Neurovascular Status Research Articles

Comparison of Surgical and Conservative Treatments for Gartland Type II Supracondylar Humerus Fractures: Evaluation of the Need for Surgical Treatment.

Supracondylar humerus fractures (SHFs) are common pediatric injuries, with type II fractures being a topic of debate regarding optimal treatment. Our goals are to compare the functional and radiographic outcomes of conservative and surgical treatment of type II SHFs and their subgroups and to identify parameters for determining the optimal treatment option. We retrospectively reviewed a total of 55 patients (23 conservative, 32 surgical) between 2010 and 2020. The mean follow-up was 66 months. Neurovascular status, range of motion, complications, and functional scores (Mayo elbow, Quick DASH) were evaluated. We performed radiographic assessment on initial, postreduction, and final follow-up radiographs using the humerocondylar angle (HCA), Baumann angle, and anterior humeral line (AHL). Neither groups nor subgroups showed significant differences in clinical and functional outcomes. HCA was significantly higher in the operative group than in the conservative group. The subgroup analysis revealed that the HCA difference resulted from the difference between the conservative IIb and operative IIb subgroups. None of the patients required a corrective osteotomy, but 1 patient initially treated conservatively underwent operative treatment due to loss of reduction. Reconstructing the sagittal, coronal, and rotational alignment in type II SHFs led to good mid-term results in the range of motion and functional scores for the elbow joint, whether conservative or surgical treatment was used. A limited range of remodeling might be expected in the long term. Level III-retrospective comparative study.

Unveiling the Rarity: A Case Report of Rudimentary Third Lower Limb

Extra supernumerary lower limb a very rare manifestation in human being and animals. Till date literature review reveals around 31 cases. We are presenting such a case on Pygomelia of a 3 month old baby with a rudimentary (third) lower limb arising from her right buttock. Clinical examination revealed an extra lower limb that was arising from para-medial aspect of the right gluteal region just lateral to the gluteal cleft. The limb had some degrees of movement at the hip and rudimentary knee. Radiographically, the extra limb had a compete femora with a rudimentary tibia, ankle and foot. The knee and ankle joints were not well formed. After giving a racquet-shaped incision, two neuro-vascular bundles were identified at the base of the limb that were ligated and transected. The limb was disarticulated from its pseudo-joint. Post-operative recovery was uneventful with intact neurovascular status of both normal limbs. The wound seemed well healed at 4 weeks follow-up. Surgical resection of the supernumerary extremity is advocated in patients having accessory limbs that look odd and bear a significant psycho-social impact on the patient and their parents. The complete removal of the limb from its root along with the epiphysis associated with its pseudo-joint is necessary to prevent regrowth of the femur from the left over physis.

Surgical Margins in Musculoskeletal Sarcoma.

» Negative margin resection of musculoskeletal sarcomas is associated with reduced risk of local recurrence.» There is limited evidence to support an absolute margin width of soft tissue or bone that correlates with reduced risk of local recurrence.» Factors intrinsic to the tumor, including histologic subtype, grade, growth pattern and neurovascular involvement impact margin status and local recurrence, and should be considered when evaluating a patient's individual risk after positive margins.» Appropriate use of adjuvant therapy, critical analysis of preoperative advanced cross-sectional imaging, and the involvement of a multidisciplinary team are essential to obtain negative margins when resecting sarcomas.

Management of post-traumatic ankle deformities in children.

