Artery as a Recipient Vessel for Free Flaps.

Introduction The axial vessels like the anterior and posterior tibial emerge as the first choice of recipient vessels, in free flaps for lower limb trauma. When the defects are located more proximally in the leg, the deeper course of the axial vessels makes the dissection more tedious. Alternative vessels like the descending genicular, medial genicular, and distal end of the descending branch of the lateral circumflex femoral can be used for an end-to-end anastomosis, well away from the zone of trauma. The objective of this study was to define the indications and technique of the use of the sural vessels as the recipient pedicle for proximal and middle third leg defects. Patients and Methods For the period 2006 to 2022, 18 leg defects following road traffic accidents were covered with latissimus dorsi muscle flap using sural vessels as the recipient pedicle. Results Among 18 patients, 8 patients had defect in proximal third, 8 had a combined defect in proximal and middle third leg, and 2 had defect in middle third leg. Two patients developed arterial thrombosis and one patient had venous thrombosis for which re-exploration was performed. Two flaps were lost and sixteen had successful wound coverage. Conclusion The sural vessels as recipient pedicle are easier to access and can be considered as a reliable option for free flaps in limb defects of proximal and middle third leg. Using the submuscular part of the vessel ensures a better distal reach of the flap.

The Relationship of the COVID-19 pandemic with the Incidence and Management of Upper Limb Fractures: Double-Centre Study.

Background: The COVID-19 pandemic brought about the placement of severe social restrictions in the United Kingdom, limiting activity and impacting public behavior. Limited studies have been published on the relationship of the coronavirus pandemic with the presentation and management of upper limb fractures. The aims of this study were first to assess the change in the incidence of upper limb fractures at key points during the COVID-19 pandemic such as the enactment and lifting of lockdowns, and second to evaluate the relationship between local COVID-19 burden and measures of service efficiency across our trust. Methods: We undertook a retrospective analysis of all upper limb fracture referrals, admissions, and surgical procedures from the 1st of March 2020 to the 28th of February 2021. Changes in upper limb fracture incidence were mapped to significant changes in social restrictions. Measurements of service efficiency including time from admission to theatre and length of stay for admitted upper limb fracture patients were mapped to local COVID-19 burden. Subgroup analysis was undertaken to compare across age groups, including the pediatric population, all adults, and the elderly. Results: The study involved 1251, 659, and 641 patients with upper limb fracture referrals, admissions, and procedures across the trust, respectively. Referrals (n=128) and procedures (n=72) both peaked in August 2020. Admissions peaked in both May and December 2020 (63 for both). Admissions and procedures both demonstrated a decrease in March and April 2020 compared to the rest of the study period (40 and 38 admissions, as well as 48 and 29 procedures respectively). Across the cohort, referrals and admissions did not demonstrate a statistically significant relationship with the relaxing of social restrictions (P=0.504). There were statistically significant differences among referrals, admissions, and procedures when stratifying patients by age (p =<0.001). Length of stay demonstrated an inverse relationship with COVID-19 burden throughout the study period, with the shortest average length of stay recorded in months with the highest number of local COVID-19 cases. The average time from injury occurrence to theatre increased during the winter months (P=0.001). Conclusion: There is a relationship between changes in social restrictions and the incidence of upper limb fractures. These changes also had differing impacts on upper limb fracture rates when stratifying by patient age groups. The orthopedic service demonstrated adaptability in response to the local COVID-19 burden, and further research is needed to determine what effect this had on clinical outcomes.

Coping With the Fear of Compartment Syndrome Without Compromising Analgesia: A Narrative Review.

