Trauma Clinic Research Articles

Virtual Reality for Subacute Pain After Orthopedic Traumatic Musculoskeletal Injuries: A Mixed Methods Pilot Study.

Acute orthopedic traumatic musculoskeletal injuries are prevalent, costly, and often lead to persistent pain and functional limitations. Psychological risk factors (eg, pain catastrophizing and anxiety) exacerbate these outcomes but are often overlooked in acute orthopedic care. Addressing gaps in current treatment approaches, this mixed-methods pilot study explored the use of a therapeutic virtual reality (VR; RelieVRx ), integrating principles of mindfulness and cognitive-behavioral therapy, for pain self-management at home following orthopedic injury. We enrolled 10 adults with acute orthopedic injuries and elevated pain catastrophizing or pain anxiety from Level 1 Trauma Clinics within the Mass General Brigham health care system. Participants completed daily RelieVRx sessions at home for 8 weeks, which included pain education, relaxation, mindfulness, games, and dynamic breathing biofeedback. Primary outcomes were a priori feasibility, appropriateness, acceptability, satisfaction, and safety. Secondary outcomes were pre-post measures of pain, physical function, sleep, depression, and hypothesized mechanisms (pain self-efficacy, mindfulness, and coping). The VR and study procedures met or exceeded all benchmarks. We observed preliminary improvements in pain, physical functioning, sleep, depression, and mechanisms. Qualitative exit interviews confirmed high satisfaction with RelieVRx and yielded recommendations for promoting VR-based trials with orthopedic patients. The results support a larger randomized clinical trial of RelieVRx versus a sham placebo control to replicate the findings and explore mechanisms. There is potential for self-guided VR to promote evidence-based pain management strategies and address the critical mental health care gap for patients following acute orthopedic injuries.

Routine Urology Consultation and Follow-up After Pediatric Blunt Renal Trauma is Likely Unnecessary

IntroductionThis study examines the outcomes of high-grade renal trauma in pediatric patients and evaluates the intervention rate. In our hospital, we routinely consult urology on all high-grade injuries. We anticipated minimal intervention, casting doubt on the need for routine urology consultation and follow-up. MethodsWe conducted a retrospective review at a single pediatric trauma center from January 2018 to June 2023, focusing on patients with severe (grade III-V) renal injuries. Data collected included demographics, trauma-related variables, hospital course, interventions, and follow-up. When the grade was not readily available in the electronic medical record, we had a board-certified pediatric radiologist review the imaging and provide the grade. Follow-up was included only if it was with a pediatric urologist. ResultsThere were 92 patients that met our inclusion criteria. Of these, 47 were grade III, 32 were grade IV, and 13 were grade V. Six (6.5%) patients required inpatient renal stent procedures. Follow-up occurred in 55/92 (60%) patients with a pediatric urologist. Follow-up by grade is as follows: 22/47 (47%) grade III, 22/32 (69%) grade IV, and 11/13 (85%) grade V. Overall 5.8% of patients required antihypertensive medications and this was more likely as injury grade increased. All stents were removed outpatient and there were 3 (3.3%) additional outpatient interventions, all in patients that were symptomatic. ConclusionGiven the low prevalence of interventions after discharge, routine consultation and follow-up with urology is likely unnecessary in the absence of an inpatient urologic procedure during the index hospitalization. Patients with high-grade injuries should instead follow up with a trauma clinic or general provider with urology follow-up based on symptoms. Type of StudyRetrospective Review. Level of EvidenceLevel III.

Scoping an interdisciplinary model of student dental therapists in maxillofacial trauma.

Introduction This paper outlines a short pilot programme to assess the feasibility of an interdisciplinary model of involving student dental therapists in the management of maxillofacial trauma patients. It involved dental therapy students attending an oral and maxillofacial surgery trauma review clinic at a major trauma hospital in London, UK.Approach The small cohort of 15 second-year dental hygiene and therapy (BSc in Oral Health) students attended the trauma clinic once a week in pairs, over a period of six weeks, after which they completed a survey questionnaire.Findings No students had previous experience of dealing with trauma patients. The majority (81.8%) had learnt something by attending the clinic. Almost all (91.7%) had not thought previously about the importance of oral hygiene in maxillofacial trauma patients. By the end of the pilot programme, ten students (83.3%) felt that they had a role to play in the care of these trauma patients and they felt valued as members of the wider team.Conclusion These initial findings suggest that the scheme has potential for incorporation of maxillofacial trauma experience within the formal dental therapy curriculum. This would prepare them for future involvement in the management of maxillofacial trauma patients to promote oral health benefits and more widely, to work as a team member in interprofessional health care.

