Fractures In Emergency Department Research Articles

Ultrasound-guided femoral nerve block versus fascia iliaca compartment block for femoral fractures in emergency department: A randomized controlled trial.

Femoral fractures are one of the most debilitating injuries presenting to the emergency departments (EDs). The pain caused by these fractures is typically managed with opioids and adjunctive regional analgesia. These approaches are often associated with adverse side effects. Thus, appropriate alternative methods should be thoroughly investigated. To evaluate ultrasound-guided femoral nerve block (FNB) with ultrasound-guided fascia iliaca compartment block (FICB) in femoral fractures, to determine which provides better analgesia and less opioid requirement. This study was a randomized clinical trial performed on adult patients presenting to the ED within 3 h of isolated femoral fracture with initial numerical pain rating scale (NRS-0) score of more than 5. The patients were randomized to receive FNB or FICB. The outcomes were block success rates, pain at 20 (NRS-20) and 60 (NRS-60) min after the end of the procedures, as well as the number and total dose of fentanyl administration during ED stay. Eighty-seven patients were recruited (40 FNB and 47 FICB). Success rates were 82.5% in FNB and 83.0% in FICB group, with no significant difference between the groups. NRS-20, NRS-60, the number of patients who received supplemental fentanyl, and the total dose of administered fentanyl were significantly lower following FNB. However, the length of the procedure was significantly lower in the FICB group. Both FNB and FICB are effective in pain reduction for fractures of femur, but FNB provides more pain relief and less need for supplemental fentanyl.

Comparative Study of Radial and Median Nerve Blocks with Hematoma Block under Ultrasound Guide in Distal Radius Fracture Reduction: A Randomized Clinical Trial.

Distal radius fractures are one of the most common upper extremity fractures, and their incidence continues to increase due to an aging population and an increase in osteoporosis. Various methods of analgesia for distal radius fractures have been described-including hematoma blocks and nerve blocks. Hematoma blocks are a simple and effective method of providing analgesia; nonetheless, their efficacy may be limited in some cases. On the other hand, nerve blocks provide more targeted analgesia and may be more effective in reducing pain during fracture reduction. This study aimed to compare the analgesic effectiveness of radial and median nerve blocks with hematoma blocks under ultrasound guidance in treating distal radius fractures. Also, this study aimed to compare the analgesia of radial and median nerve blocks with hematoma blocks under ultrasound guidance to reduce distal radius fractures. In this prospective trial, patients with distal radius fractures referring to 2 academic centers were placed into 2 randomized groups, including hematoma block, and radial median block, both of which were ultrasound-guided. The patient's pain levels were measured and recorded based on the visual analog scale before the block, 5, 10, and 15 minutes after the block, at the start of reduction, during reduction, and 5, 10, and 15 minutes after reduction. Patient satisfaction and physician satisfaction rates were assessed, and side effects were also observed for 1 week. Quantitative variables were reported as mean ± standard deviation, and number and frequency percentages were reported for qualitative variables. The Student t test and the chi-square test were used on a case-by-case basis. The significance level was set at P ˂ 0.05. In this study, 120 patients were included. The groups had no significant differences in pain reduction during the procedure. Analgesic medication was needed during the procedure for 17 patients; nerve blocks were applied for 6 patients, and hematoma blocks for 11 patients, which was statistically significant (P = 0.041). Satisfaction rates for patients and physicians performing the procedure were significantly higher in the nerve block group than in the hematoma block group ( P = 0.001; P ˂ 0.001, respectively). The results of this study suggest that ultrasound-guided radial and median nerve blocks can be used as alternative methods of analgesia with other techniques in the reduction of distal radius fractures in emergency departments.

