Improving Identification of Cognitive Impairment in Fragility Fracture Patients: Impact of Educational Guidelines on Current Practice.

INTRODUCTION: Cognitive impairment can hinder a fracture patient's capacity to consent to surgery and negatively impact their postoperative recovery and rehabilitation. National guidelines recommend screening for cognitive impairment upon admission, and the Abbreviated Mental Test Score (AMTS) is a commonly used tool for this. This project aimed to assess current practice regarding documentation of AMTS among frail fracture patients upon admission and to improve AMTS documentation following a simple intervention. METHODS: Baseline data were obtained by inpatient chart review throughout November to December 2018 in a district general hospital with emergency fracture services. All patients admitted with a fragility hip fracture and patients over 65 years with any fracture were included. National guidelines and baseline results were then distributed among junior doctors. Following an intervention, further data were collected throughout January to February 2019. RESULTS: Preintervention, 40 suitable patients (mean age: 82 years) were identified; 9 (22.0%) of whom had an AMTS recorded upon admission. Among the hip fracture subgroup (n = 25), 7 (26.9%) had an AMTS recorded. Postintervention, 39 patients (mean age: 80 years) were identified; 15 (38.5%) of whom had an AMTS recorded. Among the hip fracture subgroup (n = 30), 11 (36.7%) had an AMTS recorded. Statistical analysis demonstrated a significant improvement in AMTS documentation both among the overall cohort (P = .001) and hip fracture patients (P = .019). No significant association was found between AMTS documentation and patient age (P = .566), grade of admitting doctor (P = .058), or prior cognitive/mental health disorder (P = .256). DISCUSSION: A small yet significant improvement in AMTS documentation among elderly/hip fracture patients was observed following distribution of educational material. Further work should explore the effect of cognitive impairment on outcomes related to orthopedic injuries beyond hip fractures.

Extensor tendon sheath fistula formation as a complication of wrist arthroscopy.

The indications and applications for wrist arthroscopy continue to expand as new techniques and instrumentation evolve. Wrist arthroscopy is now the gold standard investigation for chronic wrist pain before definitive surgery. Although complications are uncommon, they may include infection, neuroma formation, tendon injury, dorsal skin slough, tourniquet neurapraxia, and reflex sympathetic dystrophy. We describe extensor tendon sheath fistula formation arising from the 3/4 portal after diagnostic wrist arthroscopy and our management in this novel case. The formation of a patent communication between the radiocarpal joint and the tendon sheath permitting the collection of synovial fluid has not previously been described.