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O' Reilly M, Wallace E, Merghani K, Conlon B, Breathnach O, Sheehan E. Trauma Assessment Clinic: A virtual fracture clinic model that delivers on its PROMise! J Telemed Telecare 2024; 30:579-588. [PMID: 35285739 DOI: 10.1177/1357633x221076695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of virtual fracture clinics across the United Kingdom and Ireland is growing and have been shown in an increasing number of studies to be safe, cost-effective and associated with good functional outcomes and patient satisfaction rates for certain fracture types. Initially pioneered at Glasgow Royal Infirmary, many centres have adopted similar templates, or variations of, and the overall aim of this study was to assess functional outcomes and injury recovery satisfaction rates of patients discharged directly following review in a specific virtual fracture clinic model known as the Trauma Assessment Clinic (TAC). METHODS A prospective observational study was carried out of paediatric (aged <17 years) and adult (aged >17 years) patients, with the five most commonly observed fracture types, who were discharged directly following review at the TAC in a single hospital centre over a 12 month period from January to December 2018. Primary and secondary outcomes were assessed via telephone administered questionnaires and patient reported outcome measures (PROMs). RESULTS A total of 198 patients were included in the study (n = 98 paediatric and n = 100 adult). Overall, 192 (97%) patients or parents/guardians of patients stated that they either strongly agreed (n = 148, 74.9%) or agreed (n = 44, 22.1%) that they were satisfied with their own or their child's recovery from their injury at a median follow-up of 9 months post direct discharge from the TAC. Adult patients had an EQ-5D-5L index median value of 1 (range 0-1), an EQ-VAS median of 87 (range 0-100), a QuickDASH median score of 0 (range 0-100) and a median LEFS of 80 (range 0-80). CONCLUSION The virtual management of trauma patients via the TAC model is a safe and patient-centred approach to treating certain injuries and fracture patterns. This study reports excellent patient reported outcome measures and patient injury recovery satisfaction rates. The use of current available technology in tandem with up-to-date best clinical practice and guidelines play a central role in this novel care pathway.
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Affiliation(s)
- Marc O' Reilly
- Department of Trauma and Orthopaedic Surgery, Midlands Regional Hospital, Tullamore, Ireland
| | - Emma Wallace
- Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Khalid Merghani
- Department of Trauma and Orthopaedic Surgery, Midlands Regional Hospital, Tullamore, Ireland
| | - Breda Conlon
- Department of Trauma and Orthopaedic Surgery, Midlands Regional Hospital, Tullamore, Ireland
| | - Oisin Breathnach
- Department of Trauma and Orthopaedic Surgery, Midlands Regional Hospital, Tullamore, Ireland
| | - Eoin Sheehan
- Department of Trauma and Orthopaedic Surgery, Midlands Regional Hospital, Tullamore, Ireland
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Baykan A, Hartley RL, Ronksley PE, Harrop AR, Fraulin FOG. Prospective Validation of the Calgary Kids' Hand Rule: A Clinical Prediction Rule for Pediatric Hand Fracture Triage. Plast Surg (Oakv) 2024; 32:92-99. [PMID: 38433811 PMCID: PMC10902491 DOI: 10.1177/22925503221101939] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/22/2022] [Accepted: 03/04/2022] [Indexed: 03/05/2024] Open
Abstract
Introduction: Pediatric hand fractures are common and routinely referred to surgeons, yet most heal well without surgical intervention. This trend inspired the development of the Calgary Kids' Hand Rule (CKHR), a clinical prediction rule designed to predict "complex" fractures that require surgical referral. The CKHR was adapted into a checklist whereby the presence of any 1 of 6 clinically or radiologically identifiable fracture characteristics predicts a complex fracture. The aim of this study was to assess the accuracy of the CKHR in a prospective sample of children with hand fractures. Methods: Physicians were asked to complete the CKHR checklist when referring pediatric patients (< 18 years) to hand surgeons at a Canadian pediatric hospital (April 2019-September 2020). Completed checklists represented predicted outcomes and were compared to observed outcomes (determined via chart review). Predictive accuracy (primary outcome) was evaluated based on sensitivity and specificity. Secondary outcomes were interrater reliability between referring physicians and surgeons, and survey assessment of CKHR user satisfaction. Results: In total 365 fractures were included, with only 16 requiring surgical intervention. Overall performance of the CKHR was good with 84% sensitivity and 71% specificity. Percent agreement between referring physicians and surgeons ranged from 84.1% to 96.3% on individual predictors, with 78.1% agreement on the presence of any predictors. Survey results showed general user satisfaction but also identified areas for improvement. Conclusion: This study posits the CKHR as an accurate and clinically useful prediction rule and highlights the importance of education for its effective use and eventual scale and spread.
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Affiliation(s)
- Altay Baykan
- Department of Surgery, University of Calgary, Canada
| | - Rebecca L. Hartley
- Department of Surgery, University of Calgary, Canada
- Sections of Pediatric Surgery and Plastic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Paul E. Ronksley
- Department of Surgery, University of Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alan R. Harrop
- Department of Surgery, University of Calgary, Canada
- Sections of Pediatric Surgery and Plastic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Frankie O. G. Fraulin
- Department of Surgery, University of Calgary, Canada
- Sections of Pediatric Surgery and Plastic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Waite E, Ahmed Z. How safe and effective are paediatric virtual fracture clinics? A systematic review. Front Digit Health 2023; 5:1261035. [PMID: 37964895 PMCID: PMC10641786 DOI: 10.3389/fdgth.2023.1261035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
Introduction Virtual fracture clinics (VFC) involve a consultant-led multidisciplinary team meeting where cases are reviewed before a telephone consultation with the patient. VFCs have the advantages of reducing waiting times, outpatient appointments and time off school compared to face-to-face (F2F) fracture clinics. There has been a surge in VFC use since the COVID-19 pandemic but there are still concerns over safety in the paediatric population. Fractures make up a large burden of paediatric injuries, therefore research is required on the safety and efficacy of paediatric VFCs. This systematic review will look at the safety and effectiveness of paediatric VFCs, as well as determine the cost-effectiveness and parent preferences. Methods As per the PRISMA guidelines two independent reviewers searched the following databases: Medline, Embase and Web of Science. Studies were included if children under 18 years old presented to A&E with a suspected or confirmed simple un-displaced fracture and were referred to a VFC. The primary outcomes assessed were effectiveness and safety, with the secondary outcomes of cost-effectiveness and parent satisfaction. Results Six studies met the inclusion criteria for this systematic review. There was a high rate of direct discharge from the VFC leading to reduced outpatient appointments. All patients were seen within 72 h of presentation. There were limited incidences of missed fractures and the rates of re-presentation were similar to that of F2F orthopaedic clinics. There were significant cost savings for the hospitals and high parent satisfaction. Discussion VFCs have shown to be safe and effective at managing most stable, low operative risk paediatric fractures. Safety must be ensured with a telephone helpline and an open return to fracture clinic policy. More research is needed into specific paediatric fracture types to be managed in the VFC. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/#searchadvanced, identifier: CRD42023423795.
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Affiliation(s)
- Emma Waite
- College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
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Lafreniere AS, Baykan A, Hartley R, Ronksley P, Love S, Harrop AR, Fraulin FO, Campbell DJ, Donald M. Healthcare Providers and Parents Highlight Challenges of Pediatric Hand Fracture Care. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4815. [PMID: 36817271 PMCID: PMC9937106 DOI: 10.1097/gox.0000000000004815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/20/2022] [Indexed: 02/19/2023]
Abstract
Pediatric hand fractures are common, and many are referred to hand surgeons despite less than 10% of referrals requiring surgical intervention. We explored healthcare provider and parent perspectives to inform a new care pathway. Methods We conducted a qualitative descriptive study using virtual focus groups. Emergency physicians, hand therapists, plastic surgeons, and parents of children treated for hand fractures were asked to discuss their experiences with existing care for pediatric hand fractures, and perceptions surrounding the implementation of a new care pathway. Data were analyzed using directed content analysis with an inductive approach. Results Four focus groups included 24 participants: 18 healthcare providers and six parents. Four themes were identified: educating parents throughout the hand fracture journey, streamlining the referral process for simple hand fractures, identifying the most appropriate care provider for simple hand fractures, and maintaining strong multidisciplinary connections to facilitate care. Participants described gaps in the current care, including a need to better inform parents, and elucidated the motivations behind emergency medicine physicians' existing referral practices. Participants also generally agreed on the need for more efficient management of simple hand fractures that do not require surgical care. Healthcare providers believed the strong preexisting relationship between surgeons and hand therapists would facilitate the changes brought forward by the new care pathway. Conclusion These findings highlighted shortcomings of existing care for pediatric hand fractures and will inform the co-development and implementation of a new care pathway to enable more efficient management while preserving good patient outcomes.
