Authors:
Alex Denning, Rory Ormiston, Saharish Saleem, Jonathan Quayle

Hospital:
Salisbury District Hospital NHS Foundation Trust

Introduction:
The aging population has increased the incidence of femoral fractures. The BOAST – Care of the Older or Frail Orthopaedic Trauma Patient Guidelines state these patients should be full weight-bearing (FWB) within 36 hours. This standard is often not applied to non-NOF fractures.

Methods:
This single-centre retrospective audit assessed compliance with this guidance. Patients admitted in 2021 that underwent surgery for fragility peri-prosthetic or non-NOF femoral fractures were included. Our primary outcome was prescribed weight-bearing status. Reasons for restricted weight bearing (RWB) were then analysed. Secondary outcomes included time to theatre, LOS and discharge destination.

Results:
25 patients met the inclusion criteria. This included 4 mid shaft fractures, 6 distal femoral fractures and 15 peri-prosthetic fractures (8 THR, 7 TKR). 40% of patients were FWB post-operatively. Retrospective analysis suggested that within the RWB group, fixation was sufficient to allow FWB in 10 patients, 2 patients would have required alternative fixation to allow FWB, 3 patients had appropriately restricted weight-bearing. Neither group required revision fixation. Average LOS was 22.4 days – LOS was 16 days if FWB and 24 days if RWB. Patients were discharged to their pre-hospital residence at similar rates in each group (50% v 52%).

Conclusions:
Despite guidelines advising early intervention with intention to FWB patients, only 40% of patients were prescribed to do so. Patients allowed to FWB post operatively had a shorter LOS. Fixation was appropriate to allow FWB in the majority of cases.

Authors:
Ryan Higgin, Jon Palmer, Amir Qureshi, Nicholas Hancock

Hospital:
University Hospital Southampton

Aims:
Open tibial fractures are often life-changing injuries and outcomes remain poor despite national management guidelines. The longer-term impact to the patient can be considerable but is frequently overlooked in the literature. This study aims to establish the functional, physical, and psychosocial impact of sustaining an open tibial fracture.

Methods:
We reviewed 69 consecutive Gustilo-Anderson grade IIIB and IIIC open tibial fractures presenting to our MTC between September 2012 and April 2018. Participants were interviewed and sent patient-reported outcome questionnaires a minimum of 12 months following injury. Our primary outcome was the Lower Extremity Functional Scale (LEFS). Secondary outcomes included the Short-Form 36 Healthy Survey (SF-36), Sickness Impact Profile 128 (SIP) and return to occupation. Subgroups were analysed according to age, Injury Severity Score (ISS) and limb amputation.

Results:
Our study response rate was 72% with mean follow up 43 months. The mean LEFS was 42 (IQR 21.5 – 58.5). All total and sub-domain scores within the SF-36 and SIP questionnaires were reduced compared to normative population data. 48% of patients returned to full time employment. Subgroup analysis revealed significantly reduced LEFS, SIP and SF-36 subdomain scores for those with a presenting ISS>14 and those undergoing limb amputation.

Conclusions:
Patients have significant risk of longer-term functional, physical and psychosocial harm after suffering an open tibial fracture. Those sustaining major polytrauma or amputation demonstrated greatest risk of poor outcome. Early identification of these individuals likely to suffer most from their injury would help direct appropriate resources to those with greatest need at the earliest opportunity.

Authors:
Alex, Choudhary, Kizzie Peters, Henry Colaco, Iain MacLeod

Hospital:
Hampshire Hospitals NHS Foundation Trust

Introduction:
Anecdotally, pendulous breasts have often been associated with inferior outcomes from non-operative management of diaphyseal humerus fractures. However, this assertion is without basis in the literature.

Aims:
To produce radiographic measurements of chest wall soft tissue thickness and determine association with nonunion and angulation in diaphyseal humerus fractures.

Methods:
217 patients who underwent conservative management for a diaphyseal humeral fracture were identified retrospectively from 2008-2017. Radiographic chest wall soft tissue thickness (STT) measurements were taken at three standardised points (upper, middle and lower) using a simple reproducible method. Ratios were also derived, dividing these figures by the mid-humerus diameter. Bivariate and multivariate analysis was used to assess association with nonunion.

Results:
There were 58 (26.7%) cases of nonunion. On multivariate analysis, the middle (OR 1.39, 95% p<0.001) and lower (OR 1.23, p=0.009) STT measurements were independently associated with nonunion. Additionally, the middle (OR 1.85, p<0.001), lower (OR 1.47, p=0.005) and maximum (OR 1.40, p<0.001) STT ratios were independently associated with nonunion. A receiver operating characteristic curve was used to determine threshold values for middle STT of 6.2cm (sensitivity 62.1%, specificity 61.6%) and middle STT ratio of 3.0 (sensitivity 69.0%, specificity 62.3%). A middle STT of ≥6.2cm (OR 2.68, p=0.004) and a middle STT ratio of ≥3.0 (OR 3.73, p<0.001) were each independently predictive of nonunion.