752 How Do We Manage Open Fractures in Emergency Department? – a Closed Loop Audit

Abstract Aim Patient with an open fracture is resuscitated mainly by the emergency physician prior to being referred to the relevant surgical specialties. Yet, there is lack of uniform guidance in managing open fractures. This audit aimed to evaluate the existing guidelines at the emergency department. Method A retrospective search was performed at the Tertiary trauma center. Four main parameters were evaluated 1.) the photo documentation. 2.) Antibiotic administration rate 3.) Tetanus prophylaxis utilisation. 4.) Systematic evaluation of neurovascular status pre and post splint. Results 41 patients (M: F, 63%:37%) were analysed. The most common open-fracture were lower-limb long bone (39%) and phalanx (39%) , followed by upper-limb long bone fracture (9.8%), head (7.3%), facial (2.4%) and pelvis (2.4%). Multiple fractures were seen in 20.9%. Multiple open fractures were only seen in 1 case. The average transfer time by ambulance to the hospital was 116 mins. 97.5% of open fractures received antibiotics: 13.3%, 60%, and 100% of patients received antibiotics respectively within 1hr, 3hr, and 6hr from the time of injury. 48.8% received tetanus prophylaxis, and only 4.87% have documented tetanus assessment. 100% has a neurovascular examination. 72% of open fractures required surgical intervention. The average time to the theatre was 16.7 hours. Conclusions Antibiotic administration within the first hour from the timing of the injury is not practical in real-life situations. Future work should focus on creating a universe open fracture grading system, beyond lower-limb fracture, to better inform clinicians of the prognosis of open fracture and help with risk stratification.

Efficacy of Hematoma Block VS Conscious Sedation in Terms of Pain Relief for Manipulation and Reduction of Distal Radius Fracture

Objective: To compare the efficacy of hematoma block versus conscious sedation for closed reduction of distal radius fractures. Study Design and Setting: This was a Randomized Control Trial was conducted at Dr. Ziauddin University Hospital between 1st July 2018 and 31st July 2020. Methodology: A total of 158 patients underwent closed reduction of distal radius fractures in emergency department; these patients were divided in two groups of 79 each. Hematoma block was used as an analgesic in group A whereas conscious sedation was used on the patients in group B. Both groups were then compared for effectiveness in terms of pain reduction and SPSS software version 25 was used for data analysis. Results: Median age in group A was 44 years (IQR=37-48.5 years) and 40 years (IQR=30-47.50 years) in group B. The median pain score in group A [3 (IQR=2-5)] was significantly lesser than group B [5 (IQR=3-6)] with p=0.001. In group A effectiveness was achieved in patients was 69.6% and in group B effectiveness was achieved in patients was 35.44%. Statistically there was significant difference observed in proportion of efficacy between groups with p=0.001. Conclusion: This study show that hematoma block is more effective than conscious sedation in closed manual reduction of distal radius fractures in terms of pain relief.

Profiles of patients with maxillofacial fractures in emergency department of head and neck surgery division of Dr. Soetomo General Hospital Surabaya in 2021 during COVID-19 pandemic

Background: Maxillofacial fracture is the most common injury in head and neck trauma patients. The Coronavirus disease 2019 (COVID-19) pandemic affects many sectors including restrictions on community mobility. This study aims to determine the profile of patients with maxillofacial fractures during the COVID-19 pandemic. Methods: This descriptive observational study will evaluate the profile of maxillofacial fracture patients who came to the Emergency Department of Head and Neck Surgery Division of Dr. Soetomo General Hospital Surabaya in 2021. Results: Subjects were grouped by gender, age, month of visit and trauma mechanism. The ratio of prevalence between males and females was 5.7:1. The highest age distribution was in the range of 21-30 years (29.8%). Based on the month, the highest number of patients was in January (19.1%). Traffic accidents are the most frequent mechanism of injury by 85.1%. Isolated maxillofacial fractures occur mostly in the mandible by 47.6% and in multiple maxillofacial fractures on the maxillary bone by 76.9%. Associated trauma was found in 78.7% of the subjects, with the highest pattern being intracranial trauma as much as 34.1%. Conclusion: There was a decreasing incidence of maxillofacial fracture cases in 2021. The highest prevalence was in males and most of the patients were in 21-30 years age group.