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Affiliation(s)
| | - Altay Baykan
- From the University of Calgary, Calgary, Alberta, Canada
| | | | - Paul Ronksley
- From the University of Calgary, Calgary, Alberta, Canada
| | - Shannan Love
- From the University of Calgary, Calgary, Alberta, Canada
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Merckaert S, Chaibi E, Meriem S, Kwiatkowski B, Divjak N, Zambelli PY. Epidemiology of Pediatric Upper Extremity Fractures in a Tertiary Care Center in Switzerland. Pediatr Emerg Care 2021; 37:e825-e835. [PMID: 32106152 DOI: 10.1097/pec.0000000000002047] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Fractures in children are common and account for 10% to 25% of injuries in children with considerable effects on activity restriction and subsequent high socioeconomically impact. Eighty percent of all fractures in children occur at the upper extremity. The article investigates the epidemiology and fracture pattern of the upper extremity within a pediatric population consulting a tertiary referral hospital in Switzerland. METHODS Study population included all patients younger than 18 years presenting with an upper extremity fracture. Recorded data were age, sex, side, season of the year, mechanism, type of fracture, and applied treatment. RESULTS Fractures of the upper extremities represented 76% with a mean age of 9 years and 7 months. Compared with girls, boys had a risk ratio of 1.35 (1.14-1.6) of having a traumatic injury. The radius, with 298 fractures (37%), was the most injured bone. Overall simple fall from his or her height and soccer represented the main injury mechanisms accounting for 26% and 9%, respectively. Eighty-six percent of fractures were treated by cast with or without closed reduction, 11% (92) by closed reduction and pinning or elastic stable intramedullary, and only 3% of fractures were treated by open reduction and internal fixation. CONCLUSIONS Eighty-six percent of all fractures could be treated by conservative methods. Only 17% need surgical treatments by orthopedic surgeons. This shows how important it is to train residents in pediatrics for the treatment of upper limb fractures in children.
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Affiliation(s)
- Sophie Merckaert
- From the Department of Women, Mother, and Child's Health Care, Paediatric Surgery, Unit of Paediatric Orthopedic Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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Meschino D, Adamich J, Rioux Trottier E, Camp M. Fifth metatarsal fractures in skeletally immature patients do not need routine orthopedic surgeon assessment and follow-up. Paediatr Child Health 2021; 26:349-352. [PMID: 34676013 DOI: 10.1093/pch/pxaa124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/06/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives The aim of this study was to determine the rate of delayed or nonunion of fifth metatarsal fractures in skeletally immature patients. Using this information, we sought to develop an evidence-based clinical care pathway in order to mitigate unnecessary patient radiation exposure, costs to families, and costs to the health system. Methods We retrospectively reviewed the charts and radiographs of patients who presented to an academic tertiary-care paediatric hospital between 2009 and 2014 with isolated fifth metatarsal fractures. Results A total of 114 patients (61 males and 53 females) with mean age of 11.2 (SD 3.0) years old were included in the study. No patients required operative management. There was one case of delayed union and no cases of nonunion. There was no association of these complications with fracture type, location, or mechanism of injury. There was no association of complications with immobilization type or immobilization period. Despite the low complication rate and need for surgery, fracture clinic resource utilization was significant. Fractures were managed with a mean number of 3.1 (SD 0.89) clinic visits and a mean number of 2.7 (SD1.0) radiology department visits where a mean total of 7.9 (SD 3.4) x-rays were performed. Conclusions Based on our retrospective review, skeletally immature patients presenting with isolated fifth metatarsal fractures have a very low rate of delayed or nonunion. A selective follow-up strategy will decrease radiation exposure, reduce costs to families and the healthcare system, without compromising clinical outcomes.
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Affiliation(s)
- Danielle Meschino
- Division of Orthopaedics, The Hospital for Sick Children, Toronto, Ontario
| | - John Adamich
- Division of Orthopaedics, The Hospital for Sick Children, Toronto, Ontario
| | - Eliane Rioux Trottier
- Division of Orthopaedics, The Hospital for Sick Children, Toronto, Ontario.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario
| | - Mark Camp
- Division of Orthopaedics, The Hospital for Sick Children, Toronto, Ontario.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario
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Clinical utility and economic impact of routine delayed follow-up radiographs in children with uncomplicated distal radius Salter-Harris 2 fractures. Pediatr Radiol 2021; 51:1231-1236. [PMID: 33544191 DOI: 10.1007/s00247-021-04967-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 11/03/2020] [Accepted: 01/07/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Salter-Harris 2 fractures of the distal radius are common in pediatrics. Children with these fractures have a theoretical risk of developing a physeal bridge with subsequent growth disturbance. OBJECTIVE The purpose of this study was to investigate the clinical utility and economic impact of obtaining routine delayed radiographs in asymptomatic patients with uncomplicated Salter-Harris 2 fractures of the distal radius. MATERIALS AND METHODS Radiology records were searched retrospectively between Jan. 1, 2016, and Jan. 1, 2018, to identify patients with an acute Salter-Harris type 2 fracture of the distal radius and delayed wrist radiography 3 to 8 months after the injury. Exclusion criteria included distal radius surgery, clinical symptoms, secondary wrist trauma or a history of infection. The financial cost associated with follow-up imaging was determined based on standard charges associated with wrist/forearm radiography, wrist magnetic resonance imaging (MRI) and orthopedic clinical care. RESULTS A total of 381 children with Salter-Harris 2 fractures of the distal radius and delayed radiographs were identified, 56% male (ages 1-18 years, mean: 9.8 years). Four children were excluded because of surgical intervention or clinical symptoms to the same wrist resulting in 377 subjects. There were five confirmed positive cases (1.3%) of distal radius physeal bridge formation, with four cases confirmed on MRI and one case confirmed clinically and radiographically. Based on routine institutional charges for the wrist/forearm radiographs and orthopedic clinic visits, the total billed charges for the 377 patients would equal $245,804, or $49,161 in billed charges per identified physeal bridge. Only three of the five positive cases of confirmed physeal bridge went on to surgical treatment. The billed charges per identified physeal bridge requiring surgery were $81,935. CONCLUSION In asymptomatic children with uncomplicated Salter-Harris 2 fractures of the distal radius, detection of a physeal bridge on delayed radiographs is rare. The financial burden of routine delayed follow-up in asymptomatic patients, a common clinical practice, is an important consideration.
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Kennedy J, Blackburn C, Barrett M, O’Toole P, Moore D. One and done? Outcomes from 3961 patients managed via a virtual fracture clinic pathway for paediatric fractures. J Child Orthop 2021; 15:186-193. [PMID: 34211594 PMCID: PMC8223081 DOI: 10.1302/1863-2548.15.200235] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The aim of this paper is to describe our experience with a virtual fracture management pathway in the setting of a paediatric trauma service. METHODS All patients referred to the virtual fracture clinic service from the Paediatric Emergency Department (PED) were prospectively collected. Outcome data of interest (patients discharged, referred for urgent operative treatment, referred back to emergency department for further evaluation, referred for face-to-face clinical assessment and all patients who re-presented on an unplanned basis for further management of the index injury) were compiled and collated. Cost analysis was performed using established costing for a virtual fracture clinic within the Irish Healthcare System. RESULTS There were a total of 3961 patients referred to the virtual fracture clinic from the PED. Of these, 70% (n = 2776) were discharged. In all, 26% (n = 1033) were referred to a face-to-face appointment. Of discharged patients, 7.5% (n = 207) required an unplanned face-to-face evaluation. A total of 0.1% (n = 3) subsequently required operative treatment relating to their index injury. Implementation of the virtual fracture clinic model generated calculated savings of €254 120. CONCLUSION This prospective evaluation has demonstrated that a virtual fracture clinic pathway for minor paediatric trauma is safe, effective and brings significant cost savings. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Jim Kennedy
- Consultant Orthopaedic Surgeon, Dept. of Orthopaedics, Children’s Health Ireland at Crumlin, Dublin, D12 N512, Republic of Ireland.,Correspondence should be sent to Mr Jim Kennedy, Consultant Orthopaedic Surgeon, Dept. of Orthopaedics, Children’s Health Ireland at Crumlin, Dublin, D12 N512, Republic of Ireland. E-mail:
| | - Carol Blackburn
- Consultant in Emergency Medicine, Dept. of Emergency Medicine, Children’s Health Ireland at Crumlin, Dublin, D12 N512, Republic of Ireland
| | - Michael Barrett
- Consultant in Emergency Medicine, Dept. of Emergency Medicine, Children’s Health Ireland at Crumlin, Dublin, D12 N512, Republic of Ireland
| | - Patrick O’Toole
- Consultant Orthopaedic Surgeon, Dept. of Orthopaedics, Children’s Health Ireland at Crumlin, Dublin, D12 N512, Republic of Ireland
| | - David Moore
- Consultant Orthopaedic Surgeon, Dept. of Orthopaedics, Children’s Health Ireland at Crumlin, Dublin, D12 N512, Republic of Ireland
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Derivation and Internal Validation of a Prediction Model for Pediatric Hand Fracture Triage. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3543. [PMID: 33889473 PMCID: PMC8057756 DOI: 10.1097/gox.0000000000003543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/14/2021] [Indexed: 12/23/2022]
Abstract
Background: Pediatric hand fractures are common, and most can be managed by a period of immobilization. However, it remains challenging to identify those more complex fractures requiring the expertise of a hand surgeon to ensure a good outcome. The purpose of this study was to develop a prediction model for identification of complex pediatric hand fractures requiring care by a hand surgeon. Methods: A 2-year retrospective cohort study of consecutively referred pediatric (<18 years) hand fracture patients was used to derive and internally validate a prediction model for identification of complex fractures requiring the expertise of a hand surgeon. These complex fractures were defined as those that required surgery, closed reduction, or four or more appointments with a hand surgeon. The model, derived by multivariable logistic regression analysis, was internally validated using bootstrapping and then translated into a risk index. Results: Of 1170 fractures, 416 (35.6%) met criteria for a complex fracture. Multivariable regression analysis identified six significant predictors of complex fracture: open fracture, rotational deformity, angulation, condylar involvement, dislocation or subluxation, and displacement. Internal validation demonstrated good performance of the model (C-statistic = 0.88, calibration curve p = 0.935). A threshold of ≥1 point (ie, any one of the predictors) resulted in a simple, easy-to-use tool with 96.4% sensitivity and 45.5% specificity. Conclusions: A high-performing and clinically useful decision support tool was developed for emergency and urgent care physicians providing initial assessment for children with hand fractures. This tool will provide the basis for development of a clinical care pathway for pediatric hand fractures.
