Mechanical assessment of proprietary and improvised pelvic binders for use in the prehospital environment.

INTRODUCTION: Pelvic fractures often result from high-energy trauma and are associated with a 10% mortality rate and significant morbidity. Pelvic binders are applied in suspected pelvic injury to stabilise fractured bone, decrease bleeding and potentiate tamponade. A binder must hold the pelvis with sufficient force for this effect to be achieved. This study aims to quantify the ability of proprietary and improvised pelvic binders to hold a target tensile force over time. METHODS: The ability of three proprietary and three improvised binders to hold a binding force for 2 hours was tested. A uniaxial materials testing machine was used to tension each binder to 150 N and then hold the displacement for 2 hours; the drop in tension over time was recorded for each binder. The ability to hold tension above 130 N after 2 hours was set as the metric of binder performance. RESULTS: The median tension at 2 hours was above 130 N for the SAM Pelvic Sling II and T-POD Pelvic Stabilisation Device and was below 130 N for the Prometheus Pelvic Splint, field-expedient pelvic splint (FES) and the Personal Clothing System-Multi-Terrain Pattern Combat Trousers binders. The tension in the improvised FES after 2 hours was approximately at the target 130 N; however, in 40% of the tests, it held above 130 N. CONCLUSIONS: Binders varied in their ability to maintain sufficient tension to treat a pelvic fracture over the 2-hour testing period. The FES performed well under our testing regime; with relatively low cost and weight, it represents a good alternative to proprietary binders for the austere environment.

Emergency first responder management of combat injuries to the torso in the military, remote and austere settings.

Traumatic injuries to the torso account for almost a quarter of all injuries seen in combat and are typically secondary to blast or gunshot wounds. Injuries due to road traffic collisions or violence are also relatively common during humanitarian and disaster relief efforts. There may also be multiple injured patients in these settings, and surgical care may be limited by a lack of facilities and resources in such a non-permissive environment. The first responder in these scenarios should be prepared to manage patients with severe injuries to the torso. We aim to describe the management of these injuries in the military and austere environment, within the scope of practice of a level 5 registered prehospital practitioner.

Protocol for the Weight-bearing in Ankle Fractures (WAX) trial: a multicentre prospective non-inferiority trial of early versus delayed weight-bearing after operatively managed ankle fracture.

BACKGROUND: Unstable ankle fractures represent a substantial burden of disease, accounting for a mean hospital stay of nine days, a mean cost of £4,491 per patient and 20,000 operations per year. There is variation in UK practice around weight-bearing instructions after operatively managed ankle fracture. Early weight-bearing may reduce reliance on health services, time off work, and improve functional outcomes. However, concerns remain about the potential for complications such as implant failure. This is the protocol of a multicentre randomised non-inferiority clinical trial of weight-bearing following operatively treated ankle fracture. METHODS: Adults aged 18 years and over who have been managed operatively for ankle fracture will be assessed for eligibility. Baseline function (Olerud and Molander Ankle Score [OMAS]), health-related quality of life (EQ-5D-5L), and complications will be collected after informed consent has been obtained. A randomisation sequence has been prepared by a trial statistician to allow for 1:1 allocation to receive either instruction to weight-bear as pain allows from the point of randomisation, two weeks after the time of surgery ('early weight-bearing' group) or to not weight-bear for a further four weeks ('delayed weight -bearing' group). All other treatment will be as per the guidance of the treating clinician. Participants will be asked about their weight-bearing status weekly until four weeks post-randomisation. At four weeks post-randomisation complications will be collected. At six weeks, four months, and 12 months post-randomisation, the OMAS, EQ-5D-5L, complications, physiotherapy input, and resource use will be collected. The primary outcome measure is ankle function (OMAS) at four months post-randomisation. A minimum of 436 participants will be recruited to obtain 80% power to detect a non-inferiority margin of -6 points on the OMAS 4 months post-randomisation. A within-trial health economic evaluation will be conducted to estimate the cost-effectiveness of the treatment options. DISCUSSION: The results of this study will inform national guidance with regards to the most clinically and cost-effective strategy for weight-bearing after surgery for unstable ankle fractures. TRIAL REGISTRATION: ISRCTN12883981 , Registered 02 December 2019.

Remote training for combat medics during the COVID-19 era: lessons learnt for future crises?