Antibiotic Sensitivity Against Klebsiella spp. in the Post Debridement Culture an Open Fracture in Emergency Department of dr. Soebandi Hospital Jember

Surgical site infection (SSI) in open fracture is often caused by bacterial contamination in the management of open fracture. Because of that, one of the most important thing in handling open fracture is debridement. Prophylactic antibiotics given are Cephalosporin and Aminoglycosides. Post-debridement culture is important in predicting the incidence of infection. One of the bacteria that is often found in post-debridement culture is Klebsiella spp. which can produce ESBL to fight β-lactam class of antibiotics. The purpose of this study was to determine antibiotic sensitivity against Klebsiella spp. in the post-debridement culture of cases of open fractures in the emergency department of dr. Soebandi hospital Jember. This study uses a laboratory exploratory research design. The sample of this study was the isolate of Klebsiella spp. which amounts to 5 from post debridement culture of open fracture patients in the emergency department of dr. Soebandi hospital Jember from March to May 2019.The method used is diffusion (Kirby Baurer) by matching using the CLSI standard table to determine sensitive, intermediate, or resistant. The results of this study showed that most antibiotics had resistance to Klebsiella spp., including β-lactam antibiotics, such as Amoxicillin, Ceftriaxone, Cefixime, Penicilin, Meropenem, and Cefadroxil. Vancomycin antibiotics are still sensitive to Klebsiella spp. in all patients. Gentamicin, Ciprofloxacin, Tetracycline, and Chloramphenicol antibiotics were sensitive in 1 patient. Erythromycin intermediates antibiotics against Klebsiella spp.. The conclusion of this study is that all β-lactam group antibiotics are resistant to Klebsiella spp while the most sensitive antibiotic is Vancomycin.

Hip effusions or iliopsoas hematomas on ultrasound in identifying hip fractures in the emergency department

ObjectiveWe evaluated the sensitivity, specificity, predictive values, and likelihood ratios of hip effusion and/or iliopsoas hematoma on point-of-care ultrasound (POCUS) performed by ultrasound fellows and fellowship trained emergency providers to identify hip fractures in emergency department (ED) patients with a high suspicion of hip fracture. MethodsThis was a prospective observational study of a convenience sample of patients with high suspicion of hip fracture at two academic EDs between 2018 and 2021. Patients with negative x-rays who did not receive further imaging with magnetic resonance imaging (MRI) or computed tomography (CT) were excluded. Sonographers were blinded to clinical data and ED imaging results. At the primary site, 8 ultrasound fellows and 4 emergency ultrasound fellowship-trained emergency providers performed the ultrasonographic examinations. At the secondary site, 2 ultrasound fellows, 4 emergency ultrasound-fellowship trained physicians, and 1 sports medicine fellowship-trained emergency provider performed the ultrasonographic examinations. A positive ultrasound was defined as either the presence of a hip effusion or iliopsoas hematoma on the affected extremity. The primary outcome measures were sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) of POCUS findings for identification of a hip fracture compared with a ranked composite reference standard consisting of x-ray, CT, or magnetic resonance imaging (MRI); the highest-level test performed for each patient was used for comparison. ResultsAmong 213 patients analyzed, all 213 received an x-ray, 116 received a CT scan, and 14 received an MRI; 113/213 x-rays (53.1%), 35/116 CT scans (30.2%), and 7/14 MRIs (50.0%) were positive for a hip fracture. A total of 123 patients were diagnosed with a hip fracture (57.7%). There were 13 false negative x-ray results. Overall, compared with the reference standard of x-ray, CT, or MRI, POCUS had a sensitivity of 97% (95% CI: 94%, 100%), specificity of 70% (95% CI: 61%, 79%), PPV of 82% (95% CI: 75%, 88%), and NPV of 94% (95% CI: 88%, 100%) in the identification of hip fractures; with a positive likelihood ratio of 3.22 (95% CI: 2.35, 4.43) and negative likelihood ratio of 0.05 (95% CI: 0.02, 0.12). ConclusionIn a convenience sample of ED patients with high clinical suspicion for hip fracture, the presence of a hip effusion and/or iliopsoas hematoma on POCUS performed by expert emergency ultrasonographers showed high sensitivity in diagnosing patients with a hip fracture.