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Moon RJ, Curtis EM, Woolford SJ, Ashai S, Cooper C, Harvey NC. The importance of maternal pregnancy vitamin D for offspring bone health: learnings from the MAVIDOS trial. Ther Adv Musculoskelet Dis 2021; 13:1759720X211006979. [PMID: 33889216 PMCID: PMC8040612 DOI: 10.1177/1759720x211006979] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 03/12/2021] [Indexed: 12/17/2022] Open
Abstract
Optimisation of skeletal mineralisation in childhood is important to reduce childhood fracture and the long-term risk of osteoporosis and fracture in later life. One approach to achieving this is antenatal vitamin D supplementation. The Maternal Vitamin D Osteoporosis Study is a randomised placebo-controlled trial, the aim of which was to assess the effect of antenatal vitamin D supplementation (1000 IU/day cholecalciferol) on offspring bone mass at birth. The study has since extended the follow up into childhood and diversified to assess demographic, lifestyle and genetic factors that determine the biochemical response to antenatal vitamin D supplementation, and to understand the mechanisms underpinning the effects of vitamin D supplementation on offspring bone development, including epigenetics. The demonstration of positive effects of maternal pregnancy vitamin D supplementation on offspring bone development and the delineation of underlying biological mechanisms inform clinical care and future public-health policies.
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Affiliation(s)
- Rebecca J. Moon
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, Hampshire SO16 6YD, UK
| | - Elizabeth M. Curtis
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, Hampshire, UK
| | - Stephen J. Woolford
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, Hampshire, UK
| | - Shanze Ashai
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, Hampshire, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, Hampshire, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
- NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Nicholas C. Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, Hampshire, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Hughes AJ, Moloney DP, Fraser C, Dembo J, O'Brien L, Corcoran M, Crowley M, Conlon B, Sheehan E. Remote Delivery of the Satellite Virtual Fracture Clinic - a Pilot Report of the First 500 Cases. Injury 2021; 52:782-786. [PMID: 33257019 DOI: 10.1016/j.injury.2020.11.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 02/02/2023]
Abstract
Presenting to the fracture clinic carries economic, social and societal consequences. The virtual fracture clinic (VFC) has proven to be a safe, patient-focused, cost-effective means of delivering trauma care, whilst reducing unnecessary clinic attendances. Within our institution, a Satellite VFC was established, so as to accommodate an offsite referring emergency department. The VFC database was accessed to identify the first 500 patients who were referred to the Satellite VFC. The decision made for each patient, the rate of returns to the clinic, and the rate of referrals requiring surgical intervention, following discussion at the VFC, ,were identified. A cost analysis and cost comparison was carried out between the Satellite VFC and the traditional "face to face" fracture clinic. There were 500 patients referred to the Satellite VFC within the study period. Of such patients, 288 (58%) were discharged directly following review at the Satellite VFC, 141 patients (28%) were referred to physiotherapy, 50 (10%) were redirected to the trauma clinic, 11 (2%) were sent directly to hand therapy, and 10 (2%) were sent to the ED review clinic. Patients who returned to the fracture clinic accounted for 3.8% of all referrals, and 0.2% of all referrals necessitated surgical intervention. This pilot initiative saved the Dublin Midlands Hospital Group over €50,000. The Satellite VFC is the first of its kind in the literature. Rural communities worldwide would benefit from remote orthopaedic management of suitable fracture patterns. The true value of the Satellite VFC process comes from its use of robust patient care pathways, rationalising resource use and minimising patient travel, whilst demonstrating reliable outcomes and promoting safety.
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Affiliation(s)
- Andrew J Hughes
- Department of Trauma and Orthopaedic Surgery, Dublin Midlands Hospital Group, Tullamore, Co. Offaly, Ireland.
| | - Darren P Moloney
- Department of Trauma and Orthopaedic Surgery, Dublin Midlands Hospital Group, Tullamore, Co. Offaly, Ireland
| | - Caroline Fraser
- Emergency Department, Dublin Midlands Hospital Group, Portlaoise Co. Laois, Ireland
| | - Joan Dembo
- Emergency Department, Dublin Midlands Hospital Group, Portlaoise Co. Laois, Ireland
| | - Louise O'Brien
- Department of Physiotherapy, Dublin Midlands Hospital Group, Portlaoise Co. Laois, Ireland
| | - Marie Corcoran
- Department of Physiotherapy, Dublin Midlands Hospital Group, Portlaoise Co. Laois, Ireland
| | - Michelle Crowley
- Department of Trauma and Orthopaedic Surgery, Dublin Midlands Hospital Group, Tullamore, Co. Offaly, Ireland
| | - Breda Conlon
- Department of Trauma and Orthopaedic Surgery, Dublin Midlands Hospital Group, Tullamore, Co. Offaly, Ireland
| | - Eoin Sheehan
- Department of Trauma and Orthopaedic Surgery, Dublin Midlands Hospital Group, Tullamore, Co. Offaly, Ireland; School of Medicine, University of Limerick, Co. Limerick, Ireland
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Are Postcast Removal X-rays and a Second Follow-up Necessary in the Treatment of Nondisplaced Supracondylar Humerus Fractures? J Pediatr Orthop 2021; 41:105-110. [PMID: 33298765 DOI: 10.1097/bpo.0000000000001726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The utility of routine follow-up radiographs for the treatment of nondisplaced pediatric supracondylar humerus fractures has not been established. The purpose of this study is to (1) determine the frequency that postcast removal x-rays change patient management and (2) determine the role of routine follow-up for range of motion evaluation after cast removal in the treatment of nondisplaced supracondylar humerus fractures. METHODS We conducted a single center retrospective chart review of patients under the age of 18 years old that sustained nondisplaced supracondylar humerus fractures between January 1, 2010 and July 1, 2018. Demographic information, fracture characteristics, time to follow-up and each appointment outcome were recorded. A change in patient management after postcast removal x-ray was defined as a need for an additional period of immobilization, a delay in initiation of range of motion exercises, or need for operative intervention. In addition, the appointment for range of motion evaluation was considered to alter management if further activity restriction was required, a formal physical therapy program was recommended or an additional office visit required. Unscheduled appointments were also noted. RESULTS A total of 489 patients met inclusion criteria. The average age was 4.90±2.68 years and 51.8% were female. A total of 487 patients had routine follow-up x-rays after cast removal. No patient had a change of management based on postcast removal radiographs. In all, 290 patients returned for range of motion follow-up with 94.8% of patients being discharged from care. There were 14 patients whose management changed based on this evaluation (4.8%). The most common reason was an additional appointment for range of motion evaluation (12/14 patients, 86%). There were 13 patients with unscheduled evaluation after discharge from care, 77% were secondary to repeat injury. CONCLUSION This study suggests that postcast removal x-rays and routine follow-up after cast removal rarely change patient management and may not be necessary in the treatment of nondisplaced pediatric supracondylar humerus fractures. LEVEL OF EVIDENCE Level IV-case series.