The objective of this clinical appraisal was to assess the clinical-radiological results of ankle deformity correction secondary to physeal injury, utilizing the methods based on the age of the child, site & severity of the deformity, remaining growth potential, condition of the soft tissue envelop and integrity of neurovascular status. Fifteen subjects ≤ 16 years of age, with angular deformities of the ankle secondary to physeal injury, were included. Deformities secondary to infection and pathological fractures were excluded. Demographic data, type of injury, treatment method, and follow-up were recorded from the case files. Treatment categories included osteotomies for acute correction (> 10 years) and growth modulation (≤ 10 years). Male to female ratio was 7:8, with an average age of 11.8 ± 2.31 years (range 9-16 years). The right and left ratio was 7:8. Mean duration of follow-up was 1 year and 4 months. Gradual deformity correction was done in 2 cases utilizing the principle of growth modulation, while acute correction by osteotomy was done in 13 cases. The average pre-operative ankle deformity was 20.8 ± 3.11 degrees (Range -25 to 24 degrees). Radiological union was attained at a mean of 11 weeks (8-24). Nine patients achieved neutral ankle alignment. The mean residual varus was 2.3°, and the valgus was 4°. There was a statistically significant improvement of the AOFAS score by 17 points from a mean pre-operative score of 57 (44-84) to 74 (56-100) points at the final follow-up (p-value < 0.001). The average pre-operative shortening was 2.36 ± 0.21 cm, which was completely corrected in 9 individuals. Management of angular deformities around the ankle calls attention to correcting the resultant angular deformity and/or limb length disparity, utilizing acute or gradual correction. A successful outcome depends on early recognition and patient-specific treatment of paediatric ankle fracture patterns. Correlating the results of our study with the available literature, we feel that both acute or gradual correction for angular deformities around the ankle is a feasible solution as long as principles of deformity correction are adhered to. Techniques for salvaging and restoring the viability of injured physeal plate warrant additional research.

Abstract 150: Arterial Calcification and Neural Metabolic Activity: Assessing Neurovascular Status Through FDG and NaF PET/CT Imaging

Introduction Atherosclerosis, the occlusion of arteries due to the accumulation of fatty substances, cholesterol, calcium, and fibrin in the arterial walls, can result in reduced blood flow and a subsequent decrease in oxygen delivery to the organs supplied by the affected artery, including the brain. Positron emission tomography‐computed tomography (PET‐CT) utilizing 18F‐fluorodeoxyglucose (FDG) and 18F‐Sodium Fluoride (NaF) have demonstrated efficacy in the assessment of cerebral glucose metabolism and atherosclerotic calcification, respectively. However, the reported literature has not clearly correlated arterial disease throughout the body with cerebral hypometabolism. Utilizing a novel integration of FDG and NaF PET/CT imaging, our study explores the link between cardiovascular risk factors and regional cerebral metabolism. Methods We compared 79 healthy controls (mean age 44.5 ± 13.8 years, 53.2% males) and 40 individuals (mean age 55.9 ± 11.9 years, 50% males) at increased risk for cardiovascular disease (CVD) as assessed by the systematic coronary risk evaluation (SCORE) tool. All subjects underwent whole‐body FDG‐PET/CT imaging. [18F]fluoride PET/CT imaging was performed using hybrid PET/CT scanners with image correction and reconstruction processes following standard protocols. The quantitative regional analysis of PET images was performed using MIMneuro version 7.1.5 (MIM Software, Inc., Cleveland, Ohio). 70 whole brain structures were analyzed in each subject. MIMneuro provided region‐based analysis, with z‐scores generated by comparing the patient to the selected age‐matched set of normal controls. Using OsiriX MD software, [18F]fluoride PET/CT scans were analyzed with regions of interest (ROIs) manually drawn to assess carotid calcification and standardized uptake value mean (SUVmean), along with ROI volume values. Correlations between the degree of molecular calcification and cerebral FDG uptake in patients with cardiovascular risk factors were evaluated using Pearson’s R, with the significance threshold set at P &lt; 0.05. Results Unhealthy patients demonstrated significant negative correlations between increased calcification in the carotid arteries, as assessed by NaF‐PET, and metabolic activity in the anterior cingulate (r = ‐0.42, p = 0.008) and cingulate regions (r = ‐0.34, p = 0.036). Conversely, healthy patients exhibited significant positive correlations in the pons (r = 0.25, p = 0.042) and pontine tegmentum (r = 0.34, p = 0.005), suggestive of a compensatory mechanism to maintain autonomic and motor functions. Conclusion The present study provides insight regarding the interplay between arterial calcification and neural metabolic activity, particularly as it pertains to regions supplied by the anterior cerebral artery. Our investigation suggests that calcification in the carotid arteries, which give rise to the ACA, has a deleterious impact on the function of the cingulate gyrus. Additionally, the observed positive correlation in the pons and pontine tegmentum in healthy individuals raises intriguing questions regarding potential compensatory mechanisms that may help maintain autonomic and motor functions despite vascular impediments. Understanding the temporal progression of vascular calcification allows for the optimization of surgical strategy and timing, potentially reducing stroke risk and improving patient outcomes. These findings underscore the necessity of persistent surveillance and targeted management strategies concerning carotid calcification.