Profile of Patients with Maxillofacial Fracture in Emergency Department, Head-Neck Surgery Division, Dr. Soetomo Public Hospital Surabaya in 2020

Maxillofacial fracture is the most common form of injury in trauma patients, especially in patients with motor vehicle accidents. The COVID-19 pandemic has affected various sectors, including restrictions on people's mobility. This study aims to determine the profile of patients with maxillofacial fractures during the COVID-19 pandemic. A descriptive observational study was conducted to evaluate maxillofacial fracture patients who came to the Emergency Department of the Head-Neck Surgery Division of the Dr. Soetomo Surabaya Hospital in 2020. Subjects were grouped according to sex, age, month of visit and the mechanism of trauma. The ratio between men and women was 4.92:1. The largest age distribution is in the 11-20 years range, as much as 39.2%. The most distribution based on the month of visit was in February as much as 16.9%. Most trauma mechanisms were due to traffic accidents (90.1%). Most locations in single maxillofacial fractures in maxillary bone were 37.8% and multiple maxillofacial fractures in zygoma bones were 79.4%. Accompanying trauma was found in 73.2% of subjects, with the highest pattern of intracranial trauma as much as 80.8%. The incidence of single maxillofacial fractures was 47.9% and multiple maxillofacial fractures were 52.1%, with concomitant trauma occurring in 73.2% of subjects.

Prevalence of inadequate vitamin D level and its predictors in children presenting with torus fractures.

Review of the published articles does not show any study done to see if children with torus fracture are with Vitamin D deficiency. The aim of this study was to determine association of inadequacy of Vitamin D level with torus fracture and its predictors in children in Karachi Pakistan. Patient underage of 13years came with torus fracture were included in study, and managed non-operatively with below elbow cast. Proforma was made which includes demographic data (age, gender, nutritional status) and exposure to sunlight, dietary habits, kind to apparel and type of accommodation they were living at. All participants underwent measurement of serum vitamin D level. Out of 558 children presented with limb fractures in emergency department, 190 (34.05%) had torus fracture, with mean age of 6.0 ± 4.2years. 93 (48.94%) in pre-school group, 59 (31.05%) in school and 38 (20%) were breast-fed. On nutritional status, malnourished were 72 (37.89%), out of which 32 (44.44%) had first-degree malnutrition. On vitamin D level status only 52 (27.36%) participants had Vitamin D within normal range while 86 (45.26%) were found Vitamin D deficient. We found that vitamin D level is directly related to nutritional status, duration of sun exposure maternal vitamin d levels and not significantly related to age, gender, type of accommodation and different fabric types. In this study torus fracture in children is significantly associated with Vitamin D deficiency, with common predictors including nutritional status, maternal Vitamin D level for lactating mothers and duration of exposure of sunlight. Vitamin D supplementation in children can prevent a significant number of fractures via national programs for food fortification and increase the awareness of general population on the importance of sunlight exposure and intake of food rich in Vitamin D.

Diagnostic Accuracy of the Sonographic Ottawa Foot and Ankle Rules for Ankle and Foot Fractures in Emergency Department

Diagnostic Accuracy of the Sonographic Ottawa Foot and Ankle Rules for Ankle and Foot Fractures in Emergency Department

The diagnostic performance of ultra-low-dose 320-row detector CT with different reconstruction algorithms on limb joint fractures in the emergency department.