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Hammer OL, Jakobsen RB, Clementsen S, Fuglesang H, Bjornelv GW, Randsborg PH. Cost-Effectiveness of Volar Locking Plate Compared with Augmented External Fixation for Displaced Intra-Articular Wrist Fractures. J Bone Joint Surg Am 2020; 102:2049-2059. [PMID: 32947595 DOI: 10.2106/jbjs.19.01288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of the present study was to estimate the cost-effectiveness of treating displaced, intra-articular distal radial fractures with volar locking plate fixation compared with augmented external fixation. METHODS A cost-utility analysis was conducted alongside a randomized, clinical trial comparing 2 surgical interventions for intra-articular distal radial fractures. One hundred and sixty-six patients were allocated to either volar locking plate fixation (84 patients) or external fixation (82 patients) and were followed for 2 years. Health-related quality of life was assessed with the EuroQol-5 Dimensions and was used to calculate patients' quality-adjusted life-years (QALYs). Resource use was identified prospectively at the patient level at all follow-up intervals. Costs were estimated with use of both a health-care perspective and a societal perspective. Results were expressed in incremental cost-effectiveness ratios, and uncertainty was assessed with use of bootstrapping methods. RESULTS The average QALY value was equivalent between the groups (1.70463 for the volar locking plate group and 1.70726 for the external fixation group, yielding a nonsignificant difference of -0.00263 QALY). Health-care costs were equal between the groups, with a nonsignificant difference of &OV0556;52 (p = 0.8) in favor of external fixation. However, the external fixation group had a higher loss of productivity due to absence from work (5.5 weeks in the volar locking plate group compared with 9.2 weeks for the external fixation group; p = 0.02). Consequently, the societal costs were higher for the external fixation group compared with the volar locking plate group (&OV0556;18,037 compared with &OV0556;12,567, representing a difference of &OV0556;5,470; p = 0.04) in favor of the volar locking plate group. Uncertainty analyses showed that there is indifference regarding which method to recommend from a health-care perspective, with volar locking plate treatment and external fixation having a 47% and 53% likelihood of being cost-effective, respectively. From the societal perspective, volar locking plate treatment had a 90% likelihood of being cost-effective. CONCLUSIONS External fixation was less cost-effective than volar locking plate treatment for distal radial fractures from a societal perspective, primarily because patients managed with external fixation had a longer absence from work. LEVEL OF EVIDENCE Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ola-Lars Hammer
- Akershus University Hospital, Akershus, Norway.,University of Oslo, Oslo, Norway
| | - Rune Bruhn Jakobsen
- Akershus University Hospital, Akershus, Norway.,University of Oslo, Oslo, Norway
| | - Stale Clementsen
- Akershus University Hospital, Akershus, Norway.,University of Oslo, Oslo, Norway
| | | | | | - Per-Henrik Randsborg
- Akershus University Hospital, Akershus, Norway.,Hospital for Special Surgery, New York, NY
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McIntyre TV, Kelly EG, Clarke T, Green CJ. Design and implementation of an acute Trauma and Orthopaedic ePlatform (TOP) referral system utilising existing secure technology during the COVID-19 pandemic. Bone Jt Open 2020; 1:293-301. [PMID: 33215117 PMCID: PMC7659629 DOI: 10.1302/2046-3758.16.bjo-2020-0041.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction Virtual fracture clinics (VFCs) are being increasingly used to offer safe and efficient orthopaedic review without the requirement for face-to-face contact. With the onset of the COVID-19 pandemic, we sought to develop an online referral pathway that would allow us to provide definitive orthopaedic management plans and reduce face-to-face contact at the fracture clinics. Methods All patients presenting to the emergency department from 21March 2020 with a musculoskeletal injury or potential musculoskeletal infection deemed to require orthopaedic input were discussed using a secure messaging app. A definitive management plan was communicated by an on-call senior orthopaedic decision-maker. We analyzed the time to decision, if further information was needed, and the referral outcome. An analysis of the orthopaedic referrals for the same period in 2019 was also performed as a comparison. Results During the study period, 295 patients with mean age of 7.93 years (standard error (SE) 0.24) were reviewed. Of these, 25 (9.8%) were admitted, 17 (5.8%) were advised to return for planned surgical intervention, 105 (35.6%) were referred to a face-to-face fracture clinic, 137 (46.4%) were discharged with no follow-up, and seven (2.4%) were referred to other services. The mean time to decision was 20.14 minutes (SE 1.73). There was a significant difference in the time to decision between patients referred to fracture clinic and patients discharged (mean 25.25 minutes (SE 3.18) vs mean 2.63 (SE 1.42); p < 0.005). There were a total of 295 referrals to the fracture clinic for the same period in 2019 with a further 44 emergency admissions. There was a statistically significant difference in the weekly referrals after being triaged by the VFC (mean 59 (SE 5.15) vs mean 21 (SE 2.17); p < 0.001). Conclusion The use of an electronic referral pathway to deliver a point of care virtual fracture clinic allowed for efficient use of scarce resources and definitive management plan delivery in a safe manner. Cite this article: Bone Joint Open 2020;1-6:293–301.
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Affiliation(s)
- Tom Vincent McIntyre
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland at Temple Street, Dublin, Ireland
| | - Enda Gerard Kelly
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland at Temple Street, Dublin, Ireland
| | - Trevor Clarke
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland at Temple Street, Dublin, Ireland
| | - Connor J Green
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland at Temple Street, Dublin, Ireland
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15
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Baker C, Larson N, Shaughnessy W, Stans A, Milbrandt T. Rate of Complications and Subsequent Shoulder Complaints for Non-operatively Managed Pediatric Proximal Humerus Fractures. Front Surg 2020; 7:48. [PMID: 32850945 PMCID: PMC7418452 DOI: 10.3389/fsurg.2020.00048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 06/24/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose: The purpose of the study was to describe the early complications and delayed shoulder complaints of non-displaced or minimally displaced pediatric proximal humerus fractures treated non-operatively. Methods: Retrospective review of all pediatric proximal humerus fractures at a single institution from 2001 to 2016. Inclusion criteria were: AP and axillary radiographs upon presentation and final follow up, one follow up appointment, either a non-displaced or minimally displaced fracture, and open physis. Exclusion criteria were: pathologic fractures, re-fractures, bone metabolic disorders. Patient demographics, injury characteristics, radiographic measurements and clinical exam findings were reviewed. Delayed shoulder complaints were defined as a visit to any provider for an ipsilateral shoulder or arm complaint after final scheduled fracture appointment. Results: Sixty-nine of 177 total pediatric proximal humerus fractures met inclusion criteria. Mean age was 10 years (SD = 3.4). Sixty-five had angulation <20 degrees. Median time to last scheduled follow up was 1.4 months (Interquartile range 0.8–1.4). At last scheduled follow up, 9 (13.0%) fractures had an altered exam. One (1.4%) fracture had a complication of a fall and re-fracture. Extraphyseal fractures were more likely to increase in angulation at short term follow up, but had no association with short or long term complications. No patient initially treated with non-operative management subsequently underwent operative treatment. There were three presentations (4.3%) to health professionals for subsequent shoulder complaints; one was treated with short courses of physical therapy and the other two were simply observed. Conclusions: Non-displaced or minimally displaced proximal humerus fractures treated non-operatively sustain rare short or long term complications with no cross over to operative management. Once non-operative management is pursued, these fractures may be amenable to surveillance with primary care or allied orthopedic staff after initial evaluation by pediatric orthopedic providers. Level of Evidence: Level III retrospective cohort study.
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16
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McIntyre TV, Kelly EG, Clarke T, Green CJ. Design and implementation of an acute Trauma and Orthopaedic ePlatform (TOP) referral system utilising existing secure technology during the COVID-19 pandemic. Bone Jt Open 2020. [DOI: 10.1302/2633-1462.16.bjo-2020-0041.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Virtual fracture clinics (VFCs) are being increasingly used to offer safe and efficient orthopaedic review without the requirement for face-to-face contact. With the onset of the COVID-19 pandemic, we sought to develop an online referral pathway that would allow us to provide definitive orthopaedic management plans and reduce face-to-face contact at the fracture clinics. Methods All patients presenting to the emergency department from 21March 2020 with a musculoskeletal injury or potential musculoskeletal infection deemed to require orthopaedic input were discussed using a secure messaging app. A definitive management plan was communicated by an on-call senior orthopaedic decision-maker. We analyzed the time to decision, if further information was needed, and the referral outcome. An analysis of the orthopaedic referrals for the same period in 2019 was also performed as a comparison. Results During the study period, 295 patients with mean age of 7.93 years (standard error (SE) 0.24) were reviewed. Of these, 25 (9.8%) were admitted, 17 (5.8%) were advised to return for planned surgical intervention, 105 (35.6%) were referred to a face-to-face fracture clinic, 137 (46.4%) were discharged with no follow-up, and seven (2.4%) were referred to other services. The mean time to decision was 20.14 minutes (SE 1.73). There was a significant difference in the time to decision between patients referred to fracture clinic and patients discharged (mean 25.25 minutes (SE 3.18) vs mean 2.63 (SE 1.42); p < 0.005). There were a total of 295 referrals to the fracture clinic for the same period in 2019 with a further 44 emergency admissions. There was a statistically significant difference in the weekly referrals after being triaged by the VFC (mean 59 (SE 5.15) vs mean 21 (SE 2.17); p < 0.001). Conclusion The use of an electronic referral pathway to deliver a point of care virtual fracture clinic allowed for efficient use of scarce resources and definitive management plan delivery in a safe manner. Cite this article: Bone Joint Open 2020;1-6:293–301.
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Affiliation(s)
- Tom Vincent McIntyre
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland at Temple Street, Dublin, Ireland
| | - Enda Gerard Kelly
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland at Temple Street, Dublin, Ireland
| | - Trevor Clarke
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland at Temple Street, Dublin, Ireland
| | - Connor J. Green
- Department of Trauma and Orthopaedic Surgery, Children's Health Ireland at Temple Street, Dublin, Ireland
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Epidemiology of paediatric lower extremity fractures in a tertiary care center in Switzerland. Eur J Trauma Emerg Surg 2020; 48:3449-3459. [PMID: 32462374 DOI: 10.1007/s00068-020-01400-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/16/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE About 20% of all fractures in children occur at the lower extremity. This study aims to investigate the epidemiology and injury pattern of lower extremity fractures within the pediatric population consulting a tertiary referral hospital in Switzerland. METHODS Study population included all patients up to 16 years presenting with a lower extremity fracture over a period of one year. Recorded data were age, gender, side, season of the year, mechanism, type of fracture and applied treatment. RESULTS Fractures of the lower extremity represent 23% of all fractures with a mean age of 9 years and 6 months. The tibia, with 94 fractures (38%), represents the most frequently injured bone. Peak incidence is seen in winter and 24% of tibia shaft fractures were due to board sports. Overall, 82% of fractures were treated by cast with or without closed reduction, and only 18% requested surgery. CONCLUSION Board sports seems to be a leading cause of tibial shaft fracture in our region. Nevertheless, only 18% of fractures had recourse to an orthopedic surgeon, hence the importance of the teaching quality of pediatric residents for conservative fracture treatment.