Delayed vascular complication after collagenase injection for Dupuytren disease

BackgroundVascular adverse events after collagenase injection for Dupuytren disease are absent in large trials and systematic reviews. The aim of this study is to present a case series of delayed vascular complications after collagenase treatment.MethodsA prospective evaluation of 1181 consecutively treated patients at one orthopedic department identified three patients reporting symptoms of possible vascular complication. Baseline demographics and description of symptoms were collected, with a physical examination documenting extension deficit and neurovascular status. All patients completed the Cold Intolerance Symptom Severity (CISS) scale (range 4-100, lower is better) and underwent Doppler sonography examination of the digital arteries.ResultsAll patients were treated in the small finger and two had an isolated proximal interphalangeal joint contracture. All patients had a delayed presentation of a few months, with episodes of white discoloration of the treated finger relieved within 30 min and associated with variable pain, paresthesia, stiffness and weakness. Two of the patients reported cold exposure as an episode trigger and had a pathological CISS score (40 and 36, respectively). Doppler sonography identified a nonpatent ulnar digital artery in one patient.ConclusionsDelayed vascular complication after collagenase treatment is rare, but surgeons and patients should be aware of the risk, especially when treating the small finger.

295 Education and Training to Improve Compliance to the BOAST Guidelines on Assessing and Documenting Peripheral Nerve Status and Injury

Abstract Introduction Peripheral nerve injuries affect 2-3% of trauma patients, with potentially high morbidity, and associations with litigation. BOAST guidelines were introduced in December 2021 outlining standards in assessing and documenting neurovascular status in trauma patients. Key elements included nerve-specific documentation and assessments pre- and post-interventions such as manipulation. Aim This project assessed departmental performance against the BOAST standards, then presented the results to both orthopaedic and emergency departments, as well as setting up teaching sessions to orthopaedic junior doctors in the assessment of neurovascular status and updating awareness on the guidelines. Method 50 patient records were analysed retrospectively for the first arm, and 50 records prospectively for the second arm. Acute trauma presentations with a risk of peripheral nerve injury met the inclusion criteria. Intervention included practical senior-led teaching on clinically assessing neurovascular status, and the importance of detailed documentation, as well as when to repeat the examination. Results Results were improved drastically from initial audit against standards to post-intervention audit; documentation improved from 70% to 95% (n = 50 for both arms), with appropriate detail in documentation improving from 11% to 49%. Conclusions Neurovascular status is critical to be documented in detail, both pre and post-interventions. By using BOAST guidance as a standard, the initial inadequacies of the departmental practice were highlighted, and significantly improved through active teaching, distribution of the guidelines, raising the standards, clinical assessment, and documentation, thus improving patient care, and robustness of legal documentation.