The aim of the study was to evaluate whether ultra-low-dose computed tomography (ULD-CT) could replace conventional-dose CT (CD-CT) for diagnosis of acute wrist, ankle, knee, and shoulder fractures in emergency departments (ED). We developed CD-CT and ULD-CT scanning schemes for the various joints of the four limbs and scanned emergency patients prospectively. When performing CD-CT, a conventional bone reconstruction algorithm was used, while ULD-CT used both soft tissue and bone algorithms. A five-point scale was used to evaluate whether ULD-CT image quality affected surgical planning. The image quality and diagnostic performance of different types of scanned and reconstructed images for diagnosing fractures were evaluated and compared. Effective radiation dose of each group was calculated. Our study included 56 normal cases and 185 fracture cases. The combination of bone and soft tissue algorithms on ULD-CT can improve diagnostic performance, such that on ULD-CT, the sensitivity improved from 96.7% to 98.9%, specificity from 98.2% to 100%, positive predictive value from 99.4% to 100%, negative predictive value from 90.2% to 96.6% and diagnostic accuracy ranged from 97.5% to 99.1%. There were no statistically significant differences between ULD-CT and CD-CT on diagnostic performance (p values, 0.40-1.00). The radiation doses for ULD-CT protocols were only 3.0-7.7% of those for CD-CT protocols (all p < 0.01). In the emergency department, the 320-row detector ULD-CT could replace CD-CT in the diagnosis of limb joint fractures. The combination of bone algorithm with soft tissue algorithm reconstruction can further improve the image quality and diagnostic performance.

A clinical decision aid for patients with suspected midfacial and mandibular fractures (the REDUCTION-I study): a prospective multicentre cohort study

PurposeTo assess physical examination findings related to maxillofacial trauma to identify patients at risk of midfacial and mandibular fractures and then to construct a clinical decision aid to rule out the presence of midfacial and mandibular fractures in emergency department patients.MethodsWe performed a prospective multicentre cohort study in four hospitals in the Netherlands, including consecutive patients with maxillofacial trauma. Each patient received a standardized physical examination consisting of 15 and 14 findings for midfacial and mandibular traumas, respectively. Consequently, clinical decision aids were constructed with the focus being on ruling out the presence of midfacial and mandibular fractures, and diagnostic accuracy was calculated.ResultsA total of 993 consecutive patients were identified of whom 766 and 280 patients were suspected of midfacial and mandibular fractures, respectively. Midfacial fractures were diagnosed in 339 patients (44.3%), whereas mandibular fractures were observed in 66 patients (23.6%). The decision aid for midfacial trauma consisting of peri-orbital hematoma, epistaxis, ocular movement limitation, infra-orbital nerve paresthesia, palpable step-off and tooth mobility or avulsion, produced a sensitivity of 89.7 (86.0–92.5), a specificity of 42.6 (38.0–47.4), and a negative predictive value of 83.9% (78.4–88.2). The decision aid for mandibular trauma consisting of the angular compression test, axial chin pressure test, objective malocclusion, tooth mobility or avulsion and the tongue blade bite test resulted in a sensitivity of 98.5 (91.9–99.7), a specificity of 34.6 (28.5–41.2), and a negative predictive value of 98.7% (92.8–99.8).ConclusionThe constructed clinical decision aids for maxillofacial trauma may aid in stratifying patients suspected for midfacial and mandibular fractures to reduce unnecessary diagnostic imaging.Clinical Trial RegistrationThe study was registered at ClinicalTrials.gov with the identifier NCT03314480.