Metacognitive Therapy Versus Exposure-Based Treatments of Posttraumatic Stress Disorder: A Preliminary Comparative Trial in an Ordinary Clinical Practice

Cognitive behavioral therapy, prolonged exposure, and eye movement desensitization and reprocessing are effective treatments for posttraumatic stress disorder (PTSD). They emphasize the processing of trauma-related memories and exposure as central components in treatment. In contrast, the metacognitive model emphasizes that PTSD is caused by a persistent negative thinking style, and the goal is to find alternative coping strategies and modify metacognitive beliefs without the use of exposure. In a quasi-experimental A-B design, patients diagnosed with PTSD received either MCT (n = 32) or TAU “treatment as usual” (n = 28) consisting of exposure-based treatments and were tested on different measures of symptoms. The results indicated that both treatments were effective and performed well on both trauma and anxiety symptoms. Recovery rates and clinical improvement were higher in the MCT condition at post-treatment. The study indicates that MCT could potentially be a viable alternative to trauma-focused treatment of PTSD.Clinical trial registration: The study is a clinical and quality audit of an ordinary routinely delivered clinical service in a specialized trauma clinic involving treatments for patients with PTSD. The trial was a preliminary stage in a larger trial of chronic PTSD.

Rapid assistance for victims of acute violence-Current treatment in outpatient trauma clinics in Germany

Assistance following acute violence was previously regulated by the Victim Compensation Act (OEG). At the beginning of the current year it was replaced by the Social CodeXIV (SGBXIV). The SGBXIV defines new groups of beneficiaries, outpatient trauma clinics must be provided nationwide and binding criteria for the quality of care were established. The aim of this study was to map the current status of care in outpatient trauma clinics in accordance with the requirements of the new SGBXIV. With respect to new beneficiaries, the status of services for victims of human trafficking was recorded as an example. Outpatient clinics that provide rapid assistance under the OEG or SGBXIV were surveyed on structural and content-related aspects of their work. An online survey consisting of 10thematic modules was used. Data were obtained from atotal of N = 110 outpatient clinics (response rate 50%). The participating outpatient clinics reported awide range in terms of the number of staff and the number of people seeking counselling. Some of the outpatient clinics reported deficits with respect to structural aspects, such as the waiting time for the initial consultation and specific training in trauma treatment for staff. The majority of outpatient clinics were uncertain about how to deal with victims of human trafficking. Outpatient trauma clinics appear to reach their target population and provide appropriate services for their care; however, asignificant number of outpatient clinics need to make improvements in order to fulfil the quality criteria of SGBXIV and provide adequate care to new groups of beneficiaries.

Limited Health Literacy Among Patients With Orthopedic Injuries: A Cross-sectional Survey of Patients Who Underwent Orthopedic Trauma Surgery in a County Hospital Setting.

Patients with limited health literacy have difficulty understanding their injuries and postoperative treatment, which can negatively affect their outcomes. This cross-sectional questionnaire-based study of 103 adult patients sought to quantify patients' health literacy at a single county hospital's orthopedic trauma clinic and to examine their ability to understand injuries and treatment plans. Demographics, Newest Vital Sign (NVS) health literacy assessment, and knowledge scores were used to assess patients' comprehension of their injuries and treatment plan. Patients were grouped by NVS score (NVS <4: limited health literacy). Fisher's exact tests and t tests were used to compare demographic and comprehension scores. Multivariate logistic regression analysis was used to examine the association among low health literacy, sociodemographic variables, and knowledge scores. Of the 103 patients, 75% were determined to have limited health literacy. Patients younger than 30 years were more likely to have adequate literacy (50% vs 23%, P=.01). Patients who spoke Spanish as their primary language were 8.77 times more likely to have limited health literacy with respect to sociodemographic factors (odds ratio, 8.77; 95% CI, 1.03-76.92; P=.04). Low health literacy was 3.52 and 4.14 times more likely to predict discordance in answers to specific bone fractures and the narcotics prescribed (P=.04 and P=.02, respectively). Spanish-speaking patients have demonstrated limited health literacy and difficulty understanding their injuries and postoperative treatment plans compared with English-speaking patients. Patients with low health literacy are more likely to be unsure regarding which bone they fractured or their prescribed opiates. [Orthopedics. 2024;47(4):249-255.].

