Martyn Lovell

Whiplash disorders—a review

Crowe first used the term whiplash in 1928 [1]. Whiplash is generally considered to be a soft tissue injury of the neck, the diagnosis is made after fractures, dislocations and subluxations are excluded. The Quebec task force have suggested the term ‘Whiplash Associated Disorders’ (WAD) as a convenient term because the symptoms are not always confined to the neck [2]. Classically, a whiplash is a hyperextension injury following a rear impact. Soft tissue injuries to the neck can also occur from frontal or side impacts. Soft tissue injuries to the cervical spine have also been described by terms such as neck sprain, neck strain, soft-tissue injury, and acceleration-deceleration injuries. Confusion arises by the inclusion of bony and nerve type neck injuries within the definition and some authors include all vehicular neck injuries within their studies [3,4].

Current spinal board usage in emergency departments across the UK.

The spinal board is widely used as a means of extrication and efficient transport during the pre-hospital phase of trauma management. A number of concerns have been raised regarding its subsequent usage once the patient arrives in the emergency department. We undertook a telephone study of 100 A+E departments in the United Kingdom to ascertain current spinal board usage. Our study demonstrated great variability in practice across the UK and a marked lack of on-going audit or defined protocols governing spinal board usage following the pre-hospital phase of trauma management.

Surgery for Fractured Neck of Femur – are Patients Adequately Consented?

INTRODUCTION Obtaining valid consent is a legal and ethical obligation when performing any procedure in clinical practice. This study was performed to identify the validity and effectiveness of the new consent form and any potential improvement that could be made when taking consent. PATIENTS AND METHODS Case notes of 173 patients undergoing surgery for fractured neck of femur were retrospectively reviewed. Risks and complications of the surgery as listed on the consent form were noted. Sixty-five cases were excluded from the study as they had either old consent forms with no risks recorded or a consent form signed by a consultant due to patient inability to consent. Six of the consent forms could not be located in the notes. This left 102 consent forms to be analysed. RESULTS The number of risks documented on each form ranged from 0-8 (mean, 3.92). No risks were recorded in 2 of these 102 forms. Most commonly recorded risks were infection (95.1%), DVT/PE (81.4%) and failure of procedure (59.8%). It was shown that many of the consent forms analysed did not have all the serious or frequently occurring risks recorded on them and that a large proportion of the forms had acronyms or phrases that may mean nothing to the patient. Comparison of documented risks for different hip surgery were made using Fishers exact test showing no significant difference between the risks recorded on the forms for each type of procedure. CONCLUSIONS Although documentation of risks has been improved compared to old consent forms, patients are not necessarily given the most appropriate information to ensure consent is valid. Further refining of consent forms may be necessary to ensure that all major risks are explained and understood by patients and that there is satisfactory recording of this information.

An Unusual Presentation of a Popliteal Arteriovenous Fistula After Primary Total Knee Arthroplasty

Iatrogenic popliteal arteriovenous fistula after total knee arthroplasty is extremely rare (Int Surg. 1998 Jul-Sep;83(3):198-201). We report this complication in a 78-year-old female patient 3 years after total knee arthroplasty. She presented with symptoms of persistent swelling and recurrent cellulitis of the operated leg. A fistula was detected between the popliteal artery and vein by vascular duplex scan and confirmed by peripheral arteriography. This was successfully treated by resection of the fistula and direct repair of the artery and vein.

Assessment of Range of Movement, Pain and Disability Following a Whiplash Injury

Background: Whiplash has been suggested to cause chronic symptoms and long term disability. This study was designed to assess long term function after whiplash injury. Material & Methods: A random sample of patients in the outpatient clinic was interviewed, questionnaire completed and clinical examination performed. Assessment was made of passive cervical range of movement and Visual Analogue Scale pain scores. One hundred and sixty-four patients were divided into four different groups including patients with no whiplash injury but long-standing neck pain (Group A), previous symptomatic whiplash injury and long-standing neck pain (Group B), previous symptomatic whiplash injury and no neck symptoms (Group C), and a control group of patients with no history of whiplash injury or neck symptoms (Group D). Results: Data was analyzed by performing an Independent samples t-test and ANOVA, with level of significance taken as p<0.05. Comparing the four groups using a one-way ANOVA showed a significant difference between the groups (p<0.001). There were significant differences when comparing mean ranges of movement between Group A and Group D, and between Group B and Group D. There was no significant difference between Group C and Group D. similar differences were also seen in the pain scores. Conclusion: We conclude that osteoarthritis in the cervical spine, and whiplash injury with chronic problems cause a significantly decreased cervical range of movement with a higher pain score. Patients with shorter duration of whiplash symptoms appear to do better in the long-term.