385 Neurovascular Status Documentation in Fracture Manipulation

Abstract Aim To improve standards of documentation of neurovascular status before and following manipulation in keeping with standards set by the British Orthopaedic Association (BOAST guidelines: Peripheral Nerve Injury1). Method At a major trauma centre, we retrospectively collected data on thirty orthopaedic patients who underwent fracture manipulation in October 2022. Data included documentation of sensory, motor and vascular neurovascular status, prior and following manipulation. Posters were displayed in the emergency and orthopaedic departments on adequate neurovascular documentation, and an autotext proposed to aid senior house officers with electronic documentation. Prospective data was then collected on the subsequent thirty patients. Results Prior to manipulation, sensory neurological status was documented in 40% of patients and motor neurological status in 43.3% in patients. Post-manipulation documentation was 10% and 13.3% respectively. Documentation of vascular status prior to and post-manipulation was 40% and 16.7%. Following our intervention, pre-manipulation documentation of sensory and motor neurological status was 60% and 63.3%; post-manipulation was 20% and 13.3%. Documentation of vascular status prior and post-manipulation was 70% and 20%. Conclusions Following our intervention, there was an improvement in documentation of both sensory and motor neurological status prior to manipulation, however there was no change in motor status post-manipulation. The intervention used may not provide a sustainable improvement in documentation. Use of a designed electronic form, which can be accessed easily for electronic documentation, may improve results further.

831 Improving Documentation of Post-Operative Day 1 Checks After a Hip Hemiarthroplasty or Total Hip Replacement

Abstract Background Post-operative day 1 checks (X-ray, bloods, dressing check and neurovascular status) are essential after hemi-arthroplasty (hemi) or total hip replacements (THR) to look for peri-prosthetic fracture, dislocation, anaemia, acute kidney injury, wound site bleeding and neurovascular impairment. Senior clinicians in the T&amp;O department at the trust have raised concerns regarding documentation of post-operative day 1 checks in hemi/THR patients. Thus, offering no certainty to doctors reviewing patients at a later date that day 1 checks were carried out. Ultimately, raising the issue of patient safety. Aim The aim of this audit was to improve documentation of post-operative Day 1 checks in hemi/THR patients. Method Medical notes of those who underwent either a hemi/THR were reviewed. They were appraised on day 1 post-operative documentation of review of xray, acknowledgment of bloods results, dressing and NV status checks. Two PDSA cycles were carried out between September – November 2022. Interventions included: a) raising awareness on the junior doctor WhatsApp group; b) educating junior doctors via teaching sessions. Results 40 medical notes were reviewed during each cycle. Results showed a clear improvement in quality of documentation. Pre-intervention (cycle 1): X-ray (37.5%), bloods (25%), dressing (52.5%), NV status (47.5%). Post-intervention (cycle 2): X-ray (71.5%), bloods (75%), dressing (72.5%), NV status (77.5%). Conclusions The relatively simple interventions have been found to have an improvement in documentation of post-operative day 1 checks in hemi/THR patients. Further recommendations include: raising awareness during induction and posters on the ward to prompt junior doctors to complete these checks.

91 Introduction of a Simple Proforma Improves Documentation of Neuro-Vascular Status in Paediatric Supracondylar Humerus Fractures (Closing Loop Audit)

Abstract Introduction Supracondylar fractures of the humerus are the most common fracture around the elbow in children. There is a risk of significant complications including nerve injury, vascular compromise, compartment syndrome and clinical deformity. BOAST (British Orthopaedic Association Standards for Trauma) published guideline 11 in 2014 (updated in Oct 2020) which lists criteria that should be assessed and documented for each child with this injury. Aim Assess whether an introduction of a simple proforma will Improve documentation of the neuro-vascular status in paediatric supracondylar humerus fractures. Method a closing loop Audit to review the accuracy of documentation of the neuro-vascular status in the admission clerking against the standards published in the updated BOAST guidelines both before and after introduction of a simple documentation proforma. Results In the first audit cycle 30 patients were included and detailed documentation of the Neuro-vascular status as per the BOAST guideline was less than 40 %. After the proforma was introduced, the second closing loop cycle included 31 patients and detailed documentation of the Neuro-vascular status as per the BOAST guideline was 70 %. Conclusions The introduction of a simple proforma has improved significantly the documentation of the neurovascular status in children presenting to the ED with a supracondylar humerus fracture.

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.