Covid-19 impact on femoral fragility fractures treatment: overview and comparison of 4 years of treatment at Geriatric Department of Trauma Clinic of Sestre milosrdnice Clinical Hospital Center

Covid-19 impact on femoral fragility fractures treatment: overview and comparison of 4 years of treatment at Geriatric Department of Trauma Clinic of Sestre milosrdnice Clinical Hospital Center

Posttraumatic cognitions about the self are associated with depression symptoms in veterans endorsing a history of assaultive military sexual trauma.

Depressive symptoms are a commonly observed yet understudied mental health sequalae of military sexual trauma (MST). Prior research supports the relationship between negative posttraumatic cognitions (NPCs) and the onset and course of trauma symptoms more broadly. We hypothesized that NPCs would be associated with depression symptoms in veterans endorsing a history of MST, specifically assaultive type MST. Our clinical sample included veterans presenting for treatment related to assaultive MST (N = 158; 70.9% female, 65.2% White, 27.8% Black). Participants completed self-report measures of posttraumatic stress disorder (PTSD), depression, and NPCs during intake at a Veteran's Affairs specialty trauma clinic. Linear regressions were used to analyze the association between NPCs and depression symptoms controlling for PTSD symptom severity. PTSD severity and NPCs about the self were significantly associated with depression symptoms, explaining 46% of the variance severity, F(4, 153) = 33.16, R² = .46, p < .001. These findings newly demonstrate a relationship between NPCs about the self and depression in veterans with a history of MST. Clinicians may benefit from incorporating cognitive interventions into preexisting depression treatments to directly address NPCs in this population. Future study is needed to determine how these results may extend to other forms of MST or trauma types. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Health Disparities in Patients With Musculoskeletal Injuries: Food Insecurity Is a Common and Clinically Challenging Problem.

Health disparities have important effects on orthopaedic patient populations. Socioeconomic factors and poor nutrition have been shown to be associated with an increased risk of complications such as infection in patients undergoing orthopaedic surgery. Currently, there are limited published data on how food insecurity is associated with medical and surgical complications. We sought to (1) determine the percentage of patients who experience food insecurity in an orthopaedic trauma clinic at a large Level 1 trauma center, (2) identify demographic and clinical factors associated with food insecurity, and (3) identify whether there are differences in the risk of complications and reoperations between patients who experience food insecurity and patients who are food-secure. This was a cross-sectional study using food insecurity screening surveys, which were obtained at an orthopaedic trauma clinic at our Level 1 trauma center. All patients 18 years and older who were seen for an initial evaluation or follow-up for fracture care between November 2022 and February 2023 were considered for inclusion in this study. For inclusion in this study, the patient had to have surgical treatment of their fracture and have completed at least one food insecurity screening survey. Ninety-eight percent (121 of 123) of patients completed the screening survey during the study period. Data for 21 patients were excluded because of nonoperative treatment of their fracture, nonfracture-related care, impending metastatic fracture care, and patients who had treatment at an outside facility and were transferring their care. This led to a study group of 100 patients with orthopaedic trauma. The mean age was 51 years, and 51% (51 of 100) were men. The mean length of follow-up available for patients in the study was 13 months from the initial clinic visit. Patient demographics, hospital admission data, and outcome data were collected from the electronic medical records. Patients were divided into two cohorts: food-secure versus food-insecure. Patients were propensity score matched for adjusted analysis. A total of 37% of the patients in this study (37 of 100) screened positive for food insecurity during the study period. Patients with food insecurity were more likely to have a higher BMI than patients with food security (32 kg/m 2 compared with 28 kg/m 2 ; p = 0.009), and they were more likely not to have healthcare insurance or to have Medicaid (62% [23 of 37] compared with 30% [19 of 63]; p = 0.003). After propensity matching for age, gender, ethnicity, current substance use, Charleston comorbidity index, employment status, open fracture, and length of stay, food insecurity was associated with a higher percentage of superficial infections (13% [4 of 31] compared with 0% [0 of 31]; p = 0.047). There were no differences between the groups in the risk of reoperation, deep infection, and nonunion. Food insecurity is common among patients who have experienced orthopaedic trauma, and patients who have it may be at increased risk of superficial infections after surgery. Future research in this area should focus on defining these health disparities further and interventions that could address them. Level III, therapeutic study.