BACKGROUND: In response to COVID-19, the UK government ordered strict social distancing measures. The UK Armed Forces followed these to protect the force and ensure readiness to respond to various tasking requests. Clinical training has adapted to ensure geographically dispersed medical personnel are trained while social distancing is maintained. This study aimed to evaluate remote training for Combat Medical Technicians, Medical Assistants and Royal Air Force Medics (CMTs/MAs/RAFMs) during the COVID-19 pandemic and the views of trainers on how this should be delivered now and in the future. METHODS: A mixed quantitative and qualitative survey study was conducted to determine the experiences of a sample of Defence Medical Services personnel with remote training during the COVID-19 pandemic. Medical and nursing officers involved in teaching CMTs/MAs/RAFMs were eligible to participate. RESULTS: There were 52 survey respondents. 78% delivered remote training to CMTs/MAs/RAFMs, predominantly using teleconferencing and small-group webinars. 70% of respondents report CMTs/MAs/RAFMs received more training during the COVID-19 pandemic than before. 94% of respondents felt webinar-based remote training should continue after COVID-19. The perceived benefits of webinar-based training included reduced travel time, more training continuity and greater clinical development of learners. CONCLUSIONS: The challenge of continuing education of medical personnel while maintaining readiness for deployment and adhering to the Government's social distancing measures was perceived to have been met within our study sample. This suggests that such an approach, along with clear training objectives and teleconferencing, may enable personnel to deliver high-quality training in an innovative and secure way.

Peri-operative administration of tranexamic acid in lower limb arthroplasty: a multicentre, prospective cohort study.

In the UK, tranexamic acid is recommended for all surgical procedures where expected blood loss exceeds 500 ml. However, the optimal dose, route and timing of administration are not known. This study aimed to evaluate current practice of peri-operative tranexamic acid administration. Patients undergoing primary total hip arthroplasty, total knee arthroplasty or unicompartmental knee arthroplasty during a 2-week period were eligible for inclusion in this prospective study. The primary outcome was the proportion of patients receiving tranexamic acid in the peri-operative period. Secondary outcomes included: dose, route and timing of tranexamic acid administration; prevalence of pre- and postoperative anaemia; estimated blood loss; and red blood cell transfusion rates. In total, we recruited 1701 patients from 56 NHS hospitals. Out of these, 1523 (89.5%) patients received tranexamic acid and of those, 1052 (69.1%) received a single dose of 1000 mg intravenously either pre- or intra-operatively. Out of the 1701 patients, 571 (33.6%) and 1386 (81.5%) patients were anaemic (haemoglobin < 130 g.l-1 ) in the pre- and postoperative period, respectively. Mean (SD) estimated blood loss for all included patients was 792 (453) ml and 54 patients (3.1%) received a red blood cell transfusion postoperatively. The transfusion rate for patients with pre-operative anaemia was 6.5%, compared with 1.5% in patients without anaemia. Current standard of care in the UK is to administer 1000 mg of tranexamic intravenously either pre- or intra-operatively. Approximately one-third of patients present for surgery with anaemia, although the overall red blood cell transfusion rate is low. These data provide useful comparators when assessing the efficacy of tranexamic acid and other patient blood management interventions in future studies.

Management of extra-articular fractures of the fifth metacarpal: Operative vs. Non-opeRaTive TrEatment (FORTE) - A systematic review and meta-analysis.

AIMS: Extra-articular fifth metacarpal fractures are treated operatively and non-operatively without consensus. We aim to establish whether there are differences in patient-reported outcome, objective clinical outcome and adverse events for skeletally mature patients with closed extra-articular fractures of the 5th metacarpal that are treated operatively versus non-operatively. PATIENTS: Skeletally mature patients with closed, extra-articular 5th metacarpal fractures. METHODS: A systematic review and meta-analysis of randomised controlled trials using methodology adapted from the Cochrane Handbook for Systematic Review of Interventions and compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. (PROSPERO CRD42018091633). RESULTS: Two trials of 5th metacarpal neck fractures met the inclusion criteria and were included in the final pooled analysis (n = 125). There were no significant differences in patient-reported, objective clinical or radiographic outcomes between the operative and non-operative groups at 12 months. Operatively managed patients reported greater time off work and were more likely to suffer an adverse event. CONCLUSION: Existing trial data is limited and inconclusive in terms of patient-reported outcome measures. Given that there remains wide variation in the treatment of these common injuries around the world, there is a need for further high-quality evidence to guide clinical practice.