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18
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Abstract
Casts are commonly used for fracture management and postoperative immobilization in pediatric patients. However, cast immobilization is not without complications (eg, thermal injuries, pressure sores, infection, and neurovascular injury) and may be associated with additional costs and increased loss of school/work days for cast removal or other complications. The disadvantages of traditional casting can be minimized by alternative management strategies: waterproof casts to facilitate bathing and swimming; a Pavlik harness in infants, a single-leg spica cast, or flexible intramedullary nails to avoid complications with double-leg spica casts for femur fractures; and braces or splints to manage buckle and minimally displaced distal radius fractures, toddler's fractures, and stable foot/ankle fractures.
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19
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Introducing a Virtual Fracture Clinic Increases Efficiency and Reduces Costs in Torus Fracture Management. Pediatr Qual Saf 2019; 4:e202. [PMID: 32010848 PMCID: PMC6946224 DOI: 10.1097/pq9.0000000000000202] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 07/16/2019] [Indexed: 12/04/2022] Open
Abstract
Torus fractures of the distal radius are both a common pediatric forearm fracture and a common source of referral to orthopedic departments. Management of these injuries has moved away from traditional casting methods to using splints and softcasts.
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20
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Hartley RL, Todd AR, Harrop AR, Fraulin FOG. Pediatric Hand Fracture Referring Practices: A Scoping Review. Plast Surg (Oakv) 2019; 27:340-347. [PMID: 31763335 DOI: 10.1177/2292550319876659] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Pediatric hand fractures are common, but few require surgery; therefore, these fractures are often perceived to be overreferred. Our objective is to systematically identify and describe pediatric hand fracture referring practices. Method A scoping review was performed, searching electronic databases and grey literature up to January 2018 to identify referring practices for children (17 years and younger) with hand fractures (defined as radiographically confirmed fractures distal to the carpus) to hand surgeons. All study designs were included, and study selection and data extraction were independently performed in duplicate by 2 reviewers. Outcomes included referring rates, necessity of referral, referring criteria, and management of fractures. Results Twenty (10 cross-sectional, 7 prospective cohorts, and 3 narrative reviews) studies reporting on referring practices or management of 21,624 pediatric hand fractures were included. Proportion of pediatric hand fractures referred to hand surgeons ranged from 6.5% to 100%. Unnecessary referral, defined as those fractures within the scope of primary care management, ranged from 27% to 78.1%. Ten studies reported referring criteria, with 14 unique criteria identified. The most common referring criteria were displacement (36.4%), loss of joint congruity (36.4%), and instability (36.4%). The most common justification for these criteria was increased likelihood of requiring surgery. The most common initial management was immobilization (66%-100%). Final management was provided by orthopedic or plastic hand surgeons with 0% to 32.9% of fractures requiring surgery. Conclusion Referring practices vary widely in the literature. Major gaps in the literature include objective measures and justification for referring criteria and primary care education on hand fracture referring practices.
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Affiliation(s)
- Rebecca L Hartley
- Department of Surgery, Section of Plastic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Anna R Todd
- Department of Surgery, Section of Plastic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Alan R Harrop
- Department of Surgery, Section of Plastic Surgery, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Frankie O G Fraulin
- Department of Surgery, Section of Plastic Surgery, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital, Calgary, Alberta, Canada
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21
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Woolford SJ, Cooper C, Harvey N, Moon RJ. Prenatal influences on bone health in children. Expert Rev Endocrinol Metab 2019; 14:193-202. [PMID: 31023107 DOI: 10.1080/17446651.2019.1607727] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/11/2019] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Optimising bone health might reduce the burden of both fractures in childhood and fragility fractures in later life. A number of maternal dietary and non-dietary factors have been identified that might influence offspring bone health and represent targets for intervention. AREAS COVERED This article will outline the accrual of bone mineral throughout the life course and how observational and intervention studies have shown that maternal diet, in particular maternal calcium and 25-hydroxyvitamin D [25(OH)D] status, and lifestyle are associated with offspring bone mineralization. Studies examining the effects of maternal micronutrient supplementation on offspring bone mineral density (BMD) will also be discussed. EXPERT COMMENTARY There is a wealth of observational evidence relating maternal diet to offspring BMD. However, high quality randomized controlled trials, such as the ongoing MAVIDOS study, are needed before these findings can be definitively translated into public health advice.
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Affiliation(s)
- Stephen J Woolford
- a MRC Lifecourse Epidemiology Unit , University of Southampton, Southampton General Hospital, , Southampton , UK
| | - Cyrus Cooper
- a MRC Lifecourse Epidemiology Unit , University of Southampton, Southampton General Hospital, , Southampton , UK
| | - Nicholas Harvey
- a MRC Lifecourse Epidemiology Unit , University of Southampton, Southampton General Hospital, , Southampton , UK
| | - Rebecca J Moon
- b MRC Lifecourse Epidemiology Unit , University of Southampton & Department of Paediatric Endocrinology, University Hospitals Southampton NHS Foundation Trust , Southampton , UK
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22
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Trauma assessment clinic: Virtually a safe and smarter way of managing trauma care in Ireland. Injury 2019; 50:898-902. [PMID: 30955873 DOI: 10.1016/j.injury.2019.03.046] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 03/07/2019] [Accepted: 03/28/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The Trauma Assessment Clinic [TAC], also referred to as Virtual Fracture Clinic, offers a novel care pathway for patients and is being increasingly utilised across the Irish and UK health care systems. The provision of safe, patient centred, efficient and cost-effective treatment via a multidisciplinary team [MDT] approach is the primary focus of TAC. The Trauma and Orthopaedic unit at Tullamore Hospital was the first centre to introduce a TAC in Ireland and this overview outlines the experiences of this pilot. METHODS AND PATIENTS Patients arriving to the Emergency Department with injuries that were TAC appropriate were treated as per a recognised protocol. They were given information regarding their injury and a removable splint or cast and told to expect a follow up phone call from the orthopaedic team. Within 24 h the patient's clinical notes and x-rays were assessed by the TAC MDT and patients were called immediately to be advised as to their planned treatment. RESULTS To date the TAC pilot in Tullamore Hospital has reviewed 2704 patients. 35% of patients were discharged at the TAC review stage, 27% were referred to an appropriate clinic (e.g. Shoulder injuries referred to an upper limb specialist) or a general trauma follow-up clinic, and 38% were referred onto physiotherapy services local and community based for follow-up. A survey of patients reviewed in the TAC revealed that 97% of respondents agreed or strongly agreed that they were satisfied with their recovery. The cost of each TAC consultation was €28 versus €129 for a traditional fracture clinic appointment. CONCLUSION Our experience of the TAC is that it provides a very safe, patient focused and cost-effective means of delivering trauma care. It provides a more streamlined and improved patient journey in select patients with certain fracture patterns, allowing for patient empowerment without compromising clinical care and marries current available technology with up to date best clinical practice.
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Do toddler's fractures of the tibia require evaluation and management by an orthopaedic surgeon routinely? Eur J Emerg Med 2019. [PMID: 28628487 DOI: 10.1097/mej.0000000000000478] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The majority of uncomplicated toddler fractures of the tibia (toddler's fractures) do not need an orthopaedic surgeon's intervention or follow-up. However, inexperienced emergency room physicians, general practitioners and orthopaedic trainees and surgeons understandably defer to a cautious approach of referral and subsequent frequent clinical and radiographic follow-up. An evidence-based pathway can help prevent this overtreatment, reduce unnecessary radiation exposure and decrease the financial burden on families and the healthcare system. PATIENTS AND METHODS A retrospective analysis of patients who presented for management of toddler's fractures to The Hospital for Sick Children (SickKids) was performed. RESULTS A total of 184 (113 boys, 72 girls) patients, of a mean age of 1.99 (range: 0.2-3.9) years, were included for review. The included patients had attended 2.00±1.0 clinic visits and had had 5.86±2.7 radiographs taken on average. No complications such as cast injuries, nonunion, refracture or subsequent deformity needing assessment or intervention were identified. CONCLUSION Toddler's fractures do not require routine orthopaedic surgeon assessment, intervention or follow-up. If diagnosed and managed correctly at initial presentation, patients with toddler's fractures may be discharged safely without the need for further clinician contact. We developed a toddler's fracture clinical care pathway to reduce unnecessary orthopaedic surgeon referral and clinical and radiographic follow-up, thereby decreasing radiation exposure and costs to families and the healthcare system without risking patient outcomes.