WEIGHT BEAR THEN DISCHARGE: A SAFE MANAGEMENT STRATEGY FOR ISOLATED WEBER B LATERAL MALLEOLUS FRACTURES. OUTCOMES OF 658 PATIENTS

Myriad protocols exist for isolated Weber B lateral malleolus fractures with a congruent tibiotalar joint on initial radiographs. Stress and weight-bearing radiographs, all at various timepoints, may be employed to identify those injuries that develop significant talar shift but consensus is elusive. This study outlines a safe and reproducible protocol for such injuries, utilising a removable orthosis, immediate weight bearing and standard supine radiographs.A retrospective analysis of a prospective trauma database was analysed to identify patients with an isolated Weber B ankle fracture with adequate presentation radiographs demonstrating a congruent mortise. Patient records and radiographs were evaluated a minimum of 5 years after initial presentation to determine ankle stability, complications, and the burden on outpatient services.Between 2014 and 2016, 657 patients were referred to the specialist trauma clinic from the emergency department. Of the 657, 52 patients had inadequate ED radiographs to determine ankle congruity. At the two-week assessment, 11 of the 52 demonstrated talar shift and required intervention. Therefore 646 patients demonstrated ankle congruity at two weeks after weight bearing. No patient demonstrated talar shift at the six-week assessment. Average number of follow up appointments was 2.4 with 3.5 radiographs. Our new treatment protocol advocates discharge after a single orthopaedic assessment after two weeks of weight bearing.This study supports immediate weight-bearing of Weber B ankle fractures with a congruent mortise in an orthosis. Follow up beyond two weeks is unnecessary and our protocol offers a safe means of significantly reducing the outpatient burden.

Improved follow-up care for gun violence survivors in the Trauma Quality of Life Clinic

BackgroundOutpatient follow-up represents a crucial opportunity to re-engage with gun violence survivors (GVS) and to facilitate positive health outcomes. Current outpatient models for firearm-related injuries and trauma care are inconsistent...

A modern approach to the study of the problem of pathogenesis and prevention venous thromboembolic complications in patients with trauma (literature review)

Relevance. Patients with trauma are at increased risk of venous thromboembolic complications (VTE), which includes deep vein thrombosis of the lower extremities (DVT) and pulmonary embolism (PE). Within surgical and trauma clinics, thromboembolic complications are the most common preventable cause of in-hospital mortality. Numerous studies have shown that the incidence rate of deep vein thrombosis (DVT) in trauma patients without prevention varies from 5 to 80%.Aim. To analyze the pathogenesis of the development of venous thrombosis and explore existing approaches to prevent VTE in trauma patients.Materials and methods. In the course of the work, topical literary sources of domestic and foreign authors on a given topic were analyzed.Results. The mechanism of thrombus formation in trauma involves slowing blood flow, damage to the vessel wall and impaired blood clotting in the form of hypercoagulation. The state of hypercoagulation combined with prolonged immobility increases the risk of VTE. LMWH is the treatment of choice for the prevention of VTE in trauma. Today, there are ongoing studies related to the correction of preventive doses of LMWH and the search for a single standard, depending on numerous factors.Conclusion. Severity and multiplicity of lesions correlate with severity of systemic inflammation, hypercoagulation, and incidence of venous thrombosis. However, this correlation has not been sufficiently studied in the scientific literature. The search for specific methods for the prevention of deep vein thrombosis leading to PE is an urgent problem of surgery of injuries both peaceful and wartime.

