Clinical and Radiological Outcomes of Paediatric Forearm Fractures of the Radius and Ulna Following Fixation by Intramedullary Nailing or Plating: A Systematic Review

Ipsilateral forearm fractures of both the radius and ulna in children are one of the most common forms of injuries in this population. They often result from axial loading on the hand and wrist following a fall on an outstretched hand. These injuries can often be managed either conservatively or operatively. Non-operative management involves the use of cast immobilisation after satisfactory closed reduction. Most fractures managed conservatively have been noted to have a successful outcome. Surgical options of management include the use of intramedullary nailing (IMN), plates and screws, hybrid techniques and rarely external fixators. The purpose of this systematic review is to critically analyse the functional and radiological outcomes as well as the probability of developing a complication in children that have undergone either IMN or plating of both the radius and ulna in the paediatric population. A comprehensive electronic database search from April 2014 until April 2022 was conducted. Studies from PubMed, EMBASE and Cochrane electronic databases were retrieved. A total of 260 cohort studies with children between the ages of 5 to 17 years old were identified. After the application of both inclusion and exclusion criteria, six articles with a total of 409 patients relevant to this review were identified and analysed. There were no significant inconsistencies statistically in functional and radiological outcomes. Overall complication rate and time to fracture union were similar. Intramedullary nailing was noted to have a shorter operative and anaesthetic time, longer fluoroscopic exposure, and a better cosmetic outcome. Differences in bowing, radial bow magnitude and location had no overall bearing on rotation and daily activity. Considering the methodological limitations of this study, a larger sample size and higher level of evidence such as randomized control studies will yield a more conclusive result to resolve controversies. Based on currently available evidence, both plating and intramedullary nailing are excellent treatment modalities in both-bone forearm fractures.

Management of Cervical Spine Fractures: A Literature Review

The unique anatomy and flexibility of the cervical spine predispose it to a risk of injury. Trauma to the cervical spine encompasses a wide range of injuries from minor muscular strains to life-threatening fracture-dislocations associated with spinal cord lesions. Initial assessment and management should follow the Advanced Trauma Life Support (ATLS) protocols with adequate protection of the cervical spine through triple immobilisation to prevent any unnecessary movement, which can make the patient susceptible to further neurological injuries. Although the presence of cervical spine injury is very often overt, reliance on clinical examination alone is sometimes not sufficient and potentially requires further imaging. Clinical decision rules such as the Canadian C-Spine Rule are frequently used to risk-stratify patients needing radiography. The level of cervical spine instability and knowledge of their unique classification systems is of paramount importance and assists in the decision-making process to guide definitive management. In this review, we also propose an algorithm to aid the initial management of a patient with suspected cervical spine injury in the emergency department.

Factors Influencing Sex-Related Differences in the Quality of Life of Patients With Atrial Fibrillation: A Systematic Review

Atrial fibrillation (AF) is a growing public health concern, the impact of which is frequently underestimated. It has a profound effect on the quality of life (QoL) which appears to be disproportionately lower in female patients compared to men. We aim to explore the factors contributing to sex-related disparities in the QoL of AF patients by conducting a systematic review using the PubMed electronic search database. We used the following combination of medical subject heading (MeSH) parameters: “atrial fibrillation” and “sex” and “quality of life” with specific inclusion and exclusion criteria. We identified 13 relevant studies published between 2010 and 2020 for our review. These studies evaluated sex-related differences in QoL scores, symptom burden, and AF-related complications originating across different continents in Asia, Europe, and North America. We found that female patients reported a reduced QoL as compared to men and they were more likely to be older with multiple co-morbidities at presentation. Women also reported more frequent and severe symptoms, potentially explained by the greater prevalence of anxiety and depression and thus enhancing symptom perception. Moreover, they were less likely to be managed by anti-arrhythmic medications and invasive rhythm control strategies such as catheter ablation. Female patients with AF experienced more severe strokes, but no sex disparities were found in AF-related cognitive decline. We determined that the more prominent contributory factors towards a lowered QoL in female AF patients appear to be secondary to a higher burden and perception of symptoms as well as under-utilization of invasive treatment modalities. However, further studies are warranted to confirm these findings.

The London Major Trauma Network System: A Literature Review

Trauma is one of the leading causes of death and disability worldwide and is a major global public health problem. The provision of trauma care has been substandard in England and Wales prior to the implementation of an inclusive major trauma network system in London in 2010 and subsequently across the rest of England two years later. The implementation of the London trauma system has brought about improvements to the delivery of trauma care by decreasing the overall morbidity and mortality significantly. This framework encompasses the collaboration of emergency services, designated Major Trauma Centres (MTCs), Trauma Units (TUs) and community providers which have been optimized with the expertise and resources to provide the best outcomes for major trauma patients. Specific triage protocols, consultant-led trauma service and on-the-spot access to radiology services and operating theatres have played a pivotal role in the improvement of trauma care. In spite of several strengths, however, the London major trauma network system is by no means without its limitations. The emergence of the new coronavirus disease 2019 (COVID-19) pandemic has created major barriers to the smooth running of trauma services by exhausting resources due to infection control measures, reduced theatre space and re-deployment of medical staffs. In addition, the cancellation of elective surgeries has impacted directly on the training of surgical trainees by leaving them with significantly reduced surgical exposure. As a results of this ever changing surgical landscape, a need to urgently review these traditional surgical training methods with a view to modernize the curriculum. Although the London trauma system has evolved significantly since its implementation, its limitations should be recognized and addressed to enhance performance and improve patient outcomes.