Current concepts in the management of "Terrible Triad" injuries of the elbow.

Terrible triad injuries of the elbow are complex injuries which can result in long term complications and significant disability. They must be identified correctly, and managed appropriately in order to maximise functional outcomes. A clear understanding of the bony and ligamentous anatomy is essential to plan appropriate surgical reconstruction to provide elbow stability. Urgent reduction of the elbow, followed by 3-dimensional imaging and surgical repair or replacement of the injured structures is the mainstay of treatment in the majority of cases. This review presents a summary of the relevant anatomy and the evidence for the management of these complex injuries.

Opioid Prescription Following Wrist and Ankle Fracture Fixation in Scotland-Tradition Prevails.

The American 'opioid crisis' is rapidly spreading internationally. Perioperative opioid use increases the risk of long-term opioid use. We review opioid use following wrist and ankle fracture fixation across Scotland, establishing prescribing patterns and associations with patient, injury, or perioperative factors. Six Scottish orthopedic units contributed. A total of 598 patients were included. Patient demographics were similar across all sites. There was variation in anesthetic practice, length of stay, and AO fracture type (p < 0.01). For wrist fractures, 85.6% of patients received a discharge opioid prescription; 5.0% contained a strong opioid. There was no significant variation across the six units in prescribing practice. For ankle fractures, 82.7% of patients received a discharge opioid prescription; 17% contained a strong opioid. Dundee and Edinburgh used more strong opioids; Inverness and Paisley gave the least opioids overall (p < 0.01). Younger patient age, location, and length of stay were independent predictors of increased prescription on binary regression. Despite variability in perioperative practices, discharge opioid analgesic prescription remains overwhelmingly consistent. We believe that the biggest influence lies with the prescriber-institutional 'standard practice'. Education of these prescribing clinicians regarding the risk profile of opioids is key to reducing their use following surgery, thus lowering long-term opioid dependence.

Cycling injuries requiring orthopaedic intervention during the first COVID-19 lockdown period: A multi-centre SCottish Orthopaedic Research collaborativE (SCORE) study.

INTRODUCTION: The COVID-19 lockdown resulted in decreased vehicle use and an increased uptake in cycling. This study investigated the trends in cycling-related injuries requiring orthopaedic intervention during the COVID-19 lockdown period compared with similar time periods in 2018 and 2019. METHODS: Data were collected prospectively for patients in 2020 and collected retrospectively for 2019 and 2018, from hospitals within four NHS Scotland Health Boards encompassing three major trauma centres. All patients who sustained an injury as a result of cycling requiring orthopaedic intervention were included. Patient age, sex, mechanism of injury, diagnosis and treatment outcome from electronic patient records. RESULTS: Number of injuries requiring surgery 2020: 77 (mean age/years - 42.7); 2019: 47 (mean age/years - 42.7); 2018: 32 (mean age/years - 31.3). Overall incidence of cycling injuries 2020: 6.7%; 2019: 3.0%; 2018: 2.1%. Commonest mechanism of injury: fall from bike 2020 n = 54 (70.1%); 2019 n = 41 (65.1%); 2018 n = 25 (67.6%). Commonest injury type: fracture 2020 n = 68 (79.1%); 2019 n = 33 (70.2%); 2018 n = 20 (62.5%). Commonest areas affected: Upper extremity: 2020 n = 45 (58.5%); 2019 n = 25 (53.2%); 2018 n = 25 (78.1%). Lower extremity: 2020 n = 23 (29.9%); 2019 n = 14 (29.7%); 2018 n = 7 (21.8%). CONCLUSION: A significant increase in the number of cycling related injuries requiring orthopaedic intervention, a greater proportion of female cyclists and an older mean age of patients affected was observed during the COVID-19 lockdown period compared with previous years. The most common types of injury were fractures followed by lacerations and fracture-dislocations. The upper extremity was the commonest area affected.

Injuries in Quidditch: A Prospective Study from a Complete UK Season.