Pain management in trauma or surgery with a high risk of developing compartment syndrome (CS) is always challenging due to fears of masking symptoms that could delay diagnosis and treatment. Regional anesthesia/analgesia (RA) can facilitate enhanced postoperative recovery and improve patient satisfaction by providing excellent postoperative analgesia. However, its consideration in surgeries with a high risk of developing CS remains controversial and contentious. Studies suggest focusing more on early diagnosis through regular vigilant monitoring with a high index of suspicion rather than discontinuing the analgesic method alone. The most consistent features in all reported cases of CS were altered sensation in the affected limb, disproportionate pain in the presence of a functional nerve block, and an escalating need for analgesics. Several extrinsic or intrinsic factors are responsible for the progressive increase in compartment pressure that can lead to vascular compromise and subsequent ischemic changes in muscles, tissues, and nerves. Measurement of intracompartmental pressure (ICP) has always been considered the gold standard for diagnosing CS. An ICP of 30 mm Hg is considered the cut-off point for fasciotomy that helps restore muscle perfusion and avoid irreversible tissue damage. The chronology of symptoms can sometimes provide clues to the severity of CS, the pathophysiology involved, and the management required. Therefore, it is necessary to look for warning signs, further investigate the causes, and make quick decisions to diagnose and treat CS and its complications on time. Any delay in the diagnosis and treatment of CS can result in high morbidity and poor outcomes. A well-integrated interprofessional team of health professionals can deliver the required complexity of care through a holistic and multidisciplinary approach. This review article highlights the symptoms, risk factors, and pathophysiology involved in CS. It can guide readers in choosing various options to diagnose, prevent, and treat CS. It also discusses the role of RA in patients or surgeries prone to developing CS.

Hand and Wrist Trauma: Antimicrobials and Infection (HAWAII) : a protocol for a multicentre, feasibility study of antimicrobial sutures in hand and wrist trauma surgery.

AIMS: Hand trauma accounts for one in five of emergency department attendances, with a UK incidence of over five million injuries/year and 250,000 operations/year. Surgical site infection (SSI) in hand trauma surgery leads to further interventions, poor outcomes, and prolonged recovery, but has been poorly researched. Antimicrobial sutures have been recognized by both the World Health Organization and the National Institute for Clinical Excellence as potentially effective for reducing SSI. They have never been studied in hand trauma surgery: a completely different patient group and clinical pathway to previous randomized clinical trials (RCTs) of these sutures. Antimicrobial sutures are expensive, and further research in hand trauma is warranted before they become standard of care. The aim of this protocol is to conduct a feasibility study of antimicrobial sutures in patients undergoing hand trauma surgery to establish acceptability, compliance, and retention for a definitive trial. METHODS: A two-arm, multicentre feasibility RCT of 116 adult participants with hand and wrist injuries, randomized to either antimicrobial sutures or standard sutures. Study participants and outcome assessors will be blinded to treatment allocation. Outcome measures will be recorded at baseline (preoperatively), 30 days, 90 days, and six months, and will include SSI, patient-reported outcome measures, and return to work. CONCLUSION: This will inform a definitive trial of antimicrobial sutures in the hand and wrist, and will help to inform future upper limb trauma trials. The results of this research will be shared with the medical community through high impact publication and presentation. Cite this article: Bone Jt Open 2022;3(7):529-535.

[Complications of limb trauma traditional treatment at the University Hospital Center Le Bon Samaritain in Walia (N'Djamena, Chad)]. / Complications des traitements traditionnels des traumatismes des membres au CHU Le Bon Samaritain de Walia (N'Djamena, Tchad).

Introduction: Traditional treatment of limb trauma by traditional healers is ubiquitous in Sub-Saharan Africa. These practices are the source of many complications. This study aims to clarify the profile of these complications and to identify the factors favoring the consultation of traditional healers. Material and methods: Descriptive and analytical study over 12 months, from February 1, 2018 to January 31, 2019, covering all the patients who consulted at the surgery department of the CHU Le Bon Samaritain in N'Djamena (CHUBS) for a complication of a fracture or dislocation of a limb treated by a traditional healer. Data collection was carried out using a pre-established questionnaire with an average follow-up of 14 months. Results: Out of 144 patients, 47 (33%) suffered from at least one complication of fracture or dislocation following traditional treatment. Thirty-two were included in the survey. Their mean age was 23 years (range 10-61) and the sex ratio 2.6 in favor of men. The origin was mainly rural: pupils/students and farmers/breeders were the most represented. We identified individuals from all levels of education, mainly primary level. Road accidents were the most frequent (n = 20). The influence of the entourage (n = 14) was the first factor leading to the choice of traditional treatment. The wooden splint, which did not immobilize the proximal fracture joints, associated with the ischemic bandage causing the gangrene, was the first means of restraint (n = 15). The mean time between trauma and the start of traditional treatment was 8.5 hours. The mean time from traditional treatment to onset of complications was 106 days (range 1-302). The most common complications were swelling of the limbs, malunions, gangrene and pseudarthrosis. The initial lesion was a closed fracture in most cases (n = 22) with a predominance of the pelvic limbs (n = 22). Hospital management was surgical (n = 19) or orthopedic (n = 13). Therapeutic progress has been good, fairly good or bad regarding 24, 2 and 6 cases respectively.The solicitation of traditional healers is frequent in traumatology. The influence of social background and ease of access to traditional "doctors" were noted as determining factors in the choice of this kind of treatment. The consequences of this practice have various origin: insufficient immobilization not respecting the standards; intense and untimely massages causing severe pain, secondary displacements and abnormal consolidation. Another study extended to patients who satisfied or not with the result of traditional fracture treatment in addition to those who consulted for complications would be more representative. Conclusion: The complications of traditional treatments for traumatic limb injuries are serious. The training of the traditional healers on basic notions of immobilization and the recognition of signs of seriousness, their collaboration with health structures as well as free care in hospital services would make possible to reduce this phenomenon. The media and social networks should help to reach a large audience.

