This study aimed to assess the outcomes of patients with complex rib fractures undergoing operative or non-operative management at our center over a six-year time period.

Retrospective analysis was performed to identify all patients with complex rib fractures at our center from May 2016 to September 2022. Outcome measures included mechanical ventilation, tracheostomy, pneumonia, and mortality at one year.

388 patients with complex rib fractures were identified. 37 (10%) patients fulfilled criteria for surgical management and underwent rib fracture fixation; 351 patients were managed non-operatively with anaesthetic block or analgesia alone. The fixation group had a significantly higher proportion of patients with flail chest (30 (81%) vs 94 (27%), p<0.001) and were significantly more likely to require ICU admission (30 (81%) vs. 16 (5%), p<0.001) than the non-operative group. At one year follow-up, no significant differences were seen for mortality between these groups (1 (3%) vs. 27 (7%), p=0.276).

Of the surgical management group, those that underwent fixation <72 hours post injury were significantly less likely to develop pneumonia than those who were delayed >72 hours (2 (18%) vs 15 (58%), p=0.038), with downward trends noted for ICU length of stay (6 vs 10 days, p=0.140) and duration of mechanical ventilation (5 vs 8 days, p=0.177); no significant differences were seen for tracheostomy (3 vs. 5, p=0.588) or mortality (0 vs 1, p=0.856).

Surgical fixation of complex rib fractures improves outcomes in selected patient groups. Early surgical fixation led to reduced rates of pneumonia and may improve other outcome measures.

Historically rib fractures have been managed conservatively but over recent years evidence has continued to grow in support of fixation in select cases.

Rib fractures can affect patients’ ability to adequately ventilate and increase the morbidity and mortality of patients with multiple injuries. There is increasing evidence that rib fracture fixation in certain patients is of benefit, reducing length of stay both in the Intensive Care Unit (ICU) and overall hospital stay, as well as resulting in a decreased rate of tracheostomy and pneumonia.

We commenced rib fracture fixation two years ago as a combined procedure between Trauma Orthopaedics and Cardiothoracic surgery for carefully identified patients. We instituted a multi-disciplinary decision making process involving the Orthopaedic, Cardiothoracic and ICU teams. We present the initial results for these patients.

Fourteen patients with a total of 49 ribs were fixed between November 2015 and August 2017. Nine patients were acute and multiply injured, with five patients treated with delayed fixation for ventilation problems following non-union of existing fractures.

The average length of stay was 13 days. Follow up is ongoing with a mean follow up of 192 days. There have been no deep infections or acute complications and no incidence of peri-operative pneumothorax in this initial cohort. There have been no deaths, and all of these patients have since been discharged to their own home.

The initial outcomes following the introduction of this new procedure to our unit have been encouraging, although the long term results are awaited.

Acute Kidney Injury (AKI) is an increasingly prevalent complication of lower limb arthroplasty (LLA). Even a transient decrease in kidney function has been shown to be associated with increased mortality and development of subsequent Chronic Kidney Disease (CKD).

We set out to determine which perioperative factors are associated with AKI development at our institution through a retrospective cohort methodology. Patients who underwent primary elective LLA from 01/10/16 to 31/09/17 were included, with relevant perioperative data collected from electronic patient records. AKI was classified according to the Acute Kidney Injury Network (AKIN) criteria.

Overall 6.6% of 686 patients developed an AKI post-operatively. These individuals had a significantly longer length of stay (Median 7 days vs 5 days for no AKI [p<0.001]). Independent predictors of AKI on multivariate regression analysis included: Diabetes (OR 3.10, 95% CI 1.34 to 7.20; p=0.008) CKD (OR 5.07, 95% CI 2.60 to 9.86; p=<0.001) and male sex (OR female sex 0.33, 95% CI 0.17 to 0.63; p=0.001). A model including any of these three risk factors predicted 82.2% of patients with an AKI. The overall AKI rate for this model was 11.2% compared to 2.3% for those without any of the three criteria. Only 11% of patients had IV fluid continued beyond the recovery room.

