K Porter

Fracture non-union epidemiology and treatment

Fracture non-union remains a clinical problem despite advances in the understanding of basic science and technology. Each fracture has a unique personality as does the patient suffering the injury. Thus, each case must be treated on an individual basis. This article defines the problem of fracture non-union and reports recent epidemiological studies. We discuss relevant risk factors and methods for assessing patients who have a tendency toward fracture non-union. There are many treatment options for patients with non-union, where a number of these modalities are still under review. We discuss current evidence with the use of bone morphogenic protein, platelet-rich plasma and low-intensity pulsed ultrasound to augment the treatment of fracture non-union.

Minimal patient handling: a faculty of prehospital care consensus statement

This paper outlines the emerging best practice when packaging a prehospital trauma patient while providing spinal immobilisation. The best practice described is based on the recommendations of a consensus meeting held by the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh, in the West Midlands in April 2012, where the opinion of experienced practitioners from across the prehospital and emergency care community considered the currently available evidence and reviewed current clinical practice. Initial consensus points were then subject to further review and dialogue with stakeholders from the initial meeting. The recommendations drawn from the meeting and subsequent dialogue represent a ‘general agreement’ to the principles and practices described in the paper. The recommendations will provide guidance for clinical practice and governance alongside other consensus statements from the Faculty of Pre-Hospital Care that seek to address prehospital spinal immobilisation and pelvic immobilisation.

Acute Achilles tendon rupture

Achilles tendon rupture is a common sports-related injury, with the incidence of acute ruptures continuing to increase. Achilles ruptures can be missed, or presentation may be delayed. Clinical tests assist diagnosis, with the Thompson and Matles tests being the most sensitive and specific. Ultrasound provides a valuable adjunct for diagnosing acute Achilles tendon ruptures. Traditionally, operative management has led to lower re-rupture rates than conservative treatment, but surgery increases the risk of complications such as adhesions and wound infection. More recently, however, non-operative treatment consisting of early mobilisation and rehabilitation, produces comparable re-rupture rates and functional outcomes to surgery. Percutaneous surgery may reduce the risk of operative complications, but needs to be more widely practised. In the present review we discuss the anatomy, aetiology, mechanism of injury, clinical assessment and investigations for diagnosing acute Achilles tendon ruptures. The debate regarding operative versus non-operative management is also considered.

Log-rolling a blunt major trauma patient is inappropriate in the primary survey

The article by Gill et al 1 provides further evidence that a log-roll is not useful for major trauma patients in the primary survey. Even with a GCS 15 and no influence from alcohol or opiates only 60% of patients with thoracolumbar fractures had tenderness on log-roll. The authors did not examine how many false negatives were found by examination or the impact of a distracting …

Pharmacologically assisted laryngeal mask insertion: a consensus statement

Management of the pre-hospital airway can be challenging.1 A range of techniques and adjuncts are available to the pre-hospital clinician to aid in their efforts to maximise oxygenation and support ventilation. When measures fail, management is escalated through a series of increasingly complex and invasive procedures (‘the airway management ladder’) with the aim of establishing a definitive airway secured with an endotracheal tube or other surgical airway. In the non-arrested patient the gold standard for definitive pre-hospital airway management is pre-hospital rapid sequence induction and tracheal intubation (RSI) delivered by a competent clinical team.nnThere may, however, be circumstances in which a pre-hospital RSI cannot be delivered, whether due to lack of clinical capability or lack of access to the patient. Some of these patients may benefit from advanced airway management, with the aim of promoting oxygenation, through the technique of pharmacologically assisted laryngeal mask (PALM) insertion. This technique involves sedating the trauma patient and inserting a supraglottic airway device (SAD) with the aim of improving their oxygenation and providing a degree of protection from ongoing airway contamination.nnThis article reports the conclusions of a consensus meeting held in April 2012. The meeting followed a full literature search which was presented to the meeting, to which there was an open invitation to all relevant stakeholders. The meeting examined the PALM technique and its indications and outlined the competencies required of practitioners performing the procedure. Representatives from across the pre-hospital community and emergency care who contributed to the meeting are listed in box 1. A draft document was produced reflecting the conclusions from the meeting; this document was then reviewed by the attendees prior to a final review by the key colleges, faculties and other organisations within pre-hospital care. The Royal College of Anaesthetists, although represented at the initial …