BACKGROUND: Quidditch is a mixed-gender, full-contact sport founded in the USA in 2005, played worldwide by an estimated 25,000 players. It is one of the few mixed-gender full-contact sports, yet there remain few published studies regarding injury rates and patterns. A previous study suggested that the overall rate of injury in quidditch is in line with other contact sports, however raised concerns that female players were sustaining a higher rate of concussion when compared to male players. PURPOSE: To examine injury rates and injury patterns in UK quidditch athletes over the course of a single season. STUDY DESIGN: Prospective epidemiological study. METHODS: Data were prospectively collected by professional first aid staff for the 2017-18 season spanning all major UK tournaments, involving 699 athletes. Anonymized player demographics were collected by an online survey. Time loss injury rates were measured per 1000 athletic exposures (AEs) and hours of play. RESULTS: The overall time loss injury rate was 20.5 per 1000 hours or 8.0 per 1000 AEs. The combined rate of concussion was 7.3 per 1000 hours or 2.8 per 1000 AEs. There was no statistical difference between time loss injuries in males (20.9/1000 hours and 8.1/1000 AEs) and females (13.9/1000 hours and 5.4/1000 AEs) (p=0.30) and no statistical difference between concussion rates in males (n=7) and females (n=4) (p=0.60). CONCLUSIONS: Total time loss injury rates in quidditch appear to be comparable with other full-contact sports such as football. The rate of concussions for both males and females appear higher when compared to other contact sports. LEVEL OF EVIDENCE: 3.

Perilunate Injuries: Current Aspects of Management.

Perilunate dislocations (PLD) and perilunate fracture dislocations (PLFD) are high-energy injuries which can result in long-term complications and significant disability. Early identification of these injuries, followed by prompt, appropriate management is key to optimising patient outcomes. Knowledge of the carpal anatomy is essential in order to understand the varied patterns of injury and plan appropriate definitive management. Emergent reduction and close monitoring of the median nerve, followed by prompt stabilisation or repair of the injured structures remain the mainstay of treatment. In this review, we present a summary of the current evidence regarding the identification and management of these complex injuries.

Tibial shaft fractures - to monitor or not? a multi-centre 2 year comparative study assessing the diagnosis of compartment syndrome in patients with tibial diaphyseal fractures.

AIMS: The aim of this study was to compare the outcome in patients who did and did not undergo continuous compartment pressure monitoring (CCPM) following a tibial diaphyseal fracture. PATIENTS AND METHODS: We performed a retrospective cohort study of 287 patients with an acute tibial diaphyseal fractures who presented to three centres over a two-year period. Demographic data, diagnosis, management, wound closure, complications, and subsequent surgeries were recorded. The primary outcome measure was the rate of short-term complications. Secondary outcomes were time to fasciotomy and split-skin grafting rates. RESULTS: Of the 287 patients in the study cohort, 171 patients underwent CCPM (monitored group; MG) and 116 did not (non-monitored group; NMG). There were 21 patients who developed ACS and underwent fasciotomy, with comparable rates in both groups (n=13 in the MG vs n=8 in NMG; p=0.82). There was no difference in the rate of complications between groups (all p>0.05). The mean time from admission to fasciotomy was 22.1hrs, with a mean time of 19.8hrs in the MG and 25.8hrs in the NMG (mean difference, 6hrs; p=0.301). One patient in the NMG required a below-knee amputation. There was a trend towards a reduced requirement for split-skin grafting post decompression in the MG (15% vs 50%; p=0.14). CONCLUSION: This study found no difference in the short-term complication rates in those patients that underwent CCPM and those that did not following a fracture of the tibial diaphysis. CCPM does appear to be safe with no increase in the rate of fasciotomies performed. There was a trend towards a reduced time to fasciotomy and a reduced rate of split skin grafting for wound closure with CCPM. LEVEL OF EVIDENCE: Level III (Diagnostic: Retrospective cohort study).

Hip fracture care during the 2020 COVID-19 first-wave: a review of the outcomes of hip fracture patients at a Scottish Major Trauma Centre.

BACKGROUND AND PURPOSE OF THE STUDY: This study reviewed whether the response to the Coronavirus (COVID-19) pandemic affected the care for hip fracture patients at a major trauma centre in Scotland during the first-wave lock-down period. METHODS: All patients referred to Orthopaedics with a hip fracture in a major trauma centre in Scotland were captured between 14 th March and 28 th May (11 weeks) in 2020 and 2019. Patients were identified using electronic patient records. The primary outcomes are time to theatre, length of admission and 30-day mortality. Secondary outcomes are COVID-19 prevalence, duration of surgery, proportion of patients to theatre within 36 hours and COVID-19 positive 30-day mortality from time of surgery. 225 patients were included: 108 from 2019 and 117 from 2020. THE MAIN FINDINGS: 30-day mortality was 3.7% (n=4) in 2019 and 8.5% (n=10) in 2020 (p=0.142). There was no statistical difference with time to theatre (p=0.150) nor duration of theatre (p=0.450). Duration of admission was reduced from 12 days to 6.5 days (p=<0.005). 4 patients tested positive for COVID-19 during admission, one 5 days after discharge, all underwent surgical management. 30-day mortality for COVID-19 positive patients during admission was 40%. COVID-19 prevalence of patients that were tested (n=89) was 5.62%. CONCLUSIONS: This study has shown the care of hip fracture patients has been maintained during the COVID-19 pandemic. There is no statistically significant change in mortality, time to theatre, and duration of surgery, however, the patient's admission duration was significantly less than the 2019 cohort.