AKI is a significant problem in LLA. Knowledge of associated risk factors will allow for targeted interventions to decrease AKI incidence. Continuation of IV fluids until the first post-operative morning for high risk individuals may be a simple method of reducing AKI.

Necrotising Fasciitis is a life threatening rapidly progressing bacterial infection of the skin requiring prompt diagnosis and treatment. Optimum care warrants a combination of antibiotics, surgical debridement and intensive care support. All cases of Necrotising Fasciitis over 10 years in the North East of Scotland were reviewed to investigate trends and learn lessons to improve patient care, with the ultimate aim of developing and implementing new treatment algorithms.

All cases from August 2006-February 2016 were reviewed using a combination of paper based and electronic hospital records. Data including observations, investigations, operative interventions, microbiology and clinical outcomes was reviewed and analysed with pan-specialty input from Microbiology, Infectious Disease, Trauma & Orthopaedics, Plastic Surgery and Intensive Care teams.

36 cases were identified, including 9 intravenous drug abusers. The mean LRINEC Score was 7. Patients were commonly haemodynamically stable upon admission, but deteriorated rapidly. 18/31 of cases were polymicrobial. Streptococcus Pyogenes was the most common organism in monomicrobial cases. 29/36 patients were discharged, 6 patients died acutely, giving an acute mortality rate of 17%. In total 6 amputations or disarticulations were performed from a total of 82 operations carried out on this group, with radical debridement the most common primary operation. The mean time to theatre was 3.54 hours. A grossly elevated admission respiratory rate (50 resp/min) was associated with increased mortality.

Necrotising fasciitis presents subtly, but carries significant morbidity and mortality. A high index suspicion allows timely intervention. We strongly believe that a pan-specialty approach is the cornerstone for good outcomes.

ERAS (Enhanced recovery after surgery) programs have been widely adopted in elective orthopaedic practice. Early discontinuation of Intravenous (IV) fluids in order to promote mobilisation and subsequent discharge is a key feature of such programs. However concerns have been raised regarding whether such an approach results in an increased risk of acute kidney injury (AKI).

We set out to determine the incidence of AKI in patients undergoing hip or knee arthroplasty treated as part of an ERAS program where IV fluids are removed before leaving the recovery room. Investigate whether there is a difference in incidence between patients with a pre-operative eGFR ≥ 60 or < 60 (ml/min/1.73m2). In addition to whether patients who sustain an AKI have a longer post-operative hospital stay.

The pre and post-operative blood results of patients undergoing elective total hip and total knee replacements were retrospectively analysed to determine whether they had suffered an AKI during admission. The patient's notes were reviewed for other known causes of peri-operative AKI and the length of their hospital stay.

The overall Incidence of AKI was 9.4%. There was a significant association found between pre-operative eGFR and development of an AKI p = 0.002. The incidence of AKI was 5.8% in patients with a pre-operative eGFR ≥ 60 vs 33.3% in those with an eGFR < 60. The development of an AKI was associated with a longer hospital stay p = 0.042. The median length of hospital stay was 7 days for those who suffered an AKI vs 5 days for those who did not.

Patients undergoing elective lower limb arthroplasty with a pre-operative eGFR < 60 treated as part of an ERAS program where fluids are discontinued before leaving the recovery room are at high risk of developing an AKI. Further studies are required to ascertain whether a longer duration of IV fluids is effective in reducing the incidence of AKI in this group.

Intro

Distal radial fractures are a commonly encountered fracture & anatomical reduction is the standard. Dorsal angulation is the traditional method of assessment but is inaccurate in rotated lateral xrays. Previously a relationship has been demonstrated between the dorsal cortex (DC) of the radius & the superior pole of the lunate (SL) & its sensitivity for assessing dorsal angulation & translation.