Comparison between a multicentre, collaborative, closed-loop audit assessing management of supracondylar fractures and the British Orthopaedic Association Standard for Trauma 11 (BOAST 11) guidelines.

Aims: Supracondylar fractures are the most frequently occurring paediatric fractures about the elbow and may be associated with a neurovascular injury. The British Orthopaedic Association Standards for Trauma 11 (BOAST 11) guidelines describe best practice for supracondylar fracture management. This study aimed to assess whether emergency departments in the United Kingdom adhere to BOAST 11 standard 1: a documented assessment, performed on presentation, must include the status of the radial pulse, digital capillary refill time, and the individual function of the radial, median (including the anterior interosseous), and ulnar nerves. Materials and Methods: Stage 1: We conducted a multicentre, retrospective audit of adherence to BOAST 11 standard 1. Data were collected from eight hospitals in the United Kingdom. A total of 433 children with Gartland type 2 or 3 supracondylar fractures were eligible for inclusion. A centrally created data collection sheet was used to guide objective analysis of whether BOAST 11 standard 1 was adhered to. Stage 2: We created a quality improvement proforma for use in emergency departments. This was piloted in one of the hospitals used in the primary audit and was re-audited using equivalent methodology. In all, 102 patients presenting between January 2016 and July 2017 were eligible for inclusion in the re-audit. Results: Stage 1: Of 433 patient notes audited, adherence to BOAST 11 standard 1 was between 201 (46%) and 232 (54%) for the motor and sensory function of the individual nerves specified, 318 (73%) for radial pulse, and 247 (57%) for digital capillary refill time. Stage 2: Of 102 patient notes audited, adherence to BOAST 11 standard 1 improved to between 72 (71%) and 80 (78%) for motor and sensory function of the nerves, to 84 (82%) for radial pulse, and to 82 (80%) for digital capillary refill time. Of the 102 case notes reviewed in stage 2, only 44 (43%) used the quality improvement proforma; when the proforma was used, adherence improved to between 40 (91%) and 43 (98%) throughout. Conclusion: Adherence to BOAST 11 standard 1 is poor in hospitals across the country. This is concerning as neurovascular deficit may be an indication for emergent surgery, and missed neurovascular injury can cause long-term, or even permanent, functional impairment. We present a simple proforma that improves adherence to this standard, can easily be implemented into emergency departments, and may improve patient safety. Cite this article: Bone Joint J 2018;100-B:346-51.

Prevention of brachial plexus injury-12 years of shoulder dystocia training: an interrupted time-series study.

OBJECTIVE: To investigate management and outcomes of incidences of shoulder dystocia in the 12 years following the introduction of an obstetric emergencies training programme. DESIGN: Interrupted time-series study comparing management and neonatal outcome of births complicated by shoulder dystocia over three 4-year periods: (i) Pre-training (1996-99), (ii) Early training (2001-04), and (iii) Late training (2009-12). SETTING: Southmead Hospital, Bristol, UK, with approximately 6000 births per annum. POPULATION: Infants and their mothers who experienced shoulder dystocia. METHOD: A bi-monthly multi-professional 1-day intrapartum emergencies training course, that included a 30-minute practical session on shoulder dystocia management, commenced in 2000. MAIN OUTCOMES: Neonatal morbidity (brachial plexus injury, humeral fracture, clavicular fracture, 5-minute Apgar score <7) and documented management of shoulder dystocia (resolution manoeuvres performed, traction applied, head-to-body delivery interval). RESULTS: Compliance with national guidance improved with continued training. At least one recognised resolution manoeuvre was used in 99.8% (561/562) of cases of shoulder dystocia in the late training period, demonstrating a continued improvement from 46.3% (150/324, P < 0.001) pre-training, and 92% (241/262, P < 0.001) in the early training period. In parallel there was reduction in the brachial plexus injury at birth (24/324 [7.4%, P < 0.01], pre-training, 6/262 [2.3%] early training, and 7/562 [1.3%] late training. CONCLUSIONS: There are significant benefits to long-term, embedded training programmes with improvements in both management and outcomes. A decade after the introduction of training there were no cases of brachial plexus injury lasting over 12 months in 562 cases of shoulder dystocia.