Conservative and Surgical Management Strategies of Intracranial Arachnoid Cysts: A Single Institution Experience of 136 Cases

Aim: Intracranial arachnoid cysts develop from the arachnoid membrane between the membranes called pia mater and dura mater, located on the brain and cerebellum. The aim of this retrospective study is to reveal our clinic's approach to intracranial arachnoidal cysts, which can be seen incidentally in all age groups, in the light of current literature. Materials and Methods: In our study, we retrospectively analyzed the clinical and radiological findings of a total of 136 patients diagnosed with intracranial arachnoid cysts in both genders and all age groups between January 1, 2017 and December 31, 2023. The localization of the arachnoid cyst was examined in the electronic medical records of the patients who had brain tomography and magnetic resonance imaging during the said interval. The gender, age groups, symptoms, treatment approaches and prognoses of the patients were analyzed. Results: The number of patients diagnosed with arachnoid cyst in our radiological examinations was 136. The prevalence was higher in men than in women; 94 patients were male (69.1%) and 42 patients were female (30.1%). 72 patients were 20 years of age or younger (52.9%). Among 136 patients, only 11 patients were found to have more than one arachnoid cyst in terms of localization (8.1%). In terms of localization, the most common locations were the middle fossa, 52 patients (38.2%). Retrocerebellar location was in 43 patients (31.6%), convex location was in 9 patients (6.6%), and anterior fossa location was in 32 patients (23.5%). Only 42 (30.9%) of 136 patients with radiologically detected arachnoid cysts had clinically significant symptoms. Other patients were detected incidentally during neuroradiological examinations performed for trauma or other reasons. During follow-up, an increase in the size of the cyst was observed in only 9 patients (6.6%). The number of patients operated on in our clinic was only 7 (5.1%). During the follow-up period of the remaining patients, only 3 patients had clinical improvement in their symptoms (2.2%). Conclusion: Arachnoid cysts are frequently encountered incidentally in radiological intracranial imaging today, and their incidence increases in the first 20 years of life. While very few patients show clinically significant neurological symptoms, asymptomatic patients do not require surgical treatment. It is recommended that asymptomatic patients be protected from head trauma and periodic neurosurgery outpatient clinic follow-up.

Tackling efficiency in a high demand orthopaedic clinic.

Surgical outpatient clinics continuously face challenges in delivering efficient and effective care. An expanding population and chronic staff shortages makes sustainability critical. The primary objective of this study was to identify modifiable factors contributing to longer wait times in an orthopaedic outpatient clinic. A single-centre prospective observational cohort study was conducted at Western Australia's state trauma centre. Over a four-week period, clinicians completed forms identifying delays in clinic, and clinic numbers were captured through an electronic booking system. Data was analysed using SPSS v27. Face-to-face (FTF) and telehealth (TH) clinic volumes grew by 18.9% and 361.1% respectively between 2018 and 2022. For the study period, 754 forms were completed for attending clinic patients. This captured 42.4% and 96.8% of FTF and TH actual attendance. The average wait time for doctor consultation was 63.9 min. Wait times significantly reduced when x-rays were performed prior to clinic (P < 0.001), and when an unaccredited registrar held the on-call phone (P < 0.001). Trauma clinics ran overtime in 95% of cases compared to elective clinics in which 25% ran overtime. The golden staffing ratio was one doctor for 13 patients. TH experienced few delays related to technological fault. This study demonstrates that clinic volume continues to rise. It highlights the demand for adequate staffing and identifies several modifiable factors that influence clinic efficiency. It demonstrates the growth of TH as an alternative modality for outpatient surgical services and its potential for future expansion.

P007 Quality improvement project using a bespoke Access database for trauma clinic and ward in-patients information recording and handover

P007 Quality improvement project using a bespoke Access database for trauma clinic and ward in-patients information recording and handover

Surgical treatment of post-traumatic instability of the shoulder joint in athletes. Аrthroscopic Latarjet procedure or free bone autograft?