Regional anaesthesia, and the supplementation of either general or spinal anaesthesia with nerve block is well established and becoming increasingly more popular. Femoral, sciatic and obturator nerve blockade, in alone or in combination, by means of single shot or continuous infusion has been shown to significantly improve pain control and post operative nausea and vomiting (PONV). We identify equally significant morbidity associated with this practice, with delayed post operative rehabilitation, increase in length of stay, reduction in range of movement and local adverse symptoms at the site of injection and paraesthesia at 3 months post operatively.

2 surgeons were recruited to contribute 100 consecutive total knee replacements each to this study. Each worked exclusively with a one anaesthetist. Each had a predictable and different practice. One employed either spinal or general anaesthesia which the surgeon supplemented with end of operation infiltration of soft tissues in the surgical field including the capsule and skin incision with ropivacaine 300mg, adrenaline 500μg and ketorolac 30mg with normal saline added to make a volume of 100ml. The second employed either spinal or general anaesthesia but supplemented this with a single combined femoral and sciatic nerve block performed pre-operatively. Intravenous opiate analgesia administed via patient controlled analgesia pump for 24 hours post operatively, paracetamol 1g 6 hourly and ibuprofen 300mg 8 hourly where appropriate were prescribed by both anaesthetists. We recorded the incidence of insertion of urinary catheter, deep venous thrombosis diagnosed within 3 and 12 weeks, recovery of lower limb power to grade 5/5, range of movement achieved in each postoperative day and at 12 weeks post operatively, length of stay in addition to PONV and pain scores using the visual analogue scale (VAS) and collected every 6 hours. Localised pain and tenderness at the site of injection was noted at 12 weeks, and persistent paraesthesia.

As predicted patients in the group receiving nerve block has significantly less pain and post operative nausea and vomiting (p< 0.05). There was no statistically significant difference in the use of urinary catheters (p = 0.052) or the incidence of deep venous thrombosis (p=0.58). There was however a significant difference in the recovery of lower limb power (p = 0.023), range of movement recorded at 24hr intervals (p=0.038) (at 12 weeks p=0.54) and length of stay in hospital (0.038). One patient had an almost complete femoral nerve palsy at 12 weeks and required a manipulation under anaesthesia of her knee following recovery of same.

Nerve blockade is an increasingly popular method of controlling post-operative pain. We demonstrate some adverse effects on rehabilitation following this practice in addition to the increased financial and logistical burden of a longer inpatient stay.

Restoration of normal anatomy following a distal radial fracture is an important factor in determining functional recovery. However, current methods of assessing dorsal tilt and displacement require ‘true’ lateral radiographs, and important reference points are often obscured by metalwork.

Aims: To investigate if an easily identifiable and predictable relationship exists in the normal wrist between the distal radius and lunate; and if so, to compare fractured wrists (pre and postoperatively)using conventional and new assessment methods.

Methods: 22 patients with displaced distal radial fractures treated by ORIF, were included. Patients had pre and postoperative radiographs taken of the injured and uninjured wrists. From true lateral radiographs, measurements were performed using the PACS system. A line was superimposed upon the dorsal radial cortex at least 2cm proximal to the wrist and extending distally. The following measurements were performed: lunate height, distance from the ‘line’ to the superior and inferior poles of the lunate, and conventional measurements of dorsal tilt and angulation.

Results: Uninjured wrist: Most noticeably the dorsal radial line always passed superior to the lunate, mean distance of 3.27mm (1.75–6.6mm). As a ratio, the distance from the line to the superior pole of the lunate divided by the distance to the inferior pole (‘lunate ratio’) had a mean of 0.16 (0.11–0.19).

Fractured wrist, PreORIF: Using conventional methods, the mean fracture displacement was 2.64mm (0–5.1mm) and the mean dorsal tilt was 23.3 degrees(4 degrees volar tilt to 43 degrees dorsal tilt). Using the dorsal reference ‘line’, in all cases the lunate was either above or transected by the line; mean lunate ratio of 1.61 (0.54–8.05). The mean height of the lunate projecting dorsal to the line was 9.5mm (6.1–16.1mm).