Conclusions:
Chest wall soft tissue thickness is independently associated with humeral shaft nonunion. A middle STT ratio of ≥3 was predictive of nonunion. Threshold values can assist in decision making for these fractures.

Authors:
Joe Barrett-Lee, J. Enson, A. Ahmed, R. Jamal, M. Elmahi, S. N. Anjum

Hospital:
University Hospital Southampton

Introduction:
In recent years fibula nail fixation of unstable ankle fractures has gained increased interest, particularly for high-risk cohorts. As the technique becomes more commonplace, monitoring of outcomes in the longer term is vital. We present the mid-term outcomes of patients treated with fibula nailing at our institution over a 5-year period.

Methods:
The study period was from December 2016 to December 2021. Our primary outcome measure was the Manchester-Oxford Foot Questionnaire (MOX-FQ), obtained via telephone interview at a mean of 28.9 months post-operatively. Secondary outcomes were complications, metalwork failure, re-operations, and patient satisfaction.

Results:
68 patients with unstable ankle fractures underwent fibula nailing during the study period. Mean age was 72 years (SD 12.9) and 79% were female. Mean time to surgery was 5.1 days (SD 4.1) and discharge 14.8 days (20.3). 55 medial malleoli were fixed (21 open, 34 percutaneous). 4 patients (5.9%) underwent metalwork removal: 1 medial malleolus plate, 1 fibula nail and medial screws for deep infection, and 2 syndesmotic screws for pain and prominence. There was one medial-sided surgical site infection, which was treated with antibiotics. 45 patients were contactable for telephone follow-up. The overall mean MOX-FQ score was 27.08 (SD 25.83) and metalwork failure was associated with worse MOX-FQ scores (57.29 failure versus 24.93 non-failure, p=0.034). 38 patients (84%) were satisfied with their outcome.

Conclusions:
These Results demonstrate that fibula nail fixation of unstable ankle fractures is associated with a low rate of complications and revisions. Patient-reported outcomes are favourable in most patients.

Authors:
John McFall, Mr Togay Koc and Mr Zeid Morcos

Hospital:
Queen Alexandra Hospital

Introduction:
Procedural sedation (PS) requires two suitably qualified clinicians and a dedicated monitored bed space, increasing demands on Emergency Departments to allocate resources and facilities to safely provide PS. We present the results of intra-articular haematoma blocks (IAHB), using local anaesthetic, for the manipulation of closed ankle fracture dislocations and compared resource use with PS.

Methods:
Patients received intra-articular ankle haematoma blocks for displaced ankle fractures requiring manipulation between October 2020 to April 2021. Data recorded included the patients’ pain scores, time from first x-ray to reduction and acceptability of reduction. A comparison of temporal variables and resource use was made by retrospective analysis of patients who had undergone PS for manipulation of an ankle fracture over the six-month period March – August 2020.

Results:
During the periods assessed, 25 patients received an IAHB and 28 received PS for ankle fractures requiring manipulation (mean age 57.8yr vs 55.1yr). Time from first x-ray to manipulation was 65.9 min (IAHB) vs 82.9 min (PS) (p = 0.087).
In the IAHB group mean pain scores pre, during and post manipulation were 6.1, 4.7 and 2.0 respectively (‘pre’ to ‘during’ p <0.05; ‘pre’ to ‘post’ p <0.01).
In the IAHB group, 24 (92%) had a satisfactory reduction versus 23 (82%) in the PS group. There was no significant difference in the number of unsatisfactory 1st attempt reductions between the groups.

Conclusions:
Intra-articular haematoma block of the ankle is an efficacious, safe and inexpensive means of providing analgesia for manipulation of displaced ankle fractures.

Authors:
Lucy Walker, David O’Connor, Simon Richards , Jeremy Southgate

Hospital:
University Hospitals Dorset

Introduction:
In response to the coronavirus pandemic the BOAST guidelines advised treating distal radius fractures (DRFs) non-operatively where possible. The objective of this study was to assess whether the COVID pandemic lockdown within the UK altered the management of DRFs and whether there was any subsequent change in patient outcome or complication rate.

Methods:
A retrospective cohort study was performed at a single orthopaedic centre. Patients presenting with DRFs during the first lockdown was identified through the virtual fracture clinic database. The cohort of patients from the previous year was also identified for comparison. Data was collected on patient demographics, radiological features of the fractures, management, patient outcome and subsequent complications. Comparisons were then made between the cohorts for each year.

Results:
The final cohort comprised of 268 fractures in the pre-COVID cohort and 257 fractures in the COVID cohort. There was no significant difference between the two cohorts regarding the number of patients requiring open reduction and internal fixation. The pre-COVID cohort had a significantly higher number of patients reviewed in face-to-face clinic appointments (p=0.004459) and the mean number of clinic appointments for those patients was significantly higher (p=0.014958). There was no significant difference between the cohorts regarding patient complications with a minimum ten month follow-up period.

Conclusions:
Despite comparative numbers and patterns of DRFs the burden on fracture clinic services was significantly reduced during the COVID-19 pandemic. This reduction in follow-up has not translated into an increased prevalence of complications nor requirement for further surgery.