566 Improving Neurovascular Status Assessment and Documentation in the Emergency Department: A Closed-Loop Audit

Abstract Aim To improve neurovascular status assessment and documentation in the Emergency Department. Method Clinical notes were reviewed for 55 consecutive patients presenting with extremity fractures during February and March 2022. Neurovascular (NV) assessment and documentation was reviewed at presentation and after any intervention to the limb. Semi-structured interviews were conducted with Emergency Department staff, to identify barriers to NV assessment and documentation. Changes were implemented and the audit cycle repeated in October 2022 for 56 consecutive patients. Results The main barriers to NV assessment and documentation were forgetfulness, lack of awareness of requirement to document NVS pre- and post-intervention, poor quality induction given to clinicians of the importance of documenting NVS and lack of awareness of track commands. Three changes were therefore implemented: a video on NV assessment for new starters; a teaching session for current staff; a ‘shortcut’ for typing the NV assessment in the electronic patient record. Improvements were made in all domains; documentation of NVS for ankle fractures pre-manipulation increased from 73% to 96%, and from 31% to 46% for post-manipulation between loop 1 and 2. Documentation of NVS for wrist fractures pre-manipulation increased from 93% to 96%, and from 14% to 36% for documentation post-manipulation. Improvement was most noticeable in the documentation of individually named nerves, increasing by 16.4% (p&amp;lt;0.05). Conclusions Semi-structured interviews were helpful in illuminating areas for improvement. Importantly, these were sustained for over 6 months. A third cycle is in progress, where further incremental gains are sought.

863 Management of Paediatric Forearm Fractures Presenting to the Whittington Hospital Emergency Department: An Audit of Current Practice

Abstract Aim The most common site of fractures in children is the forearm. According to BOAST standards, early closed reduction by manipulation, avoiding the need for admission and general anaesthesia, is the treatment of choice for most forearm fractures. Further, management should include a documented assessment of neurovascular status and formal consent. Our aim was to audit management of forearm fractures in our emergency department against these standards. Method Patients presenting to our emergency department with isolated and neurovascularly intact forearm fractures were retrospectively identified from Nov 2021 to April 2022. Initial case management was assessed against BOAST standards and, where early manipulation in the emergency department was not performed, cases were reviewed by an orthopaedic consultant to determine if this could have occurred. Results 24 patients were identified. The mean age at time of injury was 10 years. 62.5% of patients underwent manipulation within the emergency department of which 47% (7/15) were unsuitable to continue non-operative treatment. 37.5% of patient did not undergo manipulation, of these 44.4% (4/9) were deemed as could have been suitable for manipulation. This led to 67% (16/24) of patients requiring a procedure under general anaesthesia. Neurovascular assessment was documented for 29% and formal consent for manipulation for 0% of patients. Conclusions There is scope for more forearm fractures to undergo early closed reduction by manipulation in our emergency department, potential avoiding intervention under general anaesthesia. Documentation of neurovascular assessment and formal consent requires significant improvement. A hospital protocol is currently being produced to help standardise care of such injuries.

Early Management of Paediatric Wrist and Forearm Fractures in a Busy District General Hospital Emergency Department: A Retrospective Cohort Comparison Study and Audit of BOAST Guidelines.

In response to the strain that the COVID-19 pandemic put on hospitals in the UK, the British Orthopaedic Association, in May 2021, set out British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guidelines for the early management of distal forearm fractures in children. Following this, a local pathway was introduced at our Trust to manage these injuries in the Emergency Department (ED).The aim of this audit was to monitor compliance with the BOAST guidelines and compare the practice with a similar pre-COVID cohort. A fixed-date retrospective cohort study was conducted that included cases that presented to the emergency department during a six-month period (August 1, 2021 to January 31, 2022). Data was analysed for rates of primary EDmanipulation, documentation of consent and neurovascular status in the notes, orthogonal X-ray data, time till the clinic follow-up, theatre time saved and complications. The ED fracture manipulation rate was also compared with another similar pre-COVID cohort (August 1, 2019 to January 31, 2020) to look for any improvement in the practice. A total of 86.31% cases were found to have primary fracture manipulation in the ED following the introduction of Trust guidelines in accordance with the BOAST recommendations. This is an improvement in comparison to the 31.94% fracture manipulation rate before the COVID pandemic. Implementation of the Trust pathway in accordance with the BOAST guidelines along with staff education has standardized the practice at our Trust. It saved approximately 63 hours of trauma theatre time for the six-monthdata collection period. Our findings also suggest that this has favourable outcomes for the patients with no complications.