Efficacy of fascia iliaca nerve block in daily routine for children with femoral fractures in a pediatric emergency department

ObjectivesWe aimed to evaluate the efficacy of fascia iliaca nerve block (FINB), routinely used for children with femoral fractures, in a pediatric emergency department (PED). MethodsThis retrospective, single-center, observational study examined FINB using ropivacaine and a 1% lidocaine hydrochloride solution, in all patients under 18 years of age admitted with a femoral fracture from January 2012 to December 2016. Pain was assessed using two validated pediatric pain scales: EVENDOL or a visual analog scale. A level of ≥ 4 on either scale indicates the need for an analgesic. The primary outcome was the percentage of patients who were pain free after the FINB procedure defined by a pain score of < 4. Secondary outcomes were the time spent between PED admission and FINB, the need of additional analgesics, side effects, and the success rate of FINB. ResultsOf 161 patients screened, 144 were included. The median age was 3.2 years (range 2 months to 16 years) and 74% were boys. The number of children determined to be pain free (pain score < 4) increased from 36 (25%) before the FINB to 123 (85%) after the FINB (absolute risk difference 60%, 95% CI: 51%–70%). Overall, 21 children (15%) required a second analgesic after the FINB. ConclusionThe routine use of FINB with ropivacaine and lidocaine by pediatric ED physicians provided effective pain relief for children admitted for a femoral fracture in the emergency department. Our data support the efficiency and feasibility of FINB for the antalgic management of children with femoral fracture.

Wrist Reduction Instruction with Simulation Technology For Emergency Medicine Residents

Introduction: Distal radius (Colles’) fractures account for one-sixth of all adult fractures and one-third of pediatric fractures in Emergency Departments (ED). One-third of ED-reduced Colles fractures are inadequately reduced and require further treatment. In light of orthopedic simulation literature supporting realistic Colles' fracture management with reliable performance metrics, the investigators implemented an interdisciplinary simulation-based training intervention to improve Emergency Provider (EP) Colles' fracture reduction skills. Methods: Twenty eligible EPs with limited Colles’ fracture reduction experience were enrolled from 2016 to 2017 at a single tertiary academic center. Learner performances were assessed using a commercial Colles’ fracture simulator model and a mini-C arm to measure post-reduction fracture angulation and displacement. Learners completed a baseline-simulated reduction and a repeat-simulated reduction, then received a video didactic on expert distal radius reduction techniques, followed by a third reduction. The differences in post-reduction measurements were compared across the subjects' three reductions with a one-way ANOVA. Acceptable angulation ranges were 10° dorsal angulation and 5° radial angulation. Results: Learners exhibited significant improvements in completing adequate simulated reductions with respect to adequate AP (anterior-posterior) displacement and lateral displacement (p<0.005); composite scores for reduction adequacy showed improvement (p=0.003). Post-reduction measurements across simulations improved for AP angulation, lateral angulation, and lateral displacement (p<0.05). Conclusion: The use of a Colles’ fracture model with video didactic and hands-on support from senior orthopedic clinicians can improve EP reduction performance. Future studies will be required to determine the educational intervention knowledge retention rate, patient outcomes, and inter-facility patient transfers for orthopedic consultations.

Pain Passport as a tool to improve analgesic use in children with suspected fractures in emergency departments.

BackgroundIn the emergency department (ED), adequate pain control is essential for managing patients; however, children with pain are known to receive less analgesia than adults with pain. We introduce the Pain Passport to improve pain management in paediatric patients with suspected fractures in the ED.MethodsThis was a before-and-after study. We reviewed the medical records of paediatric patients who were primarily diagnosed with fractures from May to August 2015. After the introduction of the Pain Passport, eligible children were enrolled from May to August 2016. Demographics, analgesic administration rates, time intervals between ED arrival and analgesic administration, and satisfaction scores were obtained. We compared the analgesic prescription rate between the two periods using multiple logistic regression.ResultsA total of 58 patients were analysed. The baseline characteristics of subjects during the two periods were not significantly different. Before the introduction of the Pain Passport, 9 children (31.0%) were given analgesics, while after the introduction of the Pain Passport, a significantly higher percentage of patients (24/29, 82.8%) were treated with analgesics (P < 0.001). The median administration times were 112 (interquartile range [IQR], 64-150) minutes in the pre-intervention period and 24 (IQR, 20-74) minutes in the post-intervention period. The median satisfaction score for the post-intervention period was 4 (IQR, 3-5). The adjusted odds ratio for providing analgesics in the post-intervention period was 25.91 (95% confidence interval, 4.36-154.02).ConclusionsPatient-centred pain scoring with the Pain Passport improved pain management in patients with suspected fractures in the paediatric ED.