Fractured wrist, PostORIF: Apart from one radiograph, the ‘line’ passed superior to the lunate; mean distance of 2.64mm (0–3.9mm), with a mean lunate ratio of 1.13 (0.61–2.74). These measurements correlated well with measurements of dorsal tilt and displacement.

Discussion: Our study suggests that there is a strong relationship between the distal radius and the lunate that could be used to assess fracture displacement and quality of reduction. Its main advantages are simplicity and ease of use despite the presence of metalwork.

Aim: To assess the ability of volar locking plates to maintain fracture reduction when used to treat dorsally displaced extra and intra-articular distal radial fractures.

Methods: This prospective study was conducted over a 12 month period. Consenting patients who had sustained a closed, dorsally displaced distal radial fracture, treated by open reduction and internal fixation using a volar distal radial locking plate, were included in the study. Radial inclination, volar tilt and ulnar variance were measured from radiographs taken at least 3 months after surgery and compared with radiographs of the uninjured side. Only two of the eight participating surgeons have a specialist interest in upper limb surgery.

Results: Thirty-three patients were included in the study. There were 23 females and 10 males. The mean age was 49.5 years, range 26–82 years. According to the OTA classification there were 19 Type A, 1 Type B and 13 Type C fractures. The mean restoration of volar tilt was 1° of under-correction, median 1.1° under-correction with a range of 7.3° of under-correction to 3.7° of over-correction, when compared with the uninjured side. The mean restoration of radial inclination was 1.9° of under-correction, median 1.6° under-correction with a range of 10° of under-correction to 8.4° of over-correction. As a group the mean ulnar variance was 0mm with a range of 2mm of relative ulnar shortening to 3.5mm of ulnar prominence when compared with the uninjured side.

Conclusion: In the hands of general trauma surgeons, the volar approach combined with the application of a suitable volar locking plate is a good treatment for restoring and maintaining the anatomy of dorsally displaced intra and extra-articular distal radial fractures.

Restoration of normal anatomy following a distal radial fracture is an important factor in determining functional recovery. However, current methods of assessing dorsal tilt and displacement require ‘true’ lateral radiographs, and important reference points are often obscured by metalwork.

Aims: to investigate if an easily identifiable and predictable relationship exists in the normal wrist between the distal radius and lunate; and if so,to compare fractured wrists (pre and postoperatively)using conventional and new assessment methods.

22 patients with displaced distal radial fractures treated by ORIF, were included. Patients had pre and postoperative radiographs taken of the injured and uninjured wrists. From lateral radiographs, measurements were performed using the PACS system. A line was superimposed upon the dorsal radial cortex 2cm proximal to the wrist passing distally. The following measurements were performed: lunate height, distance from the ‘line’ to the superior and inferior poles of the lunate, and conventional measurements of dorsal tilt and angulation.

Uninjured wrist: Most noticeably the dorsal radial line always passed superior to the lunate, mean distance of 3.27mm (1.75-6.6mm). As a ratio, the distance from the line to the superior pole of the lunate divided by the distance to the inferior pole (‘lunate ratio’) had a mean of 0.16 (0.11-0.19).

Fractured wrist, PreORIF: Using conventional methods, the mean fracture displacement was 2.64mm (0-5.1mm) and the mean dorsal tilt was 23.3 degrees(4 degrees volar tilt to 43 degrees dorsal tilt). Using the dorsal reference ‘line’, in all cases the lunate was either above or transected by the line; mean lunate ratio of 1.61 (0.54-8.05). The mean height of the lunate projecting dorsal to the line was 9.5mm (6.1-16.1mm).

Fractured wrist, PostORIF: Apart from one radiograph, the ‘line’ passed superior to the lunate; mean distance of 2.64mm (0-3.9mm), with a mean lunate ratio of 1.13 (0.61-2.74). These measurements correlated well with measurements of dorsal tilt and displacement.

Our study suggests that there is a strong relationship between the distal radius and the lunate that could be used to assess fracture displacement and quality of reduction. Its main advantages are simplicity and ease of use despite the presence of metalwork.