BACKGROUND: Surgical therapy for post-traumatic shoulder includes a variety of procedures, such as the Latarjet operation, Bankart, and the use of free bone autograft. Each of the offered approaches has advantages and disadvantages. As a result, techniques for plastic surgery of the articular surface of the scapula have been developed in the last 10 yr.&#x0D; OBJECTIVE: To comprehensively evaluate the outcomes of biomechanical studies of the shoulder joint in the postoperative period after arthroscopic Latarjet operation and arthroscopic stabilization using a free bone graft in professional athletes.&#x0D; MATERIALS AND METHODS: From 2017 to 2022, the Clinic for Sports, Ballet, and Circus Trauma, named after Z.S. Mironova (N.N. Priorov National Medical Research Center for Traumatology and Orthopedics), performed 27 arthroscopic procedures on patients with post-traumatic shoulder joint instability.&#x0D; RESULT: According to the results of a comparative study of the biomechanics of the shoulder joint in the postoperative period in 27 athletes, conducted by us in the scientific department of medical rehabilitation of the N.N. Priorov, under the guidance of I.S. Kosov, it was revealed that the use of arthroscopic Latarjet operation reduces the strength characteristics of the shoulder joint and violates proprioceptive sensitivity, resulting to fine coordination of movements.&#x0D; CONCLUSIONS: The surgical treatment of post-traumatic shoulder joint instability in athletes is determined by the sport. A free bone block allows you to maintain fine coordinated movements, which is vital in gymnastics, synchronized swimming, and other sports, and a free autograft does not reduce strength characteristics after surgery. The Latarjet operation can be used in team sports (basketball and volleyball) without affecting the outcome of the game.

Getting it Right First Time in Trauma Clinic: How a Pandemic Improved Service Provision for Orthopaedic Patients

Introduction: The 2019 coronavirus outbreak (COVID-19) fast became a global pandemic. In the United Kingdom, guidlines were introduced to help control the spread of this virus. Hospitals made significant changes to accommodate for the change in demand. Orthopaedic trauma services needed to remain, however, the management of orthopaedic trauma needed modifying to comply with government and hospital guidelines. Method: Queens’s hospital, Burton, is a level III trauma unit. The orthopaedic department manages upper and lower limb trauma as well as head and chest and spine trauma. Injured patients can be referred to the orthopaedic team from the community or from the Major and Minor Emergency Department. To accommodate new guidelines, the orthopaedic department introduced a ‘virtual clinic’ and a ‘trauma clinic’. The virtual clinic took place in the morning and discussed referrals from the day before. The ‘trauma clinic’ followed on from the virtual clinic and lasted the remainder of the day. Results: The intervention introduced to Queens’s hospital was beneficial for patients, staff and for the hospital. It improved waiting times, reduced the time patients spent in hospital, reduced the number of hospital attendees and enhanced knowledge of common orthopaedic injuries for staffing involved in reviewing and managing these injuries. Conclusion: For our department, these changes improved service provision, staff education and patient safety. These benefits could be seen in other trusts if a similar method of managing trauma patients was introduced.

Improving outcome after paediatric concussion: challenges and possibilities.

The term concussion has permeated mainstream media and household vocabulary mainly due to awareness regarding the risks of concussion in professional contact sports, yet it occurs across a variety of settings and ages. Concussion is prevalent in infants, preschoolers, children, and adolescents, and is a common presentation or reason for referral to primary care providers, emergency departments, and specialised trauma clinics. Its broad range of symptoms and sequelae vary according to multiple individual, environmental, and clinical factors and can lead to health and economic burden. More than 20 years of research into risk factors and consequences of paediatric concussion has revealed as many questions as answers, and scientific work and clinical cases continue to expose its complexity and heterogeneity. In this Review, we present empirical evidence for improving outcome after paediatric concussion. We consider work pertaining to both sports and other injury mechanisms to provide a perspective that should be viewed as complementary to publications focused specifically on sports concussion. Contemporary challenges in prevention, diagnosis, prognosis, and intervention are discussed alongside pathways and future directions for improving outcome.

Using Lean Six Sigma in a Private Hospital Setting to Reduce Trauma Orthopedic Patient Waiting Times and Associated Administrative and Consultant Caseload.

