Orthopaedic assessment unit: a service model for the delivery of orthopaedic trauma care in a major trauma centre during the global pandemic (COVID-19).

INTRODUCTION: We describe a new service model, the Orthopaedic Assessment Unit (OAU), designed to provide care for trauma patients during the COVID-19 pandemic. Patients without COVID-19 symptoms and isolated musculoskeletal injuries were redirected to the OAU. METHODS: We prospectively reviewed patients throughput during the peak of the global pandemic (7 May 2020 to 7 June 2020) and compared with our historic service provision (7 May 2019 to 7 June 2019). The Mann-Whitney and Fisher Exact tests were used to test the statistical significance of data. RESULTS: A total of 1,147 patients were seen, with peak attendances between 11am and 2pm; 96% of all referrals were seen within 4h. The majority of patients were seen by orthopaedic registrars (52%) and nurse practitioners (44%). The majority of patients suffered from sprains and strains (39%), followed by fractures (22%) and wounds (20%); 73% of patients were discharged on the same day, 15% given follow up, 8% underwent surgery and 3% were admitted but did not undergo surgery. Our volume of trauma admissions and theatre cases decreased by 22% and 17%, respectively (p=0.058; 0.139). There was a significant reduction of virtual fracture clinic referrals after reconfiguration of services (p<0.001). CONCLUSIONS: Rapid implementation of a specialist OAU during a pandemic can provide early definitive trauma care while exceeding national waiting time standards. The fall in trauma attendances was lower than anticipated. The retention of orthopaedic staff in the department to staff the unit and maintain a high standard of care is imperative.

Broken guidewire intramedullary: what to do now?

Instrument breakage during orthopaedic procedures is relatively uncommon, but it remains a challenging problem to orthopaedic surgeons. We report a case of a broken guidewire during intramedullary nail fixation of a proximal femur fracture with subtrochanteric extension. We also report a simple yet effective technique for removal of a broken guidewire from the medulla of the proximal femur without causing much iatrogenic trauma.

Magnetic resonance imaging investigation of radio-lunate relations: use in assessing distal radial fracture reduction.

Reformatted magnetic resonance imaging scans of 27 normal wrists were examined in incremental degrees of rotation around the central axis of the radial shaft to 30° in both directions from true lateral. A line was superimposed on the outer border of the radial dorsal cortex and continued distally to the carpal region. Measurements were made from the superior pole of the lunate to this line. This distance did not change significantly with rotation. This allows a quick and accurate way of assessing distal radial fracture reduction from poorly taken lateral radiographs. In addition, the relevant landmarks are not obscured by implants or casts. LEVEL OF EVIDENCE: III, diagnostic study.

Surgical decompression for thoracic outlet syndrome.

Fifty consecutive surgical decompression operations for thoracic outlet syndrome (TOS) were performed in 43 patients over a 7-year period. Of these, 54% presented with neurological symptoms alone; the others complained of symptoms of vascular or combined origin. Operations for decompression consisted of excisions of 14 cervical ribs, 22 first ribs, and 14 soft tissue or fibrous bands. In six limbs, cervical sympathectomy was also performed for patients who had secondary Raynaud's phenomenon. Surgery resulted in complete relief of symptoms in 37 limbs (74%) and an improvement was achieved in another 10 (20%). In three limbs (6%) surgery gave no benefit. There was no mortality. Thoracic outlet decompression via the supraclavicular approach gave good results in 94% of the patients.

Occult femoral artery injury in relation to fracture of the femoral shaft.

Recognized injury of the femoral artery occurs in two per cent of patients with fracture of the femoral shaft. Delay in detection of these arterial injuries has led to unsatisfactory results in a young group of patients. Therefore, 40 patients who had suffered fracture of the femoral shaft 6-20 months (mean 13 months) prior to examination, were haemodynamically assessed using Doppler ankle/arm pressure indices to determine the incidence of occult femoral artery injury. Six patients (15%) exhibited haemodynamically significant abnormalities all in relation to previously injured limbs.

Extended deep femoral angioplasty and lumbar sympathectomy as a limb salvage procedure.

Limb salvage in 27 limbs (26 patients) using the combined operations of extended deep femoral angioplasty and lumbar sympathectomy is described. A successful result was obtained in 14 cases (52%) at 6 months falling to 12 (45%) at 16 months. Prediction of outcome and postoperative progress was monitored by the measurement of the leg: arm pressure ratio using the Doppler ultrasound apparatus. No patient with a preoperative ratio of less than 0.3 had a successful result. It is proposed that lumbar sympathectomy is a logical adjunct to surgery in these patients in order to enhance the development of the collateral circulation.

Abdominal apoplexy.

Two cases of the rare condition of abdominal apoplexy are described. The two main clincial presentations of this condition are discussed as is the aetiology. It is suggested that selective visceral angiography might prove helpful in preoperative diagnosis.

Radiological study of the aetiological factors in venous obstruction of the upper limb.

This study was undertaken in an attempt to define the exact relationship between intermittent venous obstruction of the upper limb and the acute condition of primary axillary-subclavian vein thrombosis. Three groups of patients were investigated, namely those with evidence of intermittent venous obstruction in one or both upper limbs, those with a previous history of an acute primary axillary-subclavian vein thrombosis in one upper limb and the control group of patients. The patients were investigated by subclavian venography with the limbs in both adduction and abduction. All patients with intermittent venous obstruction were shown to have bilateral evidence of venous compression in abduction in the region of the root of the neck and half of them showed a similar bilateral compression in adduction. All patients with a previous acute thrombotic state showed venographic evidence of post-thrombotic changes in the affected limb and in the unaffected limb all showed evidence of venous compression in abduction and half showed evidence of venous compression in adduction. The control group exhibited no evidence of venous compression in either adduction or abduction.