Optimising fast track care for proximal femoral fracture patients using modified early warning score.

INTRODUCTION: The care for patients with a proximal femoral fracture has been dramatically overhauled with the introduction of 'fast track' protocols and the British Orthopaedic Association guidance in 2007. Fast track pathways focus on streamlining patient flow through the emergency department where the guidance addresses standards of care. We prospectively examined the impact these protocols have on patient care and propose an alternative 'streamed care' pathway to provide improved medical care within existing resource constraints. METHODS: Data surrounding the treatment of 156 consecutive patients managed at 4 centres were collated prospectively. Management of patients with a traditional fast track protocol allowed 17% of patients to leave the emergency department with undiagnosed serious medical pathology and 32% with suboptimal fluid resuscitation. A streamed care pathway based on the modified early warning score was developed and employed for 48 further patients as an alternative to the traditional fast track system. RESULTS: The streamed care pathway improved initial care significantly by treating patients according to their physiological parameters on admission. Targeted medical reviews on admission instead of the following day reduced the rates of undiagnosed medical pathology to 2% (p = 0.0068) and inadequate fluid resuscitation to 11% (p < 0.0001). CONCLUSIONS: Implementation of a streamed care pathway can allow protocol driven improvement to initial care for patients with a proximal femoral fracture and results in improved access to initial specialist medical care.

Interventions for treating acute Achilles tendon ruptures.

BACKGROUND: There is lack of consensus on the best management of the acute Achilles tendon (TA) rupture. Treatment can be broadly classified into operative (open or percutaneous) and non-operative (cast immobilisation or functional bracing). Post-operative splintage can be with a rigid cast (above or below the knee) or a more mobile functional brace. OBJECTIVES: To identify and summarise the evidence from randomised controlled trials of the effectiveness of different interventions in the treatment of acute Achilles tendon ruptures. SEARCH STRATEGY: We searched multiple databases including the Cochrane Musculoskeletal Injuries Group specialised register (to September 2003), reference lists of articles and contacted trialists. Keywords included Achilles Tendon, Rupture, and Tendon Injuries. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing different treatment regimens for acute Achilles tendon ruptures. DATA COLLECTION AND ANALYSIS: Three reviewers extracted data and independently assessed trial quality by use of a ten-item scale. MAIN RESULTS: Fourteen trials involving 891 patients were included. Several of the studies had poor methodology and inadequate reporting of outcomes. Open operative treatment compared with non-operative treatment (4 trials, 356 patients) was associated with a lower risk of rerupture (relative risk (RR) 0.27, 95% confidence interval (CI) 0.11 to 0.64), but a higher risk of other complications including infection, adhesions and disturbed skin sensibility (RR 10.60, 95%CI 4.82 to 23.28). Percutaneous repair compared with open operative repair (2 studies, 94 patients) was associated with a shorter operation duration, and lower risk of infection (RR 10.52, 95% CI 1.37 to 80.52). These figures should be interpreted with caution because of the small numbers involved. Patients splinted with a functional brace rather than a cast post-operatively (5 studies, 273 patients) tended to have a shorter in-patient stay, less time off work and a quicker return to sporting activities. There was also a lower complication rate (excluding rerupture) in the functional brace group (RR 1.88 95%CI 1.27 to 2.76). Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques (1 study, 51 patients), different non-operative treatment regimes (2 studies, 90 patients), and different forms of post-operative cast immobilisation (1 study, 40 patients). REVIEWERS' CONCLUSIONS: Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared to non-operative treatment, but produces a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay, time off work and sports, and may lower the overall complication rate.

Treatment of unstable distal radial fractures by intrafocal, intramedullary K-wires.

Displaced distal radial fractures with extensive dorsal comminution and plastic cancellous deformation are unstable and frequently cause treatment problems since there is no single, reliable method of treatment, notably in osteoporotic bone. We present a method of holding unstable distal radial fractures with blunt ended K-wires via intrafocal and intramedullary insertion, so modifying the Kapandji technique. Wires were placed dorsally, radially and when necessary from the volar direction depending on fracture configuration. Over a 7-year period (1992-1999) we treated 102 patients with unstable distal radial fractures in this way. Of these, 80 were followed up for 6-42 weeks according to clinical need and scored radiologically and functionally using modified Lidstrom scoring system. Results showed that 92 and 95% of these patients achieved good or excellent results in these scoring systems, respectively. We present this as a useful and reliable method of treating these common fractures, particularly in osteoporotic bone.

The musculoskeletal manifestations of Werner's syndrome.

Werner's syndrome is a rare condition usually presenting as premature ageing in adults. Over a period of 30 years we have followed two siblings with extensive musculoskeletal manifestations including a soft-tissue tumour, insufficiency fractures, nonunion and tendonitis, with associated problems of management. The literature is reviewed.

Role of preoperative localization in the management of primary hyperparathyroidism.

BACKGROUND: The advantages of preoperative localization in the management of primary hyperparathyroidism have not been clearly demonstrated. The aim of this study was to investigate prospectively the accuracy of three localization techniques in patients with this condition. METHODS: Forty-nine consecutive patients with primary hyperparathyroidism underwent ultrasonography, magnetic resonance imaging (MRI) and technetium-thallium (Tc-Tl) subtraction scanning before surgery, during which an attempt was made to identify all parathyroid glands. A scan was regarded as correct if it identified an enlarged parathyroid gland on the correct side of the neck as subsequently demonstrated at surgery. RESULTS: Ultrasonography had a sensitivity of 38 per cent (18 correct scans in 47 patients) with a positive predictive value of 78 per cent. The sensitivity of MRI was 72 per cent (34 of 47) with a predictive value of 92 per cent. Tc-Tl scanning was 60 per cent sensitive (28 of 47) with a predictive value of 85 per cent. Two patients with negative neck explorations were subsequently found to have mediastinal adenomas. CONCLUSION: Ultrasonography, MRI and Tc-Tl scanning have limited value as localization techniques and the relatively low sensitivity of these investigations means they are of no value before first-time surgery.