Evaluation of musculoskeletal injuries after the 2023 Kahramanmaras earthquake: A local hospital experience.

The aim of this study was to evaluate musculoskeletal injuries, clinical follow-ups and treatments of trauma patients admitted to our hospital after the 2023 Kahramanmaras earthquake. Between February 6th, 2023 and February 16th, 2023, a total of 957 trauma patients (452 males, 505 females; mean age: 36.2±19.9 years; range, 0 to 97 years) who were affected by the earthquake were retrospectively analyzed. Age, sex, presence of orthopedic consultation, diagnosis of open/closed fracture, diagnosis of dislocation, presence and classification of soft tissue injury, additional system injury, preoperative and postoperative neurovascular examination status, presence of compartment syndrome, conservative/surgical applications, operation side, fasciotomy surgery and level, amputation surgery and level, length of stay in the hospital and intensive care unit (ICU), the Mangled Extremity Severity Score (MESS) score were collected. A total of 811 of the survivors were Turkish and 146 were Syrians. Of 957 earthquake victims, 40% had soft tissue injuries, 19% had closed fractures, 8.9% had other system injuries, 7.7% had crush injuries, 4.1% had nerve injuries, 2.1% had compartment syndrome, 2.1% had vascular injury, 1.8% had dislocation, and 1.7% had open fracture. Surgical or conservative treatments were applied to 574 patients with musculoskeletal injuries. Conservative treatment was applied to 322 of 574 patients and surgical procedure was applied to 252 patients. The highest patient density is experienced within the first 24 h after a devastating earthquake. The most common injuries due to high-energy trauma are isolated soft tissue injuries and fractures. The definition of the demographic characteristics and clinical outcomes of earthquake patients is critical to the development of preparedness, response, and recovery policies for future disasters..

A Comparative Analysis of Commonly Used Surgical Approaches for Anterior Acetabular Fractures.

Introduction Fractures of the acetabulum are inherently complex due to the anatomy of the innominate bones and also the presence of several vital neurovascular structures in the vicinity. Thus, the treatment of pelvic ring and acetabulum fractures is riddled with complexities and is considered among the most challenging surgeries for an orthopedic surgeon. When anterior access is necessary, such as in the anterior column, both columns, anterior column posterior hemitransverse, transverse, and T-type fractures, both the ilioinguinal and the anterior intrapelvic (AIP) or modified Rives-Stoppa methods are employed. The aim of this study is to compare the results from acetabular fractures treated with a modified Stoppa and ilioinguinal technique. Materials and methods We conducted a prospective cohort study to compare the outcomes of anterior acetabular fracture fixation using the modified Stoppa approach and the ilioinguinal approach. The outcomes measured were the amount of intraoperative bleeding, surgery duration, postoperative quality of fracture reduction, postoperative drain collection, and postoperative neurovascular status. The functional outcome was measured at three, six, and 12 months using the Merle d'Aubigné score. The radiological outcome was measured using the Matta scoring system. Results A significant difference was noticed in the two groups in the average blood loss and surgical duration, where the mean blood loss was 911.67 ± 143.05 ml in the ilioinguinal approach and 748.33 ± 165.30 ml in the modified Stoppa approach. While the ilioinguinal approach had a mean surgical duration of 190.33 ± 29.42 minutes, the modified Stoppa approach had 151.33 ± 23 minutes. The difference in postoperative fracture reduction in both groups was insignificant. The lateral femoral cutaneous nerve was compromised in 8.33% of cases in group A. The obturator nerve was compromised in 6.67% of cases in group B. The postoperative functional outcome was assessed by the modified Merle d'Aubigné score, and the radiological outcome was evaluated by the Matta score. The results obtained in both our study arms were comparable. Conclusion Based on our results, we can safely advocate the superiority of the Stoppa approach over a more extensive ilioinguinal approach. By virtue of being shorter in surgical duration and causing lesser blood loss, the Stoppa approach seems to be a better alternative, especially in elderly or polytrauma patients. As no difference was noted in the postoperative outcomes both clinically and radiologically, no approach showed superiority over the other in terms of patients' eventual functional outcomes.