In Ireland, the extent of outpatient orthopedic waiting lists results in long waiting times for patients, delays in processing referrals, and variation in the consultant caseload. At the study site, the Define, Measure, Analyze, Improve, and Control (DMAIC) Lean Six Sigma framework was applied to evaluate sources of Non-Value-Added (NVA) activity in the process of registering and triaging patients referred to the trauma orthopedic service from the Emergency Department. A pre- (October-December 2021)/post- (April-August 2022) intervention design was employed, utilizing Gemba, Process Mapping, and the TIMWOODS tool. Embracing a person-centered approach, stakeholder Voice of Customer feedback was sought at each stage of the improvement process. Following data collection and analysis, a co-designed pilot intervention (March 2022) was implemented, consisting of a new triage template, dedicated trauma clinic slots, a consultant triage roster, and a new option to refer directly to physiotherapy services. This resulted in the total wait time of patients for review being reduced by 34%, a 51% reduction in the process steps required for registering, and an increase in orthopedic consultant clinic capacity of 22%. The reduction in NVA activities in the process and the increase in management options for triaging consultants have delivered a more efficient trauma and orthopedic pathway.

Routine MRI Among Patients With a Suspected Scaphoid Fracture Risks Overdiagnosis.

In the setting of a suspected scaphoid fracture, MRI may result in overdiagnosis and potential overtreatment. This is in part because of the low prevalence of true fractures among suspected fractures, but also because of potentially misleading variations in signal that may be more common than fracture-related signal changes. To better understand the risk of overdiagnosis, we first need insight into the relative prevalence of useful and potentially distracting signal changes among patients with a suspected scaphoid fracture. What is the proportion of signal changes representing definite and possible scaphoid fractures relative to other types of signal changes on MRI among patients with a suspected scaphoid fracture? In a retrospective study in an orthopaedic trauma clinic associated with a Level I trauma center, we evaluated MR images of patients 16 years and older with a clinically suspected scaphoid fracture. At our institution, patients with symptoms and signs of a possible scaphoid fracture and negative radiographs undergo MRI scanning. Between January 1, 2012, and September 1, 2019, a total of 310 patients 16 years or older had an MRI to evaluate a suspected scaphoid fracture. Exclusion criteria included a scaphoid fracture that was visible on radiographs before MRI as reported by the radiologist (four patients), no available radiographs before MRI (two), MRI more than 3 weeks after injury (28), unknown date of injury (nine), and repeat or bilateral MRI scans (11), leaving 256 MR images for analysis. Sixty percent (153) of patients were women, and the median age was 34 years (IQR 21 to 50 years). The images were taken a median of 8 days (IQR 2 to 12 days) after injury. MR images were screened for the presence of scaphoid signal changes. We identified the following patterns of signal change with a reliability of kappa 0.62: definite scaphoid fracture, possible scaphoid fracture, signal in the waist area other than possible or definite fractures, and other signal changes. A definite scaphoid fracture was defined as a linear, focal, and bicortical signal abnormality, with adjacent edema and a relatively transverse orientation relative to the scaphoid long axis. The transverse linear signal was visible on more than one cut in multiple planes. A possible scaphoid fracture had a transverse linear signal on more than one cut on sagittal or coronal planes, with or without adjacent edema. Six percent (16 of 256) of MR images were categorized as revealing definite (2% [four of 256]) or possible (5% [12 of 256]) scaphoid fractures, whereas 29% (74 of 256) were categorized as revealing nonspecific signal changes at the waist (14% [35 of 256]) and other areas (15% [39 of 256]). Of the 51 patients with scaphoid waist signal changes, 69% (35) were categorized as having distracting and potentially misleading MRI findings. The high prevalence of signal changes that are distracting and potentially misleading, the low prevalence of signal changes that clearly represent a scaphoid fracture, and the low pretest odds of a true fracture among patients with a suspected scaphoid fracture illustrate that routine MRI of suspected scaphoid fractures carries a notable risk of overdiagnosis and potential overtreatment. Two alternative strategies are supported by preliminary evidence and merit additional attention: more-selective use of MRI in people deemed at higher risk according to a clinical prediction rule and strategies for involving the patient in decisions regarding how to manage the notably small risk of future symptomatic nonunion. Level IV, diagnostic study.