Sedoanalgesia Versus Infraclavicular Block for Closed Reduction of Pediatric Forearm Fracture in Emergency Department: Prospective Randomized Study.

Procedural sedoanalgesia is commonly used in pediatric patients in the emergency department (ED) for interventional procedures, diagnosis, and treatment. However, this method causes serious systemic complications, such as respiratory and cardiac depression. To minimize these complications, ultrasound-guided regional anesthesia methods have been used in recent years. We aimed to compare the use of procedural sedoanalgesia (PSA) and infraclavicular block (ICB) in the pain management of pediatric patients who underwent closed reductions of forearm fractures. This prospective, randomized, clinical study included patients aged 3 to 15 years who presented to the ED with forearm fractures. The patients were divided into 2 groups: the procedural sedoanalgesia group (group PSA, n = 30) and ultrasound-guided ICB group (group ICB, n = 30). Pain scores of the patients were evaluated using the Wong-Baker FACES Scale before and during the procedure. Pain scores and parental and operator satisfaction were compared between the groups. There was no statistical significance in terms of demographic data. The pain scores observed during the procedures were significantly higher in the group PSA than in the group ICB (3.07 ± 1.55 vs 0.47 ± 0.86, respectively; P < 0.001). The parental and operator satisfaction of the ICB group was significantly higher than that of the PSA group (P < 0.001). Ultrasound-guided ICB is a safe and effective method in the management of pain during closed reduction of forearm fracture in pediatric patients in EDs. It can be used safely in emergency rooms and has a high level of both parental and operator satisfaction.

Radiologic discrepancies in diagnosis of fractures in a Dutch teaching emergency department: a retrospective analysis

BackgroundMissed fractures in the emergency department (ED) are common and may lead to patient morbidity.AimTo determine the rate and nature of radiographic discrepancies between ED treating physicians, radiologists and trauma/orthopaedic surgeons and the clinical consequences of delayed diagnosis. A secondary outcome measurement is the timeframe in which most fractures were missed.MethodsA single-centre retrospective analysis of all missed fractures in a general teaching hospital from 2012 to 2017 was performed. Data regarding missed fractures were provided by the hospital’s complication list and related database. Additional data were retrieved from the electronic medical records as required for the study.ResultsA total of 25,957 fractures were treated at our ED. Initially, 289 fractures were missed by ED treating physicians (1.1%). The most frequently missed fractures were the elbow (28.6%) and wrist (20.8%) in children, the foot (17.2%) in adults and the pelvis and hip (37.3%) in elderly patients. Patients required surgery in 9.3% of missed fractures, received immobilization by a cast or brace in 45.7%, had no treatment alterations during the first week in 38.1%. Follow-up data were lacking for 6.9% of cases. 49% of all missed fractures took place between 4 PM and 9 PM. There is a discrepancy in percentages of correctly diagnosed fractures and missed fractures between 5 PM and 3 AM.ConclusionAdequate training of ED treating physicians in radiographic interpretation is essential in order to increase diagnostic accuracy. A daily multidisciplinary radiology meeting is very effective in detecting missed fractures.

