Reducing unnecessary fixation of midshaft clavicle fractures

PURPOSE

Displaced midshaft clavicle fractures have a non-union rate of 10-20%. Those who unite with conservative treatment have similar outcomes to those who undergo operative treatment; therefore, protocols to identify potential non-unions are important to avoid unnecessary surgery. The aim of this study is to report one such protocol.

METHODS

A protocol was introduced, where all isolated closed displaced midshaft clavicle fractures were initially managed non-operatively in a sling. At 2 weeks patients were assessed clinically and those who were struggling with their symptoms were offered surgery, with the remainder mobilised as comfortable. All cases treated at one centre over a three-year period, with a minimum follow-up of one-year underwent case note review.

RESULTS

Between 2015 and 2017 613 clavicle fractures were managed through clinic. 347 were middle third (56%), 75% were male, mean age 41(range16-97). Forty-one middle third clavicle fracture patients underwent early fixation. Eleven patients required late fixation for symptomatic delayed, non- or malunion, 6 for symptomatic non-unions and 1 was a symptomatic malunion. For displaced fractures the early operative rate was 17.8%, and symptomatic non/malunion rate was 3.2%. This led to a total operative rate of 21%.

CONCLUSION

A protocol for managing clavicle fractures has demonstrated an effective management of these injuries. It is cost-effective reducing the number of patients with displaced fractures requiring fixation with a fixation rate of 21% whilst reducing the rate of symptomatic non- and malunion (3.2%). The management pathway is simple and could be introduced into any orthopaedic outpatient department with ease.

P14 Acute management of traumatic anterior shoulder dislocations during COVID-19: are we meeting published national standards for treatment during the pandemic?

Background

BESS/BOA Patient Care Pathways provide national guidelines for acute management of traumatic anterior shoulder dislocations with respect to emergency reduction and clinic follow-up. COVID-19 posed challenges in terms of analgesia choice for reductions and altered follow-up arrangements. This study aimed to assess variance from the care pathway.

Methodology

We performed a retrospective case note analysis of all emergency presentations with acute traumatic anterior shoulder dislocations at the MTC in Bristol. We compared 01 Apr to 31 May in 2019 to the same period in 2020 to analyse the effects of the COVID-19 pandemic on the management of these injuries. Data parameters collated included examinations and imaging pre- and post-reduction, choice of analgesia, follow-up rates, referral to physiotherapy, and further imaging requested.

Results

We identified 32 patients in 2019, and 24 in 2020. Use of Entonox fell during the pandemic in favour of Penthrox. Use of conscious sedation (requiring full PPE) remained around 20%. Pre- and post-reduction orthogonal radiographs was near 100% in both cohorts. Referral to follow-up was 88% in 2019 but fell to 38% in 2020. Of those assessed in clinic during COVID-19, fewer were mobilised early or referred to outpatient physiotherapy compared to the previous year.

Conclusions

The acute management of anterior shoulder dislocations during the early COVID-19 pandemic faced two main challenges: choice of suitable analgesia whilst minimising AGPs; and limiting access to ’face-to-face’ follow-up to minimise hospital attendances. A key concern was a significant decrease in patient follow-up, thus limiting the access to optimal aftercare such as physiotherapy and further imaging.

P6 A proforma to improve the acute management of traumatic anterior shoulder dislocations to meet published national standards for treatment

Background

BESS/BOA Patient Care Pathways provide national guidelines for the acute management of traumatic anterior shoulder dislocations with respect to emergency reduction and follow-up assessment. COVID-19 posed increased challenges in terms of analgesia choice and altered follow-up arrangements. This study aimed to assess adherence to the care pathway and improve patient care.

Methodology

We retrospectively analysed all acute traumatic anterior shoulder dislocations at the MTC in Bristol. We collected data during 01/04/2019-31/05/2019 and 01/04/2020-31/05/2020 to analyse the quality of their management. Data parameters collated included examinations and imaging performance, choice of analgesia, follow-up rates, and physiotherapy referrals.

Results

We identified 32 patients in 2019, and 24 in 2020. Full neurovascular examinations pre- and post-reduction were poorly documented. Peri-reduction imaging utilization was near 100%. Referral to follow-up was 88% in 2019 but 38% in 2020. Of those assessed in clinic during COVID-19, fewer were mobilised early or referred to outpatient physiotherapy.

Conclusions

We have created a proforma/prompt to improve the quality of the management of these injuries, and successfully liaised with the Emergency Department for this to be included in their documentation. This proforma improves documentation quality, access to follow up and physiotherapy. During a ‘second wave’ we encourage patient access to BESS online resources.

Beware of glenoid dysplasia mimicking bone trauma in the injured shoulder

The term 'primary glenoid dysplasia' is used to describe a rare developmental abnormality of the shoulder. The symptomatic presentation of glenoid dysplasia has two definite age-related peaks. The first peak is in adolescents and young adults; they generally present with symptoms of instability related to high levels of activity. The second is in the fifth or sixth decade when presumed degenerative changes occur in the gleno-humeral joint. It can crop up as an incidental finding, during chest X-ray, for example, or may present as marked upper limb disability.This study reports an unusual presentation of this rare condition and describes it with clear illustrations of radiological and surgical investigations and treatment undertaken. It is presented as an 'aide-memoire' for orthopedic surgeons to consider this diagnosis when confronted with unusual X-rays or scans in their practice.

Propagation of stress fracture of the patella

Anterior knee pain in athletes is common and usually self limited. There should be a high index of suspicion and low threshold for special imaging in cases with acute onset and specific tenderness. The risk of propagation of stress fracture of the patella in athletes is highlighted. The case report presented illustrates the potential sequence of events.

Superior mesenteric artery syndrome following surgery for scoliosis

STUDY DESIGN

A retrospective report of three cases outlining upper intestinal obstruction as a rare complication following surgery for scoliosis.

OBJECTIVE

To present the clinical features, progression, and management of duodenal obstruction due to superior mesenteric artery compression after surgical treatment of scoliosis.

SUMMARY OF BACKGROUND DATA

Superior mesenteric artery or cast syndrome has been reported historically in the literature. Many causes are described, among which is the complication of the surgical and nonoperative treatment of scoliosis.

METHODS

Three adolescent patients were investigated for nausea and vomiting following surgical correction of scoliosis.

RESULTS

Contrast radiography confirmed extrinsic obstruction of the third part of the duodenum by the superior mesenteric artery in all three patients. They were jointly managed with the gastrointestinal surgeons. Two patients recovered with conservative treatments, but the third required operative intervention with a laparotomy.

CONCLUSIONS

Vomiting following surgery for scoliosis should be investigated thoroughly, as superior mesenteric artery syndrome carries significant morbidity, protracted hospital stay, and potential mortality.

A prospective, randomised study to compare extracorporeal shock-wave therapy and injection of steroid for the treatment of tennis elbow

We undertook a prospective, randomised study to compare the analgesic effect of injection of steroid and of extracorporeal shock-wave therapy (ESWT) for the treatment of tennis elbow. Group 1 received a single injection of 20 mg of triamcinolone with lignocaine while group 2 received 2000 shock waves in three sessions at weekly intervals. After six weeks there was a significant difference between the groups with the mean pain score for the injection group falling from 66 to 21 compared with a decrease from 61 to 35 in the shock-wave group (p = 0.05). After three months, 84% of patients in group 1 were considered to have had successful treatment compared with 60% in group 2. In the medium term local injection of steroid is more successful and 100 times less expensive than ESWT in the treatment of tennis elbow.