Determining the appropriate use of Technology Enabled Care Services (TECS) to manage upper-limb trauma injuries during the COVID-19 pandemic: A multicentre retrospective observational study.

BACKGROUND: The COVID-19 pandemic created a unique opportunity to explore the use of Technology Enabled Care Services (TECS), which remains novel for many service providers. This study assesses the factors that affect adaptation to remote monitoring of patients after upper-limb trauma injury. A standardised risk-stratified screening tool is further developed here to support clinical staff in both the determination of appropriate use of TECS and the optimisation of patient care. OBJECTIVES: 1: To explore the patient and injury factors that determine the appropriate use of TECS for patients with upper-limb injury. 2: To use these findings to refine a standardised screening tool for the appropriate choice of follow-up format. METHODS: A retrospective review of patient management was undertaken across three NHS upper-limb trauma units during the first UK COVID-19 lockdown. Data were collected, and themes were analysed across a number of predetermined categories. This was underpinned by a review of contemporary policy guidance and literature. RESULTS: A total of 85% of patients were offered an appropriate format of follow-up; this was defined by the ability to achieve desired patient-clinician goals and lack of complications. Key factors in determining appropriate follow-up included extent of injury, mental health considerations, and the need for face-to-face (F2F) assessment and treatment. CONCLUSION: Study findings demonstrate consistency between units in the factors determining the appropriate use of TECS. The refined screening tool provides a risk-stratified, standardised approach to the choice of follow-up format, F2F or TECS. It is hoped that this will support future clinical decision-making processes to ensure optimal patient care.

Immediate Versus Late Flap Coverage for Traumatic Soft Tissue Defects of Lower Extremity: A Comparative Observational Study.

Background The lower extremity trauma in patients often gets operated on late for the wound coverage and is associated with more health costs and other resources. Therefore, this study has been conducted to compare the outcome in terms of flap survival, complication rates, and hospital stay between immediate and late flap coverage of lower extremity traumatic wounds. Methods The comparative analysis of outcome is done in terms of flap survival, complication rates, and hospital stay after immediate and late flap coverage of 25 (n = 25) patients of lower extremity traumatic wounds in each group. The patients were observed, and data obtained were tabulated in a Microsoft Excel spreadsheet. The statistical analysis was done using IBM SPSS (V26.0, IBM Corporation, Armonk, NY, USA) statistical software. The chi-square test was used for descriptive data and the student's unpaired t-test for discrete-continuous data analysis. The p-value of less than 0.05 is considered significant. Results The mean defect size with SD in the immediate flap cover group is 54.5 ± 29.5 cm2, while in the late flap cover group, it is 85 ± 65 cm2 with a significant p-value of 0.0378. The mean flap size with SD in the immediate flap coverage group is 70.5 ± 34.5 cm2, while in the late flap coverage group, it is 117 ± 87.5 cm2, and the difference is statistically significant. The mean hospital stay with SD in the immediate flap coverage group is 7.5 ± 2.5 days. In contrast, in the late flap coverage group, it is 29.5 ± 8.5 days, and the difference is statistically very significant. Conclusion There are equivalent results in patients undergoing immediate and late flap coverage for the traumatic soft tissue defects of the lower extremity. There is a significant decrease in the hospital stay after immediate flap reconstruction, which subsequently reduces both direct and indirect health costs. However, there is a larger size flap requirement in cases of immediate lower extremity wound coverage.