Use of a syringe as a drill sleeve for core decompression of the femoral head in osteonecrosis

Copyright© Taylor & Francis 2006. ISSN 1745–3674. Printed in Sweden – all rights reserved. DOI 10.1080/17453670610013574 Core decompression is one of the treatment methods (Camp and Colwell 1986, Hungerford 1988, Hopson and Silverhus 1988, Arlet and Ficat 1990) for stage I and II osteonecrosis of the femoral head (Steinberg et al. 1995). In core decompression, the osteonecrotic part of the head is drilled and the bone tissue is removed. The power drill requires a drill bit that is thicker in diameter than conventional drill bits, so there are no drill sleeves available for the protection of the soft tissues. As a skin incision of minimal size is used, the drill very often leads to soft tissue injury of the skin, fascia lata and vastus lateralis muscle. We describe a simple method of using a syringe to avoid this complication. We could not find this method described in a search of the current literature. The patient is positioned supine on a fracture table, and under fluoroscopic guidance a 15-mm lateral incision is made in the skin inferior to the greater trochanter. The bone is exposed in line with the incision. A guide wire is then passed through the femoral neck to the part of the femoral head which is osteonecrotic. Normally the drill is passed over the guide wire, in direct—damaging—contact with the soft tissues surrounding it. We improvise a drill sleeve by cutting the tip-end from the barrel of a 5-mL syringe using a scalpel blade on the instrument table (Figure 1). The sleeve fits snugly over the drill bit and provides excellent protection whilst drilling (Figure 2). The sleeve can be readily fashioned during surgery with no special equipment. The syringe is radiolucent and therefore does not interfere with image intensification. Furthermore, we suggest that if bone grafting is required, the syringe can act as a portal, and the plunger of the syringe can be used to introduce the bone graft whilst maintaining a minimally invasive technique.

Influence of bearing devices on the dose effect and image quality of trauma whole-body CT scans.

After spinal board immobilization of the trauma victim and transport to the hospital, the patient should be removed from the spinal board as soon as possible to prevent skin breakdown. The Loewenhardt paper [1] published recently in Injury, is quite contradictory, quoting ‘‘trauma patients should remain stabilised in bearing devices until diagnostic imaging is finished and spine injury diagnosis is definitively verified or excluded’’. The use of spine boards for spinal immobilization in trauma care has recently come under increased scrutiny, and early removal from the board is considered optimal practice. In 2008, Stagg et al. reported that patients being left on spinal boards until radiological clearance had been reduced from 43% to 21% [2]. A recent observational study performed at a level 1 academic trauma centre found patients had a mean total spinal board time of around an hour [3], further suggesting a trend towards early removal, prior to whole body CT (WBCT). Thus the influence of bearing devices on WBCT dose effects and image quality seems to be of diminishing relevance. Loewenhardts’ paper also quotes from the German trauma registry, which has seen a rise in WBCT from 5% in 2002 to 40% in 2008%. Spinal board use is associated with iatrogenic pain, skin ulceration, increased use of radiographs, aspiration and respiratory compromise [4,5]. With such a rapid rise in WBCT, it seems imperative that spinal boards are not maintained until radiological

Re: Patel VP, et al. Development of electronic software for the management of trauma patients on the orthopaedic unit [Injury 2009;40:388-96].

Further to the recent article in your journal, we have developed a similar database aimed at ensuring smooth handover between on call shifts and easing data collection in research and audit. We also undertook to contact a number of trusts with an acute trauma service throughout the UK to see how widespread the use of electronic databases is. In addition we asked about how the trauma service was run and about peoples’ experience in gathering data about trauma patients for the purposes of research and audit. The on call SHO was contacted by telephone in 20 teaching hospitals and 20 district general hospitals. They were asked 3 questions:

Helicopter Transfers – Need for Implication Assessment

On reading this article, we noted some similarities with our recent audit. We have received 37 helicopter transfers over the last 24 months. Our hospital built a helicopter pad to receive plastic surgical re-implantation patients; the orthopaedic department noticed it on a return to work after a weekend. We do not have neurosurgery on site but are otherwise well served by all specialties. Other local hospitals are not similarly blessed with such helicopter pads. The majority of transfers have been orthopaedic at 14 cases and plastic surgery at 2 cases. Unfortunately, four head injury cases might have been more fortuitously taken to a local neurosurgical centre which was flown over in one instance. One child was sent to a local paediatric hospital after initial assessment in the accident and emergency department. Twenty-eight cases were from out of the area and an equivalent of 15 trauma lists have been used for these outlying patient displacing our local patients with their more routine trauma. Thirteen cases were discharged directly from the casualty, one or two being bewildered by the transfer (anxiety provoking?) and some wondered how they would get home. We acknowledge that we have far fewer cases, but wonder if Swindon has received appropriate funding and staffing for this extra work. We have not.

Comment on: Helicopter transfers--need for implication assessment.

COMMENTS ON doi 10.1308/003588407X202074 JTK Melton, S Jain, B Kendrick, SD Deo. Helicopter Emergency Ambulance Service (HEAS) transfer: an analysis of trauma patient case-mix, injury severity and outcome. Ann R Coll Surg Engl 2007; 89: 513–6