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Handoll HHG, Elliott J, Iheozor‐Ejiofor Z, Hunter J, Karantana A. Interventions for treating wrist fractures in children. Cochrane Database Syst Rev 2018; 12:CD012470. [PMID: 30566764 PMCID: PMC6516962 DOI: 10.1002/14651858.cd012470.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Wrist fractures, involving the distal radius, are the most common fractures in children. Most are buckle fractures, which are stable fractures, unlike greenstick and other usually displaced fractures. There is considerable variation in practice, such as the extent of immobilisation for buckle fractures and use of surgery for seriously displaced fractures. OBJECTIVES To assess the effects (benefits and harms) of interventions for common distal radius fractures in children, including skeletally immature adolescents. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, trial registries and reference lists to May 2018. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing interventions for treating distal radius fractures in children. We sought data on physical function, treatment failure, adverse events, time to return to normal activities (recovery time), wrist pain, and child (and parent) satisfaction. DATA COLLECTION AND ANALYSIS At least two review authors independently performed study screening and selection, 'Risk of bias' assessment and data extraction. We pooled data where appropriate and used GRADE for assessing the quality of evidence for each outcome. MAIN RESULTS Of the 30 included studies, 21 were RCTs, seven were quasi-RCTs and two did not describe their randomisation method. Overall, 2930 children were recruited. Typically, trials included more male children and reported mean ages between 8 and 10 years. Eight studies recruited buckle fractures, five recruited buckle and other stable fractures, three recruited minimally displaced fractures and 14 recruited displaced fractures, typically requiring closed reduction, typically requiring closed reduction. All studies were at high risk of bias, mainly reflecting lack of blinding. The studies made 14 comparisons. Below we consider five prespecified comparisons:Removable splint versus below-elbow cast for predominantly buckle fractures (6 studies, 695 children)One study (66 children) reported similar Modified Activities Scale for Kids - Performance scores (0 to 100; no disability) at four weeks (median scores: splint 99.04; cast 99.11); low-quality evidence. Thirteen children needed a change or reapplication of device (splint 5/225; cast 8/219; 4 studies); very low-quality evidence. One study (87 children) reported no refractures at six months. One study (50 children) found no between-group difference in pain during treatment; very low-quality evidence. Evidence was absent (recovery time), insufficient (children with minor complications) or contradictory (child or parent satisfaction). Two studies estimated lower healthcare costs for removable splints.Soft or elasticated bandage versus below-elbow cast for buckle or similar fractures (4 studies, 273 children)One study (53 children) reported more children had no or only limited disability at four weeks in the bandage group; very low-quality evidence. Eight children changed device or extended immobilisation for delayed union (bandage 5/90; cast 3/91; 3 studies); very low-quality evidence. Two studies (139 children) reported no serious adverse events at four weeks. Evidence was absent, insufficient or contradictory for recovery time, wrist pain, children with minor complications, and child and parent satisfaction. More bandage-group participants found their treatment convenient (39 children).Removal of casts at home by parents versus at the hospital fracture clinic by clinicians (2 studies, 404 children, mainly buckle fractures)One study (233 children) found full restoration of physical function at four weeks; low-quality evidence. There were five treatment changes (home 4/197; hospital 1/200; 2 studies; very low-quality evidence). One study found no serious adverse effects at six months (288 children). Recovery time and number of children with minor complications were not reported. There was no evidence of a difference in pain at four weeks (233 children); low-quality evidence. One study (80 children) found greater parental satisfaction in the home group; low-quality evidence. One UK study found lower healthcare costs for home removal.Below-elbow versus above-elbow casts for displaced or unstable both-bone fractures (4 studies, 399 children)Short-term physical function data were unavailable but very low-quality evidence indicated less dependency when using below-elbow casts. One study (66 children with minimally displaced both-bone fractures) found little difference in ABILHAND-Kids scores (0 to 42; no problems) (mean scores: below-elbow 40.7; above-elbow 41.8); very low-quality evidence. Overall treatment failure data are unavailable, but nine of the 11 remanipulations or secondary reductions (366 children, 4 studies) were in the above-elbow group; very low-quality evidence. There was no refracture or compartment syndrome at six months (215 children; 2 studies). Recovery time and overall numbers of children with minor complications were not reported. There was little difference in requiring physiotherapy for stiffness (179 children, 2 studies); very low-quality evidence. One study (85 children) found less pain at one week for below-elbow casts; low-quality evidence. One study found treatment with an above-elbow cast cost three times more in Nepal.Surgical fixation with percutaneous wiring and cast immobilisation versus cast immobilisation alone after closed reduction of displaced fractures (5 studies, 323 children)Where reported, above-elbow casts were used. Short-term functional outcome data were unavailable. One study (123 children) reported similar ABILHAND-Kids scores indicating normal physical function at six months (mean scores: surgery 41.9; cast only 41.4); low-quality evidence. There were fewer treatment failures, defined as early or problematic removal of wires or remanipulation for early loss in position, after surgery (surgery 20/124; cast only 41/129; 4 studies; very low-quality evidence). Similarly, there were fewer serious advents after surgery (surgery 28/124; cast only 43/129; 4 studies; very low-quality evidence). Recovery time, wrist pain, and satisfaction were not reported. There was lower referral for physiotherapy for stiffness after surgery (1 study); very low-quality evidence. One USA study found similar treatment costs in both groups. AUTHORS' CONCLUSIONS Where available, the quality of the RCT-based evidence on interventions for treating wrist fractures in children is low or very low. However, there is reassuring evidence of a full return to previous function with no serious adverse events, including refracture, for correctly-diagnosed buckle fractures, whatever the treatment used. The review findings are consistent with the move away from cast immobilisation for these injuries. High-quality evidence is needed to address key treatment uncertainties; notably, some priority topics are already being tested in ongoing multicentre trials, such as FORCE.
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Affiliation(s)
- Helen HG Handoll
- Teesside UniversityHealth and Social Care InstituteMiddlesbroughTees ValleyUKTS1 3BA
| | - Joanne Elliott
- The University of Manchester, Medical SchoolDivision of Musculoskeletal and Dermatological Sciences1st Floor Stopford BuildingOxford RoadManchesterUKM13 9PT
| | - Zipporah Iheozor‐Ejiofor
- The University of Manchester, Medical SchoolDivision of Musculoskeletal and Dermatological Sciences1st Floor Stopford BuildingOxford RoadManchesterUKM13 9PT
| | | | - Alexia Karantana
- University of NottinghamDepartment of Academic Orthopaedics, Trauma and Sports Medicine, School of MedicineDivision of Rheumatology, Orthopaedics and Dermatology, School of MedicineRoom WC1375, C Floor, West Block, Queen's Medical Centre, Derby RoadNottinghamUKNG7 2UH
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Abstract
OBJECTIVES Although many uncomplicated pediatric fractures do not require routine long-term follow-up with an orthopedic surgeon, practitioners with limited experience dealing with pediatric fractures will often defer to a strategy of frequent clinical and radiographic follow-up. Development of an evidence-based clinical care pathway can help unnecessary radiation exposure to this patient population and reduce costs to patient families and the health care system. METHODS A retrospective analysis including patients who presented to the Hospital for Sick Children (SickKids) for management of clavicle fractures was performed. RESULTS Three hundred forty patients (227 males, 113 females) with an average age of 8.1 years (range, 0.1-17.8) were included in the study. The mean number of clinic visits including initial consultation in the emergency department was 2.1 (1.3). The mean number of radiology department appointments was 1.8 (1.3), where patients received a mean number of 4.2 (3.0) radiographs. Complications were minimal: 2 refractures in our series and no known cases of nonunion. All patients achieved clinical and radiographic union and returned to sport after fracture healing. CONCLUSIONS Our series suggests that the decision to treat operatively is made at the initial assessment. If no surgical indications were present at the initial assessment by the primary care physician, then routine clinical or radiographic follow-up is unnecessary. Our pediatric clavicle fracture pathway will reduce patient radiation exposure and reduce costs incurred by the health care system and patients' families without jeopardizing patient outcomes.
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Electronic referrals for virtual fracture clinic service using the National Integrated Medical Imaging System (NIMIS). Ir J Med Sci 2018; 188:371-377. [PMID: 30229444 DOI: 10.1007/s11845-018-1901-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Virtual fracture clinics (VFC) are now prevalent across many orthopaedic services in the UK and Ireland. The management of a variety of musculoskeletal injuries using the VFC model has been demonstrated to be safe, cost-effective and associated with high levels of patient satisfaction. Referrals were made available through the National Integrated Medical Imaging System (NIMIS). NIMIS allows for electronic movement of patient images throughout the Irish health service. METHODS A retrospective review of 157 orthopaedic fracture referrals from a regional hospital was performed. The referrals were received during a 6-week period between May 2016 and June 2016. Each of these referrals was sent electronically. These referrals were reviewed each day by a consultant-led multi-disciplinary team. RESULTS Thirty (93%) patients agreed or strongly agreed that they received adequate information in relation to the VFC when they attended the emergency department (ED). All patients except for one either agreed or strongly agreed that they were satisfied with their recovery (97%). Fifteen parents advised us that they would have had to take time off to attend fracture clinic with their child. Two patients attended their general practitioner (GP) or ED to seek further pain relief following their injuries. Only one patient reported a poor clinical outcome. Nine (28%) patients reported that they would have preferred a face-to-face appointment rather than being treated by the VFC. CONCLUSION Virtual review of orthopaedic trauma patients results in satisfactory patient outcomes. Clinical outcomes were acceptable with minimal additional medical attention required following injury. Electronic transfer of information allows for the virtual service to operate from sites long distances from the primary orthopaedic centre. The NIMIS is a safe and confidential means of collaborating with other institutions and has huge potential in the areas of trauma care delivery, clinical conferencing and other image-based disciplines.