Prehospital spinal immobilisation: an initial consensus statement

Spinal injuries are thankfully relatively uncommon but have the potential to cause very signiEcant morbidity and mortality. It is reported that between 0.5% and 3% of patients presenting with blunt trauma suffer spinal cord injury (SCI). The incidence varies globally and time has yielded increased numbers of injuries annually. American Egures estimate an incidence in the region of 40 cases per million per year. In the UK, the majority of traumatic SCI are attributable to land transport (50%), followed by falls (43%), then sport (7%). Of those fractures causing SCI, half involve fractures of the cervical spine, with 37% due to thoracic spine injury and 11% due to lumbar spine injury. Of the C-spine, 50% occur at the C6/7 junction and a third at C2. Data show a crossover rate in the region of 10%–15% of patients with a conErmed cervical fracture also having a thoracolumbar fracture. It is well recognised that immobilisation is not without harm but the ‘number needed to treat’ in order to include one actual injury is high. SCI occurs when unstable spinal fractures (only diagnosed by imaging in hospital) cause direct mechanical damage as a result of traction and compression, following which ischaemia and cord swelling ensues. Unstable fractures are those where there is disruption of two or three vertebral columns. The anterior column is formed by the anterior longitudinal ligament and the anterior half of the vertebral body, disc and annulus, the middle column by the posterior half of the vertebral body, disc and annulus and the posterior longitudinal ligament and the posterior column by the facet joints, ligamentum Favum, the posterior elements and the interconnecting ligaments. Immobilisation is based on the logical premise that preventing movement should decrease the incidence of SCI or further deterioration of existing damage. This is undertaken by, in effect, adding external supports to the body, preventing secondary injury during extrication, resuscitation, transport and evaluation. Immobilisation is a routinely performed procedure in the prehospital environment. Its potentially serious adverse sequelae and the litigious nature of modern medicine have seen the development of an extraordinarily conservative approach to immobilisation where it is applied in many cases in which neither the mechanism of injury nor the clinical Endings would support its use. Methods vary and research has drawn together consensus opinion on immobilisation techniques. Common practice involves the use of a rigid cervical collar, head blocks with straps or tapes and a long board with straps. A number of organisations use the orthopaedic scoop stretcher or Kendrick Extrication Device. The scoop stretcher is of value in reducing the amount of handling to which victims of trauma are subjected and the Faculty of Pre-Hospital Care is shortly to issue consensus guidance regarding minimal handling protocols in trauma. The vacuum mattress is indicated in prolonged transportation to minimise the risks explained below. A pelvic sling should therefore be placed in the correct position in the vacuum mattress and the patient transferred in the scoop onto the mattress and the pelvic binder fastened appropriately. Once on a vacuum mattress, the scoop can be removed in such prolonged transfers.

Posterior cruciate ligament injuries

Posterior cruciate ligament (PCL) injuries occur following both high-velocity trauma (motor vehicle collisions) and low-velocity trauma (sporting injuries) with the most common cause being high-velocity trauma resulting in so-called ‘dash board injuries’. In majority of the cases, clinical examination will reveal the presence of a PCL tear; however, magnetic resonance imaging remains the imaging modality of choice if the diagnosis is in doubt. For the most part, isolated PCL tears are relatively benign and can be treated conservatively. PCL avulsion injuries or grade III ruptures may require operative intervention. Postoperative rehabilitation is also an important part of the healing process.

Hangman’s fracture from noose to neurosurgery

A fracture through the pars interarticularis of the axis is colloquially known as the ‘hangman’s fracture’. The origin of the name is self-explanatory; however, in modern times the hangman’s fracture is rarely seen in suicide by hanging. This short article aimed at the non-spinal surgeon will take the reader through a brief timeline from the days of capital punishment to the modern day road traffic collision and the management of the hangman’s fracture.

Minimal patient handling: a Faculty of Pre-hospital Care consensus statement

INTRODUCTION Safe and effective patient packaging is a vital step in the safe transport of trauma patients to definitive care. A significant proportion of patients are treated with spinal immobilisation precautions based on their examination findings or on the mechanism of injury. Current UK practice commonly involves the use of a cervical collar and blocks usually secured to a rigid spinal board. Alternatively, and increasingly commonly, immobilisation is achieved using either a scoop stretcher or a vacuum mattress.

A review of current concepts in the management of proximal humerus fractures

Fracture of the proximal humerus is a common orthopaedic injury and is likely to increase in incidence. This fracture type is associated with a wide variety in fracture morphology and as a direct result there are many treatment options available. It is often not clear what treatment modality should be utilised. This article reviews the current literature on proximal humerus fractures offering evidence for care pathways and management strategies from presentation to rehabilitation.