INTERTROCHANTERIC FEMUR FRACTURE

Introduction: Intertrochanteric fractures are a type of extracapsular fractures of the proximal femur occurring between the greater and lesser trochanter. They are frequently seen in the elderly because their incidence is higher as life expectancy increases. Objective: to describe the current information related to epidemiology, anatomy, presentation, classification, evaluation and management of intertrochanteric fractures. Methodology: a total of 35 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 27 bibliographies were used because the other articles were not relevant to this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: transtrochanteric, intertrochanteric, femur, fracture, fratura. Results: Intertrochanteric fractures have a bimodal presentation. They have a female to male ratio ranging from 2:1 to 8:1, possibly due to changes in bone metabolism after menopause. They are frequently seen in the elderly because their incidence is higher as life expectancy increases. Plain radiographs are still the initial choice to complement the diagnosis in this type of fractures. It is preferable to take anteroposterior (AP), AP and lateral cross pelvis projections of the affected hip and full body radiographs of the affected femur. Surgical treatment is preferred over conservative treatment except in cases that contraindicate surgery or anesthesia. Conclusions: Intertrochanteric fractures are a type of extracapsular fractures of the proximal femur occurring between the greater and lesser trochanter. Femur fractures have several classifications, recently the classification of intertrochanteric fractures is based on the stability of this area. It is of vital importance to evaluate whether it is an open or closed fracture, in addition to assessing the neurovascular status. The surgical treatment has the mission of providing a stable internal fixation that allows early mobilization and full weight bearing. There are several tools and techniques to provide surgical treatment, however, in our current reality, intramedullary nails are the most used devices in the treatment of intertrochanteric fractures. Regardless of the therapeutic alternative chosen, the mortality risk is 20% to 30% in the first year after the fracture, with males being more affected than females. KEY WORDS: transtrochanteric, intertrochanteric, femur, fracture.

Avascular Necrosis and Posttraumatic Arthritis After Proximal Humerus Fracture Internal Fixation: Evaluation and Management.

Avascular necrosis (AVN) and posttraumatic arthritis (PTA) are common complications following both conservative treatment and open reduction and internal fixation (ORIF) of proximal humerus fractures (PHFs). Despite the frequent utilization of ORIF, information regarding these leading causes of failure is limited. This review includes a discussion of incidence, risk factors, and evaluation of AVN and PTA following PHF. The mechanisms of treatment options and associated outcomes are also reviewed. Recent best available evidence demonstrates significant rates of AVN and PTA following ORIF of PHF. This is particularly true of complex fracture patterns. A thorough workup is required in the setting of failure caused by AVN and PTA. This includes a careful patient history, clinical exam, plain film radiographs, and CT scans. EMG and/or aspiration may also be indicated. Special consideration is given to the examination of the deltoid muscle, neurovascular status, rotator cuff function, and the possibility of infection. Biological supplementation, anatomic total shoulder replacement (aTSA), and fusion are rarely employed in the treatment of AVN and/or PTA. Due to satisfactory patient outcomes, reverse total shoulder replacement (rTSA) has increased in popularity for the elderly population, while hemiarthroplasty (HA) may be appropriate for some young, active patients. With careful patient selection and meticulous surgical technique, AVN and PTA can be mitigated. Careful indications for ORIF may decrease the frequency of these complications. For most patients, rTSA is the optimal treatment option. Given the frequent utilization of ORIF and the higher than acceptable complication and failure rates, AVN and PTA warrant our attention.

