The zebra sign: an unknown known

A 65-year-old woman became obtunded following routine laminectomy and was found to have bilateral cerebellar haemorrhage and convexity subarachnoid haemorrhage. We discuss the possible mechanisms of remote cerebellar haemorrhage—cerebellar haemorrhage that develops after spinal or intracranial surgery—giving rise to the ’zebra sign' and the possible mechanism of convexity subarachnoid haemorrhage in this context [corrected].

Failure in the application of fragility fracture prevention guidelines

INTRODUCTION

The cost of fragility fractures to the UK economy is predicted to reach £2.2 billion by 2025. We studied our hip fracture population to establish whether national guidelines on fragility fracture prevention were being followed, and whether high risk patients were identified and treated by local care services.

METHODS

Data on a consecutive series of trauma hip fracture admissions were collected prospectively over 14 months. National Institute for Health and Care Excellence (NICE) and National Osteoporosis Guideline Group (NOGG) recommendations and FRAX(®) risk calculations were applied to patients prior to their admission with a new hip fracture.

RESULTS

Overall, 94 patients were assessed against national guidelines. The mean population age was 77 years. Almost a quarter (22%) of patients had suffered a previous fragility fracture. The mean FRAX(®) ten-year probability of hip fracture was 7%. According to guidelines, 45% of the study population required treatment, 35% fulfilled criteria for investigation and reassessment, and 20% needed no further management. In practice, 27% received treatment, 4% had undergone dual energy x-ray absorptiometry and were untreated, and 69% had not been investigated and were untreated. In patients meeting intervention thresholds, only 33% of those who required treatment were receiving treatment in practice.

CONCLUSIONS

In conjunction with NICE and NOGG recommendations, FRAX(®) was able to identify 80% of our fracture population as intermediate or high risk on the day of fracture. Correct management was evident in a third of cases with a pattern of inferior guideline compliance seen in a London population. There remains a lack of clarity over the duty of care in fragility fracture prevention.