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Inappropriately Timed Pediatric Orthopaedic Referrals From the Emergency Department Result in Unnecessary Appointments and Financial Burden for Patients. J Pediatr Orthop 2018; 38:e128-e132. [PMID: 29324529 DOI: 10.1097/bpo.0000000000001132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Musculoskeletal injuries are among the most common reasons for emergency department (ED) visits in the pediatric population. Many such injuries can be managed with a single follow-up outpatient visit. However, untimely (ie, premature) referrals by emergency physicians to orthopaedic surgeons are common and may inadvertently create need for a second visit, generating unnecessary expenditures. We sought to elucidate the cost of premature musculoskeletal follow-up visits to the patients, families, and the health care system. METHODS We performed a retrospective review of pediatric patients with acute musculoskeletal injuries referred from our ED (without a formal orthopaedic consult) to our outpatient clinic. Patients were retrospectively reviewed in a consecutive fashion. The appropriateness of the recommended follow-up time interval was determined for each patient, and the direct and indirect cost of the inappropriate services were calculated utilizing a combination of traditional cost accounting techniques and time-driven activity-based costing. The characteristics of patients with appropriate and untimely follow-up referrals were compared. RESULTS Two hundred consecutive referrals from the ED were reviewed. Overall, 96.5% of the follow-up visits recommended by the ED were premature, which led 106 (53%) patients to require a second visit to complete their clinical care. Patients who required a second visit were significantly younger (P=0.005), more likely to be male (P=0.042), more likely to have a fracture (P<0.001), and less likely to have a sprain (P<0.001) or dislocation/subluxation (P<0.001). Over 40% of second visits were accounted for by 3 diagnoses (distal radius buckle fractures, nondisplaced Salter-Harris 1 fractures of the ankle, and buckle fractures of the finger). Across the whole cohort, the total financial impact of untimely visits was $36,265.78, representing an average cost of $342.93 per patient. CONCLUSIONS Untimely referrals for follow-up of acute pediatric musculoskeletal conditions are very common and represent a significant financial burden to patients, families, and the health care system. Over 40% of unnecessary visits resulted from just 3 diagnoses. Improved orthopaedic follow-up guidelines, particularly for these readily recognizable conditions, and feedback to referring providers may reduce poorly timed clinic visits and decrease costs in the treatment of common orthopaedic injuries in pediatric patients. LEVEL OF EVIDENCE Level III.
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Bian J, Cao D, Shen J, Jiang B, Chen D, Bian L. N-methyl pyrrolidone promotes ankle fracture healing by inhibiting inflammation via suppression of the mitogen-activated protein kinase signaling pathway. Exp Ther Med 2018; 15:3617-3622. [PMID: 29545891 DOI: 10.3892/etm.2018.5842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 11/15/2017] [Indexed: 01/22/2023] Open
Abstract
N-methyl pyrrolidone (NMP), a small bioactive molecule, has the potential to stimulate bone formation and inhibit osteoclast differentiation. The aim of the present study was to investigate the effect of NMP on the inflammatory response and underlying molecular mechanisms in MG-63 cells. The mRNA and protein expression of cytokines from peripheral blood in children with or without ankle fracture were determined by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and ELISA, respectively. MG-63 cells were pre-treated with/without NMP and stimulated with 1 µM bradykinin (BK). The production of cytokines from MG-63 cells was assessed by western blotting and RT-qPCR. The expression of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) mRNA and protein were measured using western blotting and/or RT-qPCR. Western blotting was used to examine the activation level of mitogen activated protein kinase. Compared with healthy children, levels of tumor necrosis factor (TNF-α), interleukin (IL)-1β and IL-6 mRNA and protein were upregulated in children with ankle fracture. NMP treatment did not induce cytotoxicity in MG-63 cells. The BK-induced upregulation of TNF-α, IL-1β, IL-6, iNOS and COX-2 mRNA and protein was reversed in a dose-dependent manner by NMP. Furthermore, NMP downregulated the activation of c-Jun NH2-terminal kinase and p38 pathways, but not the extracellular signal-related kinase pathway. Therefore, the results of the current study demonstrate that NMP inhibits inflammation dependent on the mitogen-activated protein kinase pathway in MG-63 cells, indicating that it may be beneficial in the healing of fractures.
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Affiliation(s)
- Jun Bian
- Department of Orthopedic, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210009, P.R. China
| | - Dan Cao
- Department of Orthopedic, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210009, P.R. China
| | - Jie Shen
- Department of Orthopedic, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210009, P.R. China
| | - Bo Jiang
- Department of Orthopedic, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210009, P.R. China
| | - Dan Chen
- Department of Orthopedic, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210009, P.R. China
| | - Lanzheng Bian
- Department of Surgery, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210009, P.R. China
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Camp MW, Barnes JR, Damany M, Donnan LT. Impact of web-based clinical practice guidelines on paediatric fracture clinics. ANZ J Surg 2017; 88:232-235. [DOI: 10.1111/ans.14260] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 06/25/2017] [Accepted: 09/05/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Mark W. Camp
- Department of Surgery; University of Toronto; Toronto Ontario Canada
- Division of Orthopaedic Surgery; The Hospital for Sick Children; Toronto Ontario Canada
| | - James R. Barnes
- Paediatric Trauma and Orthopaedic Surgery; Bristol Royal Hospital for Children; Bristol UK
| | - Mohita Damany
- Department of Surgery; The Royal Children's Hospital; Melbourne Victoria Australia
| | - Leo T. Donnan
- Department of Surgery; The Royal Children's Hospital; Melbourne Victoria Australia
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Paediatric fracture clinic re-design: Incorporating a virtual fracture clinic. Injury 2017; 48:2101-2105. [PMID: 28807427 DOI: 10.1016/j.injury.2017.08.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/19/2017] [Accepted: 08/02/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The use of virtual fracture clinics (VFCs) and home management protocols is increasing. The main aim of this research is to determine whether a paediatric home management programme and VFC can be used safely to manage a range of suitable fractures in children. MATERIALS AND METHODS Protocols for the home management of stable paediatric fractures were designed by two consultant paediatric orthopaedic surgeons. These were for children between the ages of 18 months and 15 years 364 days. A new tariff was negotiated with the clinical commissioning groups (CCGs) for a VFC new patient review. A prospective analysis was performed for the first 2 months of the programme. Further review periods were undertaken 6 months later and 12 months after that. RESULTS Sixty-five patients were reviewed in the first 10 VFCs (mean 6.5 cases per week). After 6 months, 164 patients were reviewed in a 3-month period in the VFC, a mean of 11 cases per week. A year later the number of patients reviewed in the VFC had continued to increase with a total of 253 patients in 3 months, mean 21 cases per week. This gave a saving to the CCG of £45,000 per year and to the hospital of £106,000 per year. There were no serious adverse consequences to any patients from the use of the pathway. DISCUSSION AND CONCLUSION We have reported on the introduction of a paediatric VFC and a home management programme for stable paediatric fractures. We are not aware of any reports in the orthopaedic literature that have described such a comprehensive and innovative re-organisation of paediatric fracture services. We estimate that the NHS could save approximately £10.1 million if all hospitals in England introduced this.
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Handoll HHG, Elliott J, Iheozor-Ejiofor Z, Hunter J, Karantana A. Interventions for treating wrist fractures in children. Hippokratia 2016. [DOI: 10.1002/14651858.cd012470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Helen HG Handoll
- Teesside University; Health and Social Care Institute; Middlesbrough Tees Valley UK TS1 3BA
| | - Joanne Elliott
- The University of Manchester, Medical School; Division of Musculoskeletal and Dermatological Sciences; 1st Floor Stopford Building Oxford Road Manchester UK M13 9PT
| | - Zipporah Iheozor-Ejiofor
- The University of Manchester, Medical School; Division of Musculoskeletal and Dermatological Sciences; 1st Floor Stopford Building Oxford Road Manchester UK M13 9PT
| | | | - Alexia Karantana
- University of Nottingham; Department of Academic Orthopaedics, Trauma and Sports Medicine, School of Medicine; Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine Room WC1375, C Floor, West Block, Queen's Medical Centre, Derby Road Nottingham UK NG7 2UH
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Holm AGV, Lurås H, Randsborg PH. The economic burden of outpatient appointments following paediatric fractures. Injury 2016; 47:1410-3. [PMID: 27138840 DOI: 10.1016/j.injury.2016.04.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/05/2016] [Accepted: 04/09/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Paediatric fractures are common and frequently followed-up. The aim of this study is to quantify the private costs for the affected families, as well as the costs for society due to paediatric fracture clinic follow-up appointments. PATIENTS AND METHODS 295 paired parent and surgeon questionnaire regarding the cost related to a scheduled follow-up appointment for an upper limb fracture in children aged 6-13 years were collected prospectively over 7 months. In addition, the medical appropriateness of the appointment and whether or not the control changed the management of the fracture was investigated. RESULTS The direct cost of attending a paediatric upper limb fracture clinic was estimated to €48.5 while the cost for society due to productivity loss was €78.4 per consultation. In 89.2% of the cases the surgeons found the appointment necessary, it was deemed unnecessary or inconclusive in 10.6%. The treatment plan was altered in 6.8%, and an extra follow up was scheduled in 5.8%. Fractures of the clavicle were most often regarded as unnecessary to follow up clinically or radiologically by the surgeons. DISCUSSION The direct cost for the affected families and the costs for society due to productivity loss of paediatric fracture follow-up appointments are noticeable. Although most patients and surgeons deem these controls as valuable, they lead to a change in treatment plan in only 12.6% of the cases. A stringent management protocol can safely reduce the number of clinical and radiographical follow-ups.
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Affiliation(s)
- Anne Guro Vreim Holm
- Department of Orthopedic Surgery, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Hilde Lurås
- Health Services Research Centre, Akershus University Hospital, 1478 Lørenskog, Norway; Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway
| | - Per-Henrik Randsborg
- Department of Orthopedic Surgery, Akershus University Hospital, 1478 Lørenskog, Norway.
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Moon RJ, Harvey NC, Curtis EM, de Vries F, van Staa T, Cooper C. Ethnic and geographic variations in the epidemiology of childhood fractures in the United Kingdom. Bone 2016; 85:9-14. [PMID: 26802259 PMCID: PMC4841386 DOI: 10.1016/j.bone.2016.01.015] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 01/12/2016] [Accepted: 01/18/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Fractures are common in childhood, and there is considerable variation in the reported incidence across European countries, but few data relating to ethnic and geographic differences within a single country. We therefore aimed to determine the incidence of childhood fractures in the United Kingdom (UK), and to describe age-, ethnicity- and region- specific variations. METHODS The Clinical Practice Research Datalink (CPRD) contains anonymised electronic health records for approximately 7% of the UK population. The occurrence of a fracture between 1988 and 2012 was determined from the CPRD for all individuals <18years of age, and used to calculate fracture incidence rates for age, sex and ethnicity. Regional fracture incidence rates were also calculated based on general practitioner location within 14 Strategic Health Authorities (SHA) within the UK. RESULTS The overall fracture incidence rate was 137 per 10,000 person-years (py). This was higher in boys (169 per 10,000 py) than girls (103 per 10,000 py) and white children (150 per 10,000 py) compared to those of black (64 per 10,000 py) and South Asian (81 per 10,000 py) ethnicity. Marked geographic variation in incidence was observed. The highest fracture rates were observed in Wales, where boys and girls had 1.82 and 1.97 times greater incidence, respectively, than those residing in Greater London. CONCLUSION In the period 1988-2012, there was marked geographic and ethnic variation in childhood fracture incidence across the UK. These findings also implicate lifestyle and socio-economic differences associated with location and ethnicity, and are relevant to policy makers in the UK and internationally.
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Affiliation(s)
- Rebecca J Moon
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK; Paediatric Endocrinology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK; NIHR Southampton Nutrition Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK, SO16 6YD, UK
| | - Elizabeth M Curtis
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK
| | - Frank de Vries
- Department of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Tjeerd van Staa
- Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, 1.003 Vaughan House, Portsmouth, Road, M13 9PL, UK; Department of Pharmacoepidemiology & Clinical Pharmacology, University of Utrecht, Utrecht, the Netherlands, 3508, TB
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK; NIHR Southampton Nutrition Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK, SO16 6YD, UK; NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, OX3 7LD, UK.
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Moon RJ, Lim A, Farmer M, Segaran A, Clarke NMP, Harvey NC, Cooper C, Davies JH. Validity of parental recall of children's fracture: implications for investigation of childhood osteoporosis. Osteoporos Int 2016; 27:809-13. [PMID: 26286627 PMCID: PMC4778270 DOI: 10.1007/s00198-015-3287-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/11/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED Fracture history is an important component of osteoporosis diagnosis in children. One in six parentally reported lifetime fractures in children were not confirmed on review of radiographs. Care should be taken to avoid unnecessary investigations for possible osteoporosis due to parental over-reporting of soft tissue injuries as fractures. INTRODUCTION The diagnosis of osteoporosis in children requires either a vertebral compression fracture, or a significant fracture history (defined as ≥2 long bone fractures <10 years or ≥3 long bone fractures <19 years, excluding high impact fractures) and low bone mineral density. As children with frequent fractures might benefit from further evaluation, we determined whether parental reports of lifetime fracture were accurate compared to radiological reports and if they appropriately selected children for further consideration of osteoporosis. METHODS Parents of children (<18 years) with a musculoskeletal injury completed a questionnaire on their child's fracture history, including age, site and mechanism of previous fracture(s). Radiological reports were reviewed to confirm the fracture. RESULTS Six hundred sixty parents completed the questionnaire and reported 276 previous fractures in 207 children. An injury treated at our hospital was recorded in 214 of the 276 parentally reported fractures. Thirty-four of 214 (16 %) were not a confirmed fracture. An injury was recorded for all parentally reported fractures in 150 children, but for 21 % children, there were inaccurate details (no evidence of fracture, incorrect site or forgotten fractures) on parent report. Eighteen of 150 children had a significant fracture history on parental report alone, but following review of radiology reports, 2 of 18 (11 %) did not have clinically significant fracture histories. CONCLUSIONS Approximately one in six fractures reported by parents to have occurred in their child's lifetime had not resulted in a fracture. One in nine children with a significant fracture history could have been investigated unnecessarily.
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Affiliation(s)
- R J Moon
- Paediatric Endocrinology, University Hospitals Southampton NHS Foundation Trust, Southampton, UK, SO16 6YD.
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK, SO16 6YD.
| | - A Lim
- Paediatric Endocrinology, University Hospitals Southampton NHS Foundation Trust, Southampton, UK, SO16 6YD
| | - M Farmer
- Paediatric Endocrinology, University Hospitals Southampton NHS Foundation Trust, Southampton, UK, SO16 6YD
| | - A Segaran
- Paediatric Endocrinology, University Hospitals Southampton NHS Foundation Trust, Southampton, UK, SO16 6YD
| | - N M P Clarke
- Paediatric Orthopaedics, University Hospitals Southampton NHS Foundation Trust, Southampton, UK, SO16 6YD
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK, SO16 6YD
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK, SO16 6YD
| | - J H Davies
- Paediatric Endocrinology, University Hospitals Southampton NHS Foundation Trust, Southampton, UK, SO16 6YD
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Huntley JS. Paediatric fracture clinic design--current practice and implications for change. BMC Res Notes 2014; 7:96. [PMID: 24555762 PMCID: PMC3933002 DOI: 10.1186/1756-0500-7-96] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 02/17/2014] [Indexed: 11/30/2022] Open
Abstract
Background In our region there has been considerable success in the redesign of adult fracture clinics. The aim of this study was to define our paediatric fracture clinic load, to assess the feasibility of increasing efficiency by decreasing inappropriate attendance. Findings Prospective case notes review of all attendees at 6 serial fracture clinics at the Royal Hospital for Sick Children (Glasgow) which has both local and tertiary referrals. Of 234 consecutive attendances across 6 fracture clinics, 34 (15%) were judged inappropriate: 13 had fractures not requiring orthopaedic follow-up (radial torus/clavicle/undisplaced metacarpal), and 21 had diagnoses or situations that were not appropriate. Of the 200 attendances deemed appropriate (172 fractures, 11 soft-tissue injuries, 9 infections and 8 acute atraumatic limps), there were 33 new referrals from the emergency department, and a further 39 were first-time attenders at the fracture clinic after an acute admission (37 were post-operative and 2 were non-operative). Of these 200, the treatment plan was changed for 67 (34%), a cast removed or exchanged for 92 (46%), and radiographs taken for 153 (77%). The overall discharge to return ratio was 76:158 (1:2.1), and for appropriate attenders 61:139 (1:2.3). Conclusions Tighter discipline can be applied to indications for fracture clinic appointments, including certain fracture types being discharged from the emergency department without unnecessary review - our particular fracture clinic numbers can be decreased by 15%. In the remaining attendances there are high radiograph and intervention rates, such that it seems unlikely that further reductions in attendance would be feasible.
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Affiliation(s)
- James S Huntley
- Department of Orthopaedics, Royal Hospital for Sick Children, University of Glasgow, Yorkhill, Dalnair Street, Glasgow G3 8SJ, UK.
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Affiliation(s)
- Per-Henrik Randsborg
- Department of Orthopaedic Surgery, Akershus University Hospital, NO-1478 Lørenskog, Norway.
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Kim SJ, Shin YW, Yang KH, Kim SB, Yoo MJ, Han SK, Im SA, Won YD, Sung YB, Jeon TS, Chang CH, Jang JD, Lee SB, Kim HC, Lee SY. A multi-center, randomized, clinical study to compare the effect and safety of autologous cultured osteoblast(Ossron) injection to treat fractures. BMC Musculoskelet Disord 2009; 10:20. [PMID: 19216734 PMCID: PMC2656455 DOI: 10.1186/1471-2474-10-20] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 02/12/2009] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We performed a multicenter, open, randomized, clinical study of autologous cultured osteoblast injection for long-bone fracture, to evaluate the fracture healing acceleration effect and the safety of autologous cultured osteoblasts. METHODS Sixty-four patients with long-bone fractures were randomly divided into two groups, i.e. those who received autologous cultured osteoblast injection and those who received no treatment. The sum of the difference in the callus formation scores after four and eight weeks, was used as the first efficacy variable. RESULTS The autologous cultured osteoblast injection group showed fracture healing acceleration of statistical significance, and there were no specific patient complications when using this treatment. CONCLUSION Autologous cultured osteoblast injection should therefore be considered as a successful treatment option for treating long-bone fracture.
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Affiliation(s)
- Seok-Jung Kim
- Department of Orthopedic Surgery, Catholic University College of Medicine, Seoul, Korea.
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Hamilton PD, Gaddipati M. Re: the socio-economical impact of paediatric fracture clinic appointments. Injury 2007; 38:642. [PMID: 17266960 DOI: 10.1016/j.injury.2006.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2006] [Accepted: 10/26/2006] [Indexed: 02/02/2023]
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