Can intravenous paracetamol reduce opioid use in preoperative hip fracture patients?

Pain due to intra- and extracapsular hip fractures is usually treated with opioid medication. Paracetamol (acetaminophen in North America) has better bioavailability when given intravenously than orally and has been successfully used in the postoperative care of orthopedic patients. However, no study has evaluated its use in the preoperative trauma patient. Our unit conducted a prospective, consecutive cohort study to investigate the opioid-sparing effect of regularly administered intravenous paracetamol compared with oral paracetamol in preoperative hip fracture patients. The total opioid dose given, based on conversion to intravenous morphine, and the reported pain score were evaluated in 75 patients. There were 28 patients in the control group who were give routine oral paracetamol and oral opioids, with morphine for breakthrough pain. There were 47 patients in the study group who received only routine intravenous paracetamol, with opioids reserved for breakthrough pain. The patients in the 2 groups had similar characteristics. The mean preoperative oral paracetamol dose for the control group was 7.2 g compared with 6.3 g in the study group. There was a significant reduction (P<.005) in the mean total intravenous morphine with intravenous paracetamol (6.5 mg) compared with oral paracetamol (21.8 mg). There was no difference in the mean pain score between the groups, 2.1 vs 1.8 (P=.3). Intravenous paracetamol had a significant opioid-sparing effect and satisfactory pain relief in preoperative hip fracture patients.

Interobserver and intraobserver variations in tibial pilon fracture classification systems.

BACKGROUND: Tibial pilon injuries are a complex group of fractures, whose classification and radiological assessment has been under constant reform. Till date, there is no universally accepted classification system. OBJECTIVE: To determine the interobserver agreement and intraobserver reproducibility of Ruedi and Allgower, AO, and Topliss et al. classification systems for tibial pilon fractures, with CT scans. METHOD: Forty-seven CT scans of tibial pilon fractures were evaluated independently by 5 orthopaedic surgeons. Fractures were classified according to Ruedi and Allgower, AO and Topliss et al. types. Assessment was done on two occasions, eight weeks apart. RESULTS: The interobserver reliability and intraobserver reproducibility for Ruedi and Allgower, AO and Topliss et al. classifications showed only moderate agreement. The interobserver agreement was dependent on the familiarity and specificity of the classification system. CONCLUSION: Currently used classification systems for tibial pilon fracture have moderate interobserver and intraobserver agreements, even with the help of CT scans. Therefore Tibial pilon fracture classification still remains largely undetermined.

An anomalous hindfoot insertion of the posterior tibialis tendon.

The posterior tibialis tendon has numerous insertions but none into the hindfoot has ever been reported in the literature. We present the operative and histological findings of an anomalous insertion slip into the sustentaculum tali in an adult patient with flatfoot deformity.