Quality of Documentation in Paediatric Supracondylar Fractures: A Quality Improvement Project.

Introduction Supracondylar fractures are the most common elbow fractures in children. Their documentation and management must be done fully and correctly. This Quality Improvement Project (QIP) assessed the quality of documentation for paediatric supracondylar fractures admitted, in accordance with the British Orthopaedic Association Standards for Trauma (BOAST). Methods We present a case series of supracondylar fractures presenting to a single UK-based district general hospital from January 2018 - October 2021. We performed a quality improvement intervention starting in November2020. The retrospective data prior to intervention (January 2018-November 2020) were deemed "pre-intervention". Prospective "post-intervention" data were collected from April to October 2021.After "pre-intervention" data analysis, an intervention in the form of a documentation proforma was developed and multidisciplinary teaching sessions were delivered. Post-intervention prospective data collection followed from April - October 2021. Results There were 48 and 26 patients in cycles one and two, respectively. The mean age was 6.4(SD 3.5) and 6.5 (SD 2.7) years, respectively; 42/48 in cycle one and all 26/26 in cycle two required operative management.The mean time to surgery was 1.3 and 0.96 days, respectively. Post-intervention, cycle two showed a reduction in patients with "no neurovascular documentation" pre-reduction (17% vs 12%) and an increase in patients documented as having "neurovascular status intact" (NVI) (44% vs 69%). In post-operative documentation, there was an improvement in documentation with 73% of patients having a post-operative neurovascular assessment documented, versus 50% in thepre-intervention cohort. Conclusion This QIP provided some early improvement in the documentation but with room for future progress as the project continues. It showed proformas can be an effective tool in implementing positive change. It also highlights the need for continuous clinical education across the multidisciplinary teams managing trauma.

Coronary stent-graft use to salvage a juxta-anastomotic arterial rupture complicating a case of radio-cephalic fistuloplasty

BackgroundStenosis is a common complication of haemodialysis arteriovenous accesses. Endovascular approaches with percutaneous transluminal fistuloplasty have largely replaced open surgical approaches as first line treatment. Vessel rupture is an uncommon complication of fistuloplasty and most reports describe venous rupture. Stent-graft deployment can salvage this, however, its use requires careful assessment of the distal vasculature. Arterial rupture with fistuloplasty has rarely been described in the literature. This is a novel case describing the use of a BeGraft coronary stent-graft to manage juxta-anastomotic arterial rupture and pseudoaneurysm complicating fistuloplasty.Case presentationA 77 year old female with end stage renal failure secondary to systemic amyloid light chain type amyloidosis was referred for a suspected radio-cephalic arteriovenous fistula stenosis after difficulty cannulating with poor flow during dialysis and clinical reduction in the fistula thrill. Both Doppler ultrasound and intravenous fistulography confirmed a venous stenosis 2 cm distal to the anastomosis. The stenosis was treated by fistuloplasty, however, this was complicated by a rupture of the juxta-anastomotic arterial segment intraoperatively. Intermittent balloon tamponade was used to minimise extravasation although a pseudoaneurysm formed within the damaged arterial segment. The patient’s distal neurovascular status was assessed using the Barbeau test and we sonographically confirmed adequate retrograde arterial flow via a complete palmar arch directing blood from the ulnar artery. After discussion with the renal transplant team, a 4 mm BeGraft coronary stent-graft was deployed to control haemorrhage and bypass the pseudoaneurysm until adequate haemostasis and fistula flow was achieved. Follow-up 3 months post-procedure reported the patient continued with haemodialysis using the stented fistula with no further complications.ConclusionsTo our knowledge, this is the first case report describing the application of BeGraft coronary stent-grafts to salvage fistuloplasty of a radio-cephalic arteriovenous fistula stenosis complicated by juxta-anastomotic arterial rupture and pseudoaneurysm formation. We demonstrate the safety and short-term efficacy of this technology.