Kinesiotaping for isolated rib fractures in emergency department

IntroductionRib fractures, which are among the most common injuries in blunt thoracic trauma, are usually encountered in Emergency Departments. Kinesiotape (KT) is a drug-free elastic therapeutic tape used for treating various musculoskeletal problems such as injury, dysfunction and pain. We aimed to investigate whether kinesotaping should be used safely and effectively in rib fractures in emergency setting. Materials and methodsThis was a prospective, randomized controlled study conducted in an Emergency Department of a University Hospital. Patients diagnosed with isolated rib fractures were included in the study. Pain severity of patients assessed with 0–10 cm visual analog scale (VAS), then patients assigned into 2 treatment groups. One of them received treatment with flurbiprofen 200 mg/day and the other group received kinesiotaping in addition to the same oral therapy. On the 4th day of the procedure, both groups were assessed with VAS in the followup visit. ResultsTotal of 82 patients presented with rib fractures, 52 of them were excluded. Remaining 30 constituted the study group and randomly allocated to kinesiotaping (n = 16) or control group (n = 14). In both groups, pain intensity on the 4th day was significantly reduced when compared with baseline (p for both<0.01). Additionally, considering the reducing the pain intensity on 4th day, kinesiotaping was significantly superior than the control group (p < 0.01). ConclusionThis study investigated the use of kinesiotaping in emergency departments. When compared to NSAID therapy alone, combined kinesiotaping and NSAID therapy appears to be more effective in terms of pain reduction in rib fractures.

Assessment and management of patients with tibial plateau fractures in emergency departments.

Tibial plateau fractures are complex injuries and relatively common presentations in emergency departments (EDs), yet the diagnosis is not always obvious. Patients with this injury are managed increasingly in EDs by registered advanced nurse practitioners (RANPs), who are recognised in Ireland as senior clinical decision-makers. RANPs are broadening their scope of practice to maximise their responses to current and emerging challenges in healthcare services. They use a range of skills, including taking comprehensive health histories, problem solving, clinical decision-making and using their expert judgement to diagnose and create management plans for patients who attend EDs. In Ireland, RANP is a protected title and practitioners work within an agreed scope of practice, meeting criteria set by the Nursing and Midwifery Board of Ireland to register. RANPs ensure continuity of care, improve the quality of care, provide a quick response to patient care, reduce waiting times and improve flow of patients through EDs. The main scope of RANPs' practice in emergency care includes management of patients with non-life-threatening limb conditions or injures, such as a tibial plateau fracture. This article gives an overview of tibial plateau fractures, including anatomy, and presents a case study to analyse critically the management of a patient with this injury and the care provided by a RANP. In the context of the case study, the article reviews the RANP's diagnostic decisions and the available management options.

Applications and critical evaluation of fascia iliaca compartment block and quadratus lumborum block for orthopedic procedures.

SUMMARYAnterior section of the hip joint capsule is innervated by femoral nerve and obturator nerve, and posterior section is innervated by the nerve to quadratus femoris muscle and occasionally by the superior gluteal (posterolateral region) and sciatic nerve (posterosuperior region). One of the regional anesthesia options for hip surgery is the fascia iliaca compartment block (FICB) that affects nerves important for hip innervation and sensory innervation of the thigh - femoral, obturator and lateral femoral cutaneous nerve. FICB can be easily performed and is often a good solution for management of hip fractures in emergency departments. Its use reduces morphine pre-operative requirement for patients with femoral neck fractures and can also be indicated for hip arthroplasty, hip arthroscopy and burn management of the region. Quadratus lumborum block (QLB) is a block of the posterior abdominal wall performed exclusively under ultrasound guidance, with still unclarified mechanism of action. When considering hip surgery and postoperative management, the anterior QLB has shown to reduce lengthy hospital stay and opioid use, it improves perioperative analgesia in patients undergoing hip and proximal femoral surgery compared to standard intravenous analgesia regimen, provides early and rapid pain relief and allows early ambulation, thus preventing deep vein thrombosis and thromboembolic complications etc. However, some nerve branches responsible for innervation of the hip joint are not affected by QLB, which has to be taken into consideration. QLB has shown potential for use in hip surgery and perioperative pain management, but still needs to be validated as a reliable treatment approach.