The effect of COVID-19 lockdowns on paediatric lower limb orthopaedic presentations.

INTRODUCTION: As the COVID-19 pandemic was spreading in 2020, the government imposed national lockdowns. We considered the effects these lockdowns had on the paediatric population, with a specific focus on lower limb orthopaedic trauma. We hypothesise that these restrictions will have altered the mechanisms of injury and reduced the number of referrals. MATERIALS AND METHODS: We retrospectively analysed data from 28/08/19 to 01/04/21, considering the variations in referrals and operations during these times, and analysed these data using an online statistical calculator. We examined the rate of referrals, types of fractures referred to the centre, mechanism of injury, volume of operations performed, and average wait times to undergo an operation. The data were compared in pre-lockdown and lockdown times. RESULTS: 67 paediatric patients with lower limb fractures were included in this study. Throughout the lockdown periods, the mean age of children referred was younger (6.9 from 11.1) and they were less likely to be injured as a result of sport (p = 0.0493). They were more likely to fracture their lower leg (p = 0.0016) when compared with other anatomical regions. The average weekly rate of referrals dropped (0.84-0.68), but the rate of operations almost quartered (0.39-0.16). The average wait times for operations dropped significantly, with patients waiting 80% less time from the date of their injury. CONCLUSION: This study highlights the impact of the coronavirus pandemic on the prevalence and management of lower limb paediatric trauma. The demographics and mechanisms of injury which presented to the trust over the pandemic and associated national lockdowns were significantly different. There was a drop in the number of referrals and a preference to non-operative management when patients did present.

Dual Venous Drainage for the Free Latissimus Dorsi Muscle Flap-Using the Serratus Vein Tributary-Making Virtue of a Necessity.

Background Most flap failures in the lower limb are on account of venous congestion. Literature shows a decrease in the incidence of venous failure when two veins are anastomosed. The thoracodorsal pedicle of the latissimus dorsi free flap affords the possibility of a single venous anastomosis. The lack of a second venous outflow could result in venous congestion in the distal limits of the flap, particularly when long flaps are required for large defects or when the recipient veins are smaller in diameter. Methods We describe a consecutive series of 11 cases of latissimus dorsi flaps for leg and foot defects with a mean defect size of 310 cm 2 , where the serratus anterior vein was used as a second venous outflow channel to ensure maximal venous drainage. Results There were no re-explorations for anastomotic causes. Only one case had partial distal muscle necrosis. There was a delayed anastomotic blowout due to infection resulting in amputation in one case. There was no partial distal muscle necrosis in nine of the ten cases. Conclusion Using the serratus vein as a second venous outflow is of use in reducing incidence of venous occlusion and distal muscle necrosis and can be specially indicated for large flaps and venous diameter discrepancy.

Free gracilis end-to-side microanastomosis to a peronea arteria magna: a case report.

BACKGROUND: Complex orthoplastic lower limb trauma in individuals with multiple injuries requires considerable resources and interdisciplinary collaboration for good outcomes. We present the first reported end-to-side free flap microanastomosis for lower limb trauma reconstruction involving a peronea arteria magna without radiographic collaterals. CASE PRESENTATION: A 55-year-old Caucasian gentleman involved in road traffic collision sustained an open tibial fracture on the anteromedial distal third of the left lower leg with local degloving and a subtotal right foot and ankle degloving. Both injuries were reconstructed with free tissue transfer. A left lower limb peronea arteria magna successfully received a free gracilis muscle flap by end-to-side microanastomosis and perfusion of the foot was preserved. This rare anatomical variant and its anatomy is reviewed, as well as a description of the suggested preoperative planning and technique for reconstruction. CONCLUSIONS: Successful free flap reconstruction may be performed to a lower limb with a peronea arteria magna recipient as the lone vessel supplying the foot in trauma, although preoperative counseling of the risks, benefits, and options are essential. LEVEL OF EVIDENCE: Level V, case report.