Patient-Related Outcome Measures (PROMs) With Nonoperative and Operative Management of Morton's Neuroma.

BACKGROUND: Morton's neuroma is associated with chronic pain and disability. There is a paucity of literature regarding patient-related outcome measures (PROMs) in patients managed nonoperatively. We sought to investigate nonoperative and operative management of Morton's neuroma using PROMs in patients with follow-up to 1 year. METHODS: We conducted a prospective observational study and collected data on all patients with a new diagnosis of Morton's neuroma treated from February 2016 until April 2018. Primary outcome measures were the Manchester-Oxford Foot Questionnaire (MOXFQ) for pain, EuroQoL (EQ) time trade-off (TTO), and EQ visual analog scale (VAS) taken preoperatively and at 52 weeks postoperatively. Forty-four patients were treated nonoperatively and 94 patients were treated operatively. RESULTS: Pretreatment and 52-week scores were 55.7 and 43.10 (nonoperative) and 63.7 and 40.1 (operative) for MOXFQ (pain), 0.72 and 0.82 (nonoperative) and 0.68 and 0.82 (operative) for EQ-TTO, and 71.5 and 76.2 (nonoperative) and 73.1 and 68.7 (operative) for EQ-VAS. There was a statistically significant improvement in MOXFQ (pain) in nonoperative (P = .02) and operative groups (P < .001). There was a statistically significant improvement in EQ-TTO in the operative group only (P = .01). CONCLUSION: This is the largest study investigating outcomes to 12 months of both nonoperative and operatively managed patients with Morton's neuroma. Both nonoperative and operative management lead to symptom improvement at 12 months. LEVEL OF EVIDENCE: Level III, comparative study.

Re-starting elective orthopaedic services in NHS Tayside during the COVID-19 pandemic.

BACKGROUND: Elective orthopaedic operations were suspended at the start of the COVID-19 lockdown. Three pathways were created to allow patients to undergo urgent elective operations in NHS Tayside as soon as it was deemed safe to do so. METHODS: We examined elective orthopaedic activity in NHS Tayside during and immediately after the Scottish lockdown. Elective operations performed between 27 March 2020 and 10 August 2020 were included and compared with cases performed between 27 March and 10 August in both 2018 and 2019. Primary outcomes were 30-day mortality, 30-day complications, and nosocomial infection rates of COVID-19. FINDINGS: Fewer elective operations were performed in 2020 (258) compared with 2019 (1196) and 2018 (1261). The rate of nosocomial infection in the 2020 cohort was 0%. The 30-day mortality rate was 0%. Over 98% of patients agreed to undergo surgery after a detailed consenting process. INTERPRETATION: We were able to re-start a safe elective orthopaedic service in the early stages of recovery from the COVID-19 pandemic, compatible with the guidelines set by the Royal College of Surgery of England and the British Orthopaedic Association. Our findings will serve to reassure regions with sufficient resources that it is acceptable to restart elective surgery for urgent priority cases. They may provide a template for planned surgical care in the event of further pandemics.

Tourism and the Highlands: A cross-sectional study on trauma and orthopaedic service use by tourists in 2017.

BACKGROUND: NHS Highland covers a wide geographical region encompassing the Isle of Skye, and Ben Nevis. Tourism is a significant contributor to the local economy and in 2017 the Highlands welcomed 534,000 visitors. Health services across the region treat tourists in addition to the local population. We investigated how many tourists accessed the Trauma and Orthopaedic (T&O) Department at Raigmore Hospital, Inverness. METHODS: We conducted a cross-sectional study with data collected over one year (2017). The number of tourists referred to T&O including patient demographics, country of origin, type of injury and their clinical outcome were recorded. A freedom of information (FOI) request to NHS Highland was sought to investigate associated costs incurred by tourists. RESULTS: 376 tourists accessed T&O services in 2017. Country of origin: 47 (12.5%) Scotland; 177 (47.1%) rest of UK; 74 (19.7%) EU; 45 (12.0%) non-EU. Highest referral month August (61), lowest referral month November (8). Injuries: 224 (59.6%) fracture; 62 (16.5%) soft tissue injury; 20 (5.3%) laceration. Commonest sites of injury were ankle, distal radius and finger. OUTCOMES: 28 (7.4%) Virtual clinic; 137 (36.4%) hospital admission; 193 (51.3%) advice to referring team and discharge; 13 (3.5%) direct discharge by T&O; 4 (1.1%) missing. No. of trauma cases booked: tourists 133 (9%), local population 1415 (91%). CONCLUSIONS: Tourists account for fewer than ten percent of the T&O surgical workload over one year with common injuries being fractures affecting the extremities. Seasonal variation was observed with more referrals occurring in the summer months. Just under half of tourists originated from outside the UK and EU. Health boards should consider increasing resources over the summer months to deal with expected increases in tourist numbers and should be able to recover the cost of treatment from the patient or their travel insurance companies directly at point of care.

INJURIES IN QUIDDITCH: A DESCRIPTIVE EPIDEMIOLOGICAL STUDY.

BACKGROUND: Quidditch is a fast growing, physically intense, mixed-gender full-contact sport. Originally adapted from Harry Potter novels, quidditch was first played in 2005 in the USA but is now played worldwide. It is essential to elucidate patterns of injury for the safety and growth of the sport of quidditch. It also provides a unique opportunity to study injury patterns in mixed-gender full-contact sport, an area of increasing importance with the developing culture of transition from single-gender to mixed-gender sports. PURPOSE: The purpose of this investigation was to examine the types of injuries sustained while playing quidditch in terms of their incidence, anatomical distribution and severity, and gender distribution. METHODS: An anonymous self-reporting questionnaire was distributed to all active quidditch players in the UK. Data collection included player demographics, type of injury, mechanism of injury, player position, experience and treatment required, relating to the previous 12 months. RESULTS: A total of 348 participants of 684 eligible athletes responded to the questionnaire representing a 50.87% response rate. There were 315 injuries reported by 180 athletes in total, with an overall incidence of 4.06 injuries per 1,000 hours. A statistically significantly different rate of concussion was observed with female athletes sustaining more concussion than males (p=0.006). The overall rate of concussion was 0.651/1000hrs in males and 1.163/1000hrs in females (0.877/1000 hours overall). CONCLUSIONS: This study provides the first quantitative description of injury rates in quidditch. The overall injury rates are no higher than those reported in other recreational contact sports. Female athletes were found to have a higher rate of concussion, which needs further investigation. These findings are relevant to players concerned about safety in quidditch and to governing bodies regarding governance of the sport. LEVEL OF EVIDENCE: 3b.

Blood tests: One too many? Evaluating blood requesting guidance developed for acute patients admitted to trauma and orthopaedic units.

In a recently published report from the Academy of Medical Royal Colleges, around 20% of clinical practice which encompasses blood science investigations is considered wasteful. Blood tests including liver function tests (LFTs), C-reactive protein (CRP), coagulation screens, and international normalising ratios (INR) are frequently requested for patients who undergo emergency hospital admission. The paucity of guidance available for blood requesting in acute trauma and orthopaedic admissions can lead to inappropriate requesting practices and over investigation. Acute admissions over a period of one month were audited retrospectively for the frequency and clinical indications of requests for LFTs, coagulation screens/INR, and CRP. The total number of blood tests requested for the duration of the patient's admission was recorded. Initial auditing of 216 admissions in January 2014 demonstrated a striking amount of over-investigation. Clinical guidelines were developed with multidisciplinary expert input and implemented within the department. Re-audit of 233 admissions was carried out in September 2014. Total no. of LFTs requested: January 895, September 336 (-62.5%); coagulation screens/INR requested: January 307, September 210 (-31.6%); CRPs requested: January 894, September 317 (-64.5%). No. of blood requests per patient: January (M=4.81, SD 4.75), September (M=3.60, SD=4.70). Approximate combined total cost of LFT, coagulation/INR, CRP in January £2674.14 and September £1236.19 (-£1437.95, -53.77%). A large decrease was observed in admission requesting and subsequent monitoring (p<0.01) following the implementation. This both significantly reduced cost and venepuncture rates.