Closed reduction and cast immobilization of overriding distal forearm fractures under nitrous oxide as conscious sedation without the use of imaging control

PURPOSE

The management of overriding distal forearm fractures is still controversial. This study aimed to evaluate the efficacy of immediate closed reduction and cast immobilization (CRCI) at the emergency department (ED) using equimolar nitrous oxide (eN2O2) as conscious sedation, and without the use fluoroscopic assistance.

METHODS

Sixty patients with overriding distal forearm fracture were included in the study. All procedures were performed in the ED without fluoroscopic assistance. Antero-posterior and lateral wrist radiographs were taken after CRCI. Follow-up radiographs were taken 7 and 15 days post-reduction, and at cast removal to evaluate callus formation. Depending on the radiological outcome, two groups of patients could be identified: Group 1 (satisfactory reduction and maintenance of alignment) and Group 2 (poor reduction or secondary displacement requiring further manipulation and surgical fixation). Group 2 was additionally divided into Group 2A (poor reduction) and Group 2B (secondary displacement). Pain was assessed using Numeric Pain Intensity (NPI) score, while functional outcome was measured according to Quick DASH questionnaire.

RESULTS

Mean age at the time of injury was 9.2 ± 2.4 years (range, 5-14). Twenty-three (38%) patients were aged between 4 and 9 years old, 20 (33%) patients between 9 and 11, 11 (18%) patients between 11 and 13, and 6 (10%) patients between 13 and 14. The mean follow-up time was 45.6 ± 12 months (range, 24-63). Satisfactory reduction with maintenance of alignment was achieved in 30 (50%) patients (Group 1). Re-reduction was performed in the remaining 30 (50%) patients (Group 2) due to poor reduction (Group 2A) or secondary displacement (Group 2B). No complications related to the administration of eN2O were recorded. No statistically significant difference could be identified between the three groups for any clinical variable (Quick DASH and NPI).

CONCLUSION

Overriding distal forearm fractures may be safely treated with CRCI at ED using eN2O2 as conscious sedation. However, fluoroscopic assistance during CRCI might significantly improve the quality of reduction thus avoiding further treatment as the lack of relaxed muscle can restrain reduction.

Drug Allergy Alert System in a Spanish University Hospital: Description and Dynamics of Use

INTRODUCTION

The drug allergy alert system reduces the frequency of adverse drug events, although it is subjected to collateral effects, since 80-90% of alerts are not real, and a large percentage of alerts are overridden (46.2-96.2%). We reviewed how the alert system is used at University Hospital Fundación Alcorcon (HUFA).

METHODS

Data were obtained from the drug allergy alert and the alert overriding notification forms (both in the period 2011-20). We also recorded drug allergy diagnoses at HUFA, drug consumption in primary care in 2016. We calculated the incidence of drug allergy alert activation, temporal trends in use, and correlations between the number of drugs in several datasets.

RESULTS

We collected 15,535 alerts. NSAIDs and penicillins were the drugs with the highest number of drug allergy alerts (36.55% and 26.91%, respectively). A correlation was found between the number of drug alerts and the type of drug allergy in HUFA in 2016. Only 6.83% of the alerts were removed, and, of these, 21.77% were reactivated. Approximately 100 overrides were recorded per year from 2016 (6.8% of 8,434 activated alerts during 2014-2020).

CONCLUSIONS

The number of drug allergy alerts recorded via the drug allergy alert system of HUFA correlates with the distribution of drug allergy diagnoses in the hospital, although many of the alerts could be false positives (as per current published evidence). We detected a very low frequency of removed alerts (6.83%), a relevant frequency of reactivations (one quarter), and a very low frequency of overrides (6.8%).

Treatment of the overriding fifth toe: Butler's arthroplasty is a good option

PURPOSE

The overriding fifth toe is a congenital triplane deformity that may cause aesthetic and functional concerns in children and adolescents. This study aims to evaluate the results obtained when using Butler's arthroplasty to treat this forefoot deformity.

METHODS

We performed a retrospective study, including all patients undergoing Butler's arthroplasty from January 1995 to December 2012. Clinical records were reviewed to determine age at date of surgery, gender, laterality, preoperative symptoms, success of deformity correction, postoperative pain, scarring, need for adapted shoe, rates of complications and recurrence. Patient satisfaction was evaluated through a telephone interview. All p-values < 0.05 were considered statistically significant.

RESULTS

A total of 21 patients were included in this study, the majority of which were male (57%), with a mean follow-up of 12 months (1 to 52). In the evaluation of the residual deformity (18 patients), 72% had excellent results, 17% good and 11% poor results. One patient had a keloid scar, three patients reported pain and three patients required adapted footwear. There was a partial recurrence of the deformity in three cases. The majority of patients (78%) were satisfied with the surgery. There was no statistically significant difference in terms of results, when comparing patients older and younger than seven years of age (p = 0.46).

CONCLUSIONS

Butler's operation is effective and safe in the treatment of the overriding fifth toe, yielding good functional results and patient satisfaction, with low rate of complications.

LEVEL